class1	augmentation mentoplasty using mersilene mesh  many different materials are available for augmentation mentoplasty  however  the optimal implant material for chin implantation has yet to be found  during the past several years  a number of experienced surgeons have turned to the use of mersilene mesh  mersilene mesh is a non absorbable dacron polyester fiber that can be conformed easily into layers to achieve tailored dimensions and shape  at the mccollough plastic surgery clinic pa  birmingham  ala  277 patients over a 10 year period underwent chin augmentation with mersilene mesh implants  the material provides excellent tensile strength  durability  and surgical adaptability  the overall complication rate was 3 2   nine patients   infection rate  2 5   seven patients   and removal secondary to infection  1 7   five patients   based on this 10 year experience  mersilene mesh remains our material of choice for chin augmentation  
class1	multiple intracranial mucoceles associated with phaeohyphomycosis of the paranasal sinuses  the purpose of this article is to alert clinicians to a new pathogenic fungus of the paranasal sinuses called exserohilum rostratum  exserohilum species are one of the etiologic agents of phaeohyphomycosis  a constellation of entities caused by dematiaceous fungi  this class of fungal sinus infection has emerged only in the past decade  it occurs primarily in immunocompetent individuals and produces a tenacious  progressive pansinusitis  to our knowledge  this study describes the first case of multiple intracranial mucoceles secondary to e rostratum  the diagnostic workup includes computed tomography and magnetic resonance imaging followed by direct microscopic examination of tissue biopsy specimens  a craniotomy followed by a bilateral external ethmoidectomy was necessary for complete extirpation of the infected mucoceles  aggressive surgical management of this mycotic infection is described  
class1	replacement of an aortic valve cusp after neonatal endocarditis  septic arthritis developed in a neonate after an infection of her hand  despite medical and surgical treatment endocarditis of her aortic valve developed and the resultant regurgitation required emergency surgery  at operation a new valve cusp was fashioned from preserved calf pericardium  nine years later she was well and had full exercise tolerance with minimal aortic regurgitation  
class1	the value of indium 111 leukocyte scanning in the evaluation of painful or infected total knee arthroplasties  evaluation of painful total knee arthroplasties  tkas  for infection can be difficult  indium 111  111in  leukocyte bone scanning provides a minimally invasive technique for evaluation of possible infection  thirty eight patients with a painful tka who had surgical exploration after 111in leukocyte scanning were reviewed  the scan had an accuracy of 84   a sensitivity of 83   and a specificity of 85   the 111in leukocyte scans must be interpreted in conjunction with the clinical evaluation of the patient because they are less accurate for study of tkas than of total hip arthroplasties  
class1	febrile infants less than eight weeks old  predictors of infection  febrile infants less than eight weeks old frequently are admitted and receive parenteral antibiotics for treatment of possible sepsis  the authors assess 52 infants less than eight weeks old with a rectal temperature of 38 1 degrees c or higher as having either a readily identifiable focus of infection by physical examination  appearing  toxic  without a focus  or appearing well  the authors screened patients by using white blood cell  wbc  counts  erythrocyte sedimentation rate  esr   c reactive protein  crp   and chest radiographs in addition to blood  cerebrospinal fluid and urine cultures  the authors found a 9 6  incidence of bacteria in the 52 infants evaluated  with a 4 3  incidence in those febrile infants who appeared well  five patients had positive blood cultures with group b b hemolytic streptococcus  four patients   and viridans streptococcus  one patient   a clinical assessment of toxicity and a total band count greater than or equal to 0 5 x 10 3  cells ul together were sensitive indicators of bacteremia  as were toxicity and a positive crp  a  toxic  appearance  a wbc count greater than or equal to 15 x 10 3  cells ul and an esr greater than 30 were specific indicators of bacteria  based on these data  identification of bacteremia in febrile infants may be possible with clinical assessment and screening laboratory tests  because of the relatively small sampling size of this study  the authors feel that evaluation of a larger number of patients is warranted to evaluate these sensitivities in a more diffuse patient population  
class1	superficial cultures in neonatal sepsis evaluations  impact on antibiotic decision making  the authors performed a retrospective analysis of neonatal superficial cultures and their effect on antimicrobial decision making during a nine month period at nashville general hospital  they obtained and reviewed charts of infants  n   66  having paired superficial  skin and or gastric aspirate  and deep  blood and cerebrospinal fluid  cultures for the evaluation of early onset sepsis  superficial cultures were positive for pathogens  any streptococcus or enteric gram negative  in 15   10 66  of cases  antimicrobial decision making was affected in only one of these cases  and in a seemingly inappropriate manner  in summary  there was no evidence or review that superficial cultures used in sepsis evaluation influenced physician antimicrobial decision making  in one case they may have led to unnecessary antibiotic exposure  
class1	sepsis related cardiogenic shock  to further define cardiovascular abnormalities in patients with septic shock  serial conventional hemodynamic measurements combined with two dimensional echocardiographic studies were performed at the bedside in 21 patients admitted for an acute episode of sepsis related circulatory failure  measurements obtained during the first hours of hospitalization revealed a group of six patients  group 1  with markedly depressed left ventricular function  as evidenced by a low cardiac index  ci   2 2     0 8 l min m2   reduced left ventricular ejection fraction  lvef   21     8    and an increased arterial venous oxygen content difference  right ventricular systolic function was also severely depressed  these patients were characterized as having sepsis related cardiogenic shock secondary to profound myocardial depression  which was reversible within 24 to 48 h with inotropic support  the 15 remaining patients  group 2  exhibited an initially increased ci  4 9     1 8 l min m2   with a low systemic vascular resistance  in group 2  lvef remained within the normal range despite abnormally low peripheral vascular resistance  this finding would suggest the presence of slight to moderate depression of left ventricular systolic function  all patients in this series had a normal left ventricular end diastolic volume  whether profound myocardial depression was present or not  
class1	catheter related sepsis  prospective  randomized study of three methods of long term catheter maintenance  we studied the infectious risk of different methods of managing vascular catheters during long term use  consecutive surgical icu patients requiring triple lumen catheters  pulmonary artery catheters  or arterial catheters for greater than 7 days were prospectively randomized to one of three management groups  a  percutaneous  perc  puncture with every 7 day catheter change at a new site  b  no weekly change  nwc  with a new site when changed  or c  guidewire exchange  gwx  with every 7 day catheter change at the same site  in all groups  a catheter change was mandatory for a positive blood culture  skin site infection  or sepsis without a likely source  cultures were obtained when clinically indicated and at the time of every catheter change  catheter related sepsis  crs  was defined as a positive blood culture and catheter culture with the same organism  a total of 112 patients met evaluation criteria  there were no intergroup differences in age  primary diagnosis  severity of injury or illness  number of study days  number of protocol violations  route of catheterization  number of catheters present patient day  catheter sepsis rate  or bacteremia rate  the nwc group demonstrated an increased number of days catheter  fewer catheter subcutaneous tract segment cultures patient  and a reduced incidence of catheter tip colonization  these results occurred in a setting where the number of crs episodes patient was 0 17 for gwx  0 22 for perc  and 0 16 for nwc  we conclude that there is no difference in infectious risk between these three methods of long term catheter management  the method with the least complications and expense should be used  
class1	effect of blood transfusion on oxygen consumption in pediatric septic shock  treatment plans for pediatric septic shock advocate increasing oxygen consumption  vo2   recent studies in septic shock indicate that improving oxygen delivery  do2  by increasing blood flow will increase vo2  we prospectively examined the effect on vo2 of improving do2 by increasing oxygen content  co2  with blood transfusion in eight hemodynamically stable septic shock patients  transfusion consisted of 8 to 10 ml kg of packed rbc over 1 to 2 h  hemodynamic and oxygen transport measurements were obtained before and after blood transfusion  transfusion significantly  p less than  05  increased hgb and hct from 10 2     0 8 g dl and 30     2  to 13 2     1 4 g dl and 39     4   respectively  mean     sd   do2 significantly  p less than  05  increased after transfusion  599     65 to 818     189 ml min m2   but vo2 did not change  166     68 to 176     74 ml min m2  ns   in pediatric septic shock patients  increasing co2 by blood transfusion may not increase vo2  
class1	resolution of the adult respiratory distress syndrome following colectomy and liver transplantation  a 32 year old woman with liver failure from end stage cirrhosis and ulcerative colitis developed septicemia and severe ards  subtotal colectomy and a successful liver transplantation resulted in complete resolution of the ards  
class1	effects of epinephrine on hemodynamics and oxygen metabolism in dopamine resistant septic shock  the hemodynamic effects of epinephrine were prospectively studied in 13 patients with septic shock who remained hypotensive after both fluid loading and dopamine  hemodynamic measurements were performed before and one hour after the start of epinephrine infusion  systolic  diastolic  and mean arterial pressure increased in all patients  p less than 0 01   cardiac index and systemic vascular resistance increased by 34 and 32 percent  respectively  p less than 0 05   but heart rate and pulmonary vascular resistance remained unchanged  there was a concomitant increase in oxygen delivery  p less than 0 01  and oxygen consumption  p less than 0 05   the magnitude of the latter being related to baseline lactacidemia  p less than 0 01   in view of the generally recognized physiologic goals of septic shock management  we conclude that epinephrine could be an appropriate alternative where fluid loading and dopamine have failed  
class1	short term chemoprophylaxis with ceftizoxime vs  five day aminoglycoside with metronidazole in  contaminated  lower gastrointestinal surgery  in a prospective  open  randomized controlled trial  173 patients requiring surgery for potentially  contaminated  lower gastrointestinal surgery were allocated to receive either two doses of ceftizoxime  2 gm  with one dose of metronidazole  1 5 gm  or gentamicin 3 mg kg day for five days with one dose of metronidazole  1 5 gm   eighty nine patients received ceftizoxime and 84 patients received gentamicin  the groups were comparable with respect to diagnosis  procedure  type of anastomosis  and wound closure  the incidence of withdrawal due to failure to respond to the study drug  11 5 percent  was equivalent in the two groups  there was no difference in the overall incidence of postsurgical infection between the ceftizoxime and metronidazole group  22 2 percent  and the gentamicin and metronidazole group  25 7 percent   the incidence of wound infection  ceftizoxime and metronidazole  6 9 percent  gentamicin and metronidazole  10 percent  and deep sepsis  ceftizoxime and metronidazole  15 3 percent  gentamicin and metronidazole  15 7 percent  was similar  
class1	gastrointestinal tuberculosis  report of four cases  gastrointestinal tuberculosis is a rare disease in the united states  correct identification is often delayed because it is not considered early on in the differential diagnosis  four patients with gastrointestinal tuberculosis and the symptoms  diagnosis  complications  and treatment of the disease are discussed  gastrointestinal tuberculosis should be considered in asian immigrant patients who present with symptoms and signs of inflammatory bowel disease  
class1	a small animal model of human helicobacter pylori active chronic gastritis  isolation of a spiral shaped bacterium closely related to helicobacter pylori from the cat stomach made it possible to investigate new small animal models of gastric infection  pure cultures of this bacterium  provisionally named  helicobacter felis   were fed to germ free mice  the organism colonized the stomach in large numbers in mucus and deep in the gastric pits and showed the same gastric trophism found with h  pylori  significant histopathology was seen in all h  felis infected mice  at 2 weeks postinfection  an acute inflammatory response was seen composed primarily of eosinophils and neutrophils  at 3 weeks  the polymorphonuclear response was more pronounced with large numbers of neutrophils in some areas forming small microabscesses  lymphocytes also increased in number  by 8 weeks  several relatively large lymphoid nodules were present in the submucosa  multiple small microabscesses were still present in the pyloric mucosa  this is the first animal model of bacterial gastritis to be described that shows progression from acute inflammation to persistent acute on chronic inflammation  active chronic  as is seen in human infection with h  pylori  
class1	prevention of necrotizing enterocolitis in the rat with prenatal cortisone  cortisone acetate is known to accelerate maturation of the immature intestine  the effect of prenatal administration of cortisone acetate on the morbidity and mortality of necrotizing enterocolitis was examined in a rat pup model  pregnant rats were administered cortisone acetate  20 mg 100 g of body weight  or normal saline by daily ip injection from day 18 21 of gestation  rat pups were taken from the mothers before suckling was initiated  fed a simulated rat milk formula  and subjected to daily ischemic insults to produce an animal model of necrotizing enterocolitis  both morbidity and the mortality rates were significantly improved with prenatal cortisone treatment  maturation of the intestinal mucosal barrier was accelerated with the cortisone treatment as measured by decreased serum concentrations of a fed antigen  ovalbumin  aerobic bacterial colonization of the small intestine and translocation of bacteria to the liver were decreased in the pups pretreated with steroids  these changes observed in a rat model of necrotizing enterocolitis may explain the decreased incidence of necrotizing enterocolitis in human infants born to mothers who received corticosteroids late in gestation  
class1	reduction of gastric ulcer recurrence after suppression of helicobacter pylori by cefixime  the effect on the recurrence of gastric ulcers after suppression of helicobacter pylori by combined treatment with cimetidine and the antimicrobial drug cefixime was investigated  twenty one of 43 patients with endoscopically proved gastric ulcer and h pylori infection were randomly assigned to receive cimetidine 800 mg daily for 12 weeks  the remaining 22 patients received cimetidine 800 mg daily for 12 weeks plus cefixime 100 mg daily for the last two weeks  after treatment  88  of 17 patients on cimetidine only remained h pylori positive  whereas combined administration of cimetidine and cefixime had suppressed h pylori in 78  of 18 patients  p less than 0 05   seventeen patients in the former group whose ulcers healed but who remained h pylori positive and 18 patients in the latter group whose ulcers healed and who were no longer infected with h pylori continued to be followed after treatment  these patients underwent endoscopy to detect ulcer recurrence if symptomatic  or at 12 and 24 weeks if asymptomatic  at 12 weeks  recurrence was observed in seven of 15  47   patients in whom h pylori persisted  but in only one of 14  7   patients in whom h pylori had been suppressed  p less than 0 05   at 24 weeks  however  recurrence rates were similar between the two groups  these findings indicate that h pylori infection may be closely related to early ulcer recurrence  
class1	adjuvant antibiotic therapy in duodenal ulcers treated with colloidal bismuth subcitrate  persistence of helicobacter pylori after duodenal ulcer healing is associated with high rates of ulcer relapse  we compared colloidal bismuth subcitrate alone with cbs combined with one of four antibiotic regimens in the treatment of duodenal ulcers  endoscopy and antral biopsies were performed before treatment and four weeks afterwards  biopsy specimens were examined for histological evidence of gastritis and by gram stain and culture for h pylori infection  altogether 141 patients were allocated to one of five treatment groups  giving cbs and metronidazole  400 mg tid for 7 days  with and without amoxycillin  500 mg tid  achieved higher clearance rates of h pylori than treatment with cbs alone  p less than 0 01   these two combinations also achieved higher rates of antral gastritis healing than cbs alone  p less than 0 01 and p less than 0 05 respectively   susceptibility to metronidazole was tested in 29 isolates before and in seven isolates after treatment with metronidazole by disc diffusion test and minimum inhibitory concentration assay  twenty seven  93   of the isolates were sensitive before treatment while six of seven  86   were resistant afterwards  four of the six resistant strains had acquired resistance during treatment and one of these had acquired metronidazole resistance despite concomitant treatment with amoxycillin  to which it remained sensitive  cbs with adjuvant metronidazole at a dose of 400 mg tid for seven days significantly improves the eradication of h pylori compared with cbs alone  acquired metronidazole resistance  however  seems to be an important cause of failure to eradicate h pylori  
class1	monomicrobial nonneutrocytic bacterascites  a variant of spontaneous bacterial peritonitis  spontaneous bacterial peritonitis is diagnosed when  a  the ascitic fluid culture is positive   b  the ascitic fluid neutrophil count is greater than or equal to 250 cells mm3 and  c  there is no evident intraabdominal surgically treatable source for infection  few details are available regarding the variant of ascitic fluid infection in which the culture grows bacteria  pure growth of a single type of organism   but the neutrophil count is less than 250 cells mm3  in this prospective study of 138 episodes of culture positive spontaneously infected ascites detected in 105 patients  44  31 9   were episodes of  monomicrobial nonneutrocytic bacterascites  compared with 94  68 1   episodes of spontaneous bacterial peritonitis  seventeen patients had both types of infection  the infection related mortality and hospitalization mortality were similar between the two groups  patients with bacterascites appeared to have less severe liver disease  in 62  of bacterascites episodes in which a second paracentesis was performed before any treatment the fluid spontaneously became sterile without development of ascitic fluid neutrocytosis  thirty eight percent of patients with bacterascites  who underwent a second paracentesis before treatment was started  progressed to spontaneous bacterial peritonitis  sometimes within a few hours  the concentration of the chemoattractant c5a was not decreased in the ascitic fluid of the bacterascites patients  this excludes ascitic fluid c5a deficiency as the explanation of the lack of neutrocytosis  monomicrobial nonneutrocytic bacterascites is a common variant of ascitic fluid infection that may resolve without treatment or may progress to spontaneous bacterial peritonitis  
class1	norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis  results of a double blind  placebo controlled trial  eighty cirrhotic patients who had recovered from an episode of spontaneous bacterial peritonitis were included in a multicenter  double blind trial aimed at comparing long term norfloxacin administration  400 mg day  40 patients  vs  placebo  40 patients  in the prevention of spontaneous bacterial peritonitis recurrence  at entry  both groups were similar with respect to clinical and laboratory data  ascitic fluid protein and polymorphonuclear concentrations  number of previous episodes of spontaneous bacterial peritonitis and causative organisms of the index spontaneous bacterial peritonitis  norfloxacin administration produced a selective intestinal decontamination  elimination of aerobic gram negative bacilli from the fecal flora without significant changes in other microorganisms  throughout the study in six patients in whom the effect of norfloxacin on the fecal flora was periodically assessed  fourteen patients from the placebo group  35   and five from the norfloxacin group  12   developed spontaneous bacterial peritonitis recurrence during follow up  chi 2   5 97  p   0 014   mean follow up period   6 4     0 6 mo  range   1 to 19 mo   ten of the 14 spontaneous bacterial peritonitis recurrences in the placebo group and only one of the five spontaneous bacterial peritonitis recurrences in the norfloxacin group were caused by aerobic gram negative bacilli  chi 2   8 87  p   0 0029   the overall probability of spontaneous bacterial peritonitis recurrence at 1 yr of follow up was 20  in the norfloxacin group and 68  in the placebo group  p   0 0063  and the probability of spontaneous bacterial peritonitis recurrence caused by aerobic gram negative bacilli at 1 yr of follow up was 3  and 60   respectively  p   0 0013   
class1	review of hepatic imaging and a problem oriented approach to liver masses  we believe that imaging of the liver is complicated  the sporadic appearance of incidental benign lesions and variability in scanning techniques  equipment and artifacts add difficulties to the evaluation of liver masses  therefore we emphasize the need to define the problem for which the patient is being imaged  this information helps in choosing the procedure of choice and the technique needed to give the most expedient  accurate answer  this will also help apply the lowest risk and most cost efficient care  imaging algorithms vary depending on the suspected pathological conditions  dynamic bolus enhanced ct is the modality of choice in most situations  tc99m sulfur colloid liver spleen scans are helpful in patients with suspected fnh  and tc99m tagged rbc spect scans are recommended to confirm cavernous hemangiomas  cysts are easily confirmed by us  although mri is competitive with ct  it has not become a primary modality because of cost  availability  patient selection and variability of scanner capabilities among the many manufacturers and models  it is hard to predict what future development of imaging techniques will bring  many feel that significant advances have plateaued  time and money will more likely be concentrated on improving image resolution  speed of scanning and ability to transfer this information to sites outside of the radiology department  in addition to faster scanning  we expect to soon have available safe intravenous and enteric contrast agents for mri  certainly this will lead to a new round of investigations to compare mri with ct scanning  
class1	mechanical cardiopulmonary support for refractory cardiogenic shock  from february 1982 to february 1990  38 patients  30 male patients and 8 female patients  ranging in age from 10 to 78 years  mean 49 4 years  have been supported with arteriovenous extracorporeal membrane oxygenation  ecmo  at st  louis university medical center as a resuscitative system for cardiac arrest or cardiogenic shock  all patients were unresponsive to conventional resuscitative measures including an intraaortic balloon pump in 25 patients  patients were resuscitated in the intensive care unit  cardiac catheterization laboratory  or the emergency department  diagnosis varied from acute myocardial infarctions  12 patients   ischemic disease  15 patients   end stage cardiomyopathy  7 patients   congenital heart disease  3 patients   or postoperative cardiac transplant graft rejection  1 patient   three patients could not be resuscitated with ecmo because of low flow  but the remaining 35  92   achieved hemodynamic stability with ecmo flows greater than 2 l min m2  duration of support ranged from 0 5 to 130 hours  mean 28 hours   twenty four patients were successfully weaned from ecmo support after coronary artery bypass  five patients   cardiac transplantation  two patients   or ventricular assist device insertion  eight patients   or with inotropic support  nine patients   of the 14 patients not weaned  three were inadequately resuscitated  two had percutaneous transluminal coronary angioplasty while receiving ecmo  and nine were not candidates for further intervention  nine  24   patients were discharged and are long term survivors  our results indicate that resuscitative ecmo is useful for intervals of 12 to 24 hours and can best be applied with  1  patients younger than 60 years of age   2  patients having acute events  failed percutaneous transluminal coronary angioplasty  amenable to surgical intervention  and  3  candidates for cardiac transplantation who could be switched to more sophisticated devices within 12 to 24 hours of ecmo insertion  with these criteria  ecmo  when used as a resuscitative system  can result in increased survival in selected patients with refractory cardiogenic shock or cardiac arrest  
class1	fungal pseudomeningitis superimposed on escherichia coli meningitis  pseudomeningitis is the demonstration of microorganisms from the cerebrospinal fluid by stain or culture in a patient with symptoms suggesting meningitis  this is a report of fungal pseudomeningitis superimposed on a case of nosocomial escherichia coli meningitis resulting from a neurosurgical procedure  critical care personnel need to be aware of the possibility of pseudomeningitis with or without associated meningitis in the appropriate setting  
class1	the hastings bipolar hemiarthroplasty for subcapital fractures of the femoral neck  a 10 year prospective study  in a 10 year prospective study  561 displaced subcapital fractures of the femoral neck in 546 patients were treated with the hastings bipolar hemiarthroplasty  within six months of their operations  148 patients had died  in 322 hips followed up  243 with adequate serial radiographs separated by more than one year  only 14  5 6   showed acetabular erosion  a group of 91 had been reviewed for between three and nine years  mean  4 years 10 months  and of these  95  had no pain or slight pain only  comparison with an earlier series of conventional hemiarthroplasties reported from this institution showed that the clinical results were similar  but that the erosion rate had been halved  
class1	external fixation for type iii open tibial fractures  an analysis of 51 type iii open tibial fractures treated by external skeletal fixation is presented  the fractures are subdivided according to the classification of gustilo  mendoza and williams  1984  into types iiia  iiib and iiic  the different prognoses of these fracture subtypes is examined  the use of the hoffmann and hughes external fixators in the management of type iii open tibial fractures is presented and it is suggested that the prognosis is independent of the type of fixator used  
class1	neonatal osteomyelitis  thirty four neonates with osteomyelitis were reviewed  the hip  19  was the most common site involved  swelling and pseudoparalysis were the most significant local signs  radiographic abnormalities  such as metaphyseal rarefaction and or joint subluxation were found on the initial radiographs in 18 of the 19 hips involved  all patients were treated with antibiotics and all infections involving joints were drained surgically  good results were achieved in 75  of all sites and in 68  of hips  
class1	denatured muscle grafts for nerve repair  an experimental model of nerve damage in leprosy about 20  of patients with leprosy develop localised granulomatous lesions in peripheral nerves  we report experiments in guinea pigs in which freeze thawed autogenous muscle grafts were used for the treatment of such mycobacterial granulomas  granulomas were induced in guinea pig tibial nerves and the animals were left for 7 to 100 days in order to assess maximal damage  the local area of nerve damage was then excised and the gap filled with denatured muscle grafts  clinical assessment after periods up to 150 days showed good sensory and motor recovery which correlated well with the histological findings  the muscle graft technique may be of value for the treatment of chronic nerve lesions in selected cases of leprosy  
class1	the modified schollner costoplasty  the modified schollner costoplasty is a cosmetic procedure for the correction of rib prominence deformity in scoliosis  we present the results of the procedure in 21 patients who had previously undergone spinal fusion for scoliosis  we found the procedure to be well tolerated without major complications  objective cosmetic improvement was achieved in all but one case  all but one patient considered the procedure to have been of cosmetic benefit  
class1	selection of antibiotic coverage in vascular patients undergoing cystoscopy  bacteremic seeding of prosthetic vascular grafts represents a cause for graft infection  transurethral procedures account for one source of bacteremia  therefore  a prospective study of 200 patients undergoing cystoscopy was conducted to identify the incidence of bacteruria and factors associated with it  organisms involved and their antibiotic sensitivities  positive cultures were found in 21   the incidence was 64  in in patients and 8  in out patients  positive cultures were found in 12  of patients who received antibiotics and 29  who did not  four percent showed signs of bacteremia  the cultures identified both gram positive and negative organisms  multiple organisms grew in 22   gram negative organisms were more common in in patients  candida grew in 8   the gram positive organisms were sensitive to ampicillin  92    sulfatrimethoprim  75   and cefazolin  60    gram negative to aminoglycosides  100   and cefazolin  92    in view of the unpredictable and multiple organisms  it is recommended that pre cystoscopy cultures be performed and specific antibiotic coverage be based on the sensitivities  
class1	possible role of bacterial siderophores in inflammation  iron bound to the pseudomonas siderophore pyochelin can function as a hydroxyl radical catalyst  tissue injury has been linked to neutrophil associated hydroxyl radical   oh  generation  a process that requires an exogenous transition metal catalyst such as iron  in vivo most iron is bound in a noncatalytic form  to obtain iron required for growth  many bacteria secrete iron chelators  siderophores   since pseudomonas aeruginosa infections are associated with considerable tissue destruction  we examined whether iron bound to the pseudomonas siderophores pyochelin  pch  and pyoverdin  pvd  could act as  oh catalysts  purified pch and pvd were iron loaded  fe pch  fe pvd  and added to a hypoxanthine xanthine oxidase superoxide    o2   and hydrogen peroxide  h2o2  generating system  evidence for  oh generation was then sought using two different spin trapping agents  5 5 dimethyl pyrroline 1 oxide or n t butyl alpha phenylnitrone   as well as the deoxyribose oxidation assay  regardless of methodology   oh generation was detected in the presence of fe pch but not fe pvd  inhibition of the process by catalase and or sod suggested  oh formation with fe pch occurred via the haber weiss reaction  similar results were obtained when stimulated neutrophils were used as the source of  o2  and h2o2  addition of fe pch but not fe pvd to stimulated neutrophils yielded  oh as detected by the above assay systems  since pch and pvd bind ferric  fe3   but not ferrous  fe2   iron   oh catalysis with fe pch would likely involve  o2    mediated reduction of fe3  to fe2  with subsequent release of  free  fe2   this was confirmed by measuring formation of the fe2    ferrozine complex after exposure of fe pch  but not fe pvd  to enzymatically generated  o2   these data show that fe pch  but not fe pvd  is capable of catalyzing generation of  oh  such a process could represent as yet another mechanism of tissue injury at sites of infection with p  aeruginosa  
class1	antigen specific serum antibody response to chlamydia trachomatis in patients with acute pelvic inflammatory disease  sera from 35 patients with acute pelvic inflammatory disease  pid  with and without chlamydia trachomatis confirmed by culture and sera from 19 control patients with neither evidence of pelvic infection nor c trachomatis infection were studied for the presence of serum igg  iga  and igm antibodies to c trachomatis using enzyme immunoassay  eia  and immunoblotting techniques  there was no correlation between the antibody concentrations in the eia and the spread of chlamydial infection  as determined by cervical  endometrial  and laparoscopic sampling for chlamydia  the immunoblot analysis showed antibodies to the major outer membrane protein  momp  of c trachomatis elementary bodies in all patients who had had c trachomatis isolated  reactivity was also frequently observed against the 68  62  60  45  and 31 kilodalton antigens  about 20 antigenic polypeptides were identified  differences in antibody prevalence to specific chlamydial antigens  however  were not related to the site of chlamydial isolation or serum antibody concentrations observed with the eia  the results indicate that patients with pid with and without upper genital tract infection with c trachomatis cannot be differentiated by reactivity of sera to specific chlamydial polypeptide antigens  the determination of a specific serum iga antibody response by eia was the most effective single test to discriminate between patients with and without acute chlamydial infection  
class1	serum pepsinogen i and gastrin concentrations in children positive for helicobacter pylori  serum pepsinogen i  serum gastrin concentration  and inflammatory scores were measured in a population of 71 children undergoing upper gastrointestinal endoscopy for investigation of upper abdominal pain  forty four were initially colonised with helicobacter pylori  the indices were measured before treatment  in 71 children   one month  in 41 children   and six months  in 21 children  after stopping treatment  before treatment there was a significant correlation between serum pepsinogen concentration  total inflammatory score  and h pylori state  but no correlation between serum gastrin concentrations and h pylori state  similarly  the total inflammatory score and serum pepsinogen concentrations were significantly correlated  there was no such correlation in children negative for h pylori  after treatment the inflammatory score improved in those patients in whom h pylori had been eradicated  there was also a significant fall in serum pepsinogen i and serum gastrin concentration in those patients in whom h pylori had been eradicated  these results were similar to those found six months after treatment had been stopped  these findings suggest that the serum pepsinogen i concentration could be considered a useful marker for gastritis and can be used as an index of severity of gastritis in h pylori positive subjects  the measurement of serum gastrin concentrations does not give useful information  
class1	effect of sample volume on yield of positive blood cultures from adult patients with haematological malignancy  six hundred and sixteen blood samples from patients with haematological malignancy were each distributed equally among three identical cells in a malthus microbiological growth analyser  the mean  sd  volumes inoculated into sets in which one  two  or three of the three bottles were positive were 37 7  10 1  ml  37 4  12 9  ml  and 37 7  10 5  ml  respectively  overall  clinically important organisms were isolated from one bottle only with 18 cultures  from two bottles only with 19 cultures  and from all three bottles in a set with 104 cultures  if the yield from a single bottle inoculated with a mean volume of 12 6 ml blood is taken as 100   the yield from 25 2 ml in two bottles was 110 7  and the yield from 37 7 ml in three bottles was 115 6   the increased yield from increased volume was considerably lower than that reported from unselected groups of patients  which suggests that the magnitude of bacteriaemia is greater in patients with neutropenia  the isolation of infecting organisms from the blood of patients with neutropenia is  however  particularly important in directing chemotherapy and consequently 45 ml blood samples from these patients continue to be requested  
class1	the many faces and phases of borreliosis  i  lyme disease  published erratum appears in j am acad dermatol 1991 apr 24 4  663  lyme disease is increasingly being reported throughout the united states and many parts of the world  borrelia burgdorferi  the etiologic agent of lyme disease  is a spirochete that  not unlike the treponema of syphilis  can cause a spectrum of disease from the initial skin lesion  through widely varied symptoms and signs  to chronic neurologic and arthritic disability  the borrelial spirochete and lyme disease are the subject of this review  a subsequent article will review other definite and possible cutaneous manifestations of borreliosis  
class1	skin pigmentation from clofazimine therapy in leprosy patients  a reappraisal  skin biopsy specimens from two lepromatous leprosy patients with dark brown pigmentation who were receiving long term clofazimine therapy were studied  ceroid lipofuscin pigment was demonstrated inside macrophages that contained numerous phagolysosomes  these contained lipids and clofazimine that appeared as electron lucent vacuoles and a lipofuscin pigment that was electron dense  granular  and lamellated  although the presence of the drug in tissues contributed to the skin pigmentation  the main cause was a drug induced  reversible ceroid lipofuscinosis  
class1	the many faces and phases of borreliosis ii  borrelia burgdorferi  the etiologic agent of lyme disease  has also been associated with other cutaneous conditions  acrodermatitis chronica atrophicans and lymphadenosis benigna cutis are also caused by b  burgdorferi  recent evidence links some cases of progressive facial hemiatrophy of parry romberg  benign lymphocytic infiltrate of the skin  jessner kanof   lichen sclerosus et atrophicus  morphea  and shulman syndrome with borreliae  this article reviews the manifestations of the diseases definitely linked to borreliosis and the evidence linking borreliae to progressive facial hemiatrophy  benign lymphocytic infiltrate  lichen sclerosus et atrophicus  morphea  and shulman syndrome  
class1	cutaneous lesions of disseminated histoplasmosis in human immunodeficiency virus infected patients  disseminated histoplasmosis is being diagnosed more frequently in persons infected with the human immunodeficiency virus and is often the initial manifestation of the acquired immunodeficiency syndrome  aids   disease related cutaneous features of hiv associated disseminated histoplasmosis are defined as mucocutaneous lesions from which fungal organisms were either cultured or demonstrated histopathologically  we report four hiv seropositive patients with disseminated histoplasmosis who had culture positive skin or oral lesions of histoplasmosis and review the specific cutaneous manifestations of hiv associated disseminated histoplasmosis  including our patients  disease related skin and or mucosal lesions were present in 11  of patients  26  of 239  with hiv associated disseminated histoplasmosis  the possibility of disseminated histoplasmosis should be considered in all hiv infected persons and in persons with aids risk factors who have fever  weight loss  hepatosplenomegaly  and new cutaneous lesions  an early skin or mucosal biopsy specimen for crushed tissue preparation  histologic evaluation  and fungal culture is a simple  rapid diagnostic procedure  
class1	treatment of fungal skin infections  state of the art  the number of cases of mycotic infections are increasing  presenting physicians today with an unprecedented challenge in handling the treatment and prophylactic control of these disorders  the increase in mycotic disorders is due to many factors  such as longer life span  organ transplantation  and the acquired immunodeficiency syndrome  the pharmaceutical industry is providing physicians with newer  more potent drugs to manage mycoses  an overview of current practice in the use of topical and oral agents  especially ketoconazole  are given in the following specific mycoses  tinea capitis  pityriasis versicolor  seborrheic dermatitis  trichophyton rubrum infections  vaginal candidiasis  and moist intertriginous tineas  the efficacy of ketoconazole in various vehicles and dosage schedules and of traditional agents such as griseofulvin are discussed with relation to each of the mycoses  
class1	itraconazole in tinea versicolor  a review  itraconazole  a new orally active triazole antifungal  has been tested in patients with pityriasis versicolor  a number of studies have shown that itraconazole is effective for this mild fungal skin disease  the total dose required for effective treatment is 1000 mg  and it has been given as 200 mg for 5 days or 7 days  the organisms disappear slowly from the skin  even when dead  and the results should be assessed clinically and mycologically at around 3 to 4 weeks after treatment  numerous studies have shown that itraconazole is superior to placebo and as effective as selenium sulfide  clotrimazole  and ciclopirox olamine  it is also better tolerated by patients than selenium sulfide  
class1	itraconazole in common dermatophyte infections of the skin  fixed treatment schedules  itraconazole is an effective medication against the most common dermatophytoses  it has been shown to be more active than griseofulvin and ketoconazole  ease of use  affinity for keratinized tissues  lack of toxicity  continued activity after discontinuation  and the possibility of using fixed schedules are advantages of itraconazole  the fixed schedules indicated by pharmacokinetics and clinical studies are one 100 mg capsule daily for 15 days in cases of tinea corporis and tinea cruris and the same dosage for 30 days in cases of tinea pedis and tinea manuum  these fixed treatments have some limitations  and they are not recommended for treating tinea capitis and tinea unguium  the drug is well tolerated  
class1	itraconazole in the management of chronic dermatophytosis  fifty five patients with griseofulvin unresponsive dermatophytosis caused by trichophyton rubrum were treated with itraconazole  they had either tinea corporis or  dry type  infections of the palms  soles  or nails  the following sites were affected  trunk  12 infections   soles  47   toe webs  52   palms  26   fingernails  29   and toenails  42   patients were treated with oral itraconazole until clinical and mycologic remission were achieved  response rates and mean times to recovery were as follows  trunk  100   1 5 months  soles  83   6 7 months  toe webs  90   7 2 months  palms  96   4 6 months  fingernails  90   5 4 months  and toenails  76   10 3 months   in a 6 month follow up period 7 of 30 patients with toenail infections who had responded to treatment had a clinical and mycologic relapse  usually of one nail  side effects were minimal but included abdominal discomfort  three patients   headache  one   and weight gain  two   no persistent abnormalities in blood biochemistry were seen  even in patients who received itraconazole for more than 9 months  
class1	treatment of oral candidosis with itraconazole  a review  oral candidosis is a common infection in infants  elderly persons  patients receiving immunosuppressive therapy  and patients with acquired immunodeficiency syndrome  aids   the orally active antifungal agent itraconazole has been evaluated in a number of different patient populations with oral and oropharyngeal candidosis  initial studies have shown that itraconazole  100 or 200 mg day for 14 days  is more active than placebo in treating oral candidosis  a comparative study between itraconazole capsules  200 mg once daily  and clotrimazole troches  10 mg five times daily  showed equivalent results at the end of therapy but a significantly faster response to itraconazole and a faster relapse rate with clotrimazole  a study in aids patients with oropharyngeal candidosis demonstrated that itraconazole  200 mg day  and ketoconazole  400 mg day  for 4 weeks give equivalent clinical cure rates and similar relapse rates  a pilot study with an oral solution of itraconazole has given an impressive 100  clinical and mycological response rate within 1 week of treatment  in conclusion  itraconazole in capsule or in solution form may constitute a major addition to the armamentarium of drugs against oropharyngeal candidosis  
class1	treatment of vaginal candidiasis  orally or vaginally  vaginal candidiasis continues to be the most common cause of vaginal discharge  a large variety of topical drugs and a selection of orally active antifungals are currently available  the choice between the use of oral drugs or intravaginal agents will depend on the therapeutic results obtained with the different agents  side effects  pregnancy status  and patient preference  the results obtained in the maria hospital  tilburg  the netherlands  and a review of foreign data suggest the following   1  for acute infection oral and topical agents produce equivalent results   2  for chronic infections oral medication is preferred   3  oral therapy should not be given to pregnant patients or to patients not using reliable contraceptive measures   4  half the patients prefer oral medication  only 5  prefer intravaginal therapy  and the others had no clear preference  
class1	individualizing treatment of vaginal candidiasis  clinicians have a vast array of effective antimycotics for the treatment of vaginal candidiasis  multiple topical formulations are available  yet there is little evidence to suggest that formulation per se influences outcome  a growing number of highly effective oral systemic antimycotic agents provide the practitioner with additional options  treatment regimens have also changed with the introduction of shorter  often single day single dose courses of therapy  not all therapeutic agents have the same activity against vaginal fungal pathogens in that topical azoles tend to be more active than nystatin  differences in patient characteristics  however  are more important than the differences between antimycotic agents and therapeutic regimens in determining selection of the appropriate antimycotic  patients with vaginal candidiasis vary with regard to duration and severity of symptoms and past frequency of attacks  distribution of inflammation  and pregnancy status  the clinician should consider all these variables both in selecting the appropriate antimycotic agent and the route of administration and in planning the duration of therapy  individualized therapy offers additional benefits to patients  who may then enjoy the maximum advantages of antimycotics now available  
class1	itraconazole treatment of phaeohyphomycosis  nineteen patients with phaeohyphomycosis were treated with itraconazole  of these  17 were assessable for clinical outcome  of these  two had received no prior therapy  five had failed amphotericin b therapy  four had failed ketoconazole or miconazole therapy  and five had failed both amphotericin b and azole therapy  one patient had received only prior surgical intervention  fungi of seven different genera caused disease of the skin in nine patients  soft tissue in nine  sinuses in eight  bone in five  joints in two  and lungs in two  itraconazole was given in dosages ranging from 50 to 600 mg day for 1 to 48 months  clinical improvement or remission occurred in nine patients  two patients have had stabilization of disease  six patients failed treatment  one had a relapse after initially successful treatment  itraconazole appears to be highly effective in some patients with phaeohyphomycosis  including patients refractory to other antifungal agents  
class1	european experience with itraconazole in systemic mycoses  since january 1985 more than 100 patients with deep fungal infections have been treated with itraconazole  200 to 400 mg day  in northern italy  evaluation of the drug efficacy and tolerance was possible in one patient with sporotrichosis  in 34 with aspergillosis  and in 36 with cryptococcosis  mainly patients positive for human immunodeficiency virus   response to itraconazole alone was obtained in the case of sporotrichosis and in 24 of 34 patients with different forms of aspergillosis  of the 18 patients with invasive pulmonary aspergillosis  15 were cured   patients with cryptococcosis received itraconazole for active infection and or for prevention of relapse  active infection was treated successfully with itraconazole alone in 9 of 12 patients and with itraconazole plus flucytosine in 8 of 10 patients  of the 31 patients who received itraconazole maintenance therapy for up to 27 months  4  13   had relapses  14  45   did not have relapses  and decline of serum antigen was detected in 12 of them  and 13  42   were completely cured  serum antigen titer dropped to zero   with the exception of hypokalemia in one patient  itraconazole was well tolerated even in patients who received the drug for several months or years  
class1	itraconazole therapy for nonmeningeal coccidioidomycosis  clinical and laboratory observations  itraconazole  a new oral triazole antifungal agent  was administered in 75 courses to patients with chronic coccidioidomycosis at dosages of 50 to 400 mg day for a median duration of 10 months  assessment of efficacy was made with a standardized scoring system  responses were seen in 42 of 58 assessable courses  72    nonresponse occurred exclusively in patients who had failed previous therapy and was most common in pulmonary disease  toxicity was minimal at the doses studied  pharmacokinetic analysis of itraconazole in serum at steady state showed negligible circadian variation  differences in serum concentrations among patients were large  clinical isolates of coccidioides immitis showed uniform in vitro susceptibility to itraconazole  itraconazole shows impressive activity in this series of patients with refractory coccidioidomycosis  further evaluation of itraconazole in this and in other systemic mycoses is in order  
class1	itraconazole in opportunistic mycoses  cryptococcosis and aspergillosis  striking results were obtained with oral itraconazole therapy in two opportunistic mycoses  of 28 patients with cryptococcal meningitis  18 achieved complete responses  including 16 of 24 patients with acquired immunodeficiency syndrome  other manifestations of cryptococcosis were similarly responsive  in aspergillosis 12 of 15 patients responded  including 8 of 10 immunocompromised hosts  these patients included those with invasive pulmonary disease  4 5   skeletal disease  2 2   pleural disease  1 2   and pericardial  sinus  mastoid  hepatosplenic  or nail disease  1 1   these results with itraconazole compare favorably to conventional  parenteral  therapy  and toxicity was minimal  this suggests that comparative trials are now in order  
class1	itraconazole therapy in aspergillosis  study in 49 patients  itraconazole  200 to 400 mg once daily  was administered to 49 patients with different types of aspergillosis  pulmonary aspergilloma  14 patients   chronic necrotizing pulmonary aspergillosis  14   and invasive aspergillosis  21   itraconazole was prescribed alone or in combination or after treatment with amphotericin b and flucytosine  of 14 aspergilloma patients  2 were cured and 8 had symptomatic improvement  in chronic necrotizing pulmonary aspergillosis  7 of 14 patients were cured and 6 improved significantly  in invasive aspergillosis treatment failed in 6 patients and 15 were cured  itraconazole can be an alternative to amphotericin b in the treatment of invasive aspergillosis and chronic necrotizing pulmonary aspergillosis  in aspergilloma itraconazole may be useful in inoperable cases  
class1	an external urine collection device for incontinent women  evaluation of long term use  urinary incontinence is common in aged women  may precipitate nursing home admission  and may prompt use of a urine collection device  usually an indwelling urethral catheter  the safety and efficacy of a new external urine collection device for women that is affixed to the perineum by an adhesive developed for ostomy bags was evaluated  applied to 26 aged women  78  of 2 264 devices were leak free for 24 hours and 49  for 48 hours  the incidence of new bacteriuria was less than half that found in our earlier studies of long term urethral catheters in the same institution  perineal erythema was infrequent and preexisting decubitus ulcers improved or did not change  four patients were withdrawn  one each because of periurethral itching  diminished urine output  recurrent wetness  and fracture of the proximal femur associated with severe osteoporosis  this device may offer an alternative to urethral catheters for management of urinary incontinence but should not be used on women with urine retention and should be used with care on women with severe osteoporosis  controlled trials must determine effects upon bacteriologic complications and health care costs  
class1	possible role of leukotrienes in gastritis associated with campylobacter pylori  this study was done to evaluate the role of leukotrienes  lts  in gastritis associated with campylobacter pylori  biopsy specimens of gastric mucosa were obtained endoscopically from 18 patients with nonulcer dyspepsia for bacteriological and histological examination and extraction of lts  there was correlation between the ltb4 level in the mucosa and the degree of gastritis evaluated histologically  the level was higher when infiltration of neutrophils in the gastric mucosa was more extensive  the ltb4 level in mucosa infected with c  pylori was higher than that in noninfected mucosa  these findings suggest that endogenous lts may be related to the pathogenesis of gastritis associated with c  pylori  
class1	evidence for gastric mucosal cell invasion by c  pylori  an ultrastructural study  it is now generally accepted that campylobacter pylori is closely associated with peptic ulcer disease and chronic type b gastritis  whether c  pylori is the direct etiologic cause of either or both of these illnesses remains unclear  possible pathophysiologic effects of c  pylori are still a matter of debate and conjecture  utilizing a small group of patients with gastric ulcers and chronic gastritis  we examined the ultrastructural relationship between c  pylori and gastric cells  forty eight percent of our gastric ulcer patients and 57  of our chronic gastritis patients had c  pylori in their lower corpus mucosa  examination with the transmission electron microscope indicated a very close proximation by c  pylori to the surface epithelial cells strongly suggesting adherence  we also describe for the first time the invasion of gastric cells by c  pylori  although an uncommon occurrence  we had repeated observations of c  pylori invading surface epithelial cells  parietal cells  and chief cells  most of the intracellular c  pylori were intact but other forms appearing to be degenerating organisms were also seen  we suggest that cell invasion may be one mechanism by which c  pylori causes pathologic changes in the gastric mucosa  these observations may also explain why c  pylori chronically infects gastric cells and frequently recurs after treatment  
class1	a case of unexpected pasteurella multocida bacteremia  a case of pasteurella multocida bacteremia in a previously healthy hospital employee is presented  the patient had sustained a scratch from his dog four days prior to being seen in the emergency department with adequate healing and no evidence of localized infection  he presented with an acute febrile illness  and was discharged from the emergency department with a diagnosis of viral syndrome  he was asked to return to the hospital the next day when a bacteriology report of gram negative rods in both aerobic and anaerobic blood culture bottles was received in the emergency department  pasteurella multocida bacteremia septicemia is seen most frequently in immunocompromised patients but the diagnosis should be considered in any patient with a febrile illness and exposure to cats or dogs  
class1	assessing the risk of occupational acquisition of the human immunodeficiency virus  implications for hospital policy  in determining infection control policy  it is essential to quantitatively assess the risk of transmission of human immunodeficiency virus  hiv  to health care workers and their families  the risk should be placed in perspective by comparing it with other occupational hazards  the risk of seroconversion from a needlestick injury can be calculated from the probability of a needlestick occurrence  the probability that the source patient is infected  and the probability of seroconversion  given an exposure  the risk of seroconversion due to drawing 1000 blood specimens from seropositive patients is between 86 and 470 in 100 000  the risk to surgeons from performing 25 operations on infected patients is approximately 272 in 100 000  the risk of fatal injury in the course of one year s work on a louisiana oil rig is between 188 and 283 per 100 000  
class1	duplex doppler examination of a perinephric abscess in a renal transplant  perinephric abscess has no characteristic ultrasonic appearance or location  differentiation from urinoma  lymphocele  or hematoma depends on clinical and laboratory findings  therapy consists of percutaneous catheter drainage  surgical drainage  and antibiotic therapy  acute rejection is the most common cause of decreased diastolic flow during the immediate postoperative period  acute tubular necrosis does not usually alter blood flow unless it is severe  duplex doppler ultrasonic assessment of the renal transplant during the immediate postoperative period may provide a valuable baseline for comparison if complications develop  baseline and follow up ultrasonography to evaluate diastolic flow can help determine whether a posttransplant patient should receive emergency or conservative therapy for complications  
class1	broad spectrum penicillin as an adequate therapy for acute cholangitis  in a previous study of patients with acute cholecystitis  we demonstrated equal efficacy with a broad spectrum penicillin  piperacillin  and a penicillin plus amino glycoside combination  whether a single agent broad spectrum penicillin is adequate treatment for more severe infections  such as acute cholangitis  however  is still unclear  we  therefore  conducted a three center  prospective  randomized trial to determine whether or not a broad spectrum penicillin alone is adequate therapy for patients with acute cholangitis  during a 36 month period  96 patients with sepsis and biliary obstruction were randomly assigned to receive either piperacillin  n   49  or ampicillin plus tobramycin  n   47   the two groups receiving antibiotics were similar with respect to all clinical and laboratory parameters  the incidence of blood cultures with positive results  20 versus 21 per cent  and underlying malignant lesions  51 versus 62 per cent  was also similar between the two groups  the percentage of patients with a clinical cure or significant improvement was the same in the two groups  69 versus 70 per cent   however  there was a significant difference in the cure rate between patients with benign and malignant biliary obstructions  83 versus 59 per cent  p less than 0 01   no significant differences were noted between the two antibiotic groups with respect to drug toxicity  but patients with malignant conditions were more prone to antibiotic related toxicities  2 versus 19 per cent  p less than 0 05   these data suggest that outcome of treatment in patients with acute cholangitis is similar with either a broad spectrum penicillin or a penicillin plus aminoglycoside combination and is dependent upon the nature of the biliary obstruction  
class1	ascending cholangitis  surgery versus endoscopic or percutaneous drainage  a retrospective review of 61 patients with calculous cholangitis was carried out  there were 31 men and 30 women and their mean age was 75 8 years  all patients had abdominal pain  87  had chills and fever  65  had clinical jaundice  23  were in shock  and 54  had positive blood cultures  because intravenous hydration and antibiotics did not help  33 patients underwent surgery  25 patients underwent endoscopic papillotomy  ep   and three patients underwent percutaneous transhepatic drainage of the common bile duct  ptd   morbidity in the surgery group included two wound infections  one respiratory failure  and one renal failure  morbidity in the ep ptd group was one case of arterial bleeding requiring surgery and one of pancreatitis treated conservatively  two patients  6   died in the surgery group  one of sepsis and the other of cardiorespiratory arrest  in the ep ptd group nine patients  32   died of sepsis and multisystem organ failure  these patients were considered too ill to undergo surgery and thus repeat ep ptd was carried out  cholangitis persisted  and retained common bile duct stones with sepsis was the cause of death  thus when initial ep or ptd is unsuccessful  surgical exploration of the common bile duct should be carried out to control sepsis  
class1	the hyperimmunoglobulinaemia e and recurrent infections syndrome in an adult  published erratum appears in thorax 1990 dec 45 12  984  a 27 year old white woman with a history of chronic eczema and episodes of serious infection of the chest  skin  and bone presented with acute respiratory failure  she was found to have a spontaneous right pneumothorax and a pneumatocele in the left upper lobe  despite a left upper lobectomy she was left with chronic respiratory failure  bullous lung disease  and bilateral bronchiectasis  the hyperimmunoglobulinaemia e and recurrent infections syndrome was diagnosed only in adult life  
class1	pulmonary disease following intravesical bcg treatment  bacillus calmette guerin  bcg  is an attenuated strain of mycobacterium bovis that has been used in the treatment of malignant disease for over 20 years and for the treatment of bladder cancer since 1976  major complications of this treatment are infrequent  we report two cases of systemic illness with pulmonary manifestations after treatment with intravesical bcg  
class1	renal abscess in children  three cases of renal abscesses in children are described to illustrate the variable presenting features  an additional 23 pediatric cases  reported over the past ten years  were reviewed for clinical features and therapy  fever  loin pain  and leukocytosis were common presenting features  but less than half of all abscesses were associated with either an abnormal urinalysis or a positive urine culture  the presenting features were sometimes confused with appendicitis  peritonitis  or a wilms tumor  an organism was identified in 17 cases  escherichia coli in 9 children and staphylococcus aureus in 8 children  the majority of e  coli infections occurred in girls and the majority of s  aureus infections occurred in boys  reflux was documented in 5 patients  and 2 children had a possible extrarenal source of infection  antibiotics alone produced a cure in 10 children  38    but 16 children  62   required a surgical procedure  
class1	pleuropulmonary manifestations of hepatic amebiasis pleuropulmonary manifestations of hepatic amebiasis occurred in 30 patients  18  60   presented with at least 1 pulmonary complaint and 10  33   had multiple pulmonary symptoms  in 14 patients  47    abnormalities were found on examination of the chest  in 16 chest roentgenograms  53    there was at least 1 abnormality  right sided pleural effusion  9 patients  and elevated right hemidiaphragm  8 patients  were the most common  all patients were treated with metronidazole  flagyl  and had resolution of the amebic liver abscess and pulmonary disease  pleuropulmonary disease is a common complication of amebic liver abscess  the clinical presentation and chest roentgenograms are virtually diagnostic and obviate the need for invasive procedures to confirm the diagnosis  pleuropulmonary disease resolves with amebicidal treatment of the hepatic abscess  
class1	disc space infection  a case report with mri diagnosis  vertebral disc space infection is an uncommon cause of back pain  physical findings may be unimpressive and laboratory evaluation may only disclose an elevated erythrocyte sedimentation rate  magnetic resonance imaging is particularly useful  since it reveals abnormalities earlier than plain radiographs and is more precise than bone scan  
class1	clostridium difficile invasion and toxin circulation in fatal pediatric pseudomembranous colitis  the direct involvement of clostridium difficile in the lesional tissue of pseudomembranous colitis has not been demonstrated  the organism s effects have been assumed to be strictly toxin mediated  because c  difficile cytotoxin may be found incidentally in the intestinal lumina of asymptomatic infants  the role of the organism in a variety of pediatric intestinal diseases is uncertain  the authors studied seven cases of fatal pediatric pseudomembranous colitis in which the presence of c  difficile was uniformly demonstrable in lesional tissues with the use of both an intestinal spore stain and a specific immunostain  the patients had either underlying hirschsprung s disease or hematologic malignancy  the striking pathologic features peculiar to these patients were altered mucosal mucin and immunologic barriers in the former group and neutropenia in the latter  two patients had demonstrable circulating cytotoxin in serum or ascitic fluid  and c  difficile was identified invading colonic mucosa or submucosa  such phenomena did not occur in control pediatric patients with multiple other intestinal lesions  altered host factors may be responsible for the intestinal invasion of c  difficile and its systemic toxin circulation in cases of fatal pediatric pseudomembranous colitis  
class1	cerebrospinal fluid changes after 48 hours of effective therapy for hemophilus influenzae type b meningitis  interval cerebrospinal fluid  csf  analysis is often performed to assess efficacy of treatment for bacterial meningitis  the authors reviewed 101 cases of pediatric bacterial meningitis resulting from hemophilus influenzae type b in which analysis of csf occurred on admission and between 48 and 72 hours after initiation of parenteral antibiotic therapy  of these  only one patient had a positive repeat csf culture  of the 100 cases with sterile csf on repeat culture  there was no instance of recrudescence of infection during hospitalization  the following characterized the interval changes in csf profile of this group  100  100   with persistence of pleocytosis  14  14   with differential cell count conversion from polymorphonuclear neutrophil leukocyte  pmn  predominance to relative lymphocytosis  96 of 98  98   with initial positive gram stained smear with negative results for organisms  53 of 75  71   with normalization of initial hypoglycorrhachia  and 10 of 94  11   with normalization of initial abnormally elevated protein levels  the differences in mean values of csf total white blood cell counts  percentage pmns  and glucose and protein concentrations on presentation and between 48 72 hours of therapy were highly significant  p less than 0 0001   after 48 hours of effective antibiotic therapy for h  influenzae type b meningitis  csf pleocytosis and abnormally elevated protein concentration are usually preserved  whereas hypoglycorrhachia usually resolves  it is not uncommon for the differential cell count to convert from a pmn predominance to a relative lymphocytosis  significant alteration in all csf parameters associated with h  influenzae type b meningitis can occur after 48 hours of effective parenteral antibiotic therapy  
class1	percutaneous transhepatic cholecystostomy for acute complicated cholecystitis in elderly patients  we report our experience with percutaneous transhepatic cholecystostomy in 10 elderly patients with acute cholecystitis  complicated by empyema formation  most of these patients has severe underlying disease  rendering them at high risk for surgical intervention  in all patients  the percutaneous procedure was followed by a rapid regression of clinical symptoms and of radiologic abnormalities  six were considered inoperable  three of these remain free of biliary symptoms  respectively 22  10  and 7 months after percutaneous cholecystostomy  three others died of nonbiliary disease 1 4 months after cholecystostomy  three patients underwent successful elective cholecystostomy 1 5 wk after percutaneous cholecystostomy  in one patient  cholecystectomy had to be performed because of recurrence of hydrops  1 wk after catheter removal  in our opinion  percutaneous transhepatic cholecystostomy is a safe and effective procedure in the treatment of elderly patients with acute complicated cholecystitis  it can be followed by elective cholecystectomy in good surgical candidates  or by an expectant conservative management in high surgical risk patients  
class1	hyperplastic gastric polyps associated with persistent helicobacter pylori infection and active gastritis  we report two cases of patients with 3 yr histories of upper gastrointestinal symptoms  hyperplastic gastric polyps  and active chronic gastritis  biopsies retrospectively stained with giemsa revealed the persistent presence of helicobacter pylori  hp  in gastric biopsies of both patients throughout the 3 yr  after treatment with amoxicillin and bismuth subsalicylate  both became asymptomatic  one demonstrating disappearance and recurrence of the gastric polyps in conjunction with the hp  these cases demonstrate 3 yr of hyperplastic gastric polyps associated with hp and active gastritis  
class1	disseminated  nonmeningeal gastrointestinal cryptococcal infection in an hiv negative patient  gastrointestinal cryptococcosis is extremely rare  especially in patients with no involvement of the central nervous system  we describe a 63 yr old man undergoing prednisone therapy for chronic hepatitis and cirrhosis who presented with peritonitis  colitis  and skin lesions  pathological studies revealed necrosis and numerous cryptococcal organisms in the colon  omentum  and skin  and cultures yielded cryptococcus neoformans  the patient died of multisystem organ failure following emergency exploratory surgery performed when he had onset of symptoms of a bowel perforation after an endoscopic biopsy  clinicians should be aware that gastrointestinal cryptococcosis can occur in the absence of infection of the central nervous system or lungs  and that it may affect relatively healthy patients who are immunocompromised because of splenectomy  chronic liver disease  or steroid therapy  
class1	streptococcus mitis sepsis in bone marrow transplant patients receiving oral antimicrobial prophylaxis  purpose  streptococcal infection has increasingly become a problem in neutropenic patients  we report on an outbreak of streptococcus mitis sepsis in six bone marrow transplant patients receiving oral antimicrobial prophylaxis  patients and methods  we performed an epidemiologic study of all patients in our bone marrow transplant program from 1986 to 1988  the hospital and microbiology records for all patients were reviewed  all bone marrow patients were treated according to specified protocols  including an oral prophylactic antimicrobial regimen that was changed in late 1987 from vancomycin polymyxin tobramycin to norfloxacin  identification  susceptibility testing  and whole cell protein analysis of streptococcal isolates were performed at the reference and antimicrobial investigations laboratories at the centers for disease control  results  we detected six cases of s  mitis sepsis among 21 patients undergoing bone marrow transplantation  no other concurrent pathogen was isolated from any patient at the time of the s  mitis bacteremia  bacteremia developed within 72 hours of transplant in five of six patients and was associated with severe mucositis in four patients  an environmental study failed to reveal any common source for the outbreak  and whole cell protein analysis of all six s  mitis isolates revealed each to be distinct  of 12 patients receiving oral vancomycin polymyxin tobramycin  one developed s  mitis bacteremia  versus five of nine patients receiving norfloxacin  p less than 0 03   conclusion  we believe s  mitis bacteremia is a potential complication of bone marrow transplantation and is associated with antimicrobial prophylaxis with norfloxacin  especially in the setting of mucositis  
class1	pleuritis as a manifestation of reactivation tuberculosis  purpose  the purpose of this study was to determine the frequency with which tuberculous pleuritis is a manifestation of reactivation tuberculosis and to compare the clinical manifestations of reactivation tuberculous pleuritis with  classic  tuberculous pleuritis  in which chest roentgenograms reveal no parenchymal infiltrates  patients and methods  we evaluated the medical records of 59 patients in whom tuberculous pleuritis was confirmed by histologic findings or mycobacterial culture  twenty seven patients  46   had typical chest roentgenographic findings of reactivation tuberculosis  whereas 32  54   had classic tuberculous pleuritis  the clinical and laboratory features of these two groups were compared  results  symptoms were more prolonged and pleural fluid glucose and lactate dehydrogenase concentrations were more markedly abnormal in patients with reactivation pleuritis than in those with classic pleuritis  suggesting a more chronic inflammatory process in the former group  compared with patients with classic tuberculous pleuritis  those with reactivation pleuritis had a lower frequency of reactive tuberculin skin tests  61  versus 88   and granulomatous pleural inflammation  25  versus 72    but a higher bacillary burden  manifest by a higher frequency of positive sputum smears for acid fast bacilli  50  versus 0   and positive mycobacterial cultures from sputum  60  versus 23   and pleural fluid  91  versus 66    conclusions  in contrast to previous reports  tuberculous pleuritis was a manifestation of reactivation tuberculosis in 46   27 of 59  of patients  tuberculous pleuritis is a more chronic process in patients with reactivation disease than in those with classic pleuritis  the lower frequency of reactive tuberculin skin tests and granuloma formation  combined with the higher bacillary burden in patients with reactivation pleuritis  suggest that these patients mount a less effective immune response to mycobacterium tuberculosis infection than do patients with the classic form of tuberculous pleuritis  
class1	association of helicobacter pylori infection with dyspeptic symptoms in patients undergoing gastroduodenoscopy  purpose  to determine the prevalence of helicobacter pylori in patients with non ulcer dyspepsia and ulcer disease as well as in a control population undergoing endoscopic retrograde cholangiopancreatography  ercp  for suspected pancreatic or biliary disease  patients and methods  forty six eligible patients undergoing upper endoscopy at massachusetts general hospital were studied over a period of 18 months  as well as 24 patients undergoing ercp for presumed pancreatic or biliary disease  two biopsy specimens from the fundus and two from the antrum were taken for microbiologic and histopathologic analysis  sera were examined by enzyme linked immunoabsorbent assay  all specimens were processed in a blind fashion  chi square test with yates  correction was used for statistical analysis  results  h  pylori was found in 31 of 46  67   study patients and in six of 24  25   control patients  by microbiologic or histologic techniques   p less than 0 01   h  pylori was found in all patients with peptic ulcer disease and in 60  of patients without ulcers  no association between h  pylori and any specific gastrointestinal symptom was observed  h  pylori was identified in the fundus as often as in the antrum  although in the antrum the organism was more often associated with histologic gastritis  compared with histology  serologic assays for igg and iga antibodies to h  pylori had sensitivities of 100  and 94   and specificities of 86  and 76   respectively  reexamination of selected specimens without knowledge of their identity revealed that the specificity of serology exceeded 94  while the sensitivity of histologic and microbiologic studies may have been closer to 80   conclusions  h  pylori was more common in dyspeptic patients than in our control subjects undergoing ercp  multiple biopsy sites from fundus and antrum are required to exclude infection  serologies of igg and iga were sensitive and specific for h  pylori  suggesting a possible role for non endoscopic diagnosis of this infection  the frequent association of h  pylori with active inflammation rather than with quiescent gastritis is consistent with a pathologic role of this organism  
class1	evidence of subclinical blastomycosis in forestry workers in northern minnesota and northern wisconsin  purpose  to investigate the incidence of remote subclinical blastomycosis in a high risk population of forestry workers  patients and methods  the study consisted of 39 male forestry workers from northern minnesota and northern wisconsin  areas endemic for blastomycosis but not for histoplasmosis  all subjects were histoplasmin skin test negative  and none had ever been diagnosed with blastomycosis or pneumonia  an antigen specific lymphocyte stimulation assay was performed to determine the presence of blastomycosis  results  peripheral blood lymphocytes from 12 of 39 subjects demonstrated specific antigen induced proliferation when stimulated with a purified alkali  and water soluble antigen derived from the cell wall of blastomyces dermatitidis  conclusion  the finding that 30  of these men had evidence of previous blastomycosis suggests that subclinical cases do occur sporadically  and are probably more common than diagnosed symptomatic cases  this is similar to histoplasmosis  in which the majority of infections are subclinical  however  the reservoir of persons with previous undiagnosed blastomycosis is probably small compared to the huge number of persons  perhaps 30 million  with prior histoplasmosis  
class1	sexually transmitted diseases and human immunodeficiency virus infection among women with pelvic inflammatory disease  both human immunodeficiency virus infections and pelvic inflammatory diseases are sexually acquired illnesses of great consequence to women  this study was undertaken to determine if women hospitalized with pelvic inflammatory disease  in a community endemic for human immunodeficiency virus  were at high risk to be infected with human immunodeficiency virus and if human immunodeficiency virus infections altered their hospital course  one hundred ten women hospitalized with pelvic inflammatory disease in brooklyn  in a hospital in which 2  of parturients are human immunodeficiency virus seropositive  agreed to human immunodeficiency virus testing  15  13 6   were found to be seropositive  seropositive women were significantly more likely to have an admission white blood cell count less than 10 000 mm3  p   0 001   human immunodeficiency virus seropositivity was not associated with a higher frequency of other sexually transmitted diseases although there was a trend toward more cases of syphilis among human immunodeficiency virus infected women  similarly  although there was no significant difference in rates of operative intervention  26 6  among seropositive and 8 4  among seronegative  p   0 058   there was a trend toward more surgery among those who were human immunodeficiency virus infected  women hospitalized with pelvic inflammatory disease  in a community endemic for human immunodeficiency virus  are at high risk for human immunodeficiency virus infection  more research is needed to verify a trend toward more refractory infections among human immunodeficiency virus infected women  
class1	postpartum osteomyelitis caused by group b streptococcus  postpartum infections caused by group b streptococci are generally limited in scope  we report a case of vaginal colonization with group b streptococcus that progressed in the postpartum period to osteomyelitis that necessitated total hip replacement  the patient had no risk factors predisposing to streptococcal osteomyelitis  an altered immune status in pregnancy and intrapartum bacteremia may be involved in the pathogenesis of this infection  
class1	high infectious morbidity in pregnant women with insulin dependent diabetes  an understated complication  patients with insulin dependent diabetes are prone to infection  possibly related to poor metabolic control  relative immune deficiency exists in pregnancy  we hypothesized that pregnant patients with insulin dependent diabetes are at an increased risk for infection and that infection is related to poor glycemic control  we matched 65 pregnant women with insulin dependent diabetes to 65 nondiabetic pregnant controls  at least one episode of infection before delivery occurred in 83  of the women with insulin dependent diabetes  26  in control group   the rate of postpartum infection was five times higher in the group with insulin dependent diabetes and they were susceptible to more kinds of infections  although there was no overall difference among the indices of glycemic control  hemoglobin a1 obtained before the infection was higher than during infection  we conclude that a high rate of infection exists in pregnant women with diabetes  infection and poor glycemic control may be associated  but it is unclear whether improvement in metabolic control will reduce this high infection rate  
class1	intraamniotic infection in the very early phase of the second trimester  a total of 157 consecutive patients were studied in an effort to examine prospectively the incidence of asymptomatic intraamniotic infection in the early phase of the second trimester  all patients were referred for amniotic fluid karyotyping  in addition  the amniotic fluids were examined for gram stain and were directly cultured on blood agar and macconkey agar as well as in thioglycollate broth  we found positive amniotic fluid cultures in eight cases  5 09    however  results of gram stain examinations were negative in all amniotic fluid samples  the data indicate that there is no correlation between white blood cells in the amniotic fluid and positive amniotic fluid culture results  only one pregnancy with positive amniotic fluid culture resulted in a septic abortion  therefore we can suggest that intraamniotic infection can exist early in pregnancy  even with intact membranes  and in most cases without any clinical symptoms  
class1	oral contraceptives and myocardial infarction  the risk of myocardial infarction in contraceptive users is limited to women over 35 years of age who smoke  the cause of myocardial infarction in oral contraceptive users is thrombotic and not atherosclerotic  minor lipid changes have no clinical relevance to myocardial infarction in contraceptive pill users and do not appear to increase coronary plaques  
class1	lyme borreliosis in the severe combined immunodeficiency  scid  mouse manifests predominantly in the joints  heart  and liver  the authors describe the histopathologic evolution of lyme disease in severe combined immunodeficiency  scid  and normal c b 17 and c57bl 6 mice inoculated with borrelia burgdorferi  starting on day 7 after inoculation  all scid mice infected subcutaneously in the tail with a low passage european tick isolate of b  burgdorferi had clinical evidence of arthritis characterized by reddening and swelling of tibiotarsal joints  later on  other joints  ie  metatarsal and ulnacarpal joints were also affected  the infection of scid mice resulted in a persistent spirochetemia and the development of a multisystem disease with chronic progressive inflammation of joints  heart  and liver  major histopathologic alterations included 1  severe joint lesions  characterized by the presence of hyperplastic inflamed synovial lining cells associated with the erosion and destruction of cartilage and or bone  2  pancarditis with infiltrations of mononuclear cells in the endocardium  myocardium  and pericardium  and 3  hepatitis with mononuclear cell infiltrations confined to the portal field and central vein  granulomatous reactions  and eventually the development of liver fibrosis  in addition  smaller more confined lesions were found in kidneys  lung  brain  and striated muscle  the inflammatory infiltrates in the various organs were associated mostly with mac 1  cells  largely monocytes and macrophages  as well as some polymorphonuclear leukocytes  but not b and t lymphocytes  infective spirochetes could be readily isolated from blood and joints and were found at the site of inoculum and the myocardium  in contrast  subcutaneous inoculation of normal c b 17 or c57bl 6 mice with spirochetes in general did not result in clinical signs of arthritis  only 10  to 20  of the c57bl 6 mice  but none of the c b 17 mice  showed clinical evidence of oligoarthritis  which appeared not before day 36 after inoculation  in general  the infection of normal mice resulted in minimal lesions in various organs  and no spirochetes could be visualized or reisolated from their tissues  the data demonstrate that lyme borreliosis may develop in mice in the absence of detectable specific b and t cells and thus suggest an immunologic control of the disease in this species  the scid mouse model therefore can be used to define the components of the immune system responsible for the suppression and or the progression of the disease  
class1	hemofiltration reverses left ventricular dysfunction during sepsis in dogs  depressed left ventricular  lv  contractility in sepsis has been ascribed to the presence of circulating cardiodepressant substance  filterable cardiodepressant factor in sepsis  fcs    however  this finding is controversial  the authors hypothesized that if a decrease in lv contractility indeed occurred due to a circulating depressant substance  then removal of this substance by hemofiltration would reverse by dysfunction  in this study  lv mechanics were examined before and after hemofiltration in anesthetized dogs during continuous intravenous infusion of live escherichia coli  left ventricular anterior posterior and apex base dimensions were measured by subendocardial ultrasonic crystal transducers implanted 4 weeks before the experiments  left ventricular contractility was determined from the end systolic pressure dimension relationship  the slope of this relationship  emax  is an index of contractility  after 4 h of sepsis  emax was reduced by one half  hemofiltration resulted in a return of emax to control values  the fcs activity in the plasma was also assessed by the percent reduction in isometric contraction of electrically stimulated  isolated right ventricular trabeculae obtained from nonseptic dogs  the fcs activity reached a peak 4 h after sepsis and was reduced after 2 h of hemofiltration  the results show that during experimental sepsis  a circulating substance of less than 30 000 d produces a decrease in lv contractility and that this lv dysfunction may be improved by hemofiltration  
class1	epidemiology of infection by nontuberculous mycobacteria ix  evidence for two dna homology groups among small plasmids in mycobacterium avium  mycobacterium intracellulare  and mycobacterium scrofulaceum  a 12 9 kb plasmid  pvt2  from a clinical mycobacterium avium isolate  md1  was cloned and radiolabeled for use as a dna probe to examine the relatedness of plasmids in m  avium complex  that probe hybridized with plasmids isolated from m  avium complex strains from the environment  7 of 16  and from non acquired immunodeficiency syndrome  aids   10 of 17  and aids  5 of 6  clinical isolates  the similarity of plasmids from the environment with those from patients supports the hypothesis that the environment is a source of human m  avium complex infection  more striking was the observation that pvt2 hybridized with every plasmid  13 of 13 clinical and 5 of 5 environmental isolates  of 13 5 kb or smaller  a second probe  consisting of a 15 3 kb plasmid  plr7  from another clinical isolate of the m  avium complex  hybridized with plasmids of 15 3 to 25 kb from environmental and clinical  aids and non aids  isolates  there was no hybridization between pvt2 and plr7  thus  these two probes define two different groups of small mycobacterial plasmids  
class1	manual ventilation bags as a source for bacterial colonization of intubated patients  a group of 14 intensive care unit  icu  patients were studied to determine if manual ventilation bags  mvb  could serve as a source of bacterial or fungal pathogens that could colonize the respiratory tract of intubated patients  a total of 51 cultures were simultaneously obtained of patient s sputum  the exterior mvb surface  mvb port  and mvb interior  postexhalation valve   pathogens colonizing or infecting the respiratory tract of intubated icu patients were frequently simultaneously present on the exterior surface of the mvb and inside the mvb port used to connect the mvb with the endotracheal tube  in addition  coagulase negative staphylococci and yeast were frequently present on the exterior surface of the mvb  the interior of the mvb was usually sterile  in three instances pathogens were isolated from the mvb before isolation from the patient s sputum  mvb may serve as a source for colonizing the respiratory tract of intubated icu patients and or the hands of medical personnel  the exterior surface and port of mvb should be cleaned of visible debris and disinfected at least once a day  
class1	toxic shock syndrome after inguinal hernia repair  report of a case with patient survival  a 40 year old man developed fulminant multisystem failure several days after elective repair of an inguinal hernia  toxic shock syndrome  tss  was diagnosed  there was  however  no evidence of wound infection at the time of multisystem failure  only later in his hospital course did the wound drain  staphylococcus aureus was cultured from the wound and was the presumed etiologic agent in the patient s life threatening illness  the patient recovered fully with supportive care  antibiotics  and surgical debridement of the inguinal hernia site  this case is discussed in the context of existing literature on the toxic shock syndrome  the site of infection is typically nonsuppurative  but the systemic manifestations are typically life threatening  the responsible organism is commonly believed to be a strain of s  aureus that expresses a toxin  tss toxin 1  that effects multisystem failure  but which also diminishes the local inflammatory response and explains the benign appearance of the wound  although this is a rare clinical entity  elective surgical procedures complicated by fatal tss have been reported  surgeons should understand this disease and the management necessary to avert mortality  
class1	ceftazidime clindamycin versus tobramycin clindamycin in the treatment of intra abdominal infections  in order to assess the efficacy and toxicity of ceftazidime as a substitute for aminoglycosides in the treatment of intra abdominal sepsis  a prospective randomized trial was conducted  ninety four patients  49  trauma  were randomized to receive ceftazidime clindamycin  caz c   n   47  or tobramycin clindamycin  t c   n   47   caz  2 0 gm  and c  0 9 gm  were administered intravenously every 8 hours while t dosage was adjusted to maintain peak  5 8 mg l  and trough  less than 2 mg l  concentrations  age  sex  baseline serum creatinine  and etiology of infection were comparable in the two groups  clinical cure was similar in culture positive and culture negative patients who received caz c  94  vs 88    the clinical cure rate however was significantly lower in the t c culture positive  73   than in the culture negative patients  100    p   0 016   pathogenic organisms were eradicated in 100   30 30  and 76   13 17  of caz c and t c patients  respectively  p   0 0006   nephrotoxicity nephrotoxicity or ototoxicity was observed in none of the caz c patients and in one and two t c patients  respectively  caz c more effectively eradicated the bacteria isolated from these patients and no significant difference in clinical response was observed in culture positive patients  these findings plus the lack of toxicity suggest that caz c is an effective alternative for treatment of iai  
class1	effects of method of hemostasis on wound infection rate  adequate hemostasis is important in preventing postoperative wound infection  this study compared four methods of hemostasis  specific pinpoint vessel electrocautery  spc   specific vessel ligation with 4 0 vicryl  svl   nonspecific electrocautery of vessel plus excessive surrounding tissue  nsc   and nonspecific ligation of vessel and excessive surrounding tissue with 4 0 vicryl  nsl   on the rate of wound infection in rabbits that were contaminated with 10 6  staphylococcus aureus  there was no statistical significant increase in the rate of wound sepsis when electrocautery was used in a fashion producing minimal nonviable tissue compared to specific vessel ligation  electrocautery use for specific vessel hemostasis does not result in a higher wound infection rate in contaminated wounds  
class1	congenital insensitivity to pain with neuroparalytic keratitis  congenital insensitivity to pain is a well defined entity in the group of sensory deficiency syndromes  to the best of our knowledge  unilateral neuroparalytic keratitis associated with congenital insensitivity to pain has not been reported  we report such a case to alert clinicians to this potentially blinding problem  
class1	relapse of infant botulism  we report on 3 infants who had relapse of infant botulism after apparent resolution of clinical symptoms  this group represented 5  of the infants with confirmed infant botulism who were treated at our institution since 1976  the exact cause for these relapses was unclear  but three potential mechanisms are examined  there were no historical  clinical  or electrophysiological predictors of relapse  although at the time of writing recovery from relapse appeared complete  close follow up of patients recovering from a bout of infant botulism is necessary  
class1	in vitro evaluation of nicotinamide riboside analogs against haemophilus influenzae  exogenous nad  nicotinamide mononucleotide  or nicotinamide riboside is required for the growth of haemophilus influenzae  these compounds have been defined as the v factor growth requirement  we have previously shown that the internalization of nicotinamide riboside is energy dependent and carrier mediated with saturation kinetics  thionicotinamide riboside  3 pyridinealdehyde riboside  3 acetylpyridine riboside  and 3 aminopyridine riboside were prepared from their corresponding nad analogs  these compounds and several other nicotinamide riboside analogs were evaluated for their ability to support the growth of h  influenzae and for their ability to block the uptake of  carbonyl 14c nicotinamide riboside by h  influenzae  3 aminopyridine riboside blocked the uptake of  carbonyl 14c nicotinamide riboside and inhibited the growth of h  influenzae when nad  nicotinamide mononucleotide  or nicotinamide riboside served as the v factor  the antibacterial activity of 3 aminopyridine riboside was found to be specific for h  influenzae but had no effect on the growth of staphylococcus aureus or escherichia coli  in additional experiments by reversed phase high performance liquid chromatography  it was determined that whole cells of h  influenzae degrade 3 aminopyridine adenine dinucleotide to 3 aminopyridine riboside  which is then internalized  inside the cell  3 aminopyridine riboside has the ability to interfere with the growth of h  influenzae by an undetermined mechanism  
class1	activities of clarithromycin  sulfisoxazole  and rifabutin against mycobacterium avium complex multiplication within human macrophages  the activities of clarithromycin  sulfisoxazole  and rifabutin against three virulent strains of mycobacterium avium complex isolated from patients with acquired immunodeficiency syndrome were evaluated in a model of intracellular infection  human monocyte derived macrophages were infected at day 6 of culture with m  avium complex  intracellular bacteria were counted 60 min after inoculation  extra  and intracellular bacteria were counted at days 4 and 7 after inoculation  the concentrations used were 4 micrograms of clarithromycin per ml  mics for the three strains  4  4  and 4 micrograms ml   50 micrograms of sulfisoxazole per ml  mics  50  25  and 25 micrograms ml   and 0 5 micrograms of rifabutin per ml  mics  2  0 5  and 0 5 micrograms ml   compared with controls  clarithromycin and rifabutin slowed the intracellular replication of the three strains  at day 7 after inoculation  p was less than 0 01 for the first strain and less than 0 001 for the two others   sulfisoxazole was ineffective against the three strains  clarithromycin was as effective as rifabutin  clarithromycin plus rifabutin was as effective as each single agent  clarithromycin plus sulfisoxazole was as effective as clarithromycin alone  
class1	beta lactamase production and susceptibilities to amoxicillin  amoxicillin clavulanate  ticarcillin  ticarcillin clavulanate  cefoxitin  imipenem  and metronidazole of 320 non bacteroides fragilis bacteroides isolates and 129 fusobacteria from 28 u s  centers  beta lactamase production  nitrocefin disk method  and agar dilution susceptibility of amoxicillin  amoxicillin clavulanate  ticarcillin  ticarcillin clavulanate  cefoxitin  imipenem  and metronidazole were determined for 320 bacteroides species  not bacteroides fragilis group  and 129 fusobacteria from 28 u s  centers  overall  64 7  of bacteroides species and 41 1  of fusobacteria were beta lactamase positive  among the bacteroides species  positivity rates were highest for b  bivius  85 0    followed by b  splanchnicus  83 3    b  eggerthii  77 8    and b  oralis  77 1    54 5  of black pigmented bacteroides species were beta lactamase positive  among the fusobacteria  fusobacterium mortiferum showed the highest rate of beta lactamase positivity  76 9    mics of amoxicillin  128 micrograms ml  and ticarcillin  64 micrograms ml  for 90  of all beta lactamase positive strains were reduced to 4 and 2 micrograms ml  respectively  with the addition of clavulanate  mics of amoxicillin and ticarcillin for 90  of all beta lactamase negative strains were 1 and 4 micrograms ml  respectively  and greater than or equal to 98 4  of the strains were susceptible to the beta lactams tested  of the beta lactamase producing strains  45 9  were susceptible to amoxicillin at less than or equal to 4 micrograms ml and 93 4  were susceptible to ticarcillin at less than or equal to 64 micrograms ml  the addition of clavulanate raised the rates to 90 4 and 100   respectively  all strains were susceptible to cefoxitin  imipenem  and metronidazole  the activity of amoxicillin against 29 beta lactamase producing strains  10 bacteroides species and 19 fusobacteria  was not enhanced by the addition of clavulanate  however  82 7  of these strains were susceptible to amoxicillin  and all were susceptible to ticarcillin  
class1	sch 39304 in prevention and treatment of disseminated candidiasis in persistently granulocytopenic rabbits  to investigate the potential use of sch 39304 for the prevention and treatment of disseminated candidiasis in granulocytopenic patients  we studied its in vivo antifungal activity as preventive  early  and late treatments in three models  acute  subacute  and chronic  of disseminated candidiasis in persistently granulocytopenic rabbits  sch 39304 was an effective as amphotericin b alone and fluconazole alone for the prevention of disseminated candidiasis  sch 39304 alone and fluconazole alone were as effective as amphotericin b plus flucytosine for early treatment of subacute disseminated candidiasis  when treatment was delayed for 5 days to establish chronic disseminated candidiasis  sch 39304 was less effective than amphotericin b plus flucytosine  in comparison with different treatment regimens  sch 39304 was more effective in early and preventive treatment  thus  sch 39304 was comparable to treatment control regimens in prevention and early treatment of subacute disseminated candidiasis  sch 39304 also was most effective in granulocytopenic rabbits with disseminated candidiasis when used for prevention or early treatment  
class1	activity of compound g2 isolated from alfalfa roots in experimental dermatophyte infection  compound g2 isolated from alfalfa roots was applied topically to skin lesions of guinea pigs experimentally infected with the dermatophyte trichophyton mentagrophytes var  granulare  after 12 to 15 applications  80  of the infected lesions were cured  as judged by clinical and microbial criteria  compared with 20  of the untreated lesions which healed spontaneously  p less than 0 01   
class1	in vitro susceptibility of xanthomonas  pseudomonas  maltophilia to newer antimicrobial agents  the susceptibilities of 45 clinical and 3 environmental isolates of xanthomonas maltophilia to 14 antimicrobial agents was determined by broth microdilution  the newer quinolones pd117596  pd117558  pd127391  a 56620  amifloxacin  and fleroxacin were the most active agents tested  with 70 to 99  of isolates being susceptible to these agents  all isolates were resistant to trospectomycin  the new aminoglycosides sch24120 and sch22591 were active against 12 and 1  of isolates  respectively  
class1	comparison of cilofungin and amphotericin b for therapy of murine candidiasis  we compared the efficacies of cilofungin and amphotericin b treatment in a murine model of disseminated candidiasis  three different dosages of each drug plus controls were evaluated  statistically improved survival was noted only among mice treated with 1 mg of amphotericin b per kg of body weight  p less than 0 05   while all amphotericin b regimens and the two lower dosage cilofungin regimens significantly reduced yeast cell counts in kidneys compared with the controls  the amphotericin b treated mice had a significantly higher percentage of sterile kidneys following therapy compared with those treated with cilofungin  p   0 0001   
class1	management of gastroenteritis  childhood gastroenteritis remains a common reason for admission to british paediatric units  although the severity of the disease appears to be diminishing in recent years  we studied 215 infants and children with gastroenteritis admitted consecutively to four paediatric units in south wales in order to determine the severity of the disease  the organisms isolated  the frequency of complications  and the adequacy of management before admission  stool pathogens were isolated in 125  58   patients  viruses in 65  bacteria in 30  and protozoa in 19  with multiple infection found in 11   there was a low incidence of morbidity and complications  but prolonged diarrhoea  postenteritis syndrome  was present in 24  11   cases and 77  36   had received inappropriate treatment before admission  contemporary gastroenteritis is thus a relatively mild disease in the acute phase  but management before admission to hospital is often inadequate  and prolonged diarrhoea may be a feature in a considerable number of cases  
class1	an unusual cause of thoracic mass  a previously well 10 year old boy presented with scoliosis  a mass in the chest wall  and a pleural effusion  chest radiography showed the triad of chronic consolidation  pleural effusion  and rib periostitis  investigations confirmed thoracic actinomycosis  tissue spread was evaluated by computed tomography  it was successfully treated with benzylpenicillin  which was later replaced by clindamycin  
class1	the process of microbial translocation  the process of microbial translocation was studied using candida albicans  escherichia coli  or endotoxin instilled into thiry vella loops of thermally injured guinea pigs and rats  translocation of c  albicans occurred by direct penetration of enterocytes by a unique process different from classical phagocytosis  translocation between enterocytes was not observed  internalization was associated with a disturbance of the plasma membrane and brush border  but most internalized organisms were not surrounded by a plasma membrane  passage of the candida into the lamina propria appeared to be associated with disruption of the basal membrane with extrusion of cytoplasm of the cell and candida  organisms in the lamina propria were commonly phagocytized by macrophages but also were found free in lymphatics and blood vessels  translocation of e  coli and endotoxin also occurred directly through enterocytes rather than between them  but translocated endotoxin diffused through the lamina propria and muscular wall of the bowel wall by passing between rather than through the myocytes  these descriptive phenomena provide new insight into the role of the enterocyte and intestinal immune cells in the translocation process  
class1	the prevalence of helicobacter pylori in nonulcer dyspepsia  importance of stratification according to age helicobacter pylori  formerly campylobacter pylori  is causally related to active antral gastritis and is highly associated with duodenal and gastric ulcers  however  the relationship of h pylori to nonulcer dyspepsia is less clear  we determined the presence of h pylori in unselected patients who were undergoing upper gastrointestinal tract endoscopy  and we found a prevalence of 37  in 110 patients with nonulcer dyspepsia that was similar to previous data  patients with nonulcer dyspepsia who had h pylori were found to be significantly older than patients with nonulcer dyspepsia who did not have h pylori  in addition  when stratified according to age  we detected an increased prevalence of h pylori in patients with nonulcer dyspepsia with increasing age  similar to that reported for asymptomatic control populations  this finding casts doubt as to the causal role of h pylori for most patients with nonulcer dyspepsia and stresses the importance of considering epidemiologic factors  such as age  when evaluating the role of h pylori in specific disease states  
class1	emergence of ciprofloxacin resistance in nosocomial methicillin resistant staphylococcus aureus isolates  resistance during ciprofloxacin plus rifampin therapy for methicillin resistant s aureus colonization  we initiated a randomized  single blinded trial of ciprofloxacin plus rifampin vs sulfamethoxazole and trimethoprim plus rifampin in the therapy for patients who underwent colonization with methicillin resistant staphylococcus aureus  mrsa   patients who were colonized with mrsa received 2 weeks of either regimen  the study was terminated after the enrollment of 21 subjects due to the recognition of ciprofloxacin resistance in 10 of 21 new mrsa isolates during the last 2 months of the study  five of the 10 patients with ciprofloxacin resistant mrsa isolates had never received ciprofloxacin  long term  6 month  eradication had been achieved in only three of 11 ciprofloxacin plus rifampin and four of 10 sulfamethoxazole and trimethoprim plus rifampin recipients  the use of this new fluoroquinolone for the eradication of mrsa colonization is usually not effective and may risk the development of ciprofloxacin resistance in mrsa within the hospital environment  
class1	desensitization in the management of vancomycin hypersensitivity  vancomycin is the preferred antimicrobial agent in the treatment of methicillin resistant staphylococcal infections  one of the well known hypersensitivity reactions to this agent is the  red man syndrome   which is believed to involve drug induced histamine release in certain individuals  although rate and or dose reductions may be effective in some cases  some hypersensitivity reactions necessitate the discontinuation of vancomycin  in this article one patient is described who developed vancomycin associated reactions consistent with the red man syndrome despite having tolerated vancomycin administration previously  this case was managed by sequential increments in vancomycin administration over several days that allowed for therapeutic doses of the drug to be administered  prior to desensitization  vancomycin administration at a lowered rate and dose was unsuccessfully attempted  despite the presence of combination antihistamine therapy  a loss of skin prick test reactivity to vancomycin was demonstrated after successful desensitization  this desensitization method may be useful in managing certain refractory cases of vancomycin hypersensitivity  
class1	immediate breast reconstruction following mastectomy is as safe as mastectomy alone  we evaluated wound complications and potential risk factors after mastectomy with immediate breast reconstruction and compared them with similar data after modified radical mastectomy  the incidences of infection  seroma  hematoma  and epidermolysis were compared among 395 patients  305 with modified radical mastectomies and 90 with mastectomy with immediate breast reconstruction  from virginia mason medical center  seattle  wash  between 1983 and 1989  obesity  age  60 years or older   smoking  antibiotics  and wound drainage were examined as possible risk factors  there were more wound complications in the modified radical mastectomy group  48  vs 31    and specifically  more seromas  30  vs 13    in the modified radical mastectomy group  age of 60 years or older was associated with seroma and infection  drainage greater than 30 ml per day  at time of drain removal  with seroma  and smoking with epidermolysis  in the mastectomy with immediate breast reconstruction group  obesity was associated with seroma and epidermolysis  we conclude that mastectomy with immediate breast reconstruction appears to be as safe as modified radical mastectomy alone with respect to wound complications  
class1	reoperative surgery for the morbidly obese  a university experience  patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications  to evaluate outcome following revisional procedures  we reviewed the records of 32 such patients treated at ucla between april 1986 and may 1989  twenty five women  78   and 7 men  22   with a mean age of 44 years underwent 76 reoperations  2 4 per patient  for complications of prior obesity surgery  indications for initial surgical revision consisted primarily of metabolic derangements  12 patients  and weight related problems  11 patients   in contrast  indications for the patients  final surgical procedure were commonly for bowel obstruction  41    intra abdominal sepsis  12    and gastrointestinal bleeding  6    following initial revision  23 patients  71 8   required further surgery for major complications and four patients died  12 5    while initial revisions are frequently indicated for metabolic problems  final reoperations are more frequently undertaken for urgent  life threatening complications  revisional procedures for morbid obesity should be carefully considered  and the potential for major complications and or death should be weighted heavily against proposed benefits  
class1	buccal cellulitis  buccal cellulitis  bc  is an innocuous appearing infection of the cheek that is found in children and has a high incidence of concomitant bacteremia  typically  the child is younger than 12 months and has a 2 to 8 hour prodrome of coryza and fever before developing the cellulitis on the cheek  a purplish hue on the cellulitic region is highly suggestive of hemophilus influenzae bacteremia  the differential diagnosis is reviewed  a complete blood count  blood culture  and cellulitis aspirate culture  should be obtained on all patients with bc  meningitis may be present despite the lack of meningeal signs  a lumbar puncture should be performed on all children at risk for bacteremic bc  the vast majority of these children are bacteremic and require parenteral antibiotics  a typical case of bc is presented and its management is reviewed  
class1	intraocular pressure changes and postural changes of intraocular pressure in experimentally induced hansen s disease of rhesus  mangabey  and african green monkeys  in our long term evaluation of patients with hansen s disease we have frequently found reduction of their intraocular pressure  furthermore  we noted changes in their intraocular pressure on change of posture  to determine if these changes have any significance we measured the intraocular pressures of 24 experimentally infected and 39 control monkeys in both sitting and reclining positions  we found significant reduction of intraocular pressure in 66 7  compared with controls in the sitting position  and a significant increase in intraocular pressure in 79  when checked first in the sitting then in the reclining position  we offer a possible pathophysiological explanation as to why the changes occur  
class1	seven day administration of recombinant human granulocyte colony stimulating factor to newborn rats  modulation of neonatal neutrophilia  myelopoiesis  and group b streptococcus sepsis  single pulse administration of rhg colony stimulating factor  csf  to neonatal rats was previously demonstrated to induce peripheral neutrophilia and modulate bone marrow  bm  neutrophil storage and proliferative pools  nsp   npp   in this study  we investigated the prolonged effects of 7 days of rhg csf therapy  5 micrograms kg per day   sprague dawley newborn rats  less than or equal to 24 hours  were injected intraperitoneally  ip   daily for 7 days  with rhg csf or phosphate buffered saline human serum albumin  pbs hsa   rhg csf induced a significant early and late peripheral neutrophilia  6 905     1 625  day 1  and 9 223     515 microl  day 7  v 1 275     90 microl  p less than or equal to  0001   in addition  7 days of rhg csf resulted in a significant increase in the bm nsp  3 247     190 microl v 1 677     339 microl  p less than or equal to  001   there was  however  no depletion or significant change in the bm npp  seven days of rhg csf also induced a mild increase in bm cfu gm colony formation  p less than or equal to  01   there was  however  no significant change in liver spleen cfu gm colonies or in the cfu gm proliferative rate in either the bm or liver spleen cultures  finally  7 days of prophylactic rhg csf therapy resulted in a synergistic response with antibiotic therapy and significantly modulated the mortality rate during experimental group b streptococcal sepsis  gbs   100  v 50    gvsc   p less than or equal to  001   pulse rhg csf administered at 6 hours or 18 hours after gbs inoculation  however  failed to act synergistically with antibiotics to improve survival or prevent peripheral neutropenia  this study suggests that 7 days of prophylactic rhg csf therapy induces peripheral neutrophilia  myeloid maturation  increases neutrophil bm reserves and also may provide immunologic enhancement of neonatal host defense during experimental gbs in term neonatal rats  
class1	effect of granulocyte colony stimulating factor on neutropenia due to chemotherapy for non hodgkin s lymphoma  the authors administered recombinant human granulocyte colony stimulating factor  rhg csf  to 16 patients with advanced non hodgkin s lymphoma treated with combination chemotherapy  groups of three to five patients were treated with 50  100  200  and 400 micrograms m2 per day of rhg csf by intravenous infusion for 14 days  beginning 3 days after chemotherapy  there was a strong linear relationship between the dose and the area under the curve over this dose range  the rhg csf was rapidly cleared from serum  with a mean half life of 5 97 hours for the second phase  t1 2   in patients treated with a dose of more than 100 micrograms m2 per day  the duration of neutropenia  p less than 0 01  and the duration of fever  p less than 0 05  were significantly decreased  the rhg csf was well tolerated and the only clinical observation that appeared relating to rhg csf administration was slight bone pain  this study strongly suggests that an optimum dose of rhg csf in patients after chemotherapy is 100 to 200 micrograms m2  our study shows that rhg csf is a clinically useful drug for patients treated with myelosuppressive chemotherapy  
class1	unusual case of pacemaker lead migration  pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts  we report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism  while being treated with intravenous cefuroxamine  the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent left pulmonary embolism  
class1	splenic septic emboli in endocarditis  the significance of septic emboli to the spleen is inferred by the frequency of septic emboli in general seen in patients with left sided infective endocarditis who are referred for valve replacement  to determine the proper management of splenic infarcts and abscess due to septic emboli  we retrospectively reviewed the records of 108 patients with left sided endocarditis who underwent valvular surgery at the university of illinois hospital from 1980 through 1988  intravenous drug abuse was the etiology in 68   n   73   the incidence of splenic infarcts and abscess was 19   n   20   but an incidental finding of splenic infarcts was found in 38   n   11  of 29 asymptomatic patients who had computed tomograms  streptococci and staphylococci were the causative organisms in 85   n   17   localized findings were absent in 90  of splenic infarcts and abscesses  abdominal computed tomograms were diagnostic of the sequelae of splenic septic emboli in 100   no patient had intra abdominal bleeding complications associated with cardiopulmonary bypass  splenectomy was performed in 50   n   10  of patients 3 24 days  mean  11 2 days  after valve replacement  indications for splenectomy included persistent sepsis in 60   n   6   large  greater than 2 cm  and peripheral lesions in 30   n   3   and splenic rupture in 10   n   1   perioperative mortality of patients who underwent splenectomy was 30   n   3   the following conclusions can be drawn  1  splenic septic embolus is common in endocarditis  2  abdominal computed tomography should be performed for all patients  
class1	total knee arthroplasty in diabetes mellitus  a retrospective study was done of 59 total knee arthroplasties  tkas  in 40 patients diagnosed with diabetes mellitus  the overall infection rate was 7   with an overall revision rate of 10  and an average follow up period of 4 3 years  wound complications were present in 12  of the tkas  the rate of deep joint infections in diabetic patients was statistically higher than the reported incidence of sepsis in nondiabetic patients  therefore  maximum precautions should be taken for diabetic patients having tka to minimize both wound complications and joint sepsis  
class1	prevention of nosocomial lung infection in ventilated patients  use of an antimicrobial pharyngeal nonabsorbable paste  a comparative  prospective study was made of the incidence of infection in the lower airway  purulent tracheobronchitis and pneumonia  in long term patients who were mechanically ventilated due to respiratory failure of noninfectious origin  twenty eight patients were randomly allocated into a study group  a  n   13  in which a nonabsorbable paste containing 2  tobramycin  2  amphotericin b  and 2  polymyxin e was administered locally to decontaminate the oropharynx  and a control group  b  n   15  in which a paste without antibiotics was also applied to the oropharynx  we studied the effectiveness of the prophylactic technique in decontaminating the oropharynx and trachea of organisms potentially pathogenic for the respiratory system  decontamination was successful in ten of 13 patients in group a vs  one of 15 patients in group b  p less than  001   the results demonstrated a lower rate of infection in the lower respiratory tract in the study group  three patients with tracheobronchitis and no pneumonias  than in the control group  three patients with tracheobronchitis and 11 with pneumonia   the difference between both being highly significant  p less than  001   two  15   patients in group b developed sepsis of pulmonary origin  none of the patients on prophylactic treatment developed this complication  although the overall mortality was similar in both groups  group a  30  vs  group b  33    we believe that infection contributed to a great extent to the death of two of five patients in group b  we conclude that nosocomial pneumonia  which is a frequent complication in critically ill patients on mechanical ventilation  could be prevented by local application of nonabsorbable antibiotics to the oropharynx  
class1	ringer s acetate and dextran 70 with or without hypertonic saline in endotoxin induced shock in pigs  the effects of ringer s acetate  6  dextran 70  7 5  nacl  and the combination of 7 5  nacl and dextran 70 were tested in resuscitation from endotoxin shock induced by continuous iv infusion of escherichia coli endotoxin in pigs  after about 3 h  a reproducible shock state was achieved and treatment was started  governed by the left atrial pressure  the hypertonic solutions  7 5  nacl and 7 5  nacl in dextran 70  did not show any overall advantages over the isotonic solutions  ringer s acetate and dextran 70   only transient beneficial hemodynamic effects lasting less than 30 min after infusion were seen  when dextran 70 was administered  cardiovascular function was markedly improved and oxygen delivery  do2  and survival were significantly higher compared with the crystalloid groups  ringer s acetate and 7 5  nacl   administration of large amounts of ringer s acetate resulted in an immediate deterioration of pulmonary function  it was difficult to elevate left atrial pressure or even to keep it at baseline level  and cardiac index was only transiently increased  the overall result was a deterioration of do2 and poor survival compared with the dextran 70 treated pigs  we conclude that dextran 70 is superior to ringer s acetate in resuscitation from endotoxin induced shock in pigs  furthermore  we found no role for the use of hypertonic saline  alone or in combination with dextran  in the treatment of this type of prolonged endotoxin shock  
class1	pulmonary manifestations of disseminated cryptococcosis in patients with aids  forty eight patients with disseminated cryptococcosis and aids were retrospectively studied to define the pulmonary manifestations  cryptococcus neoformans  cn  was first isolated from a pulmonary site in 12 patients  disseminated disease was subsequently documented in all these patients  symptoms and roentgenographic manifestations  normal  nodular circumscribed infiltrates  pleural effusions  lobar consolidation  were diverse  interstitial infiltrates predicted the presence of another opportunistic lung infection besides cryptococcosis in five patients  three untreated and two treated patients   infectious causes other than cryptococcosis were established by culture and clinical course in five of the ten patients who developed chest roentgenographic abnormalities during amphotericin b therapy  endobronchial abnormalities were identified in four patients at bronchoscopy  bronchoalveolar lavage  9 9  and pleural fluid  3 3  cultures were sensitive tests for detection of pulmonary involvement with cn  
class1	quality of well being before and after antibiotic treatment of pulmonary exacerbation in patients with cystic fibrosis  general quality of life has only recently been measured with an objective tool in patients with cystic fibrosis  cf   and there have been no reported attempts to document changes in patients  overall well being over time  as patients deteriorate or respond to intervention  we applied the quality of well being scale  qwb  in 28 patients with cf before and after a two week course of oral ciprofloxacin used to treat pulmonary exacerbations  there were significant correlations between changes in qwb and various pulmonary function test results  qwb vs fev1  r   0 4  p less than 0 03  qwb vs fvc  r   0 5  p less than 0 01  and qwb vs sao2  r   0 4  p less than 0 05  thus  the qwb can track changes in general well being in cf patients over a brief time and detect changes associated with pulmonary exacerbation and its treatment  
class1	subpleural mononuclear cell infiltration  significance in the differential diagnosis of pleuritis showing nonspecific histologic findings  to determine if patients who had lymphocyte rich pleural effusion and a pleural biopsy without any specific findings could be histopathologically differentiated between those with tuberculous and nontuberculous pleuritis  we histologically re evaluated the pleural biopsies of all patients whose pleural effusion was predominant with lymphocytes and contained no malignant cells  a total of 40 patients with a nonspecific histologic findings of pleural biopsy specimen were categorized based on their ultimate diagnosis as having tuberculous  n   15   carcinomatous  n   10  or nontuberculous  benign pleuritis  n   15   the pleural biopsy specimen of patients with nontuberculous  benign pleuritis frequently showed a band like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate  10 out of 15 patients   while the same finding was infrequent in those with tuberculous pleuritis  0 out of 15  p   0 0001  and pleuritis associated with carcinoma  three out of 10  p   0 082   based on these results  the presence of band like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate in pleural biopsy specimens of patients with lymphocyte rich pleural effusion suggests that the pleuritis is nontuberculous in its nature  
class1	anti kveim monoclonal antibody  new monoclonal antibody reacting to epithelioid cells in sarcoid granulomas  a monoclonal antibody to the sarcoid granulomagenic agent contained in kveim suspension was prepared by immunizing mice with kveim suspension  one monoclonal antibody  ihy 1  that reacted with the epithelioid cells in sarcoid granulomas on immunoperoxidase technique was selected  the immunoperoxidase technique was used to compare this monoclonal antibody s binding to sarcoidosis  or tuberculosis affected lymph nodes  ihy 1 is a monoclonal antibody of igm class  this antibody did not react to erythrocytes  lymphocytes  monocytes  alveolar macrophages  or the macrophage derived cell lines such as u 973 and kg 1  it reacted to granuloma epithelioid cells of sarcoidosis affected lymph nodes  the monoclonal antibody also reacted positively to epithelioid cells in tuberculous granulomas although the reaction was not as strong  since ihy 1 was found to bind to both types of granulomas  this suggests that the epithelioid cells in sarcoidosis have antigenicity common to the epithelioid cells in tuberculosis  
class1	occult fatal pulmonary embolism with disseminated intravascular coagulation  an unusual case masquerading as miliary tuberculosis  we report a fatal case of occult pulmonary embolism complicating bronchogenic carcinoma which presented with rapidly progressive pulmonary miliary shadows and respiratory failure  a clotting profile abnormality compatible with disseminated intravascular coagulation was noted  postmortem examination showed extensive clots occluding the major pulmonary vessels and areas of pulmonary infarcts  histologic examination revealed fibrin deposition in the microvasculature compatible with dic  cases of pulmonary embolism with dic have previously been reported  but this is the first case with pathologic confirmation  thus  unusual presentation with diffuse lung shadow and dic should not deter the clinician from correct diagnosis so that appropriate treatment can be promptly started  
class1	septic pulmonary emboli  a rare cause of bilateral pneumothorax in drug abusers  an intravenous drug abuser presented with bilateral pneumothorax  this is a previously unreported  to our knowledge  complication of septic pulmonary emboli secondary to right sided endocarditis  this possibility must be considered in the differential diagnosis of pneumothorax in drug addicts  
class1	yersinia enterocolitica abscess of the transverse colon  report of a case  yersinia enterocolitica abscess of the bowel is a rare entity  only five cases have previously been reported  none in the surgical literature  a unique presentation for yersinia infection  abscess of the transverse colon  is described  and the literature of y  enterocolitica intestinal perforation and abscess is reviewed  
class1	infections in alcoholic patients  alcoholic patients have an increased susceptibility to certain bacterial infections  among the more important of these infections are pneumonia  tuberculosis  spontaneous peritonitis  and bacteremia  this susceptibility is caused by alteration of immune function and mechanical defenses and are the sequel of chronic alcoholism  most notably cirrhosis  in many infections  morbidity is increased in alcoholics  with the course of the illness being more severe and complications more frequent  assessment of the alcoholic patient with suspected infection should  therefore  be thorough and treatment prompt  
class1	host response to mycobacterial infection in the alcoholic rat  animals  chronically treated with alcohol  were inoculated with mycobacteria  bacillus calmette guerin  10 2 x 10 6  organisms  into the spleen to produce a granulomatous hepatitis  before infection  chronic alcohol ingestion was associated with a depressed skin test response to phytohemagglutinin  71 7  of baseline  p   0 009   mycobacterial  bacillus calmette guerin  infection stimulated phytohemagglutinin skin test response to 417  of baseline in controls and 299  in alcoholics  p less than 0 001   the hepatic granuloma response was altered with smaller but more numerous granulomas  mean     sem  81 2     1 5 microns2 of area with a frequency of 1 8 granulomas per field in alcoholics vs  129 8     5 71 microns2 and 1 2 granulomas per field in controls  p less than 0 001   these changes were associated with a 10 fold increase in colony forming units per gram of liver  54 5     18 2 in alcoholics vs  5 6     1 83 in controls  p   0 0006   this model offers precise parameters for host response to infection and indicates that alcohol significantly impairs the clearing capacity for mycobacteria from the liver  
class1	infection control in the nursing home  the physician s role  infection control in the nursing home or long term care facility is an increasingly complex activity  the high rates  approximately 15   and special risks  group activities  crowding  for nosocomial infection demand special attention by attending physicians  some specific responsibilities include  recognition of infection  knowledge and use of basic infection control principles  appropriate antibiotic use  review of immunizations  facilitation of communications among office  hospital  and long term care facility  and involvement with infection control program s   
class1	transfusion risks  hepatitis remains the most serious transfusion risk  in terms of incidence and severity  transfusion associated aids  hemolytic reactions  trali  and anaphylaxis are severe problems that occur relatively rarely  while febrile reactions and mild allergic reactions are common but not serious  the key to avoiding all these complications is autotransfusion  see the article  autologous transfusion  in this issue   although intraoperative scavenging became available in many centers in the united states in the 1980s  it is hoped that pre deposit autotransfusion will also become widely utilized in the next decade  
class1	the patellofemoral joint after total knee arthroplasty without patellar resurfacing  one hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years  eighty four per cent of the knees were affected by osteoarthrosis  graded according to the knee rating system of the hospital for special surgery  there were eighteen excellent  fifty three good  eighteen fair  and eleven poor results  at the most recent follow up  twenty nine knees  29 per cent   nine of which were affected by rheumatoid arthritis  were still painful in the patellofemoral area  the height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively  small patients who had osteoarthrosis were exceptionally free of pain  regardless of sex  age  or level of activity  it seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain  are more than 160 centimeters tall  weigh more than sixty kilograms  and have advanced changes in the patella at the time of the operation  
class1	treatment of infection after total knee arthroplasty by debridement with retention of the components  thirty one total knee arthroplasties were followed by infection in twenty seven patients who were subsequently treated with debridement  retention of the components  and intravenous administration of antibiotics  the results were reviewed retrospectively in an effort to evaluate the function of the prostheses that had been salvaged successfully and to identify the causes of failure of those around which an infection had recurred  at the most recent follow up  average duration  8 8 years   infection had recurred around twenty four  77 per cent  of the thirty one arthroplasties  seven knees  23 per cent  remained free of infection  function remained satisfactory  although revision was subsequently needed in two knees for reasons other than infection  one cause of failure was the duration of the infection before debridement  this averaged twenty one days for the seven knees in which the prosthetic arthroplasty had been salvaged and thirty six days for the twenty four knees in which treatment had failed  another cause of failure was the type of organism  staphylococcus aureus had caused the infection in fourteen  58 per cent  of the twenty four knees in which the treatment failed but in only two of the seven knees in which the prosthetic arthroplasty was salvaged  in addition  eight infections in the first group were resistant to penicillin  whereas both infections in the second group were sensitive to penicillin  the four infections with gram negative organisms in the series were all in knees in which the treatment failed  all six hinged prostheses that were used failed  
class1	amputation or limb lengthening for partial or total absence of the fibula  thirty two patients who had ablation of the foot by the syme or boyd technique for partial or total absence of the fibula  with subsequent fitting of a prosthesis  were compared with eleven patients who had lengthening of the lower limb by the wagner method  to assess the long term results of each procedure  the final results were evaluated on the basis of pain  limp  limb length discrepancy  level of physical activity  and satisfaction of the patient  of the thirty two patients who had an amputation  twenty eight  88 per cent  had a satisfactory result  compared with only six  55 per cent  of the eleven patients who had limb lengthening  the amount of inequality between the lower limbs was classified as follows  group i  the foot of the shorter extremity was at the distal third of the contralateral  normal limb  and the percentage of shortening was 15 per cent or less  group ii  the foot of the shorter extremity was at the level of the middle third of the contralateral  normal limb  and the percentage of shortening was between 16 and 25 per cent  and group iii  the foot of the shorter extremity was at the level of the proximal third of the contralateral  normal limb  and the percentage of shortening was greater than 26 per cent  lengthening was best suited for patients in group i who had stable hips  knees  and ankles and a plantigrade foot  patients in groups ii and iii were best served by ablation of the foot and fitting of a prosthesis  
class1	an unusual late complication following surgical repair of tetralogy of fallot  a case is presented of extrusion of right ventricular outflow tract patch material through a mediastino cutaneous fistula occurring five years after repair of tetralogy of fallot  the focus of the mediastinal infection was an infected epicardial pacemaker electrode placed at the time of initial surgery  subsequent echocardiographic studies showed minimal right ventricular outflow tract or pulmonary arterial dilatation  and  with no further surgery  the child is well after two and a half years follow up  
class1	use of latex agglutination technique for detecting legionella pneumophila  serogroup 1  antibodies  following the outbreak of legionnaires  disease in stafford in 1985  500 serum samples were submitted to the indirect immunofluorescence antibody test and a latex agglutination  latex agglutination using ultrasonically disrupted legionella pneumophila antigens coupled to latex particles  proved a rapid  simple method for detecting circulating antibodies to l pneumophila in a one minute slide latex agglutination test  there was good correlation with the indirect immunofluorescence antibody test  ifat   and the specificity and sensitivity with respect to a diagnostic result were 98 3  and 97 6   respectively  using a series of well characterised sera  the latex agglutination test seems well suited as a screening test for presumptive cases of legionnaires  disease  the latex reagent is easy to prepare and seems to remain stable at 4 degrees c for up to six months  
class1	history of antifungals  until two to three decades ago  only a few drugs were available for the treatment of fungal infections  the status of antifungal therapy changed dramatically in the late 1960s with the introduction of newer broader spectrum agents  such as the iodinated trichlorophenols and the imidazoles  that acted by disruption of the fungal cell membrane  some of the more recently developed broad spectrum antifungal drugs include the triazoles terconazole  itraconazole  and fluconazole and the dimethylmorpholine amorolfine  the allylamines represent one of the newest classes of compounds shown to be effective in the management of fungal disorders  the two members of this unique chemical class that have been studied clinically  naftifine and terbinafine  are effective against a wide spectrum of fungal organisms  terbinafine has the added advantage of both topical and oral activity  
class1	problems of resistant dermatophytes  recalcitrant fungal infections are defined as infections that are difficult or impossible to eradicate despite seemingly adequate treatment with appropriate oral or parenteral antibiotics  relative or absolute microbial resistance is only one of the many causes of recalcitrance  others include failure of the patient to comply with the prescribed treatment regimen  drug degradation in the liver  drug drug interactions  reabsorption or washout of the drug from the stratum corneum  and failure of the drug to reach the stratum corneum  excretion in the eccrine sweat is the principal pathway by which griseofulvin and ketoconazole  the two currently available oral antifungal agents  are delivered to the stratum corneum  measures that promote delivery of these drugs to this site by enhancing sweating and minimizing drug run off and absorption onto clothing may aid in optimizing the therapeutic response to these agents  
class1	treatment of chronic tinea pedis  athlete s foot type  with topical terbinafine  twenty seven patients with chronic tinea pedis  athlete s foot type  were enrolled in a randomized  double blind trial of topical treatment with terbinafine 1  cream versus its vehicle  placebo   patients were examined weekly during 4 weeks of twice daily treatment and at follow up 2 weeks after the conclusion of therapy  no adverse events were reported in either treatment group  drug efficacy was evaluated in 22 patients  of whom nine  41   were treated with terbinafine and 13  59   with placebo  analysis of combined mycologic and clinical results showed that terbinafine was significantly more effective than placebo at the end of therapy  78  vs zero  and at the 2 week follow up  89  vs zero   p less than or equal to 0 001 at both intervals  
class1	a clinical trial of topical terbinafine  a new allylamine antifungal  in the treatment of tinea pedis  twenty three patients were enrolled in a randomized  double blind trial of terbinafine 1  cream compared with placebo vehicle in the treatment of tinea pedis  of the 20 patients who were evaluated for efficacy  10 received terbinafine and 10 received placebo  except for the terbinafine treated patients being an average of 11 years older than the patients receiving placebo and the median duration of disease being 6 weeks longer in the placebo group  the two groups were demographically and clinically similar  results of mycologic tests and clinical findings showed terbinafine to be significantly more effective than placebo in the treatment of tinea pedis  significantly more terbinafine treated patients than placebo treated patients showed conversion to negative culture and microscopy at end of therapy and a significant reduction in scored signs and symptoms  overall efficacy at follow up  combined mycologic and clinical findings  was also significantly greater in the terbinafine group  78   than in the placebo group  zero   p less than 0 001   unexplained elevation of liver function test results was noted in three placebo treated patients and in one terbinafine treated patient  but these changes were not considered clinically relevant or drug related  
class1	efficacy and tolerability of topical terbinafine in the treatment of tinea cruris  thirty men with clinical and mycologic evidence of tinea cruris were enrolled in a controlled  randomized  double blind trial comparing terbinafine 1  cream and its cream vehicle as placebo  patients applied the test medications to the affected area twice daily for 2 weeks  therapeutic response was evaluable in 18 patients after each week of treatment and at a follow up visit 2 weeks after therapy ended  at each visit  terbinafine was found to be more effective than the cream vehicle in the reduction of the signs and symptoms of infection and in the conversion of culture and microscopy findings to negative or normal  at the end of treatment  therapy was effective in 67  of the nine terbinafine treated patients compared with only 11  of the nine placebo treated patients  at the follow up examination  efficacy rates were 78  in the terbinafine treatment group and 33  in the placebo group  a difference of borderline statistical significance  p   0 077   possible reasons for this result may include the higher incidence of chronic disease in the terbinafine group and the large number of patients who were classified as delayed exclusions because of negative initial culture for dermatophytes  no side effects or significant alterations in laboratory or hematologic tests were observed in either treatment group  
class1	treatment of tinea cruris with topical terbinafine  twenty three patients were enrolled in a randomized  double blind trial of terbinafine 1  cream versus its vehicle  placebo  in the treatment of tinea cruris  one patient had a negative initial culture and was excluded  and two patients were dropouts  one because of poor study compliance  terbinafine  and one because of an adverse event  placebo   twenty patients were examined for efficacy of treatment  9 terbinafine treated  11 placebo treated   both groups were similar in age  sex  duration of disease  prior therapy  size and location of lesion  infecting organism  and predisposing factors  terbinafine 1  cream was more effective than vehicle cream in the reduction of the signs and symptoms of tinea cruris  in addition  there was a higher conversion rate to negative culture and normal microscopy findings in the terbinafine treated group  clinical results combined with evaluation of mycologic tests at end of therapy showed terbinafine to be a rapid and significantly more effective treatment for tinea cruris than placebo  78  vs 18  cure rate  respectively   follow up cure rates confirmed these findings  89  and 18   respectively   no significant adverse events occurred during terbinafine treatment  
class1	treatment of chronic moccasin type tinea pedis with terbinafine  a double blind  placebo controlled trial  terbinafine is an orally and topically active fungicidal drug of the allylamine series  its oral efficacy at 125 mg taken twice daily was evaluated in a randomized  double blind  placebo controlled study in moccasin type tinea pedis  the study was conducted simultaneously in two centers and consisted of 41 evaluable cases  23 terbinafine  18 placebo   mycologic cure and near to complete clearing of signs and symptoms were obtained in 59  of the terbinafine treated patients after 6 weeks of treatment and in 65  at 2 weeks after treatment  corresponding efficacy for placebo treated patients was zero at both evaluations  side effects in both groups were minimal  we conclude that terbinafine is well tolerated and highly effective in moccasin type tinea pedis  
class1	oral terbinafine versus griseofulvin in the treatment of moccasin type tinea pedis  the safety and effectiveness of oral terbinafine  125 mg twice daily  and griseofulvin  250 mg twice daily  in patients with moccasin type tinea pedis were examined in a double blind randomized trial  at the end of the 6 week treatment period  both a clinical and mycologic cure or a mycologic cure with minimal signs of infection was noted in 12  75   of the 16 terbinafine treated patients compared with only 3  27   of the 12 patients treated with griseofulvin  the overall response rate 2 weeks after the completion of treatment was 88  in the terbinafine treated group and 45  in the griseofulvin treated group  when contacted again 6 to 15 months after completion of the study  94  of the terbinafine treated patients reported sustained clearing of tinea pedis  and 88  of those with nail involvement at the time of treatment reported improvement  in contrast  tinea pedis remained cured in only 30  of the patients who had received griseofulvin  and onychomycosis improved in only 14   
class1	eosinophilic pustular folliculitis  fungal folliculitis  eosinophilic pustular folliculitis is a rare condition with no known cause  however  a fungal cause is suggested by  1  tinea like annular lesions   2  initial clinical consideration of fungal folliculitis in many reported cases   3  an association with the acquired immunodeficiency syndrome  and  4  an association with scaly and vesiculopustular lesions of palms and soles  we report a case histologically identical to eosinophilic pustular folliculitis but in which hyphal fungal organisms were demonstrated in one of the involved hair follicles  
class1	leprotic involvement of peripheral nerves in the absence of skin lesions  case report and literature review  in the absence of clinically apparent cutaneous lesions  primarily neural leprosy is uncommon  primarily neural leprosy presents clinically as a peripheral neuropathy that most frequently affects motor nerves and that occasionally involves sensory nerves as well  the long incubation period for leprosy and its occurrence outside endemic areas often lead to delayed diagnosis  we present a case of glove and stocking hypoesthesia  weakness of the flexor muscle of the right great toe  palpable thickening of the right popliteal nerve  and hypoesthetic but normal appearing areas on the back  which developed in a trinidadian immigrant who lived in canada for 16 years  a skin biopsy specimen obtained from a visibly normal but hypoesthetic area on the back demonstrated a few acid fast bacteria in small dermal nerves  in arrector pili smooth muscle  and in rare perivascular histiocytes  associated with a sparse mixed inflammatory cell infiltrate  the patient responded well to therapy with dapsone  rifampin  and clofazamine  a classification and review of primarily neural leprosy is presented  our patient represents the first reported case of primarily neural borderline lepromatous leprosy in canada  
class1	miliary tuberculosis presenting as skin lesions in a patient with acquired immunodeficiency syndrome  acute miliary tuberculosis of the skin is an extremely rare infection that occurs in immunocompromised persons  we report an intravenous drug abuser with human immunodeficiency virus infection in whom erythematous papules developed on the trunk and proximal aspect of the extremities  visceral lesions of unsuspected miliary tuberculosis were discovered at autopsy  and the cutaneous papules were found to contain mycobacterium tuberculosis  this is the first reported case of this cutaneous infection in a patient with the acquired immunodeficiency syndrome  
class1	bioaerosols  prevalence and health effects in the indoor environment  assessing the role of bioaerosols in residence related symptoms involves  1  determining that symptoms are related to the residence by medical examination and careful questioning   2  connecting reported symptoms with known or hypothesized effects of bioaerosols   3  examining the residence for bioaerosol risk factors such as overcrowding poor ventilation  inappropriate outdoor air intrusion  and dampness standing water   4  and finally  if no obvious risk factors are present  air sampling  air sampling should always be a last resort and should use a reliable volumetric method  particulate samplers  such as the burkard personal spore trap  are inexpensive alternatives to viable particle samplers and will provide data on most organisms implicated in hypersensitivity diseases  interpretation of residential bioaerosol sample data requires both qualitative and quantitative comparison with adjacent outdoor air and examination of aerosol changes related to domestic activities  recommendations that should lead to a decrease in indoor bioaerosols include the use of air conditioning to allow limitation of outdoor aerosols  prevention of dampness or moisture intrusion  and discouraging the use of humidifying devices other than steam  bioaerosol assessment in the workplace is often more complex than for residences  because the symptomatic subjects are not in charge of the environment  such situations often lead to difficult employee management relations and occasionally to litigation  it is essential that each step in workplace bioaerosol assessment be defensible and that the best possible methods are used  the approach is similar to the approach used for residences  but on a larger scale  symptom assessment must include stress and ergonomic factors  air sampling  if this is necessary  must usually be extensive with controls for ventilation rates  occupancy  and spatial variation  
class1	tuberculous peritonitis  a study comparing cirrhotic and noncirrhotic patients  tuberculous peritonitis is a rare disease  which often goes unrecognized because of the subtle clinical clues and its insidous onset  we retrospectively analyzed the records of 37 cases of tuberculous peritonitis diagnosed over a 15 year period  and compared the clinical and diagnostic features of cirrhotic and noncirrhotic patients  in cirrhotic patients  tuberculous peritonitis can simulate ascites from liver disease or spontaneous bacterial peritonitis  the diagnosis is difficult in these patients because the ascitic fluid may not be of the exudative type as a result of the low albumin level in serum  and lymphocytes do not predominate in all cases  adenosine deaminase  ada  activity in ascitic fluid was elevated  higher than 40 u l  in all 11 patients  four patients with hepatic cirrhosis   the time required to achieve a correct diagnosis was significantly longer in cirrhotic than in noncirrhotic patients  the overall mortality was 13   with deaths occurring exclusively among cirrhotic patients  we emphasize that tuberculous peritonitis in cirrhotic patients can present an atypical picture  a considerable element of suspicion is necessary  
class1	the role of human immunodeficiency virus infection in pneumococcal bacteremia in san francisco residents  human immunodeficiency virus  hiv  is an important risk factor for invasive pneumococcal disease  but information on clinical course and infecting serotypes is limited  to help develop strategies to reduce the morbidity due to invasive pneumococcal disease  episodes of pneumococcal bacteremia were identified by retrospective review of microbiology records  november 1983 november 1987  at 10 san francisco hospitals and  for patients 20 55 years old living in san francisco  hiv antibody status was determined by review of medical records  pneumococcal isolates from one hospital were serotyped  of 294 patients with pneumococcal bacteremia identified  32  11   had aids at the time pneumococcal bacteremia was diagnosed and another 43  15   were hiv infected but did not have aids  12 hiv infected patients developed aids after the episode of pneumococcal bacteremia  the rate of pneumococcal bacteremia in aids patients was estimated to be 9 4 1000 patient years  serotypes of 27  82   of 33 pneumococcal isolates from hiv infected patients and 107  90   from 119 patients without known hiv infection were among the 23 serotypes included in the currently available polysaccharide vaccine  the rate of pneumococcal bacteremia is approximately 100 fold greater in aids patients in san francisco than rates reported before the aids epidemic  but more than half the episodes of pneumococcal bacteremia in hiv infected patients occurred in patients without aids  data on pneumococcal serotypes causing invasive disease in hiv infected patients suggest that the current pneumococcal vaccine  if effective in this population  could provide significant protection against pneumococcal disease  
class1	monoclonal antibody to mouse lipopolysaccharide receptor protects mice against the lethal effects of endotoxin  specific endotoxic lipopolysaccharide  lps  binding sites on the cell membranes of murine lymphocytes and macrophages that may serve as functional receptors for lps have recently been identified using photoactivatable cross linking lps derivatives  a monoclonal antibody  mab 5d3  with specificity for this 80 kda protein has also been generated and characterized  the capacity of mab 5d3 to protect mice against the lethal effects of endotoxin was investigated  pretreatment of cf1 mice with as little as 15 micrograms of mab 5d3 provided virtually complete protection against a dose of endotoxin 10 fold greater than that required to kill all mice in an untreated control group using the galactosamine sensitization model  significant protection was also afforded normal mice given mab 5d3 relative to saline  several lines of evidence suggest that mab 5d3 mediated protection is due to the agonist properties of this antibody rather than a receptor blockade mechanism  
class1	properties of strains of escherichia coli o26 h11 in relation to their enteropathogenic or enterohemorrhagic classification  thirty seven strains of escherichia coli o26 h11 from infants and calves with diarrhea were examined for properties associated with enteropathogenic  epec  or enterohemorrhagic e  coli  ehec   strains were heterogeneous with respect to vero cytotoxin  vt  production and hybridization with the ehec plasmid specific  cvd419  probe  26 strains produced vt1  1 produced vt2  twenty four of 27 vt  strains and 5 of 10 vt  strains hybridized with the cvd419 probe and produced enterohemolysin  these properties are characteristic of ehec  the strains did not hybridize with the epec adherence factor probe  a property characteristic of some epec  nevertheless  36 strains adhered to hep 2 cells in a localized manner and were positive by the fluorescence actin staining  fas  test that is considered to correlate with the ability to cause attaching and effacing lesions in vivo  epec and ehec cause these lesions  although the fas test appeared to be the most general pathogenicity test for the o26 h11 strains  it could not be used to assign strains specifically to epec or ehec groups  
class1	fucosylated oligosaccharides of human milk protect suckling mice from heat stabile enterotoxin of escherichia coli  human milk protects suckling mice from the diarrheagenic effects of heat stabile enterotoxin of escherichia coli  st   to identify the human milk fraction responsible for this protection  pooled skimmed  deproteinated milk was passed through charcoal  whereupon lactose was separated from the oligosaccharides  the oligosaccharides contained st protective activity  the lactose did not  the neutral  but not the acidic  fraction exhibited protective activity against st  22  vs  57  mortality  respectively  p less than  001   the fucosylated  but not the nonfucosylated  subfractions of the neutral fraction contained the factor protective against st  35  vs  50  mortality  respectively  p less than  05   an oligosaccharide isolation scheme based on different principles produced confirmatory results  the commercially available neutral fucosylated oligosaccharides of human milk did not significantly protect the mice from the effects of st  thus  the protective factor against st seems to be a minor neutral fucosyloligosaccharide of human milk  
class1	platelet activating factor or a platelet activating factor antagonist decreases tumor necrosis factor alpha in the plasma of mice treated with endotoxin  when l platelet activating factor  paf  or alprazolam  a paf antagonist  was administered to lipopolysaccharide  lps  treated mice  the level of plasma tumor necrosis factor  tnf alpha  determined by either elisa or a cytotoxic assay using wehi cells was significantly lowered  the inactive stereoisomer  d paf  was not effective in lowering plasma tnf alpha levels in lps treated mice  the decrease in plasma tnf alpha induced by l paf or alprazolam was partly reversed by indomethacin  despite a decrease in plasma tnf alpha  l paf or alprazolam caused an increase in the amount of tnf alpha mrna present in the kidneys and the livers of lps treated mice  suggesting that a posttranscriptional event leading to the synthesis or release of tnf alpha was inhibited by these agents  
class1	protective effects of polyclonal sera and of monoclonal antibodies active to salmonella minnesota re595 lipopolysaccharide during experimental endotoxemia  mice were passively immunized with sera from blood donors active for rough lipopolysaccharides  lps   the j5  rc chemotype  mutant of escherichia coli o111 b4  and the re595  re chemotype  mutant of salmonella minnesota  all protected the mice against lethal challenge with smooth e  coli wf96 lps  e  coli and salmonella rough mutant lps  or free lipid a  epitopes recognized by monoclonal antibodies  mabs  reacting with the lps of s  minnesota re595 or lipid a were localized in the 2 keto 3 deoxy d manno octulosonic acid  kdo  region and on lipid a  core reactive mabs reacted with their homologous re lps and with free lipid a  one  gl11  cross reacted with the kdo alone  mabs gl6  gl11  l 4  l 6  and l 8 protected the actinomycin d sensitized mice against the lethal effects of lps from e  coli wf96  salmonella enteritidis  e  coli j5  s  minnesota re595  and free lipid a  the gl11 antibody was also protective when injected after lps challenge  these results indicate that antibodies directed against the core glycolipid of s  minnesota re595 lps may be useful as an additive form of therapy that may enable decreased mortality during gram negative bacterial sepsis  
class1	antimicrobial resistance of shigella isolates in the usa  the importance of international travelers  a nationwide sample of shigella isolates was collected and tested for resistance to 12 antimicrobial agents to assess the prevalence and epidemiologic correlates of antimicrobial resistance in shigella  of the isolates  32  were resistant to ampicillin  7  to trimethoprim sulfamethoxazole  and 0 4  to nalidixic acid  fifty  20   of 252 isolates were associated with foreign travel  the best predictor of clinically important resistance was a history of foreign travel  20  of isolates from foreign travelers showed trimethoprim sulfamethoxazole resistance  compared with only 4  of isolates from those without such a history  quinolone resistance was not identified in travel related isolates  and quinolones may be more appropriate for initial therapy of travel related shigellosis than is trimethoprim sulfamethoxazole  
class1	cefuroxime treatment failure of nontypable haemophilus influenzae meningitis associated with alteration of penicillin binding proteins  a 10 year old boy presented with nuchal rigidity and cerebrospinal fluid  csf  leukocytosis initially and again on day 6 of intravenous cefuroxime therapy  200 mg kg day   both csf specimens yielded nontypable beta lactamase negative haemophilus influenzae that were susceptible by disk tests but relatively resistant to cefuroxime  mic  8  to 16 fold greater than that of control isolates   to define the mechanism of resistance  the cefuroxime resistance marker was transformed to a susceptible h  influenzae recipient  inactivation and permeability of beta lactam substrate were tested and the penicillin binding protein  pbp  profiles were examined  inactivation of beta lactam substrate was not detected and reduced permeability was not found  however  reduced beta lactam binding to pbps 4 and 5 was observed  18  to 27 fold more penicillin and 2 5 to 4 fold more cefuroxime was required to saturate or block 50  of the binding sites of these pbps  respectively  thus  reduced affinity of pbps 4 and 5 for beta lactam substrate appears to be the mechanism of cefuroxime resistance in this strain  the reduced affinity of these targets appears to have contributed to the bacteriologic and clinical failure in this patient  
class1	prevention of catheter associated urinary tract infection with a silver oxide coated urinary catheter  clinical and microbiologic correlates  in a prospective clinical trial involving 482 acutely hospitalized patients  the overall incidence of catheter associated urinary tract infection  uti  10   was similar in recipients of a silver oxide coated urinary catheter  silver catheter  or a control silicone catheter  however  female sex and absence of antimicrobial use were independently associated with an increased risk of uti  after stratification for these variables  the silver catheter reduced the incidence of uti among women not receiving antimicrobial agents  19  for control catheter vs  0 for silver catheter  p    04  confidence interval for the difference in incidence  0 4  38   but not in the other subgroups  gram positive uti was associated with absence of antimicrobial use  the control catheter  and catheter care violations  gram negative and candidal utis were more common after 7 days of catheterization  and candidal uti was associated with being female and antimicrobial use  these findings demonstrate that several clinical variables influenced the incidence and microbiology of catheter associated uti and that the silver catheter appeared to prevent uti among women not receiving antimicrobials  
class1	restriction endonuclease analysis of total cellular dna of aspergillus fumigatus isolates of geographically and epidemiologically diverse origin  no typing system exists for aspergillus fumigatus  though isolates are distinguishable by phenotypic characteristics  dna was prepared by lysis of protoplasts  followed by deproteination  phenolchloroform extraction  and dialysis  dna prepared was of uniform size and exceeded 60 kb  after digestion with sali and xhoi endonucleases  dna was electrophoresed  stained  and photographed  differences in the mobilities of 10  to 50 kb bands distinguished isolates  reproducibility was shown by repeated preparations and animal passage  by use of a proposed notation system for describing restriction fragment length polymorphism patterns  31 epidemiologically characterized isolates from three continents revealed 24 patterns  dna types   three dna types were represented by 3 isolates each and 1 dna type by 2 isolates  20 types were unique  two groups of 3 isolates of the same dna type were from stanford university hospital  one patient isolate from stanford was the same dna type as a sewage isolate from new jersey  another stanford isolate was the same as a german isolate  these observations indicate widespread dispersal of some clones and restricted locales for others  paired isolates from airway fluids of three patients had two dna types in each  restriction endonuclease typing shows promise for investigating the epidemiology and ecology of a  fumigatus  
class1	coccidioidomycosis in human immunodeficiency virus infected patients  coccidioidomycosis is at best a complicated fungal infection  often it is life threatening  coccidioidomycosis is confined epidemiologically to the southwestern region of the usa  and most cases have occurred in that area  particularly in arizona  however  we have seen several cases in san francisco in patients with only a history of travel to endemic areas  in part because of its regional distribution  information about the clinical presentation  diagnosis  and treatment of patients with coccidioidomycosis has lagged behind information about other  more commonly encountered aids associated opportunistic infections  drs  galgiani and ampel have probably had the largest single experience with coccidioidomycosis in individuals infected with the human immunodeficiency virus  these specialists share their experience and make recommendations as to how these complicated conditions should be approached  
class1	detection of interleukin 3 in the serum of mice infected with mycobacterium lepraemurium  infection of mice by mycobacterium lepraemurium is accompanied by ablation of erythropoiesis in the bone marrow and gross enlargement of the spleen  this  together with increased monocytopoiesis and the earlier demonstration of macrophage colony stimulating factor in the serum of infected mice  suggested the activity of additional cytokines  eight weeks after infection of mice by m  lepraemurium  interleukin 3  il 3  activity was demonstrated in the serum  titer  1 3200   the serum titer of il 3 activity was maximal after 13 weeks  greater than 1 6400  and was slightly reduced after 18 weeks  1 6400   that the il 3 activity detected in the serum of the m  lepraemurium infected mice reflected the presence of il 3 itself was confirmed by a neutralization assay using anti murine il 3 antibodies  il 3 activity in the serum of mice 13 weeks after infection was completely abolished by the anti il 3 antibodies  finally  a 1 kb signal of il 3 rna was detected in the spleens of m  lepraemurium infected mice 13 weeks after infection  
class1	partial characterization of chlamydia trachomatis isolates resistant to multiple antibiotics  in vitro susceptibility testing was done on urogenital isolates of chlamydia trachomatis from five patients  four of whom were suspected treatment failures  at least one isolate from each patient was resistant to tetracycline at concentrations greater than or equal to micrograms ml  although less than 1  of a population of organisms showed high level resistance  fully resistant populations selected by passage through 8 micrograms ml tetracycline either died or lost their resistance on further passage in antibiotic free medium  relatively large inocula were required to demonstrate resistance  and morphology of inclusions was altered at high tetracycline concentrations  the observed resistance may be a new characteristic of the organism or merely newly recognized  isolates resistant to tetracycline were resistant to doxycycline  erythromycin  sulfamethoxazole  and clindamycin but sensitive to rifampin  ciprofloxacin  and ofloxacin  thus  resistance to tetracycline  erythromycin  and clindamycin occurs in c  trachomatis and may be a factor in some treatment failures  
class1	bacterial meningitis in the united states  1986  report of a multistate surveillance study  the bacterial meningitis study group  a prospective  laboratory based surveillance project obtained accurate data on meningitis in a population of 34 million people during 1986  haemophilus influenzae was the most common cause of bacterial meningitis  45    followed by streptococcus pneumoniae  18    and neisseria meningitidis  14    rates of h  influenzae meningitis varied significantly by region  from 1 9 100 000 in new jersey to 4 0 100 000 in washington state  the overall case fatality rates for meningitis were lower than those reported in several studies from the early 1970s  suggesting that improvements in early detection and antibiotic treatment may have occurred since that time  concurrent surveillance was also performed for all invasive disease due to the five most common causes of bacterial meningitis  serotypes of group b streptococcus other than type iii caused more than half of neonatal group b streptococcal disease and mortality  suggesting that an optimal vaccine preparation must be multivalent  of the organisms evaluated  group b streptococcus was the second most common cause of invasive disease in persons greater than 5 years old  
class1	a large outbreak of antibiotic resistant shigellosis at a mass gathering  in july 1987  a large outbreak of shigellosis occurred among attendees at a mass gathering in a national forest  the annual rainbow family gathering  sanitation in the campsite was poor  allowing widespread transmission of disease  probably by food  water  and person to person spread  the attack rate may have been greater than 50  among the estimated 12 700 attendees  the outbreak was caused by shigella sonnei  resistant to ampicillin  tetracycline  and trimethoprim sulfamethoxazole  the organism was of colicin type 9 and contained a 90 kilobase plasmid not found in non outbreak related strains  the dispersal of the group resulted in nationwide dissemination of the organism  and outbreaks in three states were linked to transmission from attendees at the gathering  this outbreak demonstrates the potential for rapid dissemination of disease in such a setting and the necessity for careful planning of mass gatherings  
class1	quantitation of tamm horsfall protein binding to uropathogenic escherichia coli and lectins  in quantitative experiments using elisa  binding of tamm horsfall protein  thp  to uropathogenic escherichia coli was studied with monoclonal antibody to thp  adherence to e  coli bearing type 1 fimbriae was proportional to thp concentration and size of the bacterial inoculum  type 1 fimbriae bearing e  coli bound 50 times more thp than did non type 1 fimbriated or p fimbriated strains  concanavalin a and wheat germ agglutinin bound thp in a dose dependent fashion  whereas pokeweed mitogen and vicia villosa b4 isolectin did not  addition of mannose and n acetylglucosamine reduced adherence of thp to concanavalin a and wheat germ agglutinin by 50  80   sugar inhibition studies suggested that the fimbrial receptor site for thp has lectin like properties and that thp binds to fimbriae via its mannose side chains  this quantitative assay is useful for studying the interaction between thp  uroepithelial cells  and bacteria in vitro  
class1	prevalence and diagnosis of legionella pneumonia  a 3 year prospective study with emphasis on application of urinary antigen detection  during a 3 year period the frequency of legionellosis in hospitalized patients with community acquired and nosocomial pneumonias was 3 4   23 684 cases  and 5 9   33 559   respectively  of the diagnostic tests evaluated  detection of legionella pneumophila serogroup 1 antigen in urine had the highest sensitivity  with 86  of culture proven cases being positive  sensitivities of serologic tests and examination of respiratory secretions  culture and direct immunofluorescence  were 36  and 26   respectively  the diagnostic value of serology and of examination of respiratory secretions can be low when specimens are obtained and processed under the typical conditions of hospitalization  urinary antigen detection represents an important diagnostic addition  and examination of postmortem lung tissue from fatal cases with pneumonia is an important adjunct for estimating the prevalence of legionellosis and for assessing the effectiveness of premortem diagnostic tests  
class1	tumor necrosis factor alpha plays a role in host defense against histoplasma capsulatum  tumor necrosis factor alpha was detected in supernatants collected from balb c mouse peritoneal macrophages incubated continuously with histoplasma capsulatum  the levels of tnf alpha measured by actinomycin d bioassay peaked within hours after exposure and then greatly declined by 24 h  tnf alpha was also measured in bronchoalveolar lavage fluid from balb c mice challenged intranasally with h  capsulatum  lavage fluid tnf alpha levels exhibited the same pattern as the in vitro supernatants  they peaked within hours after challenge and lower levels were detected at 24 h  treatment of mice with anti tnf alpha antibody accelerated mortality in response to systemic infection and significantly increased tissue colony counts in the liver and spleen  in the murine model  tnf alpha is produced in response to h  capsulatum and appears to play some role in host defense to infection  
class1	bacterial infections in patients with visceral leishmaniasis  bacterial infections are often seen in patients with visceral leishmaniasis  to determine the incidence of such infection and the more common infectious agents  30 consecutive patients with visceral leishmaniasis were followed throughout hospitalization  there were 24 episodes of bacterial infection in 18 patients  60    the incidence of bacterial infections in these patients was 22 2 1000 days of admission  the proportion of patients becoming infected by time was significantly greater in the visceral leishmaniasis group than in controls  p less than  01   the skin  respiratory tract  and middle ear were the most common sites of infection  and pseudomonas aeruginosa and staphylococcus aureus were the most common agents  low grade virulence bacteria  e g   serratia and providencia species  were also isolated from some cases  bacterial infections  mainly nosocomial  in patients with visceral leishmaniasis tend to be severe and can cause death  when bacterial infection is suspected in these patients  empiric antibiotic therapy should be started immediately  including coverage for p  aeruginosa and s  aureus  after appropriate diagnostic procedures are taken  
class1	confocal microscopic detection of human immunodeficiency virus rna producing cells  a central anomaly in the pathogenesis of aids is that few actively infected cd4  cells  1 in 10 4  10 5  have been detected in the peripheral blood  even though dramatic depletion  often greater than 90   of cd4  cells is the hallmark of disease progression  a sensitive  35s based human immunodeficiency virus  hiv  rna in situ hybridization technique was coupled with a new detection method  confocal laser scanning microscopy  to examine transcriptionally active hiv infected cells from individuals at different disease stages  in 35 symptomatic hiv infected individuals  aids and aids related complex   an average of 1 in 350 mononuclear cells produced hiv rna  in contrast  in an asymptomatic group of 30 individuals  an average of 1 in 2000 mononuclear cells produced hiv rna  these data  obtained using this improved detection method  suggest there are more hiv rna producing cells in hiv infected individuals than previously reported  in addition  increased numbers of hiv transcribing cells were found to correlate with declining clinical condition as assessed by karnofsky performance score  these data suggest that viremia per se may account for the pathologic consequences in hiv infection  
class1	transmission of chlamydia pneumoniae in young children in a japanese family  chlamydia pneumoniae strain twar was isolated from the respiratory tract of a 5 year old girl suffering from pneumonia  the igm and igg antibody titers to twar were 1 32 and 1 128  respectively  cultures and serology for other common bacterial and viral respiratory pathogens were negative  although she was treated with 35 mg kg day rokitamycin  twar was repeatedly isolated after treatment  her 3 year old sister developed acute bronchitis  and twar was isolated from her nasopharynx  she was treated with 43 mg kg day erythromycin with prompt improvement  and twar was not isolated after treatment  although her mother  grandmother  and 8 month old sister suffered from respiratory illness during these periods  twar was not isolated from them  the repeated isolations from the index patient suggest that infection was transmitted from sister to sister  this case represents the first reported isolation of twar from young children in the same household and the first from japan  
class1	pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit  selective decontamination of the oropharynx and gastrointestinal tract with nonabsorbable antimicrobials and sucralfate  a stress ulcer prophylactic that maintains the normal gastric acid bacterial barrier  were compared for prevention of pneumonia in a cardiac surgery intensive care unit  over 8 months  51 patients received selective decontamination and 56 received sucralfate  the selective decontamination regimen included polymyxin  gentamicin  and nystatin given as an oral paste and as a solution  patients also received standard antacid or histamine2 blocker stress ulcer prophylaxis  patients in the selective decontamination group had significantly less colonization of the oropharynx and stomach by gram negative bacilli  12  vs  55   p less than  001   significantly fewer infections due to gram negative bacilli  6  vs  20   p    02   and fewer infections overall  12  vs  27   p    04   there was one episode of pneumonia in the selective decontamination group and five in the sucralfate group  mortality and length of stay did not differ between the groups  but those receiving selective decontamination had less than one third as many days of systemic antibiotic therapy with no increase in colonization or infection with resistant gram negative bacilli  thus  selective decontamination appeared to reduce both extrapulmonary and pulmonary infections  
class1	occurrence of secondary attenuating mutations in avirulent salmonella typhimurium vaccine strains  the attenuating delta aroa554 mutation in salmonella typhimurium strain sl3261 was complemented in vitro by selecting for aroa  recombinant dna clones  sl3261 containing cloned aroa  genes did not require exogenous phenylalanine  tryptophan  tryosine  p aminobenzoic acid  or dihydroxybenzoic acid for growth in defined media  cloned aroa  genes did not restore wild type virulence to sl3261  however  in a murine typhoid model  the delta aroa554 mutation was transduced into s  typhimurium strain sr 11  a mouse virulent strain recently passaged in mice  the sr 11 delta aroa554 mutant was highly attenuated for mice challenged parenterally  the same cloned aroa  genes isolated in sl3261 restored the virulence of the sr 11 delta aroa554 mutant to that of wild type sr 11  these results suggest that while the delta aroa554 allele remains effective in reducing s  typhimurium virulence  laboratory passage of attenuated vaccine strains may lead to the accumulation of additional attenuating defects  
class1	nasal carriage of staphylococcus aureus  correlation with hormonal status in women  in view of recent observations on hormone microorganism interactions  a study of staphylococcus aureus nasal carriage in relation to sex hormone status was undertaken  prospectively in 479 women attending a colpocytologic clinic  hormonal status was assessed by determining the karyopyknotic index  ki  on smears stained by the papanicolaou method  rates of s  aureus nasal carriage were 29 3  in premenopausal women and 21 9  in postmenopausal women  p not significant   carriage rates were significantly higher  p    026  chi 2 7 32  for women with high kis  40 7   than for those with intermediate and low kis  27 03  and 25 1   respectively   s  aureus nasal carriage also correlated independently and significantly with previous antibiotic use and the presence of insulin treated diabetes mellitus  this preliminary observation confirms an association between levels of sex hormones as reflected by the ki and s  aureus nasal carriage rates  
class1	treatment evaluation of experimental staphylococcal infections  comparison of beta lactam  lipopeptide  and glycopeptide antimicrobial therapy  ly 146032  teicoplanin  vancomycin  oxacillin  cephalothin  cefamandole  ampicillin plus sulbactam  and cefoperazone plus sulbactam were studied against six isolates of staphylococci  including both staphylococcus aureus and coagulase negative staphylococci  using in vivo and in vitro methods  in vitro susceptibility measurements demonstrated that all six isolates were sensitive to ly 146032 and vancomycin and that five of six isolates were sensitive to tiecoplanin  cefamandole  ampicillin plus sulbactam  and cefoperazone plus sulbactam  comparison of antimicrobial therapy in an in vivo rabbit model demonstrated that cefoperazone plus sulbactam was active against the greatest number of isolates  five of six  based on a reduction of greater than or equal to 5 0 log10 colony forming units per milliliter  cfu ml  from growth control at the end of the animal treatment study  vancomycin and oxacillin were equal in achieving reductions of greater than or equal to 5 0 log10 cfu ml in four of the six isolates  comparing each isolate s in vivo outcome to in vitro data shows that in vitro susceptibility tests overpredict the sensitivity of these six isolates to ly 146032 and vancomycin  are variable for teicoplanin  cefamandole  ampicillin plus sulbactam  and cefoperazone plus sulbactam  and underpredict for oxacillin  
class1	a  silent  intracranial complication of frontal sinusitis  intracranial complications of frontal sinusitis  although rare today  do still develop despite widespread use of antibiotics  we report a case which demonstrates how silently a frontal lobe abscess may present with subtle changes in mood and behaviour  with no focal neurological signs  diagnosis and management are discussed and a brief review of the incidence of intracranial complications of frontal sinusitis  mode of spread  clinical presentation  investigations  treatment and bacteriology is presented  
class1	rhinosporidiosis associated with squamous cell carcinoma in the tongue  the peritumoural region of a squamous cell carcinoma of the tongue when examined with light and electron microscope showed nodular bodies in the submucosa with all the distinctive features of  sporangium and  spores  of rhinosporidiosis  the occurrence of rhinosporidiosis in the tongue along with malignancy has not been reported hitherto  some interesting observations and causal relationships are discussed  
class1	another hazard of ear syringing  malignant external otitis  a case of malignant external otitis is presented  this occurred in a healthy 72 year old non diabetic  non immuno compromised man after ear syringing  the infection was treated with oral ciprofloxacin for eight weeks with complete resolution  
class1	adult immunization in a network of family practice residency programs  a substantial proportion of morbidity and mortality associated with vaccine preventable diseases occurs among adults  teaching residents about disease prevention is mandated in the curriculum guidelines for family practice programs  a cooperative study among the kansas city family practice residency programs was begun to look at immunization behaviors in these teaching programs  a retrospective audit of medical records and a prospective survey of residents and faculty were performed  from the medical records of 400 patients seen for health maintenance examinations  the frequency of tetanus diphtheria immunizations recorded was 4 75   the pooled immunization rate recorded for pneumococcal vaccine was 25   and for influenza vaccine  24   although 93  of respondents knew patients need tetanus diphtheria immunization every 10 years  on a written questionnaire giving clinical examples  they were less likely to elect to immunize older patients eligible for tetanus diphtheria vaccine  the following immunization criteria were listed by respondents  for pneumococcal vaccine  age over 65 years  86    for influenza vaccine  age over 65 years  85    chronic diseases  69    residence in a chronic care facility  7    and being a health care worker  28    educational interventions stressing the appropriate criteria and involvement of the patient are planned at the separate programs  
class1	causes of death in hospitalized intravenous drug abusers  the authors reviewed at autopsy the causes of death of 274 patients with evidence of intravenous drug abuse who had been admitted to a large public hospital  there were 127 who died from diseases unrelated to intravenous drug abuse  and in 41  of these  chronic alcoholism was implicated  deaths from overdose syndromes and drug related organ pathology comprised only 11  of all cases  the mean age at death was 39 years  there was a male female ratio of 3 6 1  half of all patients died from infection  72 from acquired immunodeficiency syndrome  aids  alone  these findings indicate that persons hospitalized with a history of intravenous drug abuse usually die from causes other than overdose and that aids and chronic alcoholism are significant problems  emphasis should be placed upon detecting  hidden  intravenous drug deaths to provide more accurate statistical information  
class1	early hospital discharge of children with cancer treated for fever and neutropenia  identification and management of the low risk patient  children with leukemia and solid tumors are often hospitalized for empiric broad spectrum antibiotic therapy because of fever during periods of chemotherapy induced neutropenia  conventional practice dictates that parenteral antibiotics be continued until the patient is afebrile and has recovered from neutropenia  ie  until the absolute neutrophil count  anc  exceeds 500 cells per cubic millimeter  however  the practice in our center has been to discontinue parenteral antibiotic therapy and discharge many such patients before resolution of neutropenia  since the feasibility and safety of this approach has not been studied  we reviewed the records of 114 consecutive hospitalizations for fever and neutropenia in 61 patients during a 13 month period  seventy seven children  68   were discharged to their homes while still neutropenic after they had been afebrile for 1 to 2 days on parenteral antibiotics  had negative blood cultures  appeared well  and usually had some evidence of bone marrow recovery  five patients  4 4   developed recurrent fever and required rehospitalization within 7 days of discharge  only three of the 77 patients  3 9   who were sent home with neutropenia had recurrent fever  each had a brief and uneventful second hospitalization  two of the 37 children discharged with an anc over 500 cells per cubic millimeter required rehospitalization  a declining anc and advanced malignancy were risk factors in predicting recurrence of fever following discharge  a rising monocyte count was a predictor of imminent recovery from neutropenia  these results suggest that  early  discharge of an afebrile yet still neutropenic patient is safe when the patient is in remission  has no evidence of serious infection  appears clinically stable  and has indications of bone marrow recovery  the conventional approach of routinely continuing the hospitalization until resolution of neutropenia may be unnecessary in such low risk patients  
class1	subarachnoid hemorrhage caused by a fungal aneurysm of the vertebral artery as a complication of intracranial aneurysm clipping  case report  intracranial aneurysms are an uncommon manifestation of fungal infection  a case is described in which the formation of an aneurysm followed an intracranial intraoperative aspergillus infection attributable to a long period of preoperative antibiotic medication and immunosuppressive therapy with steroids  
class1	adult immunizations  are they worth the trouble  there are good data to recommend routine use of vaccines against measles  rubella  tetanus  influenza  and pneumococcal infections in adults  an adolescent or an adult born after 1956 is considered to be susceptible to measles unless he or she has received two doses of live measles vaccine or has suffered a physician diagnosed case of measles  tetanus is largely a disease of the elderly  and there is a universal need for immunizations with tetanus toxoid  influenza continues to be a major public health problem  and influenza vaccine should be given annually to the elderly and to those at high risk  the efficacy of pneumococcal vaccine in american adults is still being debated  results from case control studies show that the vaccine is about 60  effective in reducing the incidence of disease due to vaccine related strains  its use in the elderly and in those at higher risk for pneumococcal infection is recommended  
class1	gunshot injuries to the hip and abdomen  the association of joint and intra abdominal visceral injuries  a retrospective review of all gunshot injuries to the hip at our medical center over a 24 year period was performed  adequate information and radiographs were available for 49 patients  of these  five patients  10 2   had associated abdominal visceral injuries  these five patients were examined at an average of 5 9 years after their injury  and compared by utilizing the harris hip score rating  radiographs were also obtained  four of these five patients  80   had initially developed infections in their hip joints  with all four having poor functional outcomes  with an average harris hip score of 48 5 from their hip injury  careful initial evaluation and aggressive surgical and antibiotic treatment are recommended to prevent these poor results  
class1	clinical course and pharmacokinetics following a massive overdose of amphotericin b in a neonate  amphotericin is the drug of choice for the treatment of fungal infections in infants and children  when used in the recommended doses  amphotericin therapy is associated with high rates of adverse effects  including nephrotoxicity  hepatotoxicity  decrease in white blood cells  platelets and hemoglobin  chills  fever and even death  1   we report a case involving a neonate who was exposed to a 50 fold overdose of amphotericin over a three day period  
class1	fatal sepsis following intravesical bacillus calmette guerin administration for bladder cancer  intravesical administration of bacillus calmette guerin has been shown to be highly effective treatment of superficial bladder cancer  complications from bacillus calmette guerin therapy are usually minor but serious and even fatal reactions can occur  five recent cases illustrate the gravity of bacillus calmette guerin sepsis  one man with severe debility and the organic brain syndrome died acutely with a fever of 40 c  two men had frank sepsis that progressed to multiorgan failure and death  sepsis progressed despite the use of isoniazid  rifampin and streptomycin  two men who had equally progressive sepsis with intravesical bacillus calmette guerin survived with the use of cycloserine for the first 72 hours of treatment  triple antituberculous antibiotics  including cycloserine  may be lifesaving  sepsis resulted from intravenous absorption through inflamed or disrupted urothelium  bacillus calmette guerin treatment should not be administered in the presence of severe cystitis or after grossly traumatic catheterization  
class1	fatal disseminated mycobacterial infection following intravesical bacillus calmette guerin  we describe a fatal case of disseminated mycobacteriosis after intravesical bacillus calmette guerin immunotherapy  we summarize the prior safety record of this therapeutic modality  discuss local and systemic pathophysiological mechanisms by which dissemination might have occurred  and review the reported clinical experience with antituberculous chemotherapy for significant bacillus calmette guerin infection  finally  we offer suggestions for prophylaxis of certain patients with a history of exposure to intravesical bacillus calmette guerin  
class1	disseminated histoplasmosis with embolic endovascular complications  a case report  a 57 year old man had subacute embolic ischemia of his right foot and subsequent acute embolic ischemia of his left foot after angiography  thrombus removed at the time of the left femoral thromboembolectomy grew histoplasma capsulatum confirming the diagnosis of disseminated histoplasmosis  surgical revascularization of the right leg and parenteral amphotericin b was followed by chronic ketoconazole therapy for 16 months  the patient has remained asymptomatic at 30 months after operation  effective treatment of endovascular infection with ischemic complications of histoplasmosis requires surgical revascularization and intensive chemotherapeutic intervention  histoplasmosis is a ubiquitous infection in endemic areas that often has an asymptomatic subclinical course  involvement of the cardiovascular system is rarely reported  previous case reports have described infected cardiac valves and aortic aneurysms  this report describes the uncommon presentation of disseminated histoplasma capsulatum infection as a peripheral embolic event and the successful management with revascularization combined with systemic amphotericin b followed by ketoconazole therapy  
class1	association of group c beta hemolytic streptococci with endemic pharyngitis among college students throat cultures were performed throughout 2 school years to determine whether non group a beta hemolytic streptococci  nga bhs  could be isolated more frequently in 232 college students who had symptomatic pharyngitis than from 198 age matched controls with noninfectious problems  duplicate throat swabs were inoculated onto plates that contained sheep blood agar  one plate being incubated in a 5  co2 atmosphere and the other in an anaerobic environment  the bhs were grouped using latex agglutination  among the nga bhs  only those from group c were isolated significantly more often among the patients compared with the controls  26  vs 11    quantitative colony counts of isolates of group c bhs were generally higher among patients than controls  patients with group c bhs had fever  exudative tonsillitis  and anterior cervical adenopathy significantly more frequently than did patients who had throat cultures that were negative for group c bhs  group c bhs were epidemiologically associated with endemic pharyngitis in this college student population  
class1	positive lyme serology in subacute bacterial endocarditis  a study of four patients  lyme borreliosis is a multisystem inflammatory disorder caused by the tick borne spirochete borrelia burgdorferi  clinical manifestations are protean  involving the skin  joints  peripheral and central nervous systems  and the heart  however  the presentation of lyme disease often overlaps with that of other conditions  we describe four patients from a region endemic for lyme disease who had elevated levels of antibodies reactive to b burgdorferi and whose signs and symptoms were initially attributed to lyme borreliosis but whose subsequent blood cultures established a diagnosis of nonspirochetal subacute bacterial endocarditis  although immunoblots on serum samples from three of the four patients were consistent with prior infection from b burgdorferi  a positive immunoblot does not establish active infection  similarly  seropositivity to b burgdorferi only indicates possible exposure to this organism  the occurrence of positive serologies to b burgdorferi in the presence of other diseases can lead to diagnostic confusion  
class1	effect of short term intermittent antibiotic treatment on growth of burmese  myanmar  village children  to test the hypothesis that subclinical enteric infection  such as bacterial overgrowth   rice malabsorption  and growth faltering are causally linked  a field trial of low dose  short term  intermittent antibiotic treatment was carried out in 142 hydrogen producing  by lactulose breath hydrogen test  burmese village children aged 6 59 months  the children were randomly allocated treatment with metronidazole  20 mg kg or 5 mg kg daily   amoxycillin  25 mg kg daily   or placebo given 1 week per month for 6 months  a cooked rice meal breath hydrogen test was done to classify the children as rice absorbers  ra  or rice malabsorbers  rm  before treatment and monthly on the day before each cycle of treatment  there were no differences between the treatment groups  so they were considered together  factorial analysis showed that antibiotic treatment did not significantly affect the proportion of rm children  the only significant difference between antibiotic treated and placebo treated children s growth was in the subgroup of rm children aged 36 47 months  the antibiotic treated children had significantly greater linear growth  in other age groups antibiotic treatment had no effect on growth  
class1	person to person transmission of pseudomonas cepacia between patients with cystic fibrosis  ribotyping  a method of strain identification based on analysis of bacterial genomic restriction fragment length polymorphisms  was used to investigate the acquisition of pseudomonas cepacia by a patient with cystic fibrosis  analysis of isolates recovered from the index patient and his contacts showed person to person transmission of this opportunist organism  this documentation of the transmission of p cepacia from one cystic fibrosis patient to another suggests that measures to limit the acquisition of the pathogen by patients with cystic fibrosis may be worth while  
class1	buruli ulcer in benin in a study of 28 patients with mycobacterium ulcerans infection  buruli ulcer  in oinhi  benin  it became clear that the disease can regress as well as progress  and that patients can have lesions of different stages simultaneously  a system of disease staging was introduced  i   subcutaneous nodule  ii   cellulitis  iii   ulceration  iv   scar formation   research to find an effective treatment for this crippling disease is urgently needed  
class1	impact of active immunisation against enteritis necroticans in papua new guinea  enteritis necroticans  known locally as pigbel  has been a major cause of illness and death among children in the highlands of papua new guinea  after a successful trial of active immunisation against the beta toxin of the causative organism  clostridium perfringens type c  immunisation of children was begun in 1980  the effects of the immunisation programme on pigbel admissions in 3 of the 5 major highland hospitals were assessed  in each of the centres studied the proportion of admissions due to enteritis necroticans dropped significantly after immunisation was introduced  p less than 0 001  and hospital admissions for pigbel in 1984 86  when immunisation was well established  were less than one fifth of previous figures  
class1	changing epidemiology of group a streptococcal infection in the usa  to see whether changes in the epidemiology of group a streptococcal disease in the usa have been accompanied by a corresponding change in serotype distribution  epidemiological and m typing and t typing data for 5193 strains sent to the centers for disease control  atlanta  between 1972 and 1988 were analysed  the proportions of m types 1  3  and 18 increased significantly during the study period  these m types were more likely to be invasive  to cause fatal infection  and to occur in a cluster of infections than were other types  by contrast  the proportions of m types 4 and 12 decreased  they were less invasive and were less likely to be found in clusters than were other types  these data suggest that changes in the epidemiology of group a streptococcal disease may be related to changes in the distribution of m types causing infection  
class1	value of antigen detection in predicting invasive pulmonary aspergillosis two elisas were used to detect serum and urinary aspergillus antigen in 121 patients who were profoundly neutropenic after leukaemia therapy or bone marrow transplantation  the presence of antigen correctly predicted development of invasive pulmonary aspergillosis  ipa  in 16 patients  in 2 other cases antigen appeared after the clinical diagnosis had been made  while in only 1 case was antigen not detected  in 11 of 13 episodes of clinically suspected fungal infection antigen was detected before clinical diagnosis was made  by contrast  antigen was detected in only 1 of 90 patients who had no evidence of ipa  both elisas gave positive and negative predictive values for ipa of greater than 95   demonstrating the value of antigen detection in early diagnosis of aspergillus infection and the assay s ability to predict subsequent development of ipa  we conclude that neutropenic patients should be screened for aspergillus antigen  and propose that initial detection of fungal antigen justifies commencement of empirical antifungal therapy  such an approach should improve the survival of patients who are at risk of developing this usually fatal infection  
class1	infective dermatitis of jamaican children  a marker for htlv i infection in jamaican children infective dermatitis is a chronic eczema associated with refractory nonvirulent staphylococcus aureus or beta haemolytic streptococcus infection of the skin and nasal vestibule  14 children between the ages of 2 and 17 years with typical infective dermatitis  attending the dermatology clinic at the university hospital of the west indies in jamaica  were tested for antibody to human t lymphotropic virus type 1  htlv 1   all were seropositive  whereas 11 children of similar age with atopic eczema were all negative  in 2 of 2 cases of infective dermatitis  the biological mother was htlv 1 seropositive  none of the 14 patients showed signs of adult t cell leukaemia lymphoma  though experience with previous cases of infective dermatitis indicates the possibility of such progression  
class1	disseminated histoplasmosis in the acquired immune deficiency syndrome  clinical findings  diagnosis and treatment  and review of the literature  histoplasmosis is a serious opportunistic infection in patients with aids  often representing the first manifestation of the syndrome  most infections occurring within the endemic region are caused by exogenous exposure  while those occurring in nonendemic areas may represent endogenous reactivation of latent foci of infection or exogenous exposure to microfoci located within those nonendemic regions  however  prospective investigations are needed to prove the mode of acquisition  the infection usually begins in the lungs even though the chest roentgenogram may be normal  clinical findings are nonspecific  most patients present with symptoms of fever and weight loss of at least 1 month s duration  when untreated  many cases eventually develop severe clinical manifestations resembling septicemia  chest roentgenograms  when abnormal  show interstitial or reticulonodular infiltrates  many cases have been initially misdiagnosed as disseminated mycobacterial infection or pneumocystis carinii pneumonia  patients are often concurrently infected with other opportunistic pathogens  supporting the need for a careful search for co infections  useful diagnostic tests include serologic tests for anti h  capsulatum antibodies and hpa  silver stains of tissue sections or body fluids  and cultures using fungal media from blood  bone marrow  bronchoalveolar lavage fluid  and other tissues or body fluids suspected to be infected on clinical grounds  treatment with amphotericin b is highly effective  reversing the clinical manifestations of infection in at least 80  of cases  however  nearly all patients relapse within 1 year after completing courses of amphotericin b of 35 mg kg or more  supporting the use of maintenance treatment to prevent recurrence  relapse rates are lower  9 to 19   in patients receiving maintenance therapy with amphotericin b given at doses of about 50 mg weekly or biweekly than with ketoconazole  50 60    but controlled trials comparing different maintenance regimens have not been conducted  until results of such trials become available  our current approach is to administer an induction phase of 15 mg kg of amphotericin b given over 4 to 6 weeks  followed by maintenance therapy with 50 to 100 mg of amphotericin b given once or twice weekly  or biweekly  if results of a prospective national institutes of allergy and infectious disease study of itraconazole maintenance therapy document its effectiveness  alternatives to amphotericin b may be reasonable  
class1	coccidioidomycosis during human immunodeficiency virus infection  a review of 77 patients  through a retrospective review  we identified 77 previously unreported cases of coccidioidomycosis during hiv infection  patients were classified into 1 of 6 categories based on their primary clinical presentation  20 had focal pulmonary disease  group 1   31 had diffuse pulmonary disease  group 2   4 had cutaneous coccidioidomycosis  group 3   9 had meningitis  group 4   7 had extrathoracic lymph node or liver involvement  group 5   and 6 has positive coccidioidal serology without a clinical focus of infection  group 6   coccidioidal serologies were positive on initial testing in 83  of the patients in whom such serologic testing was performed  sera from 39  of patients were positive for tp antibodies while 74  had cf antibodies  eleven of 12 seronegative patients had pulmonary disease  group 1 or 2   serologic results of other patients sent to a single reference laboratory were similar  with 26  positive for immunodiffusion tp antibodies and 79  positive for immunodiffusion cf antibodies  for the 77 patients in this study  the cd4 lymphocyte count was below 0 250 x 10 9  cells l in 46 of the 55 patients who had this test performed  and a low cd4 count was significantly associated with mortality  p less than 0 01   at the time of follow up  32 of the 77 patients  42   had died  there were significantly more deaths in those with diffuse pulmonary disease  group 2  than in other groups  p less than 0 001   amphotericin b  ketoconazole  fluconazole  and itraconazole were all used as antifungal therapies  outcome could not be related to the therapy used  of note  3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions  
class1	extrapulmonary pneumocystosis  clinical features in human immunodeficiency virus infection  pneumocystis carinii infection is reported with increasing frequency as a cause of disease outside of the respiratory tract in patients with human immunodeficiency virus  hiv  infection  extrapulmonary pneumocystosis is not limited to patients in any discrete risk group for hiv infection  patients with hiv infection who develop extrapulmonary pneumocystosis frequently do not have concurrent p  carinii pneumonia  signs and symptoms of extrapulmonary pneumocystosis are nonspecific but when present are frequently referable to the tissues or organs involved  extrapulmonary pneumocystosis can be diagnosed by examination of tissue biopsies from affected sites using standard histologic techniques  therapy with antimicrobial agents used to treat p  carinii pneumonia has been effective in some patients  an association between use of aerosolized pentamidine for prevention of p  carinii pneumonia and development of extrapulmonary pneumocystosis has been suggested but remains unconfirmed  other factors such as the use of zidovudine and duration of immunodeficiency may also be important to the pathogenesis of extrapulmonary pneumocystosis  further studies are needed to better identify risk factors that may predispose patients to the development of extrapulmonary pneumocystosis  
class1	soleus specific myopathy induced by passive stretching under local tetanus  twenty four adult albino rats were injected with tetanus toxin into the right gastrocnemius muscle and then subjected to sustained dorsiflexion of the right ankle joint for 2 to 14 days  histologic examinations of the soleus after this procedure showed myopathic changes  characterized by variations in fiber diameters  myonecrosis with opaque fibers  interstitial fibrosis  and small groups of regenerated fibers  electron microscopy revealed derangement of t tubules immediately adjacent to the sarcolemma in the early degenerative stage  the size and wet weight of soleus increased compared to that of the control side between 2 and 5 days post tetanus  serum got  ldh  and creatine kinase  ck  levels were elevated especially in the early degenerative stages  peri  and endomysial fibrosis developed gradually from about 3 days post tetanus  pathomechanisms inducing these changes were discussed  
class1	a randomized  prospective field trial of a conjugate vaccine in the protection of infants and young children against invasive haemophilus influenzae type b disease background  haemophilus influenzae type b is the leading cause of invasive bacterial disease in young children  the capsular polysaccharide vaccine does not protect children at greatest risk  those under the age of 18 months   but a polysaccharide protein conjugate vaccine has proved to be more immunogenic in this age group  methods  we enrolled 114 000 infants in finland in an open  prospective  randomized trial of a h  influenzae type b capsular polysaccharide diphtheria toxoid conjugate vaccine  polyribosylribitol phosphate diphtheria toxoid  prp d    children born on odd numbered days were vaccinated at the ages of 3  4  6  and 14 to 18 months  those born on even numbered days formed the control group and received the same vaccine at the age of 24 months  results  after three doses of the vaccine there were 4 cases of verified bacteremic h  influenzae type b disease in the group receiving early vaccination  as compared with 64 cases in the control group  between the ages of approximately 7 and 24 months  the protective efficacy of the vaccine was thus 94 percent  95 percent confidence interval  83 to 98   no serious adverse effects were reported  the immune response to the conjugate vaccine was characteristic of a t cell dependent response when studied in a cohort of 120 infants  the primary immunization series resulted in a geometric mean concentration of anticapsular antibody of 0 53 micrograms per milliliter at the age of seven months  and the fourth dose evoked an anamnestic response  with a mean antibody concentration of 45 22 micrograms per milliliter  conclusions  a new conjugate vaccine consisting of the capsular polysaccharide of h  influenzae type b covalently linked to a protein carrier  prp d   administered to infants beginning at the age of 3 months  is highly effective in protecting young finnish children  7 to 24 months old  against invasive h  influenzae type b infections  
class1	limited efficacy of a haemophilus influenzae type b conjugate vaccine in alaska native infants  the alaska h  influenzae vaccine study group background  the prevention of invasive haemophilus influenzae type b disease requires a vaccine that is effective when administered during the first six months of life  the infants of alaska natives are at particularly high risk of invasive h  influenzae type b disease  methods  to evaluate the protective efficacy of a h  influenzae type b polysaccharide diphtheria toxoid conjugate vaccine  polyribosylribitol phosphate diphtheria toxoid  prp d    we enrolled 2102 alaska native infants in a randomized  double blind  placebo controlled trial in which either the vaccine or a saline placebo was administered at approximately two  four  and six months of age  results  after 3969 subject years of follow up and 32 episodes of h  influenzae type b disease  the overall incidence of invasive disease was not reduced significantly in the vaccinated subjects  6 0 cases per 1000 patient years   as compared with the placebo controls  9 6  or with other alaska native infants  6 0   after one  two  or three doses there was no significant protective efficacy with the vaccine  after three doses the efficacy was only 35 percent  95 percent confidence interval   57 to 73   the lack of efficacy was not related to the age at onset of disease  age at immunization  type of disease  degree of alaska native heritage  time after immunization  or year of the study  levels of h  influenzae type b anticapsular antibody in recipients of the vaccine became significantly higher than levels in those who received placebo only after the second and third doses  even after the third dose  only 48 percent of the vaccinated infants had antibody levels of more than 0 1 microgram per milliliter  geometric mean titer  0 18   antibody responses did not vary with the level of maternally acquired antibody  degree of alaska native ancestry  or age at time of the first or second immunizations  but they increased with increasing age at time of the third dose  p less than 0 001   conclusions  we found no evidence that the prp d vaccine provides significant protection  at least for alaska native infants  against invasive diseases caused by h  influenzae type b  the ineffectiveness of the vaccine paralleled its limited immunogenicity  
class1	the agent of bacillary angiomatosis  an approach to the identification of uncultured pathogens background  bacillary angiomatosis is an infectious disease causing proliferation of small blood vessels in the skin and visceral organs of patients with human immunodeficiency virus infection and other immunocompromised hosts  the agent is often visualized in tissue sections of lesions with warthin starry staining  but the bacillus has not been successfully cultured or identified  this bacillus may also cause cat scratch disease  methods  in attempting to identify this organism  we used the polymerase chain reaction  we used oligonucleotide primers complementary to the 16s ribosomal rna genes of eubacteria to amplify 16s ribosomal gene fragments directly from tissue samples of bacillary angiomatosis  the dna sequence of these fragments was determined and analyzed for phylogenetic relatedness to other known organisms  normal tissues were studied in parallel  results  tissue from three unrelated patients with bacillary angiomatosis yielded a unique 16s gene sequence  a sequence obtained from a fourth patient with bacillary angiomatosis differed from the sequence found in the other three patients at only 4 of 241 base positions  no related 16s gene fragment was detected in the normal tissues  these 16s sequences associated with bacillary angiomatosis belong to a previously uncharacterized microorganism  most closely related to rochalimaea quintana  conclusions  the cause of bacillary angiomatosis is a previously uncharacterized rickettsia like organism  closely related to r  quintana  this method for the identification of an uncultured pathogen may be applicable to other infectious diseases of unknown cause  
class1	clinical and pathological features of bacillary peliosis hepatis in association with human immunodeficiency virus infection background  peliosis hepatis is characterized by cystic  blood filled spaces in the liver and is seen in patients with chronic infections or advanced cancer and as a consequence of therapy with anabolic steroids  cutaneous bacillary angiomatosis is a bacterial infection that occurs in patients with human immunodeficiency virus  hiv  infection  its histologic appearance is that of a pseudoneoplastic vascular proliferation  methods  we studied liver tissue from eight hiv infected patients with peliosis hepatis  two of whom also had cutaneous bacillary angiomatosis  for comparison we examined tissue from four patients who had peliosis hepatis without hiv infection  tissues were examined histologically on routine sections and with special stains and electron microscopy  results  the histologic features seen in peliosis hepatis associated with hiv infection  but not in the four cases unrelated to hiv infection  were myxoid stroma and clumps of a granular purple material that on warthin starry staining and electron microscopy proved to be bacilli  the bacilli  which could not be cultured  were morphologically identical to those found in the skin lesions of cutaneous bacillary angiomatosis  the clinical courses of two of the patients with this  bacillary peliosis hepatis  indicate that it responds to antibiotic treatment  conclusions  hiv associated bacillary peliosis hepatis is an unusual  treatable opportunistic infection  probably caused by the same organism that causes cutaneous bacillary angiomatosis  our failure to find bacilli in non hiv associated cases implies that other pathogenetic mechanisms may also be responsible for peliosis hepatis  
class1	a newly recognized fastidious gram negative pathogen as a cause of fever and bacteremia background  we identified a motile  curved  gram negative bacillus as the cause of persistent fever and bacteremia in two patients with symptomatic human immunodeficiency virus infection  the same organism was subsequently recovered from a bone marrow transplant recipient with septicemia and from two immunocompetent persons with week long febrile illnesses  all the patients recovered after antimicrobial therapy  methods and results  primary cultures of blood processed by centrifugation after blood cell lysis yielded adherent  white  iridescent  morphologically heterogeneous colonies in 5 to 15 days  subcultures grew in four days on chocolate  charcoal yeast extract  or blood agar  the organisms stained weakly with safranin and were not acid fast  fluorescent antibody tests for legionella and francisella were negative  biochemical reactivity was minimal and difficult to ascertain  agar dilution testing revealed in vitro susceptibility to most antimicrobial agents tested  the cellular fatty acid composition of the isolates was similar  resembling that of rochalimaea quintana or brucella species  but not helicobacter pylori or species of campylobacter or legionella  as resolved by gel electrophoresis  cell membrane preparations of all isolates contained similar proteins  with patterns that differed from that of r  quintana  patterns of digestion of dna from all isolates by ecorv restriction endonuclease were virtually identical and also differed from that of r  quintana  on immunodiffusion  serum from one convalescent patient produced a line of identity with sonicates of all five isolates  conclusions  this pathogen may have been unidentified until now because of its slow growth  broad susceptibility to antimicrobial agents  and possible requirement of blood cell lysis for recovery in culture  it should be sought as a cause of unexplained fever  especially in persons with defective cell mediated immunity  
class1	seizures and other neurologic sequelae of bacterial meningitis in children  background  although the mortality rate among children with bacterial meningitis has decreased dramatically in recent decades  some patients are left with neurologic sequelae  it has not been clearly established which features of the acute illness predict the chronic neurologic sequelae  including late seizures or epilepsy  methods  we followed 185 infants and children prospectively during and after acute bacterial meningitis  the mean duration of follow up was 8 9 years  range  0 1 to 15 5   during the first six years standard neurologic examinations were performed  telephone interviews were conducted thereafter  results  one month after meningitis  69 children  37 percent  had neurologic abnormalities  many of these signs resolved within a year  leaving only 26 children  14 percent  with persistent deficits  18  10 percent  had only sensorineural hearing loss  and 8  4 percent  had multiple neurologic deficits  thirteen children  7 percent  had one or more late seizures not associated with fever  the presence of persistent neurologic deficits indicative of cerebral injury was the only independent predictor of late afebrile seizures  p less than 0 001   conclusions  after bacterial meningitis only children with permanent neurologic deficits are at high risk for epilepsy  those with normal examinations after the acute illness have an excellent change of escaping serious neurologic sequelae  including epilepsy  
class1	the sequelae of haemophilus influenzae meningitis in school age children  background  previous data on the consequences of haemophilus influenzae type b meningitis for school age children have been inconsistent  and much of the information on risk factors has been inconclusive  the present study was designed to evaluate the sequelae of this disease with a protocol for the comprehensive assessment of neuropsychological function  methods  ninety seven school age children  mean age  9 6 years   each of whom had a school age sibling  were recruited from a survey of the medical records of 519 children treated for h  influenzae type b meningitis between 1972 and 1984  at a mean age of 17 months  at the children s hospitals of toronto  ottawa  and montreal  of the 97 children  41 had had an acute neurologic complication  sequelae were assessed by comparing the index children with their nearest siblings on the basis of standardized measures of cognitive  academic  and behavioral status  results  only 14 children  14 percent  had persisting neurologic sequelae  sensorineural hearing loss in 11  unilateral in 6 and bilateral in 5   seizure disorder in 2  and hemiplegia and mental retardation in 1  although the total sample of index children scored slightly below the siblings in reading ability  the 56 children without acute phase neurologic complications  58 percent  were indistinguishable from their siblings on all measures  the differences between the groups were small even for the 41 pairs in which the index child had had an acute neurologic complication  mean full scale iq  102 for the index children vs  109 for the siblings   sequelae were also associated with lower socioeconomic status and a lower ratio of glucose in cerebrospinal fluid to that in blood at the time of the meningitis  behavioral problems were more prominent in index boys than index girls and in those who were older at the time of testing  but sex and age were not related to cognitive or academic sequelae  conclusions  we find a favorable prognosis for the majority of children who are treated for meningitis caused by h  influenzae type b  
class1	whither short course chemotherapy for tuberculous meningitis  short course chemotherapy is well established for the treatment of pulmonary tuberculosis but not for extrapulmonary disease  we present a series of 35 cases in which chemotherapy for tuberculous meningitis was given for a period of less than 2 years  short term therapy was associated with recrudescence of tuberculous meningitis and  in some cases  with the development of deep cerebral infarcts and permanent neurological deficits  we think short term chemotherapy for tuberculosis of the central nervous system is inadequate  
class1	chronic lyme disease with an expansive granulomatous lesion in the cerebellopontine angle  expansive granulomatous lesions in the posterior cranial fossa are rare and have not been reported in conjunction with lyme disease  we report a patient with verified borrelia burgdorferi infection who developed a tumor in the cerebellopontine angle  rapid growth of the tumor led to signs of cerebral compression and to hydrocephalus  surgical intervention was required despite florid meningitis  the histological examination showed inflammatory  nonspecific granulation tissue  the origin of this tissue is almost certainly causally related to the b  burgdorferi infection  signs of inflammation resolved rapidly after subtotal resection  the clinical  radiological  and biochemical course is documented  this is the first report of an expansive cerebral lesion in the chronic phase of lyme disease  
class1	infectious intracranial aneurysms  comparison of groups with and without endocarditis  a series of 12 patients with infectious intracranial aneurysms is presented  and a number of unusual features of the disorder are emphasized  a comparison of characteristics of the aneurysms and clinical course is made between patients with and without infective endocarditis  most of the unusual characteristics of infectious aneurysms  including rare locations  causative organisms  and predisposing medical conditions  occurred in the group without endocarditis  the relationship of atypical features of infectious aneurysms to the etiology of aneurysm formation is discussed  and an approach to treatment is presented  
class1	streptococcus bovis meningitis  report of 2 cases  we describe 2 cases of streptococcus bovis meningitis and review the 9 cases previously reported  this microorganism is a rare cause of meningitis in which there are no distinctive clinical or laboratory features  the gram stain of the csf is usually negative  ten of the 11 cases had some underlying disease or comorbid condition that predisposed to s bovis infection  gastrointestinal disorder  endocarditis  csf leak  polymyalgia rheumatica  and mandibular block  treatment with high dose penicillin is usually adequate  
class1	pelvic pain and infections  infectious etiologies of both acute and chronic pelvic pain are common and may involve multiple organ systems  in the evaluation of the acute pain  it is important to remember that rapidity of diagnosis is important because of the possibility of significant morbidity and even death if a condition is not attended to rapidly  in recent years  laparoscopic evaluation of the pelvis has provided a better understanding of the pathophysiology of some of these infections  as well as possible therapeutic maneuvers  the evaluation of chronic pelvic pain requires a thorough attempt at careful diagnosis with minds open to the possibility that other organ systems besides the genital tract may be involved  laparoscopy also may be an important diagnostic and therapeutic tool in the evaluation of the sequelae of pelvic inflammation leading to chronic pelvic pain  all therapeutic modalities that are instituted on the basis of the diagnostic evaluation must take into consideration that a strong emotional component is generally associated with chronic pelvic pain  such components must be addressed in order to achieve the best possible results for the patient  
class1	the prevalence of cardiac valvular pathosis in patients with systemic lupus erythematosus  the purpose of this study was to determine the prevalence of valvular pathosis in a population of patients with sle  to assess the candidacy of such patients for antibiotic prophylaxis before dental treatment  the hospital records of 112 patients with sle were reviewed and screened for endocarditis  heart murmurs  and other valvular pathosis  two of the 112 patients had confirmed cases of bacterial endocarditis  this prevalence is comparable to endocarditis prevalence rates in patients with prosthetic valves and is also three times that in patients with rheumatic heart disease  the high prevalence of endocarditis in this population of patients with sle suggests that according to present perspectives on patient management  patients with sle should be considered for antibiotic prophylaxis before dental therapies associated with formation of a bacteremia  
class1	oral histoplasmosis as a presenting disease in acquired immunodeficiency syndrome  published erratum appears in oral surg oral med oral pathol 1991 jan 71 1  76  a 43 year old homosexual man visited his dentist with painful  nodular  ulcerated lesions on the soft palate  right buccal mucosa  and right posterior maxillary gingiva  serologic studies for exposure to human immunodeficiency virus  performed before biopsy  were positive  biopsy of the maxillary gingiva demonstrated sheets of histiocytes containing small intracellular yeasts  which on culture were identified as histoplasma capsulatum  bilateral leukoplakic lesions with some vertical furrowing involving the lateral borders of the tongue were also noted  histologically  hyperkeratosis and fungal hyphae were identified  the patient was treated for histoplasmosis with amphotericin b  which resulted in significant improvement of the oral lesions  he was subsequently hospitalized for fatigue and dyspnea and was found to have pneumocystis carinii pneumonia  pulmonary status deteriorated within a 3 week period  and the patient died  autopsy findings were negative for histoplasmosis but positive for necrotizing and cavitary p  carinii pneumonia  pulmonary and hepatic herpes simplex infections  and pulmonary and intestinal cytomegalovirus infection  
class1	apical closure of mature molar roots with the use of calcium hydroxide  calcium hydroxide may induce apical root closure in affected mature teeth as well as in immature teeth  once an apical hard tissue barrier is formed  a permanent root canal filling can be safely condensed  two cases are described in which calcium hydroxide induced apical root closure in mature molar teeth where the apical constriction was lost because of chronic inflammatory process  
class1	nosocomial bacteremias in measles  the purpose of this study was to determine whether nosocomial bacteremias occurred more frequently in patients admitted with severe measles compared with general pediatric admissions  in a retrospective survey of 977 blood culture reports during a 4 year period  1985 to 1988  the incidence of nosocomial bacteremias in patients with measles was found to be on the average of 3 37 100 admissions year  approximately 6 times that of general pediatric patients  0 57   gram negative organisms  predominantly klebsiella and salmonella species  accounted for 86 5  of all isolates from measles patients  with 23  of these being multiply antibiotic resistant  all the isolates from the general patients were fully susceptible to antibiotics  the duration of hospitalization was more than doubled in both groups of affected patients  the onset of hospital acquired bacteremias occurred on an average of 11 2 days after admission in the patients with measles and 20 5 days in the general patients  our findings revealed that nosocomial bacteremias occurred with greater frequency in patients with measles and contributed to the morbidity of these patients  
class1	thrombocytosis after pneumonia with empyema and other bacterial infections in children  thrombocytosis is seen in association with many conditions  including infectious diseases  we studied thrombocytosis after severe bacterial infections  particularly pneumonia with empyema in children  a systematic survey of the phenomenon was conducted  twenty seven children admitted for pneumonia with empyema were studied  thrombocytosis  platelet counts greater than 500 x 10 3  microliters  was present in 92 5   platelet counts reached their maximum at 15 1     3 7 days  range  7 to 25  and declined to normal after 3 weeks of illness  compared with a healthy control group  significant thrombocytosis  but of lower incidence  was also noted in children with lobar pneumonia without pleural effusion  bacterial meningitis and osteomyelitis  platelet functions were examined in seven of the children but no abnormalities were observed  bone marrow aspiration of three children with pneumonia and empyema showed megakaryocytic hyperplasia  we found no correlation between thrombocytosis  neutrophilia  fever  the clinical course  complications  prognosis or treatment  neither thromboembolic nor hemorrhagic phenomena were observed  
class1	central nervous system tuberculosis in children  a review of 30 cases  the medical records of 30 children with central nervous system tuberculosis  cns tuberculosis  who were treated between march  1976  and february  1989  were reviewed  all had cranial computerized tomography scans at presentation  the mean cerebrospinal fluid leukocyte count was 200 mm3  protein 239 mg dl  glucose 25 mg dl and csf serum glucose ratio 21   mantoux skin tests with 5 tuberculin units were greater than or equal to 10 mm induration in 50   and chest radiographs were positive in 40  of patients  hydrocephalus was demonstrated by cranial computerized tomography in all 30 patients  100    cranial computerized tomography scan demonstrating hydrocephalus is a sensitive radiographic nervous system tuberculosis and should be part of the early evaluation of children with suspected central nervous system tuberculosis  
class1	the use of prophylactic furazolidone to control a nosocomial epidemic of multiply resistant salmonella typhimurium in pediatric wards  the nosocomial spread of enteric pathogens is often difficult to control in overcrowded pediatric wards  during 1983 and 1984  despite cohorting of patients and enforced hand washing  more than 200 cases of nosocomial multiply resistant salmonella typhimurium phage type r 9 were observed on two adjacent pediatric wards  most cases occurred during the summer months  after 19 new cases were detected early in the summer of 1985  oral administration of furazolidone throughout their entire hospital stay  2 5 mg kg twice daily  was recommended for all subsequently hospitalized infants  among the 114  65   infants who were appropriately treated  only one additional case  1   was detected  in contrast 11  19   cases occurred among the 59 infants who were inappropriately treated  5 of 35  14   of those who were not treated and 6 of 24  25   in whom treatment with furazolidone was delayed greater than 24 hours  p less than 0 001 between the appropriately and inappropriately treated groups   in pediatric wards where infection control measures cannot be optimally applied  prophylactic furazolidone administration may be helpful in preventing the spread of enteric pathogens  
class1	safety evaluation of prp d haemophilus influenzae type b conjugate vaccine in children immunized at 18 months of age and older  follow up study of 30 000 children  we evaluated the safety of the prp d conjugate hib vaccine  prohibit  connaught  in 29 309 children vaccinated at 18 60 months of age in the southern california kaiser permanente medical clinics during the period april 1  1988  to july 31  1989  surveillance for potential reactions involved postcard questionnaires  telephone surveys  reports of kaiser staff and review of hospitalizations and covered two periods following immunization   1  the first 48 hours and  2  days 2 through 30  surveillance for invasive hib disease involved the above methods in addition to systematic reviews of laboratory and hospital records through january 31  1990  rates of local and systemic reactions within 48 hours of vaccination with prp d alone were low  less than or equal to 2  for fever greater than 102 degrees f  local redness or swelling  and similar to those previously reported after vaccination with prp  hospitalization and seizures  0 15  and 0 09  of vaccinated children  respectively  occurring within 1 month of immunization appeared to be unrelated to vaccination  one 29 month old child had onset of a fatal episode of hib sepsis meningitis within 48 hours of vaccination  also  a 30 month old child developed hib meningitis 10 months after prp d vaccination  we conclude that prp d is safe when given alone or in combination with other childhood vaccines between 18 and 60 months of age  
class1	case control study of cryptosporidium parvum infection in peruvian children hospitalized for diarrhea  possible association with malnutrition and nosocomial infection  a retrospective  hospital based case control study was used to investigate whether there were any clinical characteristics that could distinguish cryptosporidium parvum infected children with diarrhea from other non c  parvum infected children with diarrhea  ten percent  24 of 248  of children admitted to a rehydration ward at cayetano heredia university hospital  lima  peru  were infected with c  parvum  the 24 patients infected with c  parvum  cases  were matched to an equal number of noninfected patients  controls   c  parvum infected patients were more likely to be malnourished than were children without this infection  p less than 0 05   also nosocomial infection caused by c  parvum occurred in three severely malnourished patients  two of whom died  no other clinical or laboratory characteristics were found that would distinguish children with diarrhea caused by c  parvum from other children with diarrhea  in children hospitalized for diarrhea c  parvum infection occurs most frequently in malnourished children  
class1	immunogenicity of haemophilus b conjugate vaccine  meningococcal protein conjugate  in children with prior invasive haemophilus influenzae type b disease  children younger than 2 years of age with previous invasive haemophilus influenzae  hib  type b disease may not develop protective antibodies to antigens of hib and may be at risk of developing a second episode of hib disease  twenty three children with prior hib disease were immunized with haemophilus b conjugate vaccine  meningococcal protein conjugate   children 12 to 24 months of age were given one dose of vaccine and children younger than 12 months of age were given 2 doses 2 months apart  antibody to the polysaccharide capsule of hib  prp  was measured by radioimmunoassay  eighteen children had preimmunization serum antibody concentrations less than 0 150 micrograms ml  all 18 children responded with greater than 0 150 micrograms ml of antibody after a single dose of vaccine  only 1 of the 23 children had a preimmunization serum antibody concentration greater than 1 000 micrograms ml  seventeen children ultimately responded with greater than 1 000 micrograms ml of antibody  p less than 0 0001   concentrations of antibody thought to correlate with protection  haemophilus b conjugate vaccine  meningococcal protein conjugate  is immunogenic in children with invasive hib disease  children younger than 2 years of age with invasive hib disease should be subsequently immunized with a hib conjugate vaccine  
class1	clinical features of adenovirus enteritis  a review of 127 cases  we retrospectively analyzed the clinical features of 127 hospitalized pediatric patients whose fecal samples were positive for adenovirus  ad  by electron microscopy during an 18 month period  serotyping results obtained by microneutralization tests and restriction endonuclease analysis were available for 105 of 127 cases  there were 69 males and 58 females and 94  of patients were less than 4 years of age  the average body temperature was 38 degrees c rectal  range  36 2 40 8 degrees c  with an average duration of fever of 1 6 days  the average duration of clinical illness was 8 8 days  range  1 to 32 days   although ad 40 and ad 41 were isolated in the majority of cases  59 of 105  56    ad 31 was associated with 18 of 105 cases  17    of the 18 cases associated with ad 31  14 were nosocomial and associated with diarrhea  our survey confirms the importance of fastidious enteric ad in infantile diarrhea  ad 40  ad 41  and suggests that ad 31 produces a clinical syndrome indistinguishable from that caused by ad 40 and ad 41  the occurrence of ad enteritis in patients admitted for unrelated illnesses well after initial hospitalization suggests that ad is also an important cause of nosocomial enteritis in our hospital  
class1	dexamethasone effects on the hospital course of infants with bronchopulmonary dysplasia who are dependent on artificial ventilation  a randomized double blind placebo controlled trial was conducted to evaluate the effects of enterally administered dexamethasone on the hospital course of infants with bronchopulmonary dysplasia  a total of 23 infants with a birth weight less than 1500 g who were dependent on artificial ventilation 3 to 4 weeks of age received dexamethasone  n   12  or saline placebo  n   11   dexamethasone  0 5 mg kg per day  was given in tapering doses for 7 days followed by hydrocortisone  8 mg kg per day  which was progressively reduced for a total of 17 days of therapy  infants who received dexamethasone required less oxygen on days 8 and 17  p less than  05  and were more likely to extubate 8 days after therapy than infants in the control group  respectively 8 12 vs 3 11 infants  p less than  05  p    12 after yates correction   the use of dexamethasone significantly shortened median duration of mechanical ventilation  4 vs 22 days  p less than  05  but had no effect on length of oxygen therapy  hospitalization  home oxygen therapy  occurrence and severity of retinopathy of prematurity  rate of growth  and mortality  no significant complications resulted from dexamethasone therapy  measurements of plasma dexamethasone levels confirmed the absorption of drug from the gastrointestinal tract  23 7 ng ml in dexamethasone vs 4 6 ng ml in the control group  p less than  05   dexamethasone administration resulted in short term improvements in pulmonary function but did not ameliorate the hospital course of infants with bronchopulmonary dysplasia  
class1	health assessment of the early adolescent  challenges and clinical issues  although early adolescence spans only 4 years  it is a critical time in the life of a young person in forming opinions and selecting options  specific attention to the growing and changing needs of this population is imperative if their health status is to improve  
class1	mycoplasmal pneumonia  are you thinking of atypical presentations  the presentations of mycoplasmal pneumonia can be varied and sometimes complicated  the atypical nature of this illness  as opposed to the clear pattern of findings in classic bacterial pneumonias  leads the physician to the diagnosis  appropriate therapy then allows quick improvement as a rule  with few sequelae  
class1	a rhesus monkey model for sexual transmission of a papillomavirus isolated from a squamous cell carcinoma  recently we molecularly cloned and characterized a papillomavirus from a lymph node metastasis of a primary penile carcinoma found in a rhesus monkey  this virus species  rhesus papillomavirus type 1  rhpv 1   is similar to oncogenic human papillomaviruses  hpvs   such as hpv 16 or hpv 18  in that the rhpv 1 dna was found to be integrated in the tumor cell dna  to compare the sexual transmission and oncogenic nature of rhpv 1 with these hpvs  we undertook an extensive retrospective study of a group of rhesus monkeys whose sexual mating and offspring histories were known  these animals had mated directly with the index male mentioned above or were secondarily exposed to this virus through intermediate sexual partners  this study combines cytological  histopathological  and several complementary hybridization and dna amplification techniques on multiple tissue samples to demonstrate the sexually transmitted nature of rhpv 1  the oncogenic potential of rhpv 1 is suggested in several of the infected animals by the presence of various degrees of neoplasia including squamous cell cancer of the cervix  
class1	antibiotic therapy for common infections  several important points regarding the treatment of urinary tract infections should be made  single dose and short course antibiotic therapy is appropriate only for women with acute bacterial cystitis due to e  coli  studies comparing single dose to full course therapy have not been sufficiently designed to draw valid statistical conclusions  and only tmp smx is recommended at this time  recurrent uti in women is almost always due to reinfection  which is best managed by prophylactic antibiotics  acute bronchitis and acute exacerbations of chronic bronchitis are often due to viral infections  and therefore antibiotic therapy is not always needed  in acute exacerbations of chronic bronchitis  the clearest success rates for antibiotic therapy have been in patients  who have all three of the following symptoms  increased dyspnea  increased sputum production  and sputum purulence  mupirocin is an important addition to the agents used to treat bacterial skin infections due to streptococcal and staphylococcal strains  in impetigo  mupirocin has been demonstrated to be as effective or superior to oral erythromycin  in prostatitis  data on the fluoroquinolones appears impressive  but further comparative trials are needed  they may become first line  empiric therapy  the newer oral antibiotics are not recommended as initial  empiric therapy in the outpatient management of common infections  with the possible exception of the treatment of prostatitis  these newer agents may be more important in the treatment of recurrent or resistant infections  
class1	early postoperative care of the cardiac transplantation patient  routine considerations and immunosuppressive therapy  the authors have attempted to outline the current state of the art with respect to the early postoperative management of the cardiac transplant recipient with special attention to immunosuppressive therapies  the commonly used agents  as well as the most successful combination regimens  have been described along with the current levels of expectation regarding rates of rejection and infection  much has been learned regarding the management of these problems  much remains to be learned to further decrease the incidence of postoperative infection and rejection and  equally if not more importantly  studies to investigate the etiology of transplant coronary artery disease need to be undertaken such that measures to delay or prevent its occurrence and or arrest its progression can be instituted  
class1	bacterial tracheitis  report of eight new cases and review  bacterial tracheitis  previously referred to as nondiphtheritic laryngitis with marked exudate  was commonly discussed in pediatric textbooks before 1940  it seemed to disappear as a clinical entity after that time  but it has been recorded with increasing frequency in the pediatric literature since 1979  we describe eight new cases and review 110 previously described cases  the clinical course consists of a prodromal upper respiratory illness with stridor  fever  and a variable degree of respiratory distress  unlike patients with croup  patients with bacterial tracheitis do not respond to aerosolized racemic epinephrine  most patients require endotracheal intubation  some require tracheostomy  reported complications include pneumonia  pneumothorax  formation of pseudomembranes  toxic shock syndrome  and cardiopulmonary arrest  bacterial tracheitis is a secondary bacterial infection following a primary viral respiratory infection  the most common preceding viral infection is parainfluenza  staphylococcus aureus and haemophilus influenzae are the predominant causes of bacterial tracheitis  secondary bacterial infection may occur as a result of tracheal mucosal injury or impairment of normal phagocytic function due to viral infection  
class1	hypercalcitoninemia  hypocalcemia  and toxic shock syndrome  toxic shock syndrome is a multisystem illness frequently complicated by hypocalcemia  the etiology of the hypocalcemia  which may be severe  is not well understood  we report two cases of fatal toxic shock syndrome accompanied by severe hypocalcemia  each patient also had an inappropriately elevated serum calcitonin level  which in one case was as high as 179 000 pg ml  hypercalcitoninemia may be a cause of the low serum calcium levels as well as of certain clinical manifestations of toxic shock syndrome  
class1	brucella endocarditis  the role of combined medical and surgical treatment  brucella endocarditis  although a rare complication of brucellosis  is the main cause of death related to this disease  this report describes a case of aortic endocarditis due to brucella abortus in an elderly farmer with known aortic stenosis  urgent valve replacement was performed because of progressive heart failure despite appropriate antimicrobial treatment  the infection was cured with trimethoprim sulfamethoxazole and rifampin given for 3 months after surgery  a review of the literature reports on the 38 other cases of cured brucella endocarditis made clear the need for combined antimicrobial treatment and surgical valve replacement  
class1	tuberculous psoas muscle abscess following chemoprophylaxis with isoniazid in a patient with human immunodeficiency virus infection  a 34 year old man with human immunodeficiency virus infection and disseminated mycobacterium avium and mycobacterium intracellulare infection developed a right psoas muscle abscess due to mycobacterium tuberculosis  the abscess occurred 18 months after completion of a 12 month course of chemoprophylaxis with isoniazid that was given because of a positive reaction with purified protein derivative of tuberculin  the adjacent vertebrae did not appear to be involved  the abscess was drained with a percutaneously inserted catheter  and he received standard antituberculous chemotherapy  three weeks into therapy  a second drainage with a catheter was required  the isolation of two mycobacteria in this patient and the apparent failure of chemoprophylaxis with isoniazid are noted  
class1	resolution of lung abscess due to pseudomonas aeruginosa with oral ciprofloxacin  case report  a case of lung abscess due to pseudomonas aeruginosa is presented that did not resolve with the use of conventional antipseudomonal antibiotics  including tobramycin with ticarcillin clavulanate and ceftazidime with gentamicin and ticarcillin clavulanate  oral ciprofloxacin was administered for 12 weeks  and the infection was resolved  no resistance occurred  and there was no recurrence of abscess within 18 months following therapy  
class1	pulmonary and disseminated infection due to mycobacterium kansasii  a decade of experience  fifty five patients with mycobacterium kansasii isolates  47 pulmonary and eight disseminated  were identified at a large texas hospital from 1975 to 1985  the mean age of patients was 60 years  and there was a slight male predominance  isolation of m  kansasii usually represented disease  the great majority of patients with pulmonary infection due to m  kansasii had underlying pulmonary diseases  and 70  had nonpulmonary predisposing factors  m  kansasii pulmonary disease clinically and radiographically resembled pulmonary tuberculosis  disseminated m  kansasii infection occurred in severely immunocompromised patients  who frequently had pulmonary predispositions as well  disseminated infection most of ten involved the lung  reticuloendothelial system  bone  joint  and skin and presented with signs and symptoms related to these organs  despite only moderate in vitro susceptibility of m  kansasii to routine antituberculous drugs  most patients responded to rifampin containing regimens  the prognosis of patients with m  kansasii disease was determined primarily by their underlying diseases  
class1	spectrum of cryptococcus neoformans infection in 68 patients infected with human immunodeficiency virus  sixty eight patients infected with human immunodeficiency virus  hiv  and cryptococcus neoformans who presented to three major medical centers in new orleans  louisiana  were studied retrospectively  in patients with meningitis the most common presenting symptoms were fever and headache  those without central nervous system involvement generally had an isolated pulmonary infection due to c  neoformans and presented with cough and dyspnea  csf parameters were abnormal in 41  of patients  and the india ink preparation was positive in 88  of patients with cultures of csf positive for c  neoformans  the overall median survival time for the 47 patients who died was 5 months  with a range of 0 22 months  of the 27 patients who received maintenance therapy with amphotericin b  two  7   relapsed  the only factors found to be associated with a poor prognosis were abnormal computed tomography of the head and altered mental status on presentation  c  neoformans infections in hiv infected patients remain difficult to treat and have a poor prognosis  
class1	comparison of species distribution and antimicrobial susceptibility of aerobic actinomycetes from clinical specimens  to compare the species distribution and antimicrobial susceptibility of aerobic actinomycetes  we evaluated 366 isolates referred to the centers for disease control from october 1985 through february 1988  we used conventional biochemical tests to identify the various species  four species accounted for 191  52   of aerobic actinomycete isolates  nocardia asteroides  98 isolates   actinomadura madurae  42 isolates   streptomyces griseus  28 isolates   and nocardia brasiliensis  23 isolates   sputum and wounds were the most common sources  no isolate was resistant to amikacin  no n  brasiliensis isolate was resistant to sulfamethoxazole or trimethoprim sulfamethoxazole  and no a  madurae isolate was resistant to ceftriaxone or imipenem  in summary  our findings show that unusual species of aerobic actinomycetes can cause infection  colonization  or both and that antimicrobial resistance varies markedly by species  
class1	a case of group b streptococcal pyomyositis the group b streptococcus is an opportunistic pathogen that causes a variety of serious infections including bacteremias  puerperal sepsis  and neonatal meningitis  group b streptococcal infections of muscle are rare  we report here an unusual case of group b streptococcal pyomyositis  pyomyositis arises predominantly from infections caused by staphylococcus aureus and  occasionally  streptococcus pyogenes  because of the rarity of pyomyositis in temperate climates  the common lack of localizing signs or symptoms  and the frequently negative blood cultures  considerable delay often precedes the diagnosis of pyomyositis  in fact  the infection has been initially misdiagnosed as muscle hematoma  cellulitis  thrombophlebitis  osteomyelitis  or neoplasm  diagnosis may be greatly aided by radiologic techniques that can demonstrate the sites of muscle enlargement and the presence of fluid collections  the response to antibiotics is usually rapid  but resolution of the infection may require aspiration of deeply situated muscle abscesses  this report describes a diabetic patient with an unusual presentation of pyomyositis that mimicked an acute abdomen  
class1	pneumococcal endometritis and neonatal sepsis  a recent case of postpartum maternal endometritis and neonatal sepsis due to streptococcus pneumoniae prompted this report and a review of previous citations  although this rare presentation of pneumococcal infection is potentially fatal to both mother and child  early empiric antibiotic coverage for the most frequent etiologic agents of this syndrome  group b streptococci  was and is adequate for systemic pneumococcal infections  
class1	visceral protothecosis mimicking sclerosing cholangitis in an immunocompetent host  successful antifungal therapy  a healthy 39 year old man who had clinical findings consistent with sclerosing cholangitis was found to have systemic protothecosis at surgery  severe granulomatous inflammation and palpable nodules were found in the gallbladder  on the surface of the liver  and in the duodenum  prototheca wickerhamii was detected in biopsied specimens and stool  the titer of indirect fluorescent antibody to this organism was 1 2 000  the patient recovered after a short course of treatment with amphotericin b and 3 months of oral therapy with ketoconazole  he had no other concurrent illness and had no abnormality in his immune system  this is the second reported human case of systemic protothecosis  an elevated igg level  an elevated erythrocyte sedimentation rate  eosinophilia  and abnormal levels of enzymes in the liver were found in both cases  protothecosis should be considered in the differential diagnosis of hepatic and biliary inflammatory diseases of uncertain etiology  
class1	enterobacter bacteremia in pediatric patients  enterobacter has emerged as an important human pathogen  particularly in sick  hospitalized patients  previous reports of nonepidemic enterobacter bacteremia have focused on adult patients  in this report  the epidemiologic factors  clinical characteristics  treatment  and outcome for 33 patients with enterobacter bacteremia in a large children s hospital during a 5 year period are reviewed  the ratio of males to females was 1 2 1  the patients  ages ranged from 2 days to 24 years  and 18 patients were less than 18 months old  twenty two cases were nosocomially acquired  six were polymicrobial in nature  significantly underlying conditions were present in 32 patients  the biliary tract and central venous catheters were the most common sources of bacteremia  two thirds of patients had preceding antibiotic therapy  the overall mortality was 24   mortality attributable to enterobacter bacteremia was 18   statistically significant differences in mortality were associated with an age less than 18 months  p    031  or thrombocytopenia  p    017   presence of fever was of borderline significance  p    098   enterobacter bacteremia is an important cause of morbidity and mortality in pediatric patients  
class1	endocarditis due to ampicillin resistant nontyphoid salmonella  cure with a third generation cephalosporin  a case of ampicillin resistant salmonella bacteremia complicated by endocarditis in a 78 year old man is presented  previous rheumatic valvular heart disease and the lack of response to initial treatment with chloramphenicol prompted us to consider this diagnosis  there was a good clinical response after treatment with ceftriaxone alone and corresponding improvement on the echocardiogram  this case demonstrates the possible endovascular complications of salmonella bacteremia in elderly people and that endocarditis should be included among the invasive infections due to ampicillin resistant salmonella that could potentially be treated with the newer cephalosporins  
class1	listerial myocarditis in cardiac transplantation  clinical signs of heart failure developed in two cardiac transplant recipients and were interpreted initially as graft rejection  morphologic examination of explanted hearts revealed myocarditis with abscess formation and necrosis consistent with a bacterial process  listeria monocytogenes was isolated from myocardial tissue in the first case and from blood in both  the first patient also developed signs of meningoencephalitis  but the second had no signs of infection outside the heart  antimicrobial therapy and retransplantation were successful in eradicating listeriosis  the differential diagnosis of heart failure in cardiac transplant recipients includes infectious myocarditis due to l  monocytogenes  
class1	group c streptococcal arthritis  case report and review  streptococci account for approximately 15  20  of cases of nongonococcal septic arthritis  the majority of these are due to group a streptococci  but group b and group g streptococci are being isolated more frequently  we present a case of group c streptococcal arthritis and summarize nine additional cases reported in the literature  the group c streptococci include the large colony of voges proskauer negative bacteria  streptococcus equi  streptococcus equisimilis  streptococcus zooepidemicus  and streptococcus dysgalactiae  as well as as the minute colony of voges proskauer positive streptococcus anginosus   streptococcus milleri   group c organisms  any joint may become infected  but joints affected by preexisting rheumatologic abnormalities are more frequently involved  bacteremia was documented in five of the 10 patients  one patient had an associated pneumonia  and another patient had an associated acute aortic valve endocarditis  none of the infections involved a prosthetic joint or an overlying cellulitis  associations reported for group g streptococcal arthritis  surgical drainage of the infected joint was required in six of the 10 patients  we concluded that the presence of two groups of organisms sharing the same lancefield group antigen necessitates the careful identification of isolates to determine potential clinical differences  
class1	primary meningococcal conjunctivitis  report of 21 patients and review  neisseria meningitidis is an uncommon cause of acute bacterial conjunctivitis  twenty one cases of primary meningococcal conjunctivitis  pmc  are reported herein and 63 cases published in the literature since 1899 are reviewed  in the 84 cases of pmc available for analysis  the male to female ratio was 1 76 1  nine of the patients were neonates  55 were children  and 20 were adults  conjunctivitis was unilateral in 66 3  of the patients  gram stain of conjunctival exudate disclosed gram negative diplococci in all cases in which it was done  culture of the conjunctival exudate yielded n  meningitidis in all cases  and 44  of the isolated meningococci belonged to serogroup b  ocular complications  which occurred in 15 5  of the patients  most frequently were corneal ulcers  systemic meningococcal disease developed in 17 8  of the patients  the overall mortality was 13 3  for patients with pmc complicated by systemic disease  development of systemic disease was significantly more frequent in patients receiving only topical therapy than in those treated with systemic therapy  31 71  vs  2 38   p    001   gram negative diplococci observed in conjunctival exudate are an indication for systemic antibiotic therapy because of the risk of systemic complications associated with the use of topical therapy alone  when properly treated  patients with pmc have a favorable prognosis  
class1	quinolone antibiotics in the treatment of salmonella infections the 4 fluoroquinolones are a new class of antimicrobial agents that possess broad in vitro antibacterial activity  including efficacy against enteric pathogens such as salmonella  shigella  campylobacter  yersinia  and vibrio species  these drugs are clinically effective against both drug sensitive and multiresistant strains of salmonella typhi and salmonella paratyphi that cause enteric fever  in salmonella enterocolitis  the quinolones  unlike older antimicrobial agents that may have little impact on the duration of symptomatic illness and can in fact prolong fecal carriage of salmonellae  actually shorten the course of clinical disease and terminate excretion of these organisms in the stool  similarly  for chronic carriers of both typhoidal and nontyphoidal salmonella strains  the quinolones are effective in eradicating biliary and fecal reservoirs of infection  immunosuppressed persons with salmonellosis  such as those with aids  may benefit from both short term treatment and prolonged prophylaxis with a quinolone antibiotic  the optimal agent  dose  and duration of quinolone therapy for all salmonella syndromes remain to be determined by larger controlled trials  
class1	infectious diseases as a canadian subspecialty  with projections to the year 2000  infectious diseases is a relatively new subspecialty in canada  during the past decade  however  important advances have been made  these include the formation of the canadian infectious diseases society and the development of the first royal college of physicians and surgeons examinations in the subspecialty of infectious diseases  the majority of canadians training for practice in the field of infectious diseases are now enrolled in programs in canada  despite predictions in the united states of an excess of physicians who specialize in infectious diseases  such a situation has not occurred in canada  more physicians with training in infectious diseases will be required in canada in the next decade to fill positions in patient care  microbiology  for individuals with both clinical and laboratory training   research  epidemiology and infection control  programs related to human immunodeficiency virus infections  geographic and international medicine  the pharmaceutical industry  and education and administration  in canada  the extent to which infectious diseases physicians are involved in these areas varies from that in the united states  this review suggests a continued need for physicians with appropriate training in infectious diseases  
class1	protection of mice against the lyme disease agent by immunizing with recombinant ospa  lyme borreliosis is a tick borne illness caused by borrelia burgdorferi  the gene for outer surface protein a  ospa  from b  burgdorferi strain n40 was cloned into an expression vector and expressed in escherichia coli  c3h hej mice actively immunized with live transformed e  coli or purified recombinant ospa protein produced antibodies to ospa and were protected from challenge with several strains of b  burgdorferi  recombinant ospa is a candidate for a vaccine for lyme borreliosis  
class1	syphilis  human immunodeficiency virus infection  and targeting prevention  to examine the interaction between syphilis and human immunodeficiency virus type 1  hiv 1  infection in oklahoma  we conducted an unlinked hiv seroprevalence survey using serum specimens submitted to the oklahoma state department of health for serologic test for syphilis  of specimens with positive results from fluorescent treponemal antibody absorption test  fta abs   6 3  were hiv 1 seropositive compared to 0 8  of those that had negative results from fta abs  among specimens positive for syphilis  hiv 1 seropositivity was found almost exclusively among those from persons 20 to 39 years of age and more often among those from men than those from women  9 9  vs 1 3    of syphilis positive specimens from 20  to 39 year old men  17 6  were hiv 1 seropositive  in oklahoma  an area with a relatively low overall prevalence of hiv 1 infection  targeting prevention efforts to young adults who test positive for syphilis should be an efficient way to reach some persons at high risk for hiv 1 infection  
class1	neurologic abnormalities in a patient with human ehrlichiosis  human ehrlichiosis is a tick borne rickettsial disease characterized by fever  headache  myalgias  anorexia  and occasionally rash  in our patient  changes in mental status  upper motor neuron signs  cerebrospinal fluid pleocytosis  and increased serum protein levels were found in association with serologically confirmed ehrlichiosis and were most likely due to vasculitis involving the central nervous system  intraleukocytic inclusions  although observed in our case  have been infrequently found in other reported cases of ehrlichiosis  
class1	left ventricular pseudoaneurysm complicating mitral valve replacement in a 4 year old child with acute bacterial endocarditis  a 4 year old child with acute bacterial endocarditis required mitral valve replacement  a left ventricular pseudoaneurysm developed following surgery  the etiology and diagnosis of this complication are discussed  
class1	pleuropulmonary tularemia  successful treatment with erythromycin  a 64 year old man had community acquired pneumonia that was retrospectively diagnosed as pleuropulmonary tularemia  he was successfully treated with erythromycin  we review the case and briefly discuss the literature on this point  
class1	antibodies in human tears during and after infection  the tear content of antibodies specific for various infectious agents has recently begun to be investigated  important parameters of tear analysis with respect to antibody content are the method of tear collection and the laboratory techniques used to detect specific antibodies in the lacrimal fluid  normal tears contain antibodies directed against both bacteria and viruses  and the antibody response in lacrimal fluid during immunization of animals and humans has been studied to some extent  this response has also been analyzed in humans during and after natural infection with certain viral and bacterial pathogens  it has become clear that local antibody synthesis takes place in the lacrimal gland  but at least some of these antibodies appear in tears because of lymphocyte sensitization in the common mucosal immune system  a certain degree of transudation of serum antibodies to tears is also often encountered  especially in severely inflamed eyes  much of the data currently available needs to be confirmed  and more extensive studies need to be carried out for many pathogens  potential benefits of such studies include development of new diagnostic techniques as well as a better understanding of when and how antibodies confer protection or may be potentially damaging  
class1	hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements  twenty nine patients with necrotizing fasciitis were treated from 1980 to 1988  this study evaluates how the addition of hyperbaric oxygen  hbo  therapy to surgical treatment has affected mortality and the number of debridements required to achieve wound control in these patients  two groups of patients were viewed  group 1  n   12  received surgical debridement and antibiotics only  group 2  n   17  received hbo  90 minutes at 2 5 atm  average 7 4 treatments  in addition to surgery and antibiotics  both groups were similar in age  race  sex  wound bacteriology  and antimicrobial therapy  body surface area affected was similar  however  perineal involvement was more common in group 2  53   than in group 1  12    the admitting conditions of patients in group 1  non hbo  were diabetic  33   white blood cell count more than 12 000  50   and shock  8   the admitting conditions of patients in group 2  hbo  were diabetic  47   white blood cell count more than 12 000  59   and shock  29   although group 2 patients receiving hbo were more seriously ill on admission  mortality was significantly lower  23   compared to group 1  66    p less than 0 02   in addition  only 1 2 debridements per group 2 patient were required to achieve wound control versus 3 3 debridements per group 1 patient  p less than 0 03   the addition of hbo therapy to the surgical and antimicrobial treatment of necrotizing fasciitis significantly reduced mortality and wound morbidity  number of debridements  in this study  especially among nonclostridial infections  we conclude that hbo should be used routinely in the treatment of necrotizing fasciitis  
class1	giant basilar aneurysm in the course of subacute bacterial endocarditis  we describe a man aged 42 years with mitral valve regurgitation who suffered from subacute bacterial endocarditis caused by streptococcus morbillorum  the clinical picture began with a toxic syndrome  five months later  the patient had an embolic episode and a right rostral pontine stroke  which was followed a few days later by an adversive focal seizure on the right  despite antibiotic treatment  he suffered complete third nerve palsy  arteriography  magnetic resonance imaging  and computed tomography of the brain showed a giant aneurysm in the rostral end of the basilar artery  the aneurysm was clipped  we discuss the clinical features  radiology  and characteristics of this aneurysm as a unique case of a giant bacterial aneurysm in the vertebrobasilar system  
class1	management of peyronie disease by implantation of inflatable penile prosthesis  sixty seven patients with advanced peyronie disease were treated by implantation of an inflatable penile prosthesis  ipp   twenty eight of the 67 patients had documented total erectile failure  the remaining 39 patients had significant penile curvature causing  mechanical impotence  due to inability to achieve adequate vaginal penetration and chose implantation of an inflatable penile prosthesis  in some cases  combined with a straightening procedure  rather than one of the standard penile straightening procedures  currently  63 of the 67 patients have functioning prosthetic devices  in 3 other patients the device was removed because of infection  and 1 patient was dissatisfied and had the device removed  for impotent patients with severe peyronie disease for whom other medical or surgical treatment is neither desirable nor suitable  we recommend implantation of an inflatable penile prosthesis combined with a possible straightening procedure  
class1	diagnosis and treatment of prostatic infections  the diagnosis and management of prostatitis and pelviperineal pain is a challenge to the clinician  careful examination of the prostatic fluid and bacteriologic cultures to differentiate bacterial from nonbacterial prostatitis are essential  antimicrobial therapy is effective in the majority of men with acute or chronic bacterial prostatitis  nonbacterial prostatitis is the most common type of prostatitis  the etiology is unknown and treatment with repeated antimicrobial therapy is ineffective  alpha blocking agents may relieve symptomatology  pelviperineal pain may be of prostatic origin but other nonprostatic causes should be sought  
class1	hiv disease  a review for the family physician  part ii  secondary infections  malignancy and experimental therapy  the first part of this two part article included recommendations for the initial evaluation of patients suspected of having hiv infection  the centers for disease control s classification scheme for hiv disease and current recommendations for the use of zidovudine  in this second part  secondary infections and malignancy are reviewed  and various experimental therapies are briefly discussed  
class1	effects of common illnesses on infants  energy intakes from breast milk and other foods during longitudinal community based studies in huascar  lima   peru  to assess the effects of common infections on dietary intake  131 peruvian infants were observed longitudinally  home surveillance for illness symptoms was completed thrice weekly  and food and breast milk consumption was measured during 1615 full day observations  mean      sd  energy intakes on symptom free days were 557     128 kcal d  92 4     26 5 kcal kg 1 d 1  for infants aged less than 181 d and 638     193 kcal d  77 7     25 7 kcal kg 1 d 1  for infants aged greater than 180 d  statistical models controlling for infant age  season of the year  and individual showed significant 5 6  decreases in total energy intake during diarrhea or fever  there were no changes with illness in the frequency of breast feeding  total suckling time  or amount of breast milk energy consumed  by contrast  energy intake from non breast milk sources decreased by 20 30  during diarrhea and fever  and the small decrements in total energy consumption during illness were explained entirely by reduced consumption of non breast milk foods  
class1	bacteremia in an ambulatory setting  improved outcome in children treated with antibiotics  we undertook a study of 414 bacteremic patients  167 with haemophilus influenzae and 247 with streptococcus pneumoniae bacteremia  to evaluate their clinical presentation  laboratory and clinical results  and subsequent outcomes  patients with h influenzae bacteremia were more likely to have soft tissue foci  poorer clinical appearance at presentation  and be at higher risk for subsequent serious focal infections  persistent bacteremia  and subsequent hospital admissions than patients with s pneumoniae  patients with h influenzae bacteremia had a 21 1 fold increase in risk of meningitis  95  confidence interval  ci  of 3 8 to 78 0  compared with those with s pneumoniae  the odds ratio for initial lumbar puncture was 5 25  95  ci  1 1 23 6    ambulatory patients treated with antibiotics at presentation were less likely to develop new serious soft tissue infections  persistent bacteremia  or to require subsequent hospital admissions than untreated patients  the effect of treatment was greater for patients with s pneumoniae than those with h influenzae  careful follow up and reevaluation of patients with presumptive bacteremia is essential because treated and untreated patients can still develop serious soft tissue infections  
class1	percutaneous central venous catheterization  three years  experience in a neonatal intensive care unit  prolonged venous access is desirable in very low birth weight infants and infants for whom feedings are contraindicated  we prospectively evaluated 481 small diameter venous catheters placed percutaneously in 317 patients over 3 years  of 478 catheters  241  50   were placed in infants weighing 1 kg or less  mean catheter stay was 13 days  range  less than 1 to 77 days   almost half  49   of the central and thoracic catheters  91  of placements  were removed nonelectively  43  due to problems such as leaking or clotting and 6  to suspicion of sepsis or venous occlusion  of the 23 episodes of possible sepsis in the 478 catheter stays  six  1 3   were confirmed catheter related sepsis  12  2 5   were confirmed alternate locus sepsis  three factors specific to percutaneous central venous catheter related sepsis were prolonged catheter stay  3 to 5 weeks   staphylococcus epidermidis  and weight less than or equal to 1 kg  four factors specific to alternate locus sepsis were presence of an alternate infection site  earlier infection  1 to 2 weeks   extremely low birth weight  and prolonged clinical instability  percutaneous central venous catheterizations reduced the need for the stress of repeated venipuncture  resulting in lower complication rates than those reported with surgically placed central venous catheters  and leading to identification of risk factors specific to catheter sepsis and alternate locus sepsis  
class1	 spontaneous sump syndrome   successful treatment by duodenoscopic sphincterotomy   sump syndrome  is a rare complication of side to side choledochoenterostomy operations which develops in the distal  nonfunctioning limb of the common bile duct where lithogenic bile  gastrointestinal contents  and debris accumulate  we report here a patient who developed spontaneous sump syndrome as a result of the formation of choledochoduodenal fistula  and who presented with multiple pyogenic liver abscesses  the patient s symptoms and liver abscesses resolved completely after treatment by endoscopic sphincterotomy and antibiotics  this case demonstrates that sump syndrome may occur spontaneously  that it can be a cause for pyogenic liver abscess formation  and that it may be treated effectively by endoscopic sphincterotomy  
class1	adult and pediatric peritonitis rates in a home dialysis program  comparison of continuous ambulatory and continuous cycling peritoneal dialysis  we reviewed our 115 month experience with continuous ambulatory peritoneal dialysis  capd  and continuous cycling peritoneal dialysis  ccpd  in adult and pediatric patients to determine whether there is a difference in the incidence of peritonitis between patients performing capd or ccpd  peritonitis rates were similar in patients performing capd or ccpd in both the adult and pediatric age groups  the overall capd peritonitis rate was significantly lower in adult patients when compared with pediatric patients  there was no difference in peritonitis rates for ccpd between adult and pediatric patients  when the data are divided into 3 year subgroups  the incidence of peritonitis is significantly lower in adult patients undergoing either capd or ccpd when compared with pediatric patients during the years 1986 to 1988  there is significant improvement over time in the incidence of peritonitis in both adult and pediatric patients performing ccpd  similarly  there is a trend toward improvement in patients performing capd  staphylococcus species organisms remain the most common bacterial cause of peritonitis  except in pediatric patients under the age of 2 years or with nephrostomies  where gram negative rod infections were more common  peritonitis resulted in discontinuation of peritoneal dialysis in a greater number of adult patients  these results suggest that the number of catheter manipulations is not important in determining the incidence of peritonitis  pediatric patients are more likely than adult patients to develop peritonitis with either capd or ccpd  adult patients are more likely than pediatric patients to discontinue peritoneal dialysis secondary to peritonitis  
class1	epidemiology of lyme disease in virginia  prior to january 1986  only one case of lyme disease was reported from virginia  in 1986 87  however  the virginia department of health observed an increase in reports of suspected lyme disease by physicians  despite the fact that ixodes dammini is not highly prevalent in the virginia tick population  twenty eight cases of lyme disease were identified in virginia  of which eight cases occurred in 1986 and 20 in 1987  lyme disease appears to be increasing in frequency in virginia and moving southward along the eastern atlantic seaboard  
class1	use of intrapleural streptokinase in the treatment of thoracic empyema  the incidence of pleural effusions in bacterial pneumonia may exceed 40   a factor that may be related to increased morbidity and mortality  options in the treatment of complicated pleural effusions or empyema  when unresponsive to closed tube drainage  include repositioning of the indwelling tube thoracostomy or insertion of additional chest tubes  instillation of intrapleural streptokinase  and surgical intervention  the authors describe the course of three patients wherein the use of intrapleural streptokinase was efficacious in effecting prompt drainage of previously inadequately evacuated empyema  thus eliminating the necessity for further invasive intervention  
class1	antenatal microbiologic and maternal risk factors associated with prematurity  in a prospective study of 202 women  gestational age 24     4 weeks   we evaluated possible influences of lower genital tract infection or bacterial conditions on obstetric outcomes  including preterm labor  preterm premature rupture of membranes  and preterm birth  the presence of bacterial vaginosis  18 7   was associated with an increased risk of preterm labor  relative risk  2 6  95  confidence interval  1 08 to 6 46   for women with bacterial vaginosis who also had mobiluncus species morphotypes identified on gram stain  the relative risk of preterm labor was 3 8  95  confidence interval  1 32 to 11 5   presence of vaginal mycoplasma hominis  10 8  of patients  was associated with both preterm labor  relative risk  1 8  95  confidence interval  0 77 to 4 4  and preterm birth  relative risk  5 1  95  confidence interval  1 45 to 17 9   recovery of staphylococcus aureus  3 0   was associated with preterm labor  relative risk  3 1  95  confidence interval 1 12 to 8 7   identification of two or more bacterial linked abnormalities was also associated with preterm labor  relative risk  3 3  95  confidence interval  1 44 to 7 58   an increased level of vaginal wash protease  greater than or equal to 10 trypsin units   16   was associated with preterm labor and was noted in 50  of women with preterm premature rupture of membranes  a history of prior preterm birth was the single best historical predictor of both preterm labor  relative risk  3 6  95  confidence interval  1 92 to 6 83  and preterm birth  relative risk  6 7  95  confidence interval  2 2 to 20 4   history of three or more abortions  antenatal urinary tract infection  and occurrence of medical complications during pregnancy also correlated with increased risk of preterm labor  these findings affirm and refine associations of various maternal reproductive tract infections with preterm labor  premature rupture of membranes  and birth  allowing for controlled treatment trials aimed at prevention of preterm birth  
class1	cervicovaginal microflora and pregnancy outcome  results of a double blind  placebo controlled trial of erythromycin treatment  available information suggests that some instances of preterm birth or premature rupture of membranes are associated with clinically unrecognized infection and inflammation of the lower uterine segment  decidua  and fetal membranes  various cervicovaginal microorganisms have been recovered from these sites  many of these microorganisms produce factors that may lead to weakening of the fetal membranes  release of prostaglandins  or both  this study evaluated the presence of various lower genital tract microflora and bacterial conditions in 229 women enrolled in a double blind  placebo controlled trial of short course erythromycin treatment at 26 to 30 weeks  gestation to prevent preterm birth  demographic  obstetric  and microbiologic parameters were prospectively evaluated  premature rupture of membranes occurred less frequently  p less than 0 01  among women who received erythromycin  6   versus placebo  16    preterm premature rupture of membranes also occurred less frequently  although not significantly  p   0 3  in patients who received erythromycin  2   versus placebo  5    erythromycin treatment significantly decreased the occurrence of premature rupture of membranes among women who were initially positive for chlamydia trachomatis infection  logistic regression analysis demonstrated that c  trachomatis  p   0 05  odds ratio  9   vaginal wash phospholipase c  p   0 08  odds ratio  6  and prior preterm birth  p   0 007  odds ratio 17  were associated with increased risk of preterm birth  bacterial vaginosis  mycoplasma hominis  ureaplasma urealyticum were not significantly associated with increased risk of preterm birth or preterm rupture of membranes  these findings support a role for selected lower genital tract microflora in preterm birth and premature rupture  large controlled treatment trials of specific infections or conditions associated with preterm birth and premature rupture of membranes are required to confirm the value of antimicrobial treatments in prevention of microbial associated preterm birth  
class1	pregnancy outcomes among mothers infected with human immunodeficiency virus and uninfected control subjects  between june 26  1985  and feb  24  1989  101 seropositive pregnant women and 129 seronegative pregnant women from the same prenatal clinics in brooklyn and the bronx were recruited into a prospective study of human immunodeficiency virus infection in pregnant women and their offspring  this report details the course of pregnancy and short term neonatal outcomes of 91 seropositive women and 126 seronegative women who gave birth during the study period  seropositive mothers were significantly more likely to have sexually transmitted diseases  17 6  vs 7 1   p   0 017  and medical complications  43 0  vs 25   p   0 006  during pregnancy  no other obstetric complications  e  g   chorioamnionitis  endometritis  toxemia  or placental problems  were associated with serologic status  after controlling for confounding variables  drug use  tobacco use  age of mother  and clinic   we found that the mother s serologic status was not significantly associated with birth weight  gestational age  head circumference  or apgar scores among live infants  for example  after adjustment on confounders we found that children born to seropositive mothers weighed about 7 gm more than children of seronegative mothers  95  confidence interval   180 to 194 gm   we conclude that in this population human immunodeficiency virus infection has little demonstrable impact on the status at birth of live neonates  
class1	perinatal mortality in victoria  australia  role of group b streptococcus  group b beta hemolytic streptococcus is the most common infective cause of neonatal morbidity and mortality  it is therefore surprising that no agreement exists for an approach to its prevention  there is also increasing evidence that occult infection may play an etiologic role in premature rupture of the membranes and preterm labor  in this report we review the role of group b beta hemolytic streptococcal sepsis as a cause of perinatal wastage in the state of victoria  australia during the period 1982 to 1987  group b beta hemolytic streptococcus accounted for 1 7  of overall perinatal deaths  and for 30 3   77 of 254  perinatal deaths directly attributable to infection  by comparison  over the same 6 year period  erythroblastosis accounted for 0 5  of perinatal wastage and there were only two deaths as a result of congenital syphilis  the true incidence of lethal group b beta hemolytic streptococcal infection is probably greater because of the absence of histologic and bacteriologic studies in many perinatal deaths  we believe that intrapartum chemoprophylaxis with penicillin of all group b beta hemolytic streptococcus positive carrier mothers would significantly reduce neonatal morbidity and mortality from this cause  
class1	epidemiologic differences between chlamydia and gonorrhea  to assess the prevalence  demographics  and transmission patterns of genital chlamydia infection  we screened 3 078 patients  and compared identified cases  n   511  to gonorrhea cases  n   291  diagnosed in the same setting  chlamydia cases were younger and more likely to be white than their gonorrhea counterparts  chlamydia cases were distributed diffusely  geographic overlap between the two diseases was only about 40 percent  gonococcal coinfection was noted in less than 10 percent of patients with chlamydia  nearly half of men with chlamydia and four fifths of women were asymptomatic and most cases were identified through screening or contact tracing  populations at high risk for chlamydia are seemingly different from those for gonorrhea  differences may be due to control interventions  active for gonorrhea  passive for chlamydia   chlamydia case reporting and control initiatives are recommended  
class1	garlic in oil associated botulism  episode leads to product modification  in february 1989  three cases of botulism occurred in persons who consumed garlic bread made from a garlic in oil product  testing of leftover garlic in oil showed it to have a ph of 5 7 and to contain high concentrations of clostridium botulinum organisms and toxin  this was the second episode of botulism associated with a low acid garlic in oil product which needs constant refrigeration  in response  the food and drug administration has taken steps to prevent a recurrence by requiring that microbial inhibitors or acidifying agents be added to such products  
class1	day care characteristics associated with haemophilus influenzae disease  haemophilus influenzae study group  to identify characteristics of day care facilities associated with h  influenzae disease  we compared 92 licensed facilities in which a case of h  influenzae disease had occurred with randomly selected facilities at which no cases occurred  matched univariate analysis showed that personnel at facilities where h  influenzae disease occurred were more likely than those at control facilities to use towels or handkerchiefs to wipe children s noses  admit children who were not toilet trained or had diarrhea   liberal fecal policy    had a narrower age range  were more likely than control facilities to be for profit and less likely to use volunteers  in a multivariate model that adjusted for age range  profit status and liberal fecal policy  towel or handkerchief use  or 5 5  95  ci  1 1  30  was the only variable independently associated with case facilities  this is the first association of a specific day care practice with h  influenzae disease  
class1	evidence for gonococcal transmission within a correctional system  in a study to examine sexually transmissible disease occurring within a large correctional system where sexual activity is prohibited  27 male inmates acquired culture proven gonorrhea from in jail sexual activity during a three month period  these results provide evidence to encourage inmate education about the acquired immunodeficiency syndrome  aids  and to support condom distribution programs in correctional facilities  
class1	hiv seroprevalence among male ivdus in houston  texas  hiv seroprevalence was 8 4 percent in a sample of 921 heterosexual male intravenous drug users in houston  texas who were not in drug treatment at the time of the study  males who were black  injected drugs daily  or had a history of syphilis had greater odds of being hiv positive than participants without those characteristics  
class1	south american blastomycosis  ophthalmic and oculomotor nerve lesions  a case of south american blastomycosis began with an oropharyngeal lesion which was followed by a granulomatous uveitis  the patient was treated with amphotericin b and showed a clinical regression  four months later  he developed a right 3rd cranial nerve palsy  aggravating the clinical aspect with a severe generalized involvement of the central nervous system and death  necropsy showed blastomycotic meningoencephalitis  
class1	recombinant capsular antigen  fraction 1  from yersinia pestis induces a protective antibody response in balb c mice  yersinia pestis produces a glycoprotein capsule  the biosynthesis of which appears to be temperature dependent  the fraction i  f1  component of this capsule is specific to y  pestis and the detection of f1 antibodies is the basis for several serological tests  we report the cloning of the f1 gene and its expression in escherichia coli using the phagemid vector lambda zapii and a f1 specific monoclonal antibody  the recombinant f1 antigen had a molecular weight of 17 kda  which proved to be identical to that of the f1 antigen produced by y  pestis  the recombinant cells produced f1 antigen at 37 degrees c but only minimal amounts at 27 degrees c  suggesting that the genetic features affected by temperature in y  pestis may be operating in the e  coli clone  it is not known if their similar molecular weights reflect the glycosylated nature of both proteins  f1 antigen purified from the e  coli recombinant induced a protective immune response in balb c mice challenged with up to 10 5  virulent y  pestis  the resistance of immunized mice to plague infection correlated with high titers of f1 antibody  the cloned gene expresses an immunogenically competent f1 antigen suitable for use in plague serodiagnostics and vaccine development  
class1	role of surgery in antibiotic induced pseudomembranous enterocolitis  with the increased use of prophylactic and broad spectrum antibiotics  pseudomembranous colitis has emerged as a significant clinical problem  management with specific anti clostridium difficile therapy  vancomycin or metronidazole  has reduced mortality to less than 2   nevertheless  the disease may progress to a fulminant toxic colitis or colonic perforation  additionally  another subset of patients will present with a dramatic clinical picture  suggesting acute peritonitis  eventuating in unnecessary laparotomy  this report reviews both the medical and surgical literature during the past 15 years of patients treated for pseudomembranous colitis  analysis of this clinical data has provided us with the opportunity to both define the role of surgery in this disorder and illustrate the necessity for a combined medical and surgical cooperative approach in the early management of this iatrogenic disease  
class1	blood contamination of anaesthetic and related staff the incidence of skin contamination of anaesthetic and related staff by patient s blood and saliva was studied during 270 anaesthetics in cardiff hospitals over seven continuous days in october 1989  a survey was also made of current hepatitis b immunisation status and glove wearing habits of 75 anaesthetists  blood from 35  14   patients caused skin contamination of 65 staff during 46 incidents  twenty eight  61   of the contamination incidents occurred during vessel cannulation  five  8   of the 65 staff contaminated by blood already had cuts on their hands  there were nine incidents  4   of skin contamination by saliva  fifty three  71   anaesthetists were immunised against hepatitis b  only seven  9   anaesthetists wear gloves for oral or nasal intubation  six  8   for insertion of peripheral venous cannulae  47  63   for insertion of arterial lines and 67  89   for insertion of central lines  all anaesthetic and associated staff should wear gloves on a routine basis  
class1	infection during chronic epidural catheterization  diagnosis and treatment  a potentially serious complication of long term epidural catheterization in cancer patients is infection  the early signs of infection were studied in 350 patients in whom long term epidural catheters were inserted  three areas of the catheter track were found to be involved  exit site and superficial catheter track infection  and epidural space infection  the authors identified the early signs of infection in each area and the progress of the infection from the deep track to include the epidural space in four of these patients  all 19 patients who developed deep track or epidural infections were successfully treated with antibiotics and catheter removal  none of the patients required surgery for spinal cord decompression  catheters were replaced in 15 of the 19 treated patients who requested them after treatment with no recurrent infections  it was concluded that use of long term epidural catheterization is associated with a definable epidural infection rate  the use of epidural opioid analgesia is an effective and safe means of obtaining pain relief for terminally ill patients when patients are monitored for possible infection and receive prompt treatment when the diagnosis is established  
class1	toxic streptococcal syndrome  the streptococcal toxic shocklike syndrome is a recently recognized  multisystem disorder that shares many of the features of staphylococcal toxic shock syndrome  but is caused by toxins elaborated by group a beta hemolytic streptococcus  we describe a patient who fulfilled the major criteria for the clinical diagnosis of toxic shock syndrome  fever  hypotension  multisystem dysfunction  and diffuse macular erythroderma followed by desquamation  and who demonstrated serologic evidence suggesting streptococcal infection  in patients presenting with clinical findings consistent with a toxic shocklike syndrome  the emergency physician should consider streptococcal infection as a potential etiology  
class1	tetanus immunization status and immunologic response to a booster in an emergency department geriatric population  study objectives  although effective procedures for the prevention of tetanus have long been available  serosurveys done since 1977 demonstrate that 49  to 66  of the elderly population lacks a protective antitoxin level  more than 0 01 iu ml   this study was undertaken to assess the tetanus immunization status of patients presenting to an emergency department and to evaluate their immunologic response to a tetanus booster  setting  the study was conducted in a tertiary care ed  type of participants  the patients enrolled were 65 or more years old and had breaks in their skin barriers  design  at each patient s initial presentation  pertinent demographic data and tetanus immunization history were recorded  the patient was then followed for 21 days  interventions  each patient s antitoxin titer was determined on a serum sample by elisa  and  if required by the advisory committee on immunization practices criteria  a booster was administered at the first visit  measurements and main results  serum antitoxin assays were repeated on days 7  14  and 21 after the initial visit until seroconversion  titer more than 0 01 iu ml   forty four patients  55   had protective levels at initial presentation  and in 36  45   the levels were not protective  age and sex were not predictive of protection  past military service and a definite history of three or more previous immunizations were good predictors of protection  of 34 patients who were followed serially for inadequate initial titers  only 19  56   seroconverted by day 14  patients who did not seroconvert were more likely to be older  p less than  05   conclusions  this study demonstrated that a significant number of elderly patients lacked an initial protective level of tetanus antitoxin  of these  44  failed to seroconvert within 14 days and carried a potential risk of developing tetanus  
class1	erythromycin failure with subsequent pasteurella multocida meningitis and septic arthritis in a cat bite victim  we report the case of a 75 year old woman who developed pasteurella multocida meningitis and septic arthritis while being treated for a cat bite wound infection with erythromycin  review of the literature revealed that erythromycin has poor in vitro activity against this bacterium and has been associated with serious clinical failures  we recommend that erythromycin not be prescribed for empiric therapy of established animal bite infections  suggestions for optimal empiric therapy of animal bite infections and the differential diagnosis of severe cat bite associated sepsis are discussed  
class1	the role of mucous glycoproteins in the rheologic properties of cystic fibrosis sputum  cystic fibrosis  cf  is characterized by excessive amounts of thick and tenacious mucous secretions that obstruct organ ducts and passages  in the respiratory tract this is associated with chronic infection resulting in the hypersecretion of purulent sputum  which the patient finds difficult to clear  we have studied the rheologic properties of purulent sputum from six patients with cf and five patients with chronic bronchitis to assess whether cf is associated with increased sputum viscoelasticity  in addition  we have isolated the major rheologic determinants  mucous glycoproteins  from cf and chronic bronchitis sputa and  using a magnetic microrheometer  investigated the possibility that the altered properties of mucus in cf are associated with abnormalities in these glycoproteins  creep compliance analysis indicated that the cf sputa possessed raised levels of both elasticity  p less than 0 01  and viscosity  p less than 0 01   these increases in both rheologic parameters were found to be associated with increases in the dna content  p less than 0 01  and dry weight  p less than 0 05   mucous glycoproteins were isolated from cf and chronic bronchitis sputum samples by gel filtration on sepharose cl4b  followed by concentration to form 8  wt wt gels  in the absence of other sputum components  no abnormality in the rheologic properties of cf mucin gels could be detected  however  when dna was added  the cf gels responded with increases in both elasticity and viscosity of as much as 30   p less than 0 05   an effect not observed in the chronic bronchitis gels  these results suggest that a subtle abnormality may exist in cf mucous glycoproteins and that this could have a role in the altered physical properties of mucous secretions in cf  
class1	human intestinal tissue antibiotic concentrations  clindamycin  gentamicin  and mezlocillin  an antibiotic  to be effective for prophylaxis in abdominal trauma  should quickly achieve high concentrations in the intestinal wall and at enough inhibitory levels to kill most aerobic and anaerobic bacteria that are potential contaminants at the site of surgical incision  therefore  we studied the intestinal tissue levels of clindamycin  gentamicin  and mezlocillin to see whether the tissue levels achieved by these antibiotics in the intestinal tissue were adequate  a single dose of mezlocillin  4 grams  clindamycin  600 mg and gentamicin  80 mg  quickly reached the desired concentrations  i e   52 3  9 69 and 6 1 micrograms gram of intestinal tissue respectively  these levels were high enough to inhibit the growth of most isolates of e  coli and b  fragilis  common pathogens involved in intra abdominal abscess  
class1	the inactivation of antithrombin iii by serum elastase in patients with surgical infections  the relationship between serum elastase and antithrombin iii was determined in septic surgical patients as a possible mechanism for intravascular thrombosis and hypercoagulability during sepsis  eighteen patients with surgical infections and elevated white blood cell counts had their blood assayed daily for white blood cell count  serum elastase  and antithrombin iii  until the patient s white blood cell count returned to normal  antithrombin iii was significantly lower  0 87   when elastase was above the normal range  greater than 14 2 micrograms ml   elastase was significantly higher  30 6 micrograms ml   when antithrombin iii was less than normal  these data indicate that elevated serum elastase is associated with a significant reduction in circulating antithrombin iii  stimuli that increase serum elastase  i e  surgery  trauma  or sepsis may promote intravascular thrombosis by the inhibition of antithrombin iii at the blood endothelial cell interface  
class1	effect of human immunodeficiency virus  hiv  infection on the course of syphilis and on the response to treatment  purpose  to evaluate evidence that concurrent infection with human immunodeficiency virus  hiv  alters both the natural history of syphilis  by increasing the frequency of early neurosyphilis  and the response to penicillin  data identification  review of major works on syphilis in the english language and files maintained since 1971  supplemented by a systematic search using index medicus and medlars  data extraction  the works mentioned above were critically reviewed for information on early neurosyphilis and  where relevant  hiv infection  results of data analysis  the central nervous system is regularly involved in early syphilis  standard recommended doses of benzathine penicillin provide cerebrospinal fluid levels that are probably at the borderline of efficacy  and cure relies on treatment and an adequate host immune response  early neurosyphilis  appearing within 2 years of onset of infection with treponema pallidum  was uncommon in the prepenicillin era and usually occurred after inadequate therapy  this complication was exceedingly rare in the first three decades of penicillin use  in contrast  in the past decade  40 patients with hiv infection have been reported to have asymptomatic neurosyphilis  or syphilitic meningitis  cranial nerve abnormalities  predominantly in cranial nerves ii and viii   or cerebrovascular accidents  singly or together  in 40  of cases  hiv infection was first diagnosed when neurologic symptoms appeared  of the 38 patients for whom information was available  18 had the acquired immunodeficiency syndrome  aids   7 had aids related complex  and 13 had antibody to hiv  sixteen had previously been treated for syphilis  of whom 5  31   had received benzathine penicillin within the previous 6 months  preliminary data also suggest that skin lesions and vdrl  venereal disease research laboratory  antibody in hiv infected patients with secondary syphilis respond more slowly to conventional penicillin therapy  conclusion  intensive therapy and follow up observation is indicated for early syphilis in hiv infected subjects  novel approaches to treatment deserve systematic evaluation  
class1	recurrent seizures in children with shigella associated convulsions  fifty five children with shigella associated convulsions were followed prospectively to investigate their risk of subsequent febrile or nonfebrile seizures  the duration of the follow up period was between 6 9 and 14 1 years  9 7     3 1 years   no case of nonfebrile seizures and only 2 cases  3   of subsequent febrile seizures were observed during this period  we conclude that although febrile and shigella associated convulsions share many clinical features  the natural history of these two conditions seems to be distinctly different  shigella related convulsions are not associated with an increased incidence of subsequent febrile or nonfebrile convulsions  
class1	iatrogenic contamination of multidose vials in simulated use  a reassessment of current patient injection technique  an investigation of the potential spread of iatrogenic infections through contaminated multidose vials was performed  contamination of a multidose vial was hypothesized to occur after a single syringe is used to inject an infected patient with medication  and the same syringe subsequently is used to withdraw additional medication from the multidose vial  if the contaminated multidose vial is used for another patient  an iatrogenic infection may be spread  laboratory study of this injection technique found that viral plaque forming units could be transmitted to a multidose vial in this manner  a survey of 100 fellows of the american academy of dermatology from the united states found that 24  of the respondents used this potentially unsafe procedure  the potential for iatrogenic spread of the human immunodeficiency virus and hepatitis b virus is described  recommendations to avoid patient infection are made  
class1	outcome after acute osteomyelitis in preterm infants  eight cases of skeletal infection in preterm infants were studied  all the infants were systemically unwell  with polymorpholeucocytosis  diagnosis was by blood culture  and any radiographic changes were apparent at the time of presentation  infection was often multifocal  with sites around the knee being most commonly affected  staphylococcus aureus was the pathogen isolated in six of the eight cases  in these treatment with fusidic acid was effective and well tolerated  even at doses that were less than the recommended therapeutic minimum  even with prompt diagnosis and aggressive treatment orthopaedic sequelae are common  
class1	thoracoplasty  current application to the infected pleural space thoracoplasty  once commonly used in the management of cavitary pulmonary disease  continues to find application in the obliteration of infected pleural spaces  this study reports a series of 13 patients receiving thoracoplasty between 1976 and 1989  five patients had chronic apical empyema spaces without prior resection of lung tissue  two of the empyemas were due to tuberculosis  two were due to atypical mycobacteria  and one was due to postpneumonic empyema  all patients had extensive destruction of upper lobe tissue  eight patients had undergone prior pulmonary resection  3 had persistent infected spaces in the early postoperative period  3 had development of empyemas and bronchopleural fistulas late  5 to 19 years  after pulmonary resection  and 2 had postpneumonectomy empyema  all patients had rigid cavity walls preventing space obliteration by rib removal alone and required concomitant resection of the thickened pleura and intercostal muscle tissues  bronchopleural fistulas were present in 11 patients and were closed with adjacent nonintercostal muscle  all patients survived and had successful obliteration of the infected spaces with acceptable physiological and cosmetic results  we conclude that thoracoplasty remains a useful procedure in the management of the infected pleural space in select patients  
class1	air contamination in open heart surgery with disposable coveralls  gowns  and drapes  the effect of a polypropylene coverall  replacing shirt and trousers  combined with sterile laminated gowns and drapes compared with an all cotton system was studied in regard to the dispersion of bacteria and particles in a conventionally ventilated operating theater  the operations carried out were open heart procedures in 30 adult patients  blood agar sedimentation plates were placed in the operative  anesthesia  and perfusion areas  the mean sedimentation values during 1 hour after the start of operation were as follows in the laminate group  63 colony forming units  cfu  m2 in the operative area  77 cfu m2 in the anesthesia area  and 143 cfu m2 in the perfusion area  the corresponding figures in the cotton group were 350 cfu m2  364 cfu m2  and 437 cfu m2  respectively  p less than 0 0002   at the beginning of the operation  the mean values noted for colony forming units in the air at the operative site were 8 0 cfu m3 in the laminate group and 31 cfu m3 in the cotton group  one hour later  the values were 10 cfu m3 and 22 cfu m3  respectively  p less than 0 0002   at the end of the operation  the number of particles 5 microns or larger in the air at the operative site was 278 m3 in the laminate group and 592 m3 in the cotton group  it is concluded that the use of a polypropylene coverall and laminated gowns and drapes significantly reduces the particle and bacterial contamination of the air and the bacterial sedimentation during cardiac operations  
class1	myocardial preservation using lidocaine blood cardioplegia  prevention of ventricular fibrillation after aortic unclamping using lidocaine hydrochloride as an additive to cold potassium blood cardioplegia was studied prospectively in 46 patients undergoing elective myocardial revascularization  patients were similar with respect to age  ventricular function  severity of coronary artery disease  cross clamp time  completeness of revascularization  frequency of internal thoracic artery grafting  systemic temperature at the time of cross clamp removal  and mean infusate volume and temperature  patients receiving lidocaine blood cardioplegia  group 1  23 patients  had a significant reduction in the incidence of ventricular fibrillation  22  versus 74   p less than 0 0005  and in the mean number of cardioversion attempts required to defibrillate the heart  0 5     1 3 versus 1 9     0 97  p less than 0 0005  after cross clamp removal compared with controls  group 2  23 patients   there were no differences between the two groups postoperatively with regard to cardiac enzyme release  hemodynamic measurements  or clinical outcome  patients receiving lidocaine blood cardioplegia tended to have a lower incidence of new postoperative atrial fibrillation  9  versus 26    ventricular function was preserved equally in both groups  we conclude that lidocaine is a safe additive to potassium blood cardioplegia and significantly reduces the incidence of ventricular fibrillation after aortic unclamping  
class1	antimicrobial prophylaxis for open heart operations  between 1986 and 1988  450 adults undergoing coronary artery bypass  cardiac valve replacement  or both were enrolled into a prospective  randomized  comparative trial of cephalothin versus cefamandole as perioperative prophylaxis  they were assessed during their hospitalization and at 6 weeks and 6 months after discharge for postoperative infectious complications  eleven patients had major postoperative infections including 5 with sternal wound infections  three bacteremic   6 with bacteremia  1 with prosthetic valve endocarditis  and 3 with severe venous donor graft site infections  eight major infections occurred in patients receiving cephalothin prophylaxis and three in patients receiving cefamandole  with all five sternal wound infections occurring in the cephalothin group  postoperative pathogens responsible for the major infections included gram negative aerobes in 5 patients  staphylococcus aureus in 4  and staphylococcus epidermidis in 2  preoperative colonizing staphylococcal isolates were not predictive of postoperative staphylococcal pathogens  although there was no statistically significant difference in rate of major postoperative infectious complications using either cephalothin or cefamandole prophylaxis  there was a trend in favor of cefamandole  gram negative aerobes are becoming increasingly important pathogens in this setting  
class1	treatment of postoperative infection of ascending aorta and transverse aortic arch  including use of viable omentum and muscle flaps  postoperative infection of the ascending aorta and aortic arch in 40 patients was treated by antibiotic therapy alone  4 patients  or by operation and lifelong suppressive antibiotic therapy  36 patients   complications of infection included antibiotic resistant infection  infected false aneurysm  rupture of suture line  aortocutaneous fistulas  aortic right ventricular fistulas  arterial embolus  aortic valve insufficiency  aortobronchial fistula  mediastinal abscess  and chest wall problems  these were treated by a variety of operations including composite valve graft replacement  graft replacement  patch graft closure of false aneurysm  simple suture of disrupted suture lines and false aneurysm  and debridement of mediastinum and chest wall  the area of reconstruction was covered  and mediastinal dead space was reduced by mobilization of viable tissue  including local tissue and distant structures such as flaps of muscle and omentum  thirty three patients  83   were early survivors  and 28 patients  70   were alive and well at last follow up 4 months to 6 5 years after operation  
class1	management of mycotic rupture of the ascending aorta after heart lung transplantation  a 19 year old woman underwent heart lung transplantation for obstructive bronchiolitis  eleven days later mycotic rupture of the ascending aorta occurred  emergency cardiopulmonary bypass was instituted via the femoral vessels and the chest was reopened under cardiac massage  perforation of the aorta at the site of insertion of the cardioplegic cannula in the donor aorta was seen  under circulatory arrest the infected area was excised  a pericardial patch plasty was performed  and the region was covered with a muscle flap  postoperatively  candida albicans was found in the excised specimen of the aorta  in drainage fluid  and in the bronchoalveolar lavage  high doses of antimycotics were administered intravenously and for irrigation of the mediastinum  which resulted in an eradication of fungi in all cultures 7 days later  six weeks after reoperation the patient was discharged home  and she remains well 9 months postoperatively  
class1	left recurrent laryngeal nerve paralysis  an unusual presentation of histoplasmosis  a case of histoplasmosis seen as left recurrent laryngeal nerve paralysis in a 49 year old man is described  the patient had roentgenographic findings of a solitary  noncalcified left upper lobe mass and mediastinal adenopathy  tissue diagnosis of histoplasmosis was obtained using a thoracotomy  allowing institution of appropriate treatment  
class1	job s syndrome  a rare cause of recurrent lung abscess in childhood  a clinical syndrome characterized by recurrent staphylococcal infection of the skin and respiratory tract from birth was described in 1966 and referred to as job s syndrome  marked hyperimmunoglobulinemia e was later found to be associated with this syndrome  this article describes a case of job s syndrome as a cause of recurrent lung abscess during childhood necessitating lung resection  
class1	empiric treatment of fungal infections in the neutropenic host  review of the literature and guidelines for use  persistent fever that is refractory to broad spectrum antibacterials is common in neutropenic patients undergoing induction chemotherapy of acute leukemia  clinical experience suggests that many of these patients are infected with fungi  until recently  data supporting the role of empiric antifungal therapy in this setting were limited to small groups of patients or postmortem reports  evolving evidence in larger patient populations supports data from smaller series  febrile neutropenic patients who have failed to respond to a 4  to 7 day course of broad spectrum antibacterials may benefit from the early initiation of antifungal therapy  patients with fungal colonization or pulmonary infiltrates and adult patients who have not received previous fungal prophylaxis may especially benefit from the early use of antifungal drugs  amphotericin b has been the  gold standard  for empiric antifungal therapy  although the newer azoles may be useful in certain situations  
class1	seroprevalence of helicobacter pylori in seventh day adventists and other groups in maryland  lack of association with diet  to evaluate the possible role of diet in the transmission of helicobacter pylori  we compared h pylori seroprevalence among seventh day adventists  who are vegetarian and abstain from alcohol  caffeine  and meat  n   94  and two non seventh day adventist control groups  n   168   with the use of an enzyme linked immunosorbent assay h pylori antigen prepared in a french pressure cell  we found no difference in seroprevalence among these groups  however  seropositivity strongly correlated with age and black race  
class1	recurrent meningitis in a patient with congenital deficiency of the c9 component of complement  first case of c9 deficiency in europe  we describe the first cases  to our knowledge  of c9 deficiency in europe that were detected in a swiss family  of which two members  one with a complete deficiency and the other with approximately half normal c9 levels  experienced bacterial meningitis  the index patient  a 56 year old white man with a history of purulent meningitis at the age of 23 years  presented with an acute meningococcal meningitis  no impairment of cellular immunity or immunoglobulin deficiency could be found  complement assays showed a complete deficiency of the c9 component  while the other individual component levels were normal and the hemolytic activity  measured using the ch50 assay  was only slightly reduced  a family study revealed complete c9 deficiency in the patient s healthy brother and half normal c9 concentrations in his sister  his son  who also had experienced an episode of bacterial meningitis   and his niece  consistent with an inherited c9 deficiency  this first case of recurrent meningitis in a white patient with complete c9 deficiency suggests that this complement defect may also be a risk factor for bacterial  especially neisserial  infections  
class1	aerobic and anaerobic bacteriology of wounds and cutaneous abscesses  the aerobic and anaerobic microbiologic characteristics of 584 wounds and 676 skin or soft tissue abscesses were studied and correlated with the infection site  in wounds  aerobic or facultative bacteria only were present in 223 specimens  38    anaerobes only in 177 specimens  30    and mixed flora in 184 specimens  32    in total there were 1470 isolates  558 aerobic and 912 anaerobic  an average of 2 5 isolates per wound  1 6 anaerobic and 0 9 aerobic isolates   in abscesses  aerobic or facultative bacteria were recovered in 177 specimens  26    anaerobes only in 243 specimens  36    and mixed flora in 256 specimens  38    in total there were 1702 isolates  602 aerobic and 1100 anaerobic  an average of 2 5 isolates per abscess  the highest rates of anaerobes in wounds were in the inguinal  buttocks  and trunk areas and in abscesses in the perirectal  external genitalia  neck  and inguinal areas  the predominant aerobic organisms were staphylococcus aureus  363 isolates   group a streptococci  98 isolates   and escherichia coli  97 isolates   the predominant anaerobic organisms were bacteroides species  986 isolates   peptostreptococcus species  559 isolates   clostridium species  153 isolates   and fusobacterium species  109 isolates   the predominance of certain isolates in certain anatomical sites was correlated with their distribution in the normal flora adjacent to the infected site  these data highlight the polymicrobial nature of wounds and cutaneous abscesses  
class1	does survival depend on the amount of autotransplanted splenic tissue  susceptibility to streptococcus pneumoniae infection was studied in 11 groups of rats allocated to sham operation  splenectomy  or splenic autotransplantation of 10   20   30   40   50   60   70   80   or 90  of the removed spleen  three months later  all rats were exposed intravenously to type 1 streptococcus pneumoniae  median lethal dose  ld50  for control group   survivors were killed 13 days after the bacterial challenge  autopsy showed that more splenic tissue was recovered in rats that received less than 50  splenic tissue compared with those that received 50  or more  more survivors were found among sham operated rats  47 5   95  confidence intervals  32 to 68  and rats that had 40  splenic tissue implanted  35   confidence interval  20 to 54  or those that were found to have regenerated 40  splenic tissue  we conclude that 40  of the spleen should be autotransplanted to protect the rat optimally against infection after splenectomy  
class1	antibiotic pharmacokinetics in surgery pharmacokinetics is the study of variables that affect drug concentrations at the effector site  the descriptive terms peak concentration  elimination half life  volume of distribution  and bioavailability are commonly used to express pharmacokinetic variability among drugs used in patient care  the pharmacokinetic characteristics of drugs are important for surgeons to understand because they represent differences that may assume clinical significance when selecting antibiotics for preoperative preventive indications  in addition  the changing hemodynamic pattern of the stressed and septic patient may result in changing pharmacokinetic patterns for an antibiotic  which  in turn  may require changes in the dosing regimen during the course of treatment  
class1	nontropical pyomyositis as a cause of subacute  multifocal myalgia in the acquired immunodeficiency syndrome  we report a case of nontropical pyomyositis in a patient with acquired immunodeficiency syndrome and disseminated mycobacterium avium infection  in which severe myalgia was the presenting symptom over several weeks  multifocal muscle lesions were identified by gallium scanning and magnetic resonance imaging techniques  the epidemiology  possible pathogenesis  clinical features  diagnostic imaging  and therapy are reviewed  early suspicion of nontropical pyomyositis in severely immunocompromised patients with  cryptic  myalgia is recommended  
class1	outbreak of spontaneous staphylococcal arthritis and osteitis in mice  staphylococcus aureus is the most common bacterial species found in association with nongonococcal bacterial arthritis in humans  we present here the first description of spontaneous bacterial arthritis and osteitis in mice  clinically  the most obvious findings were swelling and or ankylosis of hindpaws and nodose changes of the tail  the prevalence of arthritis and osteitis ranged from 0  to greater than 50  of the mice studied  depending on the mouse strain  the most prominent histopathologic feature of the arthritis was hypertrophy of the synovial tissue and destruction of cartilage and underlying bone  most of the s aureus infected mice displayed an identical phage type  which was also the only s aureus phage type found in skin isolates from clinically healthy mice  however  a few s aureus isolates were not typeable  indicating that an additional strain s  might cause bacterial arthritis in mice  
class1	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  
class1	acute and chronic bacterial prostatitis  a review of treatment approaches  some authors describe acute bacterial prostatitis as a self limiting disease  and as with any other acute septic condition  parenteral broad spectrum antibiotic therapy is indicated  chronic bacterial prostatitis  however  is associated with a causative organism persisting unaltered in prostatic fluid and leading to relapsing urinary tract infections  in the 1970s  several workers produced a classification system and bacteriologic localization cultures for establishing the diagnosis of prostatitis  krieger and crawford point to an important factor that is omitted in many clinical trials with episodes of chronic bacterial prostatitis in men  if localization studies of the prostate infection are attempted in the presence of bacteriuria  the urine must be sterilized with nitrofurantoin or penicillin g  urine cultures obtained from first voided urine  bladder urine  and urine voided after prostatic massage should show no growth  and the expressed prostatic secretion can then be examined for evidence of prostatic infection  this procedure reduces the contamination of the expressed prostatic secretion by the organism from the urinary tract infection  this is important  because antibiotic treatment is determined by the sensitivity of the organism isolated from the prostate as well as by the ability of the antibiotics to penetrate the prostate  meares outlines the pharmacokinetic features needed for drug diffusion into prostatic fluid and provides detailed information on the physical characteristics of the prostate during acute and chronic bacterial prostatitis  unfortunately  the choice of an ideal drug cannot be extrapolated from this information because pharmacodynamic principles cannot predict clinical efficacy  some authors find that sulfamethoxazole trimethoprim has the best cure rate in the treatment of chronic bacterial prostatitis  
class1	sexually transmitted diseases of the colon  rectum  and anus  the challenge of the nineties  during the past two decades  an explosive growth in both the prevalence and types of sexually transmitted diseases has occurred  up to 55 percent of homosexual men with anorectal complaints have gonorrhea  80 percent of the patients with syphilis are homosexuals  chlamydia is found in 15 percent of asymptomatic homosexual men  and up to one third of homosexuals have active anorectal herpes simplex virus  in addition  a host of parasites  bacterial  viral  and protozoan are all rampant in the homosexual population  furthermore  the global epidemic of aids has produced a plethora of colorectal manifestations  acute cytomegalovirus ileocolitis is the most common indication for emergency abdominal surgery in the homosexual aids population  along with cryptosporidia and isospora  the patient may present to the colorectal surgeon with bloody diarrhea and weight loss before the diagnosis of human immunodeficiency virus  hiv  disease  other patients may present with colorectal kaposi s sarcoma or anorectal lymphoma  and consequently will be found to have seropositivity for hiv  however  in addition to these protean manifestations  one third of patients with aids consult the colorectal surgeon with either condylomata acuminata  anorectal sepsis  or proctitis before the diagnosis of hiv disease  although aggressive anorectal surgery is associated with reasonable surgical results in some asymptomatic hiv positive patients  the same procedures in aids  symptomatic hiv positive  patients will often be met with disastrous results  it is incumbent upon the surgeon  therefore  to recognize the manifestations of hiv disease and diagnose these conditions accordingly  
class1	immunogenicity in animals of a polysaccharide protein conjugate vaccine against type iii group b streptococcus  the native capsular polysaccharide of type iii group b streptococcus elicits a specific antibody response in only 60  of nonimmune human subjects  to enhance the immunogenicity of this polysaccharide  we coupled the type iii polysaccharide to tetanus toxoid  prior to coupling  aldehyde groups were introduced on the polysaccharide by controlled periodate oxidation  resulting in the conversion of 25  of the sialic acid residues of the polysaccharide to residues of the 8 carbon analogue of sialic acid  5 acetamido 3 5 dideoxy d galactosyloctulosonic acid  tetanus toxoid was conjugated to the polysaccharide by reductive amination  via the free aldehyde groups present on the partially oxidized sialic acid residues  rabbits vaccinated with the conjugate vaccine produced igg antibodies that reacted with the native type iii group b streptococcal polysaccharide  3 3 rabbits   while rabbits immunized with the unconjugated type iii polysaccharide failed to respond  0 3 rabbits   sera from animals receiving conjugate vaccine opsonized type iii group b streptococci for phagocytic killing by human peripheral blood leukocytes  and protected mice against lethal challenge with live type iii group b streptococci  the results suggest that this method of conjugation to a carrier protein may be a useful strategy to improve the immunogenicity of the type iii group b streptococcus polysaccharide in human subjects  
class1	isolation of hiv 1 from the blood of seropositive adults  patient stage of illness and sample inoculum size are major determinants of a positive culture  the walter reed retroviral research group  results of hiv 1 blood cultures from 609 seropositive adults across all stages of illness at the walter reed army medical center were reviewed  hiv 1 was isolated by coculturing of patient peripheral blood mononuclear leukocytes  pbmcs  with normal blood donor target pbmcs that had been stimulated with phytohemagglutinin and interleukin 2  the hiv 1 isolation success rate at walter reed increased progressively each year from 1986 to 1989  in 1989  hiv 1 was isolated from a single blood specimen from patients in walter reed stages 1 2  3 4  and 5 6 in 75   49 65   90   37 41   and 97   30 31  of cases  respectively  none of 22 blinded negative control specimens was positive  pbmc cultures from late stage patients regularly became positive within 7 days  92    compared to only 46  of positive cultures from early stage patients  for most patients  the lowest number of serially diluted pbmcs that resulted in a positive culture was 30 000 patient pbmcs  but the range was 300 to 3 million cells  hiv 1 was isolated less frequently from plasma  5 18  28    plasma viremia was detected only in patients with relatively high titers of infected pbmcs  forty six blood specimens from  at risk  seronegative adults were also cocultured  none was positive  
class1	ocular syphilis  the ability of syphilis to mimic different ocular disorders can lead to misdiagnosis and delay in appropriate antimicrobial therapy  the authors describe their experience over the past 5 years with the ocular manifestations of syphilis in 25 patients who comprised 2 45  of 1020 new patients  uveitis was the most common ocular manifestation seen  all patients had positive results from fta abs tests  whereas only 68  had reactive serum vdrls  two of five patients tested for human immunodeficiency virus  hiv  antibody were reactive  the authors recommend routine fta abs and vdrl screening in patients with uveitis or unexplained ocular inflammation  they also recommend testing for hiv antibody in luetics and aggressive treatment with high dose aqueous penicillin for syphilis  
class1	acute syphilitic posterior placoid chorioretinitis  six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large  placoid  yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas  all eyes had vitreitis  all of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining  five patients had mucocutaneous lesions typical of secondary syphilis  all five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions  the ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis  modification of the host response to syphilis by human immune deficiency virus  hiv  infection may be partly responsible for this peculiar fundus picture  three of the four patients tested positive for hiv  
class1	the national immunization program of the netherlands  after a brief explanation of the immunization policy in the netherlands  the national immunization program is described  with special attention given to coupling of the municipal population records with a computerized database of individual immunization records at the provincial level  the dutch program achieves coverage rates greater than 90  for all routine immunizations  participation in the program is free of charge to every child living in the country up to the age of 13 years  but there is no obligation or requirement to be immunized  financing of the program is also discussed  
class1	postneonatal infectious disease mortality  the french situation  mortality caused by infectious and parasitic diseases represents a limited part of all postneonatal deaths in france  which have been stable for the past decade  this component is worthy of careful analysis because it is at least partially preventable  statistics are presented and interpreted  with discussion on which disorders should be included in assessing the impact of infection on morbidity and mortality  figures and international rankings change according to the inclusiveness of the definition chosen  there is need for epidemiologic and statistical research to make comparisons of mortality more clear  morbidity is also important because of high incidence  frequent hospitalization  and a heavy social cost  policy and services in france that relate to control and treatment of infection are described  as are shortcomings that call for further efforts  
class1	postneonatal mortality in norway  a study of recent trends and comparison with other mortality rates in norwegian children  postneonatal mortality in norway decreased rapidly from 1956 to 1980 but subsequently remained stable  in recent years the postneonatal death rate appears to be increasing  primarily due to greater numbers of deaths attributed to the sudden infant death syndrome  during the same period  mortality among older children has also decreased  with the decline evident in all leading causes  only among people aged 15 to 19 years have recent trends been less than encouraging  with the number of fatal traffic accidents in particular remaining stable or increasing  although there is room for continued improvement  the widely held belief that the health status of norwegian children is good is supported by the trends in mortality  
class1	treating systemic fungal infections in aids patients  prolonging life against the odds  fungal infections have become one of the major causes of death among immunocompromised patients  particularly patients with aids  accurate and quick diagnosis is difficult  therefore  empirical therapy is often necessary  this scenario is complicated by the fact that most antifungal agents are toxic at the doses used or relatively ineffective against deep seated mycoses  because the population of aids patients is increasing  physicians will be faced more often with the management of systemic fungal infections  despite the current bleak prognosis for these patients  several new antigen detection tests are being developed and triazole agents are proving to be effective and less toxic than their predecessors  many cases of systemic mycoses do result in mortality  but appropriate treatment can both prolong life and improve its quality  
class1	a randomized prospective study of topical antimicrobial agents on skin grafts after thermal injury  we prospectively studied 52 consecutive patients who were treated by early tangential excision and grafting following thermal injury  the usefulness of two topical antimicrobial agents  0 5  silver nitrate  ag  and neomycin  1 gm liter  plus bacitracin  50 000 units liter   nb   was compared with the effectiveness of ringer s lactate  rl  for prevention of autogenous skin graft loss due to infection  graft loss of 10 percent or more occurred in 17 patients  33 percent   due to infection in 16  skin graft loss was a minor problem in patients with less than 20 percent total body surface area  tbsa  burn  ag  0 of 6  nb  1 of 6  rl  1 of 5   the use of either antimicrobial  ag or nb  resulted in less graft loss  1 of 14  than rl  4 of 6  p less than 0 05  in the 20 to 40 percent tbsa burn group  large burns  greater than 40 percent  had a very high incidence of at least 10 percent graft loss  67 percent  regardless of treatment  infection in the area of graft loss was caused by antibiotic resistant organisms or yeast in 50 percent of the ringer s lactate group and the entire neomycin plus bacitracin group  no graft infections were caused by resistant organisms or yeast in the silver nitrate group  this study demonstrates that topical antimicrobial agents reduce infection related skin graft loss in patients with medium sized  20 to 40 percent tbsa  burns and that neomycin plus bacitracin is associated with rapid emergence of drug resistant organisms whereas silver nitrate is not  
class1	how and why aztreonam works  aztreonam is the first monocyclic beta lactam antibiotic  monobactam  to be tested clinically  its synthetic structure determines specific areas of activity  including enhanced activity against pseudomonas species  exceptional activity against gram negative bacteria  stability to beta lactamases and lack of activity against gram positive bacteria  all of which can be directly related to its chemical composition  aztreonam has a high affinity for the protein binding protein 3  pbp 3  of aerobic gram negative bacteria  most of these organisms are inhibited and killed at low concentrations of the drug  aztreonam binds poorly to pbp sites of the aerobic gram positive and anaerobic bacteria and consequently has relatively poor inhibitory effects against these bacteria  in vitro  minimum inhibition concentration  mic  values against almost all of the enterobacteriaceae and against neisseria and haemophilus strains are typically below 1 microgram per milliliter  mic values against pseudomonas aeruginosa of 8 micrograms per milliliter are comparable with those of other antipseudomonal beta lactams and the acylureidopenicillins  as combination therapy with amino glycosides  aztreonam acts in synergy against p  aeruginosa  acinetobacter and gentamicin resistant gram negative rods  aztreonam is widely distributed in the body tissues and fluids  and the average elimination half life is 1 7 hours  intramuscular dosing results in peak serum levels in approximately one hour  while intravenous dosing results in peak levels within five minutes  after a 2 gram dose given intravenously  mic90 values for most of the enterobacteriaceae are exceeded for eight hours  and those for p  aeruginosa  for almost six hours  the steady state volume of distribution is approximately 0 18 liter per kilogram  concentrations above the mic90 for most gram negative bacteria are also present within bone  prostate and cerebrospinal fluid  between 60 and 70 per cent of the drug is excreted unchanged in the urine  resulting in concentrations approximating 3 000 micrograms per milliliter two hours after a 1 gram dose given intravenously  serum clearance of aztreonam is directly proportional to creatinine clearance  dosage adjustment must  therefore  be made in the presence of reduced clearance  dosing varies between 0 5 and 2 0 grams every six to 12 hours  depending on the severity of the infection  the characteristics of aztreonam suggest that it is a useful nonnephrotoxic drug for treatment of aerobic gram negative infection  
class1	antifungal therapy and its use in surgical treatment  modern surgery continues to make significant therapeutic advances  and a major component in the adjunctive care allowing these improved procedures is the successful use of broad spectrum antibacterials  however  the widespread administration of potent antibacterials and the frequent use of a variety of catheters  along with an increase in the number of immune compromised patients requiring invasive procedures  have allowed deep seated mycoses to become more common  nosocomial fungal infections are frequent  particularly in the urinary tract and in the blood  this rise in identified fungal infections  along with frequent empiric treatment of suspected infection  has significantly increased amphotericin b therapy in surgical services in the last five years  while amphotericin b remains the standard for treatment of nosocomial mycoses  other antifungal agents are available  flucytosine  miconazole  ketoconazole and fluconazole   despite experience with the older agents and the development of new agents  many questions remain concerning the use of currently available antifungal treatments in postsurgical patients  the following discussion attempts to summarize the magnitude of the problem  the difficulties with diagnosis and laboratory evaluations  the characteristics of the antifungal agents and particular problems with antifungal treatment in surgery  
class1	vancomycin pharmacokinetics in hydrocephalic shunt prophylaxis and relationship to ventricular volume  vancomycin pharmacokinetics were determined in 25 patients receiving ventriculoperitoneal shunts for hydrocephalus  computed tomography scan derived ventricular brain ratio as an expression of hydrocephalus varied between 9 3  and 15 4   12 9      1 7    one hour prior to surgery each patient received 1 g of vancomycin infused intravenously over 60 minutes  samples of cerebrospinal fluid and venous blood were obtained 1 hour later and vancomycin levels assayed by fluorescence polarization immunoassay  there were 11 females and 14 males  with a mean age of 44 5     10 3 years and a mean weight of 72 0     11 4 kg  all had normal renal function  levels of vancomycin in the cerebrospinal fluid at 1 hour ranged from 0 1 to 1 5 micrograms ml  0 9     0 3   weight did not affect these values  p greater than 0 1   simultaneous blood vancomycin levels varied between 9 1 and 38 7 micrograms ml  22 3     8 3   ventricular volume  expressed as the ventricular brain ratio  did not correlate with cerebrospinal fluid vancomycin levels  p greater than 0 5   there was no significant increase in concentrations of vancomycin in csf as cerebrospinal fluid protein concentration increased  nor when blood vancomycin concentration was greater than 20 mg dl  therapeutic range   p greater than 0 1   no patient had evidence of infection at 6 months follow up  these results indicate minimal cerebrospinal fluid penetrance of vancomycin when administered systemically 1 hour prior to shunt surgery  in addition concentrations of vancomycin in cerebrospinal fluid bear no relationship to weight  ventricular volume  meningeal inflammation  or blood levels in the therapeutic range  the minimum inhibitory concentration of vancomycin for staphylococci is 1 5 to 3 1  and as bactericidal levels of 5 to 8 minimum inhibitory concentration are needed to kill organisms  a combination of both systemic and intraventricular vancomycin may be needed to ensure adequate cerebrospinal fluid and tissue concentration of antibiotic during shunt prophylaxis  
class1	brain stem tuberculoma in adult patients  diagnosis and treatment  a consecutive series of six adult patients ranging in age from 29 to 53 years is presented  the clinical and radiological features in each patient are described  attention is drawn to the features demonstrated on computed axial tomography  in only one patient  the first encountered  was surgical excision undertaken and histological verification obtained  one patient died before any form of treatment could be instituted  the remaining four patients were treated with antituberculous chemotherapy alone and their progress monitored by sequential computed tomography  the excellent response and good outcome in this conservatively treated group are documented  
class1	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  
class1	botulism among alaska natives  the role of changing food preparation and consumption practices  alaska natives have one of the highest rates of food borne botulism worldwide  all outbreaks have been associated with the consumption of native foods  but in recent years outbreaks have occurred in previously unaffected areas and have involved new food items  five botulism outbreaks occurred between 1975 and 1985 in an area of southwestern alaska without previous confirmed outbreaks and among one ethnic group  the yupik eskimo  of the 5 outbreaks  3 were associated with fermented beaver tail  a nontraditional native food recently introduced into the region  preparation techniques vary widely within villages and among ethnic groups  traditional fermentation techniques have changed over the past 50 years  current preparation methods used by some families and ethnic groups may be more favorable for clostridium botulinum growth  prevention efforts should be targeted at high risk subgroups of alaska natives who appear to have modified traditional practices and increased their risk of food borne botulism  
class1	high dose phenylephrine infusion in the hemodynamic support of septic shock  a 75 year old man with hyperdynamic septic shock and vasodilation was successfully supported hemodynamically for 88 5 hours through the use of a continuous infusion of phenylephrine at dosages up to 360 micrograms min  the only other vasoactive compound administered was dopamine at a dosage of 3 4 micrograms kg min  hemodynamic evaluation indicated improvements in mean arterial pressure  cardiac output  and oxygen transport parameters during the period of hemodynamic support  which did not indicate a detrimental effect on perfusion of vital organs and tissues despite the use of this vasoconstrictor  phenylephrine s pharmacologic properties may represent an advantage for its use as a vasoconstrictor over catecholamines such as norepinephrine and dopamine  particularly in patients who develop tachyarrhythmias with these agents  the pharmacology  dosage  and appropriate monitoring of therapy with phenylephrine in patients with septic shock are discussed  
class1	controversies in the treatment of streptococcal pharyngitis an increasing number of cases of sore throat caused by group a beta hemolytic streptococci occur with concomitant colonization by organisms that may  protect  the streptococci through beta lactamase inactivation of penicillin at the site of infection  the failure of penicillin to eradicate many of these bacteria  which include staphylococcus aureus  haemophilus influenzae  moraxella  branhamella  catarrhalis and a multitude of pharyngeal anaerobes  may help to explain why penicillin is sometimes ineffective for acute and recurrent group a streptococcal infections  therapeutic alternatives currently include cephalosporins  erythromycin  rifampin combined with penicillin  amoxicillin clavulanate potassium and others  
class1	concomitant neurocysticercosis and brucellosis  a young mexican woman had headache and left arm weakness develop shortly after immigrating to the united states  a solitary cerebral cysticercus was found at surgery  but  instead of the expected finding of clear fluid  the cyst contained pus from which brucella melitensis was cultured  although the patient had no signs or symptoms suggestive of brucellosis  agglutination studies revealed igm and igg antibodies consistent with active brucellosis  clinicians should be alert to the possibility of multiple infections in immigrants from countries where parasites and bacteria that are uncommon in the united states are endemic  
class1	impetigo  current etiology and comparison of penicillin  erythromycin  and cephalexin therapies  we attempted to determine the causative bacterial pathogens of impetigo in children in our area  to compare the effectiveness of three frequently used oral antimicrobial treatment regimens  and to correlate the antimicrobial sensitivity of the bacterial isolates with clinical responses to treatment  seventy three children with impetigo were randomly assigned to receive penicillin v potassium or cephalexin monohydrate  both administered in dosages of 40 to 50 mg kg per day  or erythromycin estolate administered in a dosage of 30 to 40 mg kg per day  all drugs were given in three divided doses for 10 days  treatment failure was defined as persistence of lesions 8 to 10 days after initiation of drug therapy as determined by examiners blinded to the treatment therapies  forty five  62   cultures showed staphylococcus aureus only  14  19   showed s aureus and group a beta hemolytic streptococci  six  8   showed group a beta hemolytic streptococci only  and eight  11   showed no growth or other organisms  treatment failure occurred in six  24   of 25 patients treated with penicillin v  one  4   of 25 patients treated with erythromycin estolate  and no patients treated with cephalexin  we conclude that s aureus is the most common cause of impetigo in children in our study population  that cephalexin is the most effective treatment  that erythromycin estolate is nearly equally effective and may be preferred on a cost effectiveness basis  and that penicillin v is inadequate for treatment of this infection  
class1	lung function in children following empyema  spirometry was performed and response to exercise was measured in 15 children following recovery from empyema to evaluate the impact of pleural infection on subsequent lung function  seven children underwent chest tube drainage  eight did not  the two groups were similar in age  mean     sd  6     5 years   sex distribution  bacterial pathogen producing empyema  and age at follow up evaluation  12     5 years   only one child reported recurrent respiratory symptoms  no child had restrictive spirometric changes  total lung capacity  less than 80   vital capacity  less than 80  predicted  but seven of 15 had a reduced forced expiratory volume in 1 second  less than 80  predicted  or forced expiratory flow during the middle half of the vital capacity  less than 75  predicted   suggesting mild airway obstruction  no child demonstrated reduced exercise tolerance due to restrictive ventilatory limitations  mild obstructive abnormalities in lung function were identified with equal frequency in children treated with and without chest tube drainage  
class1	ocular atopy and mycotic keratitis  in a retrospective analysis  we studied the association between ocular atopy and keratomycosis  forty one  26 3   of 156 patients with fungal corneal ulcers were found to have preexisting allergic conjunctivitis  all patients had been using a combination of antibiotics and corticosteroids before developing the corneal ulcer  fungus isolation on sabouraud s agar medium was obtained in 74 8   31 42  ulcers  the most common fungi isolated were fusarium  32 3   and aspergillus  29    one percent silver sulfadiazine was used as an antifungal agent in these patients  overall efficacy of this drug was found to be 77 8   with fusarium being the most sensitive  87 5    
class1	endophthalmitis due to sporothrix schenckii after penetrating ocular injury  a 13 year old boy developed endophthalmitis from traumatic inoculation of vegetable material penetrating his right eye  sporothrix schenckii was morphologically identified from the intraocular fluids  however  repeated attempts to culture the organism proved negative  seventeen sporotrical endophthalmitis cases have so far been reported  and before this report  only one of them was secondary to trauma  this is the sole eye to our knowledge not only to have escaped enucleation after sporotrical endophthalmitis but to have achieved useful  20 50  vision  
class1	clindamycin vs penicillin for anaerobic lung infections  high rate of penicillin failures associated with penicillin resistant bacteroides melaninogenicus  thirty seven adult patients with anaerobic lung infections  27 lung abscesses and 10 necrotizing pneumonias  were submitted to transthoracic needle aspiration and or bronchoscopic specimen brush cultures before therapy and thereafter in all cases considered to be failures  patients were randomly assigned to receive either clindamycin  600 mg intravenously every 6 hours  or penicillin g  2 million u every 4 hours for no less than 8 days  until clinical and radiological improvement became apparent  treatment was continued orally with clindamycin  300 mg every 6 hours  or penicillin v  750 mg every 6 hours  until completing a minimum of 4 weeks  ten of the 47 anaerobes initially isolated from the lung  nine bacteroides melaninogenicus and one bacteroides capillosus  were resistant to penicillin  but none were resistant to clindamycin  five of the nine patients harboring these penicillin resistant bacteroides received penicillin  and all failed to respond to therapy  overall  eight of the 18 patients in the penicillin group and one of 19 in the clindamycin group failed to respond to therapy  these drugs were equally well tolerated in both groups  the presence of penicillin resistant bacteroides is a frequent cause of penicillin failure in patients with anaerobic lung infections  in this setting  clindamycin appears to be the current therapy of choice for initial treatment  
class1	spectrum of invasive haemophilus influenzae type b disease in adults  a prospective nationwide surveillance of invasive haemophilus influenzae type b disease among adults  greater than or equal to 16 years old  was conducted in finland during 1985 through 1988  thirty one cases were identified  annual incidence  0 22 100 000   of these infections  71  occurred in patients with severe underlying conditions  the overall case fatality rate was 26   septicemia  13 patients  and pneumonia  seven patients  were the most common clinical manifestations of h influenzae type b infection  the others were epiglottitis  six patients   meningitis  three patients   and arthritis  two patients   epiglottitis occurred in significantly younger patients  all of whom were women and four of whom were previously healthy  subtyping of the h influenzae type b isolates according to the major outer membrane protein subtype  biotype  and lipopolysaccharide serotype showed that patterns that were uncommon  14   among children were more common  27   in the adults  
class1	group b streptococcus endocarditis following second trimester abortion  an 18 year old woman who underwent an elective second trimester abortion developed streptococcus agalactiae  group b streptococcus  endocarditis characterized by a large  pedunculated vegetation involving a previously normal tricuspid valve  polyarthritic symptoms  as well as multiple pulmonary emboli  were experienced  and cure followed a course of treatment using intravenous penicillin g potassium combined with gentamicin sulfate  endocarditis caused by this pathogen usually occurs among individuals compromised by underlying chronic disorders and  today  is a rare sequela of pregnancy and abortion  when planning therapy  consideration should be given to the possibility of tolerance among clinical isolates and the need for operative intervention in selected patients  
class1	toxic shock syndrome associated with use of latex nasal packing  we treated a previously healthy young man who developed toxic shock syndrome 2 days after elective septoplasty with nonabsorbent latex packing  this case emphasizes that non menstrual wound associated toxic shock syndrome can occur after surgery that does not involve absorbent splinting or packing and should be considered in patients who present within a few days after surgery with fever  sunburnlike rash  hypotension  and multisystem complaints and laboratory abnormalities  
class1	streptococcal endocarditis temporally related to transesophageal echocardiography  a case of streptococcal sanguis endocarditis temporally related to a transesophageal echocardiogram is reported  and the literature on the incidence of bacteremia occurring during transesophageal echocardiography is reviewed  on the basis of this case and review of the literature  a reevaluation of the current guidelines for endocarditis prophylaxis during this procedure is recommended  
class1	eustachian valve endocarditis  m mode and cross sectional echocardiography showed a highly mobile globular pedunculated mass 3 0 cm long with a maximum diameter of i 5 cm  attached to the eustachian valve in a heroin addict with staphylococcal endocarditis  
class1	a study of immunoglobulin g in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the log igg index  a comparison and diagnostic applications  cerebrospinal fluid and serum immunoglobulin g from 1007 patients with suspected neurological disease were analysed by 2 methods  isoelectric focusing for the detection of oligoclonal banding  and quantitative measurement of igg and albumin for the formulation of a log igg index  a comparison of the 2 methods in the detection of local synthesis of igg showed that isoelectric focusing not only gave a much higher yield overall  with 282 patients showing local synthesis versus 225 for the log igg index  but also a higher specificity  with a false positive rate of 0  versus 3 5   in addition  of the 282 patients positive by isoelectric focusing only 163  58   were positive by the log igg index  of the 1007 patients studied  206 had multiple sclerosis  ms   and isoelectric focusing showed local synthesis in 95  of clinically definite cases  with a 90  detection rate overall  the log igg index was positive in only 67  of clinically definite cases  with an overall 59  detection rate  thus with the exceptions noted above  local synthesis of igg as defined by isoelectric focusing is confined to demyelinating  inflammatory  infectious and postinfectious disorders  our results compare very favourably with the published sensitivities of magnetic resonance imaging in the detection of abnormalities in multiple sclerosis  and better than those for evoked potentials  where both these investigations are readily available isoelectric focusing provides a useful adjunct  for the majority of physicians and neurologists who do not have ready access to magnetic resonance imaging  isoelectric focusing is an excellent alternative  we would also recommend that it become the standard for the measurement of igg abnormalities in the cerebrospinal fluid and that the use of quantitative data be abandoned for routine purposes  
class1	newer concepts in antimicrobial therapy  advances in the treatment of infection have continued to increase both the length and quality of life  unfortunately  many bacteria can readily adapt to their environment and develop a tolerance to the antimicrobial agents in widespread use  during the recent past  the consumption of cephalosporins has increased so dramatically as to parallel the initial acceptance of penicillin  organisms that are resistant to the cephalosporins will no doubt continue to thrive  especially within the susceptible host  it is essential for the clinician to become familiar with the newest antimicrobial agents to more effectively treat modern infections  
class1	simplified two stage below knee amputation for unsalvageable diabetic foot infections  a simplified two stage below knee amputation for unsalvageable diabetic foot infections was done on 19 limbs with 84  good results for healing  the first stage was the standard below knee amputation with a long posterior flap in which the fascia and skin were closed in the central portion with the medial and lateral portions of the wound left open for drainage  the second stage was delayed until closure of the open wounds three to seven days after the first stage  wagner s classification of diabetic foot lesions was used to stratify these cases  grades 3 and 4 foot infections had a uniformly good prognosis for healing with this surgical technique  grade 5 foot infections had a poor prognosis for healing  especially if associated with renal failure and dialysis  even with an initial guillotine amputation  
class1	initial evaluation of human monoclonal anti lipid a antibody  ha 1a  in patients with sepsis syndrome  ha 1a  a human monoclonal immunoglobulin m antibody that binds specifically to the lipid a domain of endotoxin  was administered to septic patients to evaluate the safety  pharmacokinetics  and immunogenicity of the antibody  thirty four patients received a single infusion of either 25 mg  100 mg  or 250 mg  and were followed clinically for 14 to 21 days after treatment  ha 1a serum levels were measured before infusion and frequently after infusion with a radiometric assay  a one compartment pharmacokinetic model was fit to the measured serum levels  and accurately described the changes in ha 1a level over time in each dose group  r2    99   the mean     sem apparent volume of distribution of ha 1a was 48 5     4 5 ml kg  and the mean serum clearance was 2 8     0 4 ml kg h  the mean serum half life of ha 1a was 15 9     1 5 h  the mean serum level one hour after a 100 mg dose was 33 2     2 4 micrograms ml  and the mean concentration 24 h later was 9 1     1 6 micrograms ml  the dose administered and presence of gram negative bacterial infection did not significantly influence the volume of distribution or serum clearance  no adverse reactions to ha 1a were observed  and no antibodies against ha 1a were detected in any patient  these data indicate that the pharmacokinetics of ha 1a are well described by a one compartment pharmacokinetic model  and that ha 1a is safe and nonimmunogenic in patients with sepsis  
class1	dependence of oxygen consumption on oxygen delivery in children with hyperdynamic septic shock and low oxygen extraction  we studied the effect of increasing systemic oxygen delivery  do2  by packed rbc  prbc  transfusion on oxygen consumption  vo2  in children with hyperdynamic septic shock  after routine resuscitation with volume loading and pharmacologic support  patients were studied if they had significant derangements of oxygen transport variables defined as  baseline vo2 less than 180 ml min m2 and oxygen extraction  o2 extr  less than 24   eight studies were performed  prbc transfusion increased do2 from 636     167 to 828     266 ml min m2  p less than  01  without increasing cardiac index  5 2     1 3 vs  5 0     1 4 l min m2   vo2 increased from 112     36 to 157     60 ml min m2  p less than  01  while o2 extr was unchanged  18     3  vs  19     6    despite initial low o2 extr  vo2 can be increased in pediatric septic shock by a further increase in do2  since vo2 correlates with survival  one should consider enhancing do2 further despite initial low o2 extr and high do2  effects on morbidity and mortality require further study  
class1	accuracy in early prediction of prognosis of patients with septic shock by analysis of simple indices  prospective study  in 26 consecutive septic shock patients  we analyzed the clinical  hemodynamic  and metabolic data before and during volume infusion to test their circulatory reserve in response to fluid repletion  these patients were investigated to identify early variables that could predict outcome  there were 15 survivors  group a  and 11 nonsurvivors  group b   as a mean  group a patients were hemodynamically evaluated 2 3 h after onset of the sepsis syndrome  whereas group b patients underwent cardiac catheterization after a 12 h interval  at the initial evaluation  both groups demonstrated similarly decreased mean arterial pressure  mean heart rate  and mean cardiac filling pressure  only group a patients evidenced elevated cardiac index  ci   greater than 4 l min m2  associated with low systemic vascular resistance index  less than 7400 dyne sec cm5 m2   which is generally recognized as hyperdynamic cardiac state  however  none of the initial cardiovascular variables could serve as a predictor for survival  fluid challenge increased left ventricular preload from 6 to 12 4 and from 7 8 to 12 7 mm hg in group a and group b  respectively  the increases were associated with significant increases in ci from 4 4 to 6 9 and from 3 to 3 8 l min m2  however  at the end of fluid challenge  only group a patients exhibited normal cardiac response  as evidenced by the change in left ventricular stroke work index  lvswi  for a given increase in the pulmonary capillary wedge pressure  wp  that was referred to as left cardiac preload  
class1	femoral artery cannulation for monitoring in critically ill children  prospective study  seventy seven attempted percutaneous femoral artery cannulations were prospectively evaluated in 74 children  artery cannulation was successfully accomplished in 73  95   cases and lasted for a mean of 6 days  sixty percent of the catheters were inserted on the first attempt  fifty two  71   patients weighed less than 10 kg and 55  75   patients were less than 12 months old  fifty one  70   patients received inotropic support at the time of cannulation  and 27  37   eventually died from causes unrelated to catheter insertion  there was one episode each of line associated infection and transient distal ischemia not resulting in tissue loss  and two episodes of catheter malfunction  in eight  11   patients  signs of distal vascular insufficiency developed shortly catheter placement and resolved after catheter removal  the development of this complication correlated significantly  p less than  05  with younger age  5 5 vs  22 3 months   we conclude that femoral artery cannulation has a high degree of success in very small  critically ill children  it should be considered an acceptable alternative to small vessel cannulation when the latter is not technically achievable  or in the unstable patient where rapid establishment of reliable arterial access is necessary  
class1	incidence of colonization  nosocomial pneumonia  and mortality in critically ill patients using a trach care closed suction system versus an open suction system  prospective  randomized study  eighty four intubated  mechanically ventilated patients were prospectively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received endotracheal suctioning by an  open  suction method vs   closed  suction  trach care closed suction system  method  results show that closed suctioning is associated with a significant  67  vs  39  p less than  02  increase in colonization compared with open suctioning  however  difference in the incidence of nosocomial pneumonia was not significantly  26  vs  29   different between closed and open suctioning  differences in severity of illness  acute physiology and chronic health evaluation ii and therapeutic intervention scoring system   age  sex  presence of ng tubes  use of h2 antagonists or antacids  use of antibiotics  and history of smoking were all nonsignificant  survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed suctioning patients vs  open suctioned patients  p less than  03   this study shows that suctioning performed via the trach care closed suction system increases the incidence of colonization but not the incidence of nosocomial pneumonia  and may actually decrease mortality when compared with open suction systems  
class1	risks of human immunodeficiency virus infection to patients and healthcare personnel  the risk of nosocomial human immunodeficiency virus  hiv  infection among hospitalized patients comes almost exclusively from transfusion of fresh blood products  current estimates of the risk of hiv infection from the transfusion of blood or components vary from 1 40 000 to 1 250 000  0 0025  to 0 0004    with the most probable likelihood estimated to be 1 153 000  0 0007    the major route of transmitting such hiv infection is via blood collected during the interval between infection of the donor and development of a detectable circulating antibody level to the aids virus  i e   the  window period    the current risk to hemophiliacs receiving treated coagulation factor concentrates is negligible  the risk to healthcare personnel of acquiring hiv infection from accidental puncture wounds and from handling hiv infected blood or body fluids is 0 42  per episode  most reported seroconversions have resulted from penetrating injuries with sharp objects contaminated with hiv positive blood  the degree of risk to healthcare workers will vary with the community  the patient population served  and the frequency of penetrating injuries  
class1	cardiac involvement in aids  cardiac involvement in aids may occur at any stage of hiv disease and may manifest as congestive cardiomyopathy  potentially lethal arrhythmia  or pericardial effusion and tamponade  the heart may be affected by nearly all of the opportunistic infections and many of the malignancies associated with the syndrome  although often clinically unobtrusive  cardiac lesions may be important in the pathogenesis of significant clinical symptoms and play an often unrecognized role in the prognosis and natural history of aids  
class1	prostacyclin but not phentolamine increases oxygen consumption and skin microvascular blood flow in patients with sepsis and respiratory failure  inadequate tissue oxygenation may occur in critically ill patients with sepsis despite an apparently adequate o2 transport  qo2   and this may contribute to the development of an o2 debt and also to multiple organ failure  it has been shown that increasing qo2 by infusing a vasodilator may reveal this o2 debt in septic patients  to investigate whether the site of action of vasodilators may be of importance in unmasking such an o2 debt  we administered prostacyclin  a prostaglandin with a preferential effect on the microcirculation  and phentolamine  an arteriolar vasodilator  in 11 patients studied during the first 48 hours after the onset of sepsis  and compared their effect on whole body oxygen consumption  vo2  and skin microvascular blood flow  the results demonstrated that increasing qo2 by prostacyclin but not by phentolamine significantly increases vo2 in critically ill patients with sepsis  the site of action of vasodilators may therefore play an important role in their ability to unmask an o2 debt  
class1	pseudomonas aeruginosa compared with escherichia coli produces less endotoxemia but more cardiovascular dysfunction and mortality in a canine model of septic shock  we investigated the effects of two different gram negative bacteria and radiation induced leukopenia on endotoxemia  cardiovascular abnormalities  and mortality in a canine model of septic shock  serial hemodynamics were measured in conscious dogs using radionuclide heart scans and thermodilution cardiac output catheters  plasma endotoxin concentrations were determined with a chromogenic limulus amebocyte lysate assay  viable pseudomonas aeruginosa or escherichia coli implanted intraperitoneally produced concordant hemodynamic patterns of septic shock  p less than 0 01   endotoxin concentrations were more than tenfold lower in dogs infected with p aeruginosa compared with e coli  p less than 0 0001   despite lower endotoxin levels  p aeruginosa infected dogs had a higher mortality  p less than 0 01   more severe hypotension  p less than 0 05   and greater depression of the left ventricular ejection fraction  p less than 0 05  than dogs with e coli sepsis  a nonlethal e coli challenge combined with leukopenia  induced by a nonlethal dose of radiation  resulted in a mortality of 60 percent  p less than 0 01  without greater cardiovascular dysfunction or higher endotoxin concentrations  these findings suggest that bacterial products other than endotoxin and host related factors may be important contributors to the toxicity  cardiovascular instability  and mortality of gram negative septic shock  quantitative determinations of plasma endotoxin are unlikely to correlate with the clinical severity of septicemia in heterogeneous patient populations infected with different gram negative organisms  
class1	septic pulmonary embolism complicating a central venous catheter  bacteremia is a recognized complication in patients with indwelling central venous catheters  more recently pulmonary embolism in such patients has also been described  despite abundant clinical experience with these devices  to our knowledge  septic pulmonary embolism has not been reported in adult patients  this case illustrates such a complication  
class1	adult respiratory distress syndrome due to blastomycosis during pregnancy  a 23 year old healthy woman in her third trimester of pregnancy developed adult respiratory distress syndrome secondary to blastomyces dermatitides  pregnancy related immunosuppression was believed to be responsible for the fungal infection  following emergency delivery of the infant and a full course of amphotericin b therapy  the patient made an uneventful recovery  although the fetal and maternal sides of the placenta demonstrated fungal spores  the child remained healthy  to our knowledge  this is the first report of blastomycosis associated adult respiratory distress syndrome occurring during pregnancy  
class1	management of brucella endocarditis with aortic root abscess  three cases of brucella endocarditis with aortic root abscess are reported  two patients were successfully managed by a combination of medical therapy and surgery  the third patient died suddenly 36 hours after admission to hospital  
class1	reduction of contamination at total hip replacement by special working clothes  we assessed wound  air and operative field contamination at 50 total hip operations  performed in a zonal ventilation system  theatre staff wore either a specially designed polypropylene non woven coverall or conventional cotton shirt and trousers  the surgeons wore partially impermeable operating gowns  the polypropylene coverall was associated with significantly lower air and wound counts  the coverall was warmer than cotton but judged to be acceptable  the combined use of zonal ventilation and the coverall achieved ultra clean air conditions  
class1	why use drains  there is no firm published evidence to support the use of closed suction drains  over 20 years ago  large studies by the public health laboratory service and the national research council found that drains were risk factors for wound infection  a prospective randomised study of the use of closed suction drains after surgery for fractured neck of femur in 70 patients failed to show that drains improved wound healing  drained cases had more complications  
class1	the efficacy of pediatric blood culture sets in the determination of burn bacteremia  a blood culture is an essential laboratory procedure necessary to confirm a septic episode  however  it is important to collect the blood sample at the appropriate time with an acceptable technique  the standard method is to collect at least 5 to 10 ml blood per culture bottle from patients with fevers  however  this volume of blood is an unrealistic amount to take from the frequently febrile pediatric patient  alternatively  the pediatric blood culture bottle allows the collection of 1 ml blood per bottle to perform the same evaluation  we evaluated the two techniques of blood culture collection over a 9 month period and compared the results between adult and pediatric blood culture bottles  seventy six patients  from november 1988 through february 1989  had blood cultures performed with the adult culture bottles  which produced a total of 1314 samples  a total of 113 patients  from march through july 1989  had blood cultures performed with the pediatric culture bottles  which produced a total of 758 samples  percent recovery for the adult bottles versus the pediatric bottles was 13 95  versus 22 8   p less than 0 0001   since the amount of blood necessary to isolate an infectious agent is critical not only for laboratory identification but also for the volume of blood of pediatric patients  these data clearly establish the efficacy of pediatric blood culture bottles and the utilization of smaller amounts of blood  not only did this approach significantly enhance organism recovery rate  but it may well be more cost effective because fewer cultures need to be performed to isolate the infectious organism  
class1	lack of association between medication use and the presence or absence of bacteriuria in elderly women  this study was undertaken to determine if there is an association between medication use and the presence or absence of bacteriuria in elderly ambulatory women  of 198 women who participated in three urine culture surveys  every 6 months  during the 18 month study period  66  34 4   had bacteriuria on at least one survey  both univariate and multivariate analyses for the demographics  age  place of residence  and medication use  by drug class  revealed that only place of residence had a significant association with the presence or absence of bacteriuria  in this regard  bacteriuric subjects more commonly resided in the nursing home and less commonly lived in the apartment house complex compared with nonbacteriuric subjects  p less than  05   therefore  this study demonstrates that in elderly ambulatory women  medication use does not appear to be associated with the presence or absence of bacteriuria  
class1	absence of significant bacteremia during urinary catheter manipulation in patients with chronic indwelling catheters  the objective of this study was to quantify the microorganisms present in blood at urinary catheter removal and at reinsertion in patients with chronic indwelling urinary catheters  this was a prospective study during a 4 month period at a university affiliated geriatric medical center  our subjects were 33 patients with chronic indwelling urinary catheters and positive urinary cultures  the urinary catheter was usually changed once a month  a peripheral vein line was used for blood withdrawal and urinary cultures and quantitative blood cultures  isolator  were performed during and shortly after urinary catheter removal and insertion  all patients had significant bacteriuria  greater than 10 5  cfu ml  with an average of 2 3 microorganisms  among the 46 sequential quantitative blood cultures performed  only two patients had bacteremia from the urinary source and at a very low concentration  one patient had 0 13 cfu ml str  faecalis in blood 5 minutes after removal of the urinary catheter  and the other 0 1 cfu ml proteus mirabilis 5 minutes after reinsertion of a new urinary catheter  none of the patients had any subjective or objective clinical problem during the 36 hours after the urinary manipulation  clinical symptoms and bacteremia are rare events  and prophylactic antibiotics do not appear necessary during urinary catheter removal and reinsertion in elderly institutionalized patients  further studies are necessary to identify risk factors in the rare instances of patients with bacteremia  
class1	clinically inapparent  asymptomatic  bacteriuria in ambulatory elderly men  epidemiological  clinical  and microbiological findings  in a prospective longitudinal study  ambulatory elderly men were followed from 1 to 4 5 years to gain insight into the prevalence rates  clinical characteristics  and patterns of clinically inapparent  asymptomatic  bacteriuria  cib   the prevalence of cib was 12   29 238  and increases with age  unlike the gram negative organisms that cause overt urinary tract infection in this age group  gram positive organisms dominated the cib group  both the cib and abacteriuric patients have multiple chronic medical conditions and are indistinguishable on that basis  twenty nine elderly men with bacteriuria and 105 abacteriuric subjects were followed with serial urine cultures  during the study period the bacteriuric subjects exhibited spontaneous temporary or permanent resolution  76   22 29   intermittency  21   6 29   and probable bacterial persistence  38   11 29   no consistent pattern of bacteriuria was evident  therefore  antimicrobial therapy is not warranted in the treatment of asymptomatic or clinically inapparent bacteriuria in ambulatory elderly men  
class1	mycobacterium leprae specific t cells from a tuberculoid leprosy patient suppress hla dr3 restricted t cell responses to an immunodominant epitope on 65 kda hsp of mycobacteria  the polar tuberculoid type  tt  of leprosy  characterized by high t cell reactivity to mycobacterium leprae  is associated with hla dr3  surprisingly  dr3 restricted low t cell responsiveness to m  leprae was found in hla dr3 positive tt leprosy patients  this low responsiveness was specifically induced by m  leprae but not by m  tuberculosis and was seen only in patients and not in healthy controls  we studied this patient specific  m  leprae induced  dr3 restricted low t cell responsiveness in depth in one representative hla dr3 positive tt leprosy patient by using t cell clones  from this patient two types of t cell clones were obtained  one type was cross reactive with m  tuberculosis and recognized an immunodominant epitope  amino acids 3 to 13  on the 65 kda heat shock protein  hsp  the other type was m  leprae specific and reacted to a protein other than the 65 kda one  to examine whether these m  leprae specific t cell clones were responsible for the dr3 restricted low responsiveness to m  leprae  we tested them for the ability to suppress the proliferation of the dr3 restricted  65 kda  hsp reactive clones  the dr3 restricted  m  leprae specific t cells completely suppressed the proliferative responses of dr3 restricted  cross reactive t cell clones to the 65 kda hsp from the same patient as well as from other individuals  also  dr3 restricted responses to an irrelevant ag were suppressed by the m  leprae specific t cell clones  however  no suppression of non dr3 restricted t cell responses was seen  although the mechanism must still be elucidated  this m  leprae induced  dr3 restricted immunosuppression may at least partly explain the observed dr3 associated low t cell responsiveness in tt leprosy patients  
class1	a comparison of rapid enzyme immunoassay tests for the detection of chlamydia trachomatis cervical infections  two rapid enzyme immunoassay test kits were compared with culture for the detection of chlamydia trachomatis endocervical infections  endocervical samples for c trachomatis culture and the two enzyme immunoassay tests were evaluated from 502 county health department and planned parenthood patients  the prevalence of infection in this population was 12   sensitivity and specificity of the abbott testpack chlamydia were 51 7  and 99 5   respectively  and of the kodak surecell chlamydia were 76 7  and 98 6   respectively  the positive and negative predictive values for testpack were 93 9  and 93 8   and for surecell were 88 5  and 96 9   respectively  additionally  an in vitro investigation was used to evaluate whether typical office staff  physicians  nurses  medical technicians  receptionists  and radiology technicians  were able to perform competently the tests in each kit  office personnel tested 12 dilutions of a c trachomatis stock sample or negative control sample as unknowns for each kit in the in vitro investigation  there were no differences among office staff in performance when compared for each test kit  selective use of these enzyme immunoassay tests for high risk patients in a family practice population that has a high prevalence of patients with c trachomatis infection may be helpful when rapid test results are required and cultures are not feasible  after appropriate training  most physician office personnel were equally able to perform the enzyme immunoassay tests evaluated  
class1	neonatal interleukin 1 beta  interleukin 6  and tumor necrosis factor  cord blood levels and cellular production  in a prospective study  levels of interleukin 1 beta  il 1 beta   interleukin 6   il 6   and tumor necrosis factor  tnf  were measured in a blind fashion in cord blood plasma from 92 neonates by specific immunoassays  and were correlated with the clinical courses of the infants  including type of delivery and perinatal complications  plasma il 1 beta concentration was undetectable in infants born by normal vaginal delivery or elective cesarean section but was significantly increased in infants born after induced vaginal deliveries  142     68 pg ml  or urgent cesarean section  290     21 pg ml  both p less than 0 05 compared with normal deliveries   the il 1 beta levels were elevated in infants with severe perinatal complications  282     116 pg ml  p less than 0 001   whereas tnf and il 6 levels were not related to these complications  infants with isolated perinatal infectious complications had elevated levels of plasma il 6 compared with those of sick neonates without infection  p less than 0 001   in contrast  tnf plasma levels and il 1 beta production by cord blood leukocytes were decreased in infants with infectious complications alone  both p less than 0 05   these studies suggest that the levels of il 1 beta  il 6  and tnf in the cord plasma relate differentially to clinical complications in the perinatal period  
class1	vaginitis emphysematosa  a report of four cases  it has been hypothesized that vaginitis emphysematosa is a manifestation of trichomonal or gardnerella infection  in support of this etiologic concept  four cases of the disorder are described showing the apparent curative effect of treating the associated infection  the linkage of these and other reported cases with conditions of impaired immunity suggests that immunologic factors are involved in the pathogenesis  
class1	a general model of sexually transmitted disease epidemiology and its implications for control  achieving control of stds may be possible by integrating the activities discussed previously with further research to provide additional empiric data on sex behavior  to develop innovative strategies to access and communicate with those most at risk of std  i e   core group members   and to foster biologic study of std pathogens with the goal of vaccine development  new strategies to identify core group members aside from the currently used std repeater status would be of immense help in targeting educational efforts  laboratory screening  and vaccines  achieving more complete control of stds may be possible if recent advances in our understanding of their epidemiology and transmission dynamics can be translated into effective new interventional strategies  
class1	chlamydial infections  chlamydia trachomatis is a unique intracellular parasite that causes a number of common sexually transmitted disease syndromes  including nongonococcal urethritis in both men and women  epididymitis in men  and pelvic inflammatory disease in women  infants exposed at delivery are at risk for the development of conjunctivitis and pneumonia  there is strong evidence that chlamydia is a cause of obstructive infertility and ectopic pregnancy in women  it appears that these complications result from the chronic inflammatory response and secondary scarring that are elicited by long term asymptomatic or nearly asymptomatic fallopian tube infections  because treatment with tetracycline  doxycycline  or erythromycin is simple  effective  and inexpensive  major efforts should be put into identifying asymptomatic young women through screening of the subpopulations at highest risk  these include sexually active adolescent women and older women who are not monogamous  blacks are at higher risk than other ethnic groups for infection  the cost of diagnosing chlamydial infection has decreased with the introduction of new nonculture diagnostic tests  this should increase the availability of testing for screening purposes  it is critical to remember that male sex partners of infected women must be treated  otherwise all efforts to prevent long term complications by identifying and treating asymptomatic women are doomed to failure  
class1	syphilis in adults  this article reviews the clinical manifestations of syphilis  diagnostic tests that might help to diagnose accurately the disease  and current recommendations for therapy  the association of syphilis and human immunodeficiency virus infection raises additional questions related to transmission  diagnosis  and therapy of both diseases  
class1	chancroid and the role of genital ulcer disease in the spread of human retroviruses  chancroid is the most prevalent form of genital ulcer disease in developing countries and is undergoing a resurgence in industrialized countries  as a result of a nonspecificity of the clinical findings  the etiologic diagnosis of genital ulcer disease requires laboratory support  genital ulcer disease is a risk factor for the transmission of human retroviral infections  an understanding of this interaction is emerging and will impact on the treatment and control programs for the agents causing genital ulcer disease  
class1	human papillomavirus infections of the genital tract  infection of the genital tract by hpv is a sexually transmitted disease of increasing prevalence  the association of hpv infection with genital tract malignancies is of great concern  and further studies are needed to clarify this association  few investigators believe at this time that proof of a direct causative role exists for hpv in these cancers  but indirect evidence of such a role is abundant  there are many clinical forms of hpv infection of the genital tract  and few clinicians can easily recognize them all  treatment of condyloma acuminatum is difficult and frustrating  cryotherapy with liquid nitrogen is the safest and most effective therapy for most forms of condyloma acuminatum  recurrence of condyloma acuminatum is common with all presently used forms of therapy  probably owing to latent hpv infection in normal appearing skin  no form of treatment is ideal for all forms of condyloma acuminatum  but without continued efforts to find better therapeutic modalities and preventative measures  the epidemic of genital hpv infection will continue unchecked  
class1	the  nuisance  sexually transmitted diseases  molluscum contagiosum  scabies  and crab lice  although molluscum contagiosum  scabies  and infestation by crab lice do not carry the requirements of partner notification or other long term consequences  they are among the most commonly reported sexually transmitted disease  molluscum contagiosum is a benign viral infection of the skin epidermal layer  most often transmitted by intimate skin to skin contact  the lesions often resolve spontaneously over time  but patient discomfort or social reasons may require destructive removal of the lesions  scabies is caused by the sarcoptes scabiei mite  the victims continually itch  especially at night  and often seek over the counter topical remedies before seeing a clinician  once a correct diagnosis is made  successful resolution of this disease and its itching can be achieved  head and pubic lice account for most of the more than three million cases of louse infestation treated in the united states each year  symptoms of infestation generally include itching that leads to scratching  erythema  irritation  and inflammation  a careful diagnosis followed by disinfection  symptomatic treatment  and psychologic support should result in a complete cure with no long term effects  
class1	common nonvenereal genital lesions  there are a wide variety of local and systemic skin diseases that produce lesions in the genitoanal region  these lesions may resemble those produced by sexually transmitted microorganisms  the purpose of this article is to make physicians aware of the common skin diseases that produce lesions on the genitalia to avoid the inappropriate diagnosis of a sexually transmitted disease  
class1	approach to men with urethritis and urologic complications of sexually transmitted diseases  the most important causes of urethritis  and epididymitis in younger men  are c  trachomatis and n  gonorrhoeae  management of these syndromes requires a thorough sexual history  genital examination  evaluation for objective and laboratory evidence of infection  antimicrobial therapy directed toward the major etiologies  and evaluation and treatment of sexual partners  treatment of n  gonorrhoeae requires use of a single dose regimen active against this organism  plus a 7  to 10 day tetracycline regime active against c  trachomatis and nongonococcal urethritis  with recommended regimens  microbiologic failure is infrequent in compliant patients  recurrent urethritis is frequent  however  the management of patients with persistent or recurrent symptoms requires careful reevaluation of the patient  documentation of urethritis  and re treatment with antimicrobials if urethritis is documented by positive cultures or increased numbers of polymorphonuclear leukocytes in urethral secretions  additional treatment beyond this point usually is not indicated  even though a proportion of men will remain symptomatic and some of these will have increased numbers of polymorphonuclear leukocytes in urethral secretions  the most important causes of prostatitis  and epididymitis in older men or men with urethral structural abnormalities  are classical urinary tract pathogens rather than sexually transmitted pathogens  management of these infections includes documentation of the infection and treatment directed toward the specific pathogen  men with symptoms of  prostatitis  must be evaluated using both urine and prostatic secretions to document infection and inflammation  the majority of men with such symptoms do not have an infection that can be documented  these men respond poorly to medications  men with documented chronic bacterial prostatitis require long courses of antimicrobials to effect cure  in some cases  however  the disease is intractable  and chronic suppression with antimicrobials may be necessary  
class1	approach to the patient with genital ulcer disease  the three major diseases characterized by genital ulcers  genital herpes  syphilis  and chancroid  are common  with genital herpes being most common in industrialized countries and chancroid being most common in developing countries  one fourth to one half of patients with genital ulcers have no diagnosed cause for their illness despite diagnostic efforts  the bulk of these cases is probably constituted by one of the three diseases for which diagnostic tests are falsely negative  there is accumulating evidence that genital ulcers facilitate the transmission of human immunodeficiency virus  hiv   and they may also be markers of high risk behavior for acquisition of hiv  appropriate therapy of patients with genital ulcers  as well as their sexual partners  depends on accurate diagnosis  patients with genital ulcers  particularly those with syphilis or chancroid  should be encouraged to undergo testing for hiv infection  
class1	vaginal infections in adult women  often trivialized by the medical profession  vaginitis in adult women is not only extremely common but is the source of considerable distress and often results in marked suffering  epidemiologic studies described in this article indicate the high prevalence of vaginitis and the large number of causes  although the majority of infections in women are due to bacterial vaginosis  vvc  and trichomoniasis  it is clear that many other causes exist  and we have yet to discover the etiology of many clinical syndromes  considerable progress has been made in understanding the pathogenesis of the three common vaginitides  although excellent progress has been made by the pharmaceutical industry in providing new drugs for vaginitis  any further progress will require a better understanding of etiology and pathogenesis  vaginitis causes major symptoms and is more than a nuisance problem  clinicians owe it to their patients to attempt to make an accurate diagnosis and not to rely on empiric therapy  
class1	pelvic inflammatory disease  the costs of pid to both individuals and society are enormous  although primary prevention of pid through control of lower genital tract infections is the most effective prevention strategy  early diagnosis and treatment of acute pid may minimize some of its serious sequelae  although laparoscopy is helpful for establishing the diagnosis of salpingitis  other less invasive tests along with selected clinical criteria may also be useful  treatment of pid  which is empiric and broad spectrum  is oriented toward polymicrobial pid  whenever possible  women with pid should be hospitalized for parenteral therapy  the 1989 cdc std treatment guidelines recommend two regimens for inpatient parenteral therapy  clindamycin gentamicin and cefoxitin  or equivalent cephalosporin doxycycline  outpatient management of pid should be monitored closely  the cdc recommended regimen includes use of intramuscular cephalosporins and oral doxycycline  oral penicillins are no longer recommended  
class1	sexually transmitted arthritis syndromes  sexually transmitted infections may provoke a wide variety of rheumatic lesions  disseminated n  gonorrhoeae infection leads to septic arthritis  which may be rapidly destructive but which responds promptly to appropriate antibiotic therapy  in contrast  both gonococcal and nongonococcal infections may lead to aseptic  reactive  arthritis or reiter s syndrome  inheritance of hla b27 confers a relative risk of 30 to 50 times for the development of this condition  the demonstration of c  trachomatis antigen in joint material from a minority of patients suggests that direct interaction between microbial components and class i hla antigens in the joint may be central to the pathogenesis of this disease  arthralgia and arthritis occur in up to 50  of individuals in the prodrome of hepatitis b infection  joint symptoms may be accompanied by urticarial or cutaneous vasculitic lesions  especially on the legs  both features resolve with the onset of jaundice  hepatitis b infection is also a major cause of necrotizing vasculitis  which may or may not be associated with overt hepatitis  seronegative arthritis  including reiter s syndrome  psoriatic arthritis  and undifferentiated arthritis  a sjogren s like syndrome  vasculitis  and myopathies have been described in association with hiv infection  it is clear that synovitis occurs in those patients despite the fact that hiv is present in immune cells within the joint during inflammatory arthritis and that both antigen presentation and lymphocyte responsiveness within the joint are impaired  nevertheless  synovitis may occur in the presence of marked cd4 positive lymphocyte depletion  rheumatic syndromes  including arthralgia  inflammatory arthritis  and neuropathic arthritis  may occur during any stage of congenital or acquired syphilis  syphilitic synovitis responds well to antibiotic therapy  but neuropathic lesions cannot be treated effectively  septic arthritis has rarely been described as a complication of disseminated mycoplasma or urea plasma infections  and joint lesions sometimes associated with erythema nodosum have also been reported in lymphogranuloma venereum and granuloma inguinale  
class1	sexually transmitted causes of gastrointestinal symptoms in homosexual men  the possible etiologic agents that may cause gastrointestinal complaints in homosexually active men are multiple  and their diagnosis is complex  this article presents a logical approach to the work up and diagnosis of gastrointestinal complaints in homosexually active men and to discuss their treatment and disease intervention  
class1	the interrelationship between human immunodeficiency virus infection and other sexually transmitted diseases  the epidemiology of hiv infection in the united states is changing  with a dramatic reduction in the incidence of new hiv infection in homosexual men over the past decade because of altered sexual practices  in contrast  heterosexual transmission of hiv is increasing and is disproportionately occurring in inner city racial minorities in association with drug use  populations that are currently experiencing epidemics of previously controlled stds  sexually transmitted diseases  especially genital ulcerative diseases and perhaps c  trachomatis and t  vaginalis  facilitate sexual transmission of hiv  in addition  hiv infection itself appears to increase the severity of certain stds once they are acquired  the control of stds  particularly in those populations that are at high risk for hiv infection  should be of high priority and should be an integral component of aids control programs  
class1	amoxycillin plus probenecid versus doxycycline for treatment of erythema migrans borreliosis  72 adults with erythema migrans  early lyme borreliosis  were enrolled in a randomised prospective trial comparing amoxycillin 500 mg plus probenecid 500 mg three times a day with doxycycline 100 mg twice a day for 21 days  these antibiotic regimens were chosen because of the known in vitro sensitivity of borrelia burgdorferi  the antibiotic tissue penetration  the pharmacokinetics of the drugs  and because the organism can disseminate early in the course of infection  72 patients were evaluable  35 in the doxycycline group and 37 in the amoxycillin probenecid group   the two regimens were equally effective for treatment of erythema migrans  mild fatigue or arthralgia were the only post treatment complaints  which resolved within 6 months  none of the patients needed further antibiotic treatment for lyme borreliosis  
class1	bird attack on milk bottles  possible mode of transmission of campylobacter jejuni to man a case control study was carried out to test the hypothesis that the rise in the rate of campylobacter jejuni infection in the brigend area of south wales during may was due to the consumption or handling of milk from bottles that had been attacked by birds  32 of 36 cases meeting the case definition were interviewed  along with 2 controls per case  matched for age  sex  and area of residence  there were strong associations between campylobacter infection and doorstep delivery of milk bottles  a history of milk bottle attack by birds  milk bottle attack by birds during the week before illness  and consumption of milk from attacked bottles during the week before illness  there was a very strong dose response relation between frequency of bird attack and illness  controls with a history of milk bottle attack by birds were more likely than cases to have taken preventive measures against bird attack and consumption of contaminated milk  although few people witnessed the attacks  the likely culprits are magpies  pica pica  and jackdaws  corvus monedula   
class1	a randomized  double blind trial of nystatin therapy for the candidiasis hypersensitivity syndrome background  candida albicans infection has been proposed to cause a chronic hypersensitivity syndrome characterized by fatigue  premenstrual tension  gastrointestinal symptoms  and depression  long term antifungal therapy has been advocated as treatment for the syndrome  which is most often diagnosed in women with persistent or recurrent candida vaginitis  methods  to determine the efficacy of nystatin therapy for presumed candidiasis hypersensitivity syndrome  we conducted a 32 week randomized  double blind  cross over study using four different combinations of nystatin or placebo given orally or vaginally in 42 premenopausal women who met present criteria for the syndrome and had a history of candida vaginitis  the outcomes studied were the changes from base line in scores for vaginal  systemic  and overall symptoms and in the results of standardized psychological tests  results  the three active treatment regimens  oral and vaginal nystatin  oral nystatin and vaginal placebo  and oral placebo and vaginal nystatin  and the all placebo regimen significantly reduced both vaginal and systemic symptoms  p less than 0 001   but nystatin did not reduce the systemic symptoms significantly more than placebo  on average  the scores for systemic symptoms improved 25 percent with the three active treatment regimens and 23 percent with the all placebo regimen  a difference of only 2 percent  95 percent confidence interval   3 to 7 percent   as expected  the three active treatment regimens were more effective than placebo in relieving vaginal symptoms  p less than 0 001   all four regimens reduced psychological symptoms and global indexes of distress  there were no significant differences among the treatment regimens  conclusions  in women with presumed candidiasis hypersensitivity syndrome  nystatin does not reduce systemic or psychological symptoms significantly more than placebo  consequently  the empirical recommendation of long term nystatin therapy for such women appears to be unwarranted  
class1	interleukin 1 receptor antagonist reduces mortality from endotoxin shock  about five out of 1 000 patients admitted to hospital develop bacterial sepsis leading to shock  the mortality rate for which is high despite antibiotic therapy  the infection results in hypotension and poor tissue perfusion  and eventually leads to the failure of several organ systems  bacterial endotoxin is thought to be the direct cause of shock in gram negative sepsis  because it can cause shock in animals  and antibodies against endotoxin prevent gram negative shock in animals and in humans  but  the symptoms of septic shock are the result of the actions of host cytokines induced by the endotoxin  the cytokine interleukin 1 has been implicated as an important mediator of septic shock because it can induce tachycardia and hypotension and act synergistically with tumour necrosis factor to cause tissue damage and death  we now report that a specific interleukin 1 receptor antagonist reduces the lethality of endotoxin induced shock in rabbits  indicating that interleukin 1 does indeed play an important part in endotoxin shock  
class1	acute axonal polyneuropathy associated with anti gm1 antibodies following campylobacter enteritis  we report 2 patients with guillain barre syndrome  gbs  following campylobacter jejuni enteritis  electrophysiologic studies indicated that the predominant process was axonal degeneration of motor nerves  and clinical recovery was poor  serum testing by thin layer chromatography and enzyme linked immunosorbent assay revealed that the sera from both patients contained high titers of igg antibody against gm1 ganglioside  these cases may represent a subgroup of gbs as acute axonal polyneuropathy following c jejuni enteritis associated with anti gm1 antibodies  
class1	human immunodeficiency virus infection in pregnancy  among an estimated 1 million to 1 5 million americans infected with hiv  about 10 per cent are women  moreover  almost 30 per cent of hiv infection among women is acquired through heterosexual activity  therefore  the average obstetrician gynecologist is not sheltered from dealing with hiv  this article offers guidelines for caring for hiv infected pregnant women during antepartum  intepartum  and postpartum phases  
class1	calcitonin gene related peptide levels are elevated in patients with sepsis  calcitonin gene related peptide  cgrp   an endogenous vasoactive peptide encoded by the calcitonin gene in nerve cells  is distributed throughout the cardiovascular system and is a potent vasodilator  plasma levels of cgrp have been elevated in animal models with sepsis  this study was designed to determine whether plasma cgrp levels are elevated in patients with sepsis and perhaps contribute to the hyperdynamic cardiovascular state in sepsis  plasma cgrp levels were obtained from normal healthy volunteers and from patients with sepsis  volunteers were afebrile and had normal pulse and blood pressure  patients with sepsis were selected according to the following criteria   1  temperature higher than 38 5 degrees c   2  white blood count greater than 14 000 ml   3  positive blood culture of bacterial organisms   4  hemodynamic parameters consistent with hyperdynamic sepsis  and  5  negative history of thyroid or other endocrine abnormalities  cgrp was extracted and assayed by radioimmunoassay for iodine 125 labeled human cgrp  in patients with sepsis  the cardiac index was 5 4     0 5 l min m2  normal  3 0   systemic vascular resistance was 7 1     0 5 mm hg l min  normal  16   oxygen delivery was 1496     137 ml min  normal  1000   plasma cgrp levels were significantly elevated in the patients with sepsis  14 9     3 2 pg ml  compared to plasma cgrp levels in control volunteers  2 0     0 3 pg ml  p less than 0 0005   these elevated levels of cgrp may contribute to the decreased vascular resistance and increased cardiac output in the hyperdynamic septic state  
class1	perirenal candidial abscess  perirenal candidial abscesses are rare  with few well documented cases in the literature  we describe a case of a perinephric abscess treated with amphotericin b and nephrectomy  
class1	tetracyclines in urology  current concepts tetracyclines have an unusually broad spectrum of antimicrobial activity  they are generally well tolerated  with relatively few side effects compared with alternative antibiotic choices  tetracyclines also compare favorably with newer antimicrobials  i e   oral quinolones  with respect to cost and microbial resistance  doxycycline s and minocycline s spectrum of antibacterial activity  pharmacokinetic profile  and safety profile make them preferred drugs when tetracyclines are indicated in urologic infections  
class1	antibiotic therapy for bacillus species infections  we reviewed 36 cases of culture proven bacillus species ocular infections occurring between september 1974 and december 1989  kirby bauer disk sensitivities were available in 34 of the 36 cases  95    all bacillus species isolates were sensitive to the aminoglycoside antibiotics  n   34  and to vancomycin hydrochloride  n   32   resistance to clindamycin was found in four of 18  22   of tested isolates  although b  cereus was uniformly sensitive to these antibiotics  resistance to clindamycin occurred in four cases in the non b  cereus group  the microbroth dilution technique confirmed the kirby bauer data  the aminoglycosides were uniformly effective  but the cephalosporins  first  second  and third generation drugs  were consistently ineffective against b  cereus and varied from sensitive to moderately sensitive for the non b  cereus isolates  our microbiologic laboratory findings suggest that vancomycin hydrochloride in combination with an aminoglycoside ensures more consistent antibiotic coverage of bacillus species ocular infections  
class1	helicobacter pylori and associated duodenal ulcer  twenty three children with coexistent duodenal ulcer and helicobacter pylori infection were treated with either two weeks of amoxycillin  25 mg kg day  in addition to six weeks of cimetidine  or cimetidine alone  endoscopy with antral and duodenal biopsies for urease test  microaerophilic culture  and histological studies were performed at entry  six weeks  12 weeks  and at six months  children with persistent h pylori infection at six weeks were given a further two weeks  course of amoxycillin  h pylori persisted in all children not receiving amoxycillin treatment but cleared in six of the 13 children  46   treated with amoxycillin  with failure of h pylori clearance at six months  only two out of six  33   ulcers had healed and 50  of patients had experienced ulcer recurrence  in contrast  when h pylori remained cleared all ulcers healed and no ulcer recurred  persistent h pylori infection was associated with persistent gastritis and duodenitis despite endoscopic evidence of ulcer healing  detection and eradication of h pylori deserves particular attention in the routine management of duodenal ulceration in children  
class1	continued need for pneumococcal prophylaxis after splenectomy two children died from pneumococcal infection five and eight years after splenectomy  pneumococcal vaccination had not been given to either child  when the infection developed both children were not taking prophylactic penicillin  vaccination and daily penicillin reduce the incidence of this complication and therefore we strongly recommend that both of these measures are continued indefinitely  
class1	urinary infection following out patient flexible cystoscopy  of 161 flexible cystoscopies performed in an out patient endoscopy suite  the incidence of urinary tract infection was 7 5   infection rates were higher in patients with a history of previous urinary tract infection or where an additional procedure was also performed  no difference was noted between the infection rates in men and women  
class1	antibiotic compared with antiseptic prophylaxis for prostatic surgery  two different regimens of cephalosporin antibiotic prophylaxis were compared with antiseptic lubricating jelly to try to prevent infection and complications in 196 men after prostatic surgery  pre operative urine was cultured and prostatic chips  170 cases  were also cultured to define the source of any infection  the use of antibiotics was associated with a reduced risk of postoperative bacteriuria  no serious complications occurred  although 1 patient in the antiseptic treated group developed rigors  79 of 170 patients  46   had positive prostatic chip cultures  of whom 74 had sterile pre operative urine  there was no association between the result of chip culture and the presence of a pre operative catheter  culture positive patients had an increased risk of post operative urine infection  although the same organism was found in the prostate and urine in only 36  of cases of post operative bacteriuria and in 43  54   the organism cultured from the prostate was staphylococcus albus  this study provides further evidence of the benefit of true prophylactic antibiotic therapy for transurethral prostatic surgery and the prostatic chip data suggest that some of the risk is due to pre operative contamination of the prostate in the absence of per operative urinary infection or catheterisation  
class1	helicobacter pylori and gastric carcinoma  serum antibody prevalence in populations with contrasting cancer risks  this investigation examined the correlation between helicobacter pylori  hp  infection  as reflected in immunoglobulin g serum antibodies  and the risk of gastric cancer  serum samples were obtained from populations with contrasting gastric cancer risks  the highest prevalence of hp infection  93   was observed in the adult population at highest gastric cancer risk  the residents of pasto  colombia  in the lower risk colombian city of cali  a 63  overall prevalence rate was found  both children and adults were sampled in new orleans  louisiana  where gastric cancer rates are high for blacks but not for whites  the prevalence of hp infection was significantly higher in black than in white adults  70  versus 43   p   0 0001  a higher prevalence was also detected in black compared with white children  49  versus 32   p   0 01  however  an even greater disparity was noted when comparing children from two hospitals  regardless of race  which serve different socioeconomic groups  a prevalence rate of 54  was found at charity hospital compared with 24   p   0 0001  at children s hospital  our findings indicate that socioeconomic conditions  known to influence gastric cancer risk  are also important determinants of hp infection  
class1	metabolic regulation of renal gluconeogenesis in response to sepsis in the rat  1  the regulation of renal gluconeogenesis was studied in rats made septic by a caecal ligation and puncture technique  2  blood glucose concentrations were not markedly different in septic rats  but lactate  pyruvate and alanine concentrations were markedly increased  compared with sham operated rats  conversely  blood ketone body concentrations were significantly decreased in septic rats  both plasma insulin and glucagon concentrations were markedly elevated in response to sepsis  3  the maximal activities of glucose 6 phosphatase  ec 3 1 3 9   fructose 1 6 bisphosphatase  ec 3 1 3 11   pyruvate carboxylase  ec 6 4 1 1  and phosphoenolpyruvate carboxykinase  ec 4 1 1 49  were markedly decreased in kidneys obtained from septic rats  suggesting diminished renal gluconeogenesis  4  renal concentrations of lactate  pyruvate and other gluconeogenetic intermediates were markedly elevated in septic rats  whereas those of acetyl coa and fructose 2 6 bisphosphate were decreased and unchanged  respectively  5  the rate of gluconeogenesis from added lactate  pyruvate and glycerol was decreased in isolated incubated renal tubules from septic rats  6  sepsis decreased the arteriovenous concentration difference for glucose  lactate  and alanine  septic rats showed decreased net rates of glucose production and net rates of removal of lactate and alanine as compared with sham operated controls  7  it is concluded that the diminished capacity for renal gluconeogenesis in septic rats could be the result of changes in the maximal activities or regulation of key non equilibrium gluconeogenic enzymes or both  but the effect of other factors  e g  toxins  has not been excluded  
class1	thoracic empyema  causes  diagnosis  and treatment  thoracic empyema is a disease that has been recognized for centuries  the principles of management as stated by hippocrates remain more or less unchanged  diagnosis can be masked by the underlying cause  preemptive antibiotic treatment  or the now frequently associated debilitating diseases  with no other specific investigation  the main diagnostic test remains diagnostic thoracentesis  when an empyema is encountered  the objectives are to save life  eliminate the empyema  its complications  and chronicity  return pulmonary mechanics to normal  and reduce the duration of the hospital stay  the introduction of antibiotics has dramatically influenced the spectrum of the disease now encountered  if the original infection is adequately treated  empyema rarely occurs  penicillin has removed the major cause of empyema  and further developments in antibiotics now mean that the majority of empyemas occur when patients are disabled by other disease processes or malnutrition  or where there remains a delay in medical attention  these patients are often less able to withstand the prolongation of the infective processes that is sometimes encountered with the staged approach to treatment  developments in operative and postoperative care have meant that these patients can best be treated by more aggressive and definitive surgical management  
class1	causes  diagnosis  and treatment of pharyngitis  pharyngitis is a common disease of the respiratory tract that can be caused by several different viruses and bacterial organisms  clinically speaking  the most important causative agent is group a streptococcus  streptococcus pyogenes   although rare  postpharyngitis complications arise as a result of disease caused almost exclusively by group a streptococcus  because group a streptococcal pharyngitis usually responds well to antimicrobial treatment  it is important to diagnose it  penicillin  erythromycin  and peroral first generation cephalosporins have been documented to be effective  in addition to group a streptococcus  c  pneumoniae and m  pneumoniae have also been detected in patients with pharyngitis  the possibility of diagnosing these organisms is limited at the present  clinical surveys are still needed  moreover  to evaluate the effect of antimicrobial treatment on the disease caused by these organisms  although routine viral diagnostic methods do not help primary care physicians in treating patients with pharyngitis  information on bacteria and viruses in the immediate environment could prove to be of great help in daily clinical work  
class1	surgical wound infection and cancer among the elderly  a case control study  surgical wound infection occurs in fewer than 5  of operations  nevertheless  it represents the second most common type of hospital acquired infection and results in increased morbidity and mortality  as with all nosocomial infections  the rate of surgical wound infection increases with age  patients over 65 years of age run an approximately 15  risk of surgical wound infection  two thirds of patients with invasive cancer other than non melanotic skin cancer are aged 65 years and over  over half of them are treated surgically for their cancer  cancer and other chronic diseases have been cited as possible causes of the increased risk of nosocomial infection among the elderly  using the foothills hospital wound study data base as the sampling frame  we conducted a case control study of surgical wound infection and cancer among the elderly  cancer was found not to be a risk factor for surgical wound infection  the results are discussed in relation to the role of immunity in both disorders  
class1	endophthalmitis after placement of a molteno implant  i report a case of early postoperative endophthalmitis following placement of a molteno implant  excellent results were obtained by immediate removal of the implant and surgical management of the infection  followed by replacement of the implant  
class1	chancroid  results from an outbreak in houston  texas  a recent  and continuing  epidemic of chancroid in houston has included morphologic variation in the disease  including so called dwarf  classic  giant  transient  follicular  phagedenic  and pseudogranuloma inguinale types  most cases were clearly acquired by unprotected sexual encounters with local prostitutes  the strain of haemophilus ducreyi responsible for this outbreak was relatively easily cultured on routine media  unexpected sensitivity of this strain to vancomycin rendered the recommended  selective  growth medium much less optimal for isolation  therapeutic success uniformly followed the use of intramuscular ceftriaxone sodium  one case responded to oral ciprofloxacin hydrochloride  
class1	a resurgence of acute rheumatic fever in a mid south children s hospital  a resurgence of acute rheumatic fever  arf  has been reported in many areas of the united states in recent years  we retrospectively reviewed the medical records of inpatients with a new diagnosis of arf from 1982 through 1988 at a children s hospital that serves a six state referral area in the mid south  thirty patients were identified  21 of whom were seen in 1987  13  and 1988  8   the rate of new cases of arf per 1000 hospital discharges  0 7  was significantly greater for 1987 and 1988 than it was  0 15  from 1982 through 1986  patients with recently diagnosed arf were predominantly from nonurban areas  and polyarthritis was the most common recent major manifestation  reasons for the resurgence of arf in the us  including the mid south  are unclear  but our experience serves to support recently published guidelines for the diagnosis and management of streptococcal pharyngitis in light of this resurgence of arf  
class1	sternoclavicular septic arthritis due to haemophilus influenzae  we have reported a case of septic sternoclavicular arthritis illustrating a rare complication of infection with a relatively common pathogen  haemophilus influenze  early identification of the infecting organism and appropriate antibiotic therapy are essential to prevent further morbidity from the complications of this unusual pyoarthritis  
class1	drug therapy for helicobacter pylori infection  problems and pitfalls  antibacterial chemotherapy against helicobacter pylori is currently being assessed by open or randomized controlled clinical studies for its efficacy in eradicating this bacterium from the stomach of patients with gastritis or gastroduodenal ulcer  whereas there is presently no  optimal  agent and treatment scheme  the combination of some antibiotics  metronidazole  tinidazole  amoxicillin  with bismuth salts proves definitely superior in vivo to either of these agents administered alone  several reasons have been proposed  to explain the clinical failure after treatment  insufficient concentration of active drugs in gastric mucus  instability of some agents at an acidic ph  inappropriate formulation of drug  insufficient duration of treatment  and variable compliance of patients  recently  it has appeared from several clinical trials that h  pylori may rapidly acquire resistance to some antibiotics  and that this event might also account for clinical failure  a critical review of the literature on h  pylori treatment indicates that association of bismuth and antibiotics or of antibiotics alone both may efficiently reduce the risk of emergence of resistance and improve the therapeutic outcome  guidelines of treatment are suggested in order to avoid the future misuse of antibiotics that would increase selection of antibiotic resistant h  pylori and negatively affect the ecology of the gastric microflora  likewise  an accurate definition of a subset of patients with h  pylori who really will require treatment needs to be rapidly established  
class1	helicobacter pylori infection  a simplified diagnostic approach  we evaluated the diagnostic accuracy of endoscopic finding of nodular antritis and rapid urease test  rut  in order to simplify the approach to the diagnosis of helicobacter pylori  h  pylori  infection  forty four consecutive patients  mean age 7 9 yr  range 6 13 yr  referred because of recurrent abdominal pain as the main symptom  were prospectively investigated for the presence of h  pylori  h  pylori positivity or negativity was defined as the concordance of two of the following tests  rut  microbiologic culture  and histologic examination on bioptic samples  rut sensitivity was 100   whereas specificity was 87 5   the presence of nodular antritis had a sensitivity of 96 4  and specificity of 87 5  in h  pylori infection diagnosis  the predictivity value of combined rut and nodular antritis  whether positive or negative  was 100   only in case of discordance do we suggest the utilization of other expensive tools for diagnosis of h  pylori infection  
class1	helicobacter pylori infection in patients with acquired immune deficiency syndrome  a controlled study was conducted on patients with human immunodeficiency virus  hiv  infection referred for upper endoscopy to evaluate the prevalence of helicobacter pylori  h  pylori  infection  four different stains and culture for h  pylori were performed on biopsy specimens from the gastric antrum  sixteen  40   of 40 patients with acquired immune deficiency syndrome  aids  or aids related complex  arc  were diagnosed to be infected with h  pylori versus 14  39   of 36 age matched control patients  eight of 15 aids arc patients without aids related esophagogastroduodenal findings  53   were infected with h  pylori versus 8 25  32   with endoscopic findings typical of aids  no invasion of the lamina propria by h  pylori was noted in any patient  active chronic gastritis was present in 60  of aids arc patients and 61  of controls  fifty eight and 59   respectively  of active chronic gastritis cases were infected with h  pylori  all the h  pylori infections  except one  were found in patients with chronic gastritis  in aids arc patients  h  pylori infection and active chronic gastritis are as common as in other patients referred for upper endoscopy  they may play a pathogenic role  especially when endoscopic aids related findings are lacking  cell mediated immune deficiency does not appear to increase the risk of infection with h  pylori  
class1	comparison of two ascitic fluid culture methods in cirrhotic patients with spontaneous bacterial peritonitis  the conventional method of ascitic fluid culture detects bacteria in only 50  of cirrhotic patients with neutrocytic ascites and suspected spontaneous bacterial peritonitis  sbp   we have prospectively compared two ascites culture methods in cirrhotic patients with spontaneous bacterial peritonitis  1  conventional  on chocolate agar  blood agar  mac conkay agar  and thioglycolate broth   and 2  modified  inoculation of 10 ml of ascites in a tryptic soy broth  tsb  blood culture bottle at the patient s bedside   in a 21 month period  70 episodes of sbp were diagnosed according to our criteria in 60 cirrhotic patients  both culture methods were performed simultaneously  the conventional grew bacteria in 40 episodes  57    whereas the modified grew bacteria in 54 episodes  77    a significantly higher sensitivity  p   0 0001   in 16 cases  23    ascitic culture was negative by both methods  the mortality rate was higher among patients with culture positive sbp than those with culture negative sbp  46  vs 37    but did not reach statistical significance  we conclude that ascitic fluid inoculated into a tsb blood culture bottle at the patient s bedside should be used routinely for ascites culture in cirrhotic patients  
class1	liver abscess complicating intratumoral ethanol injection therapy for hcc  we report a patient who developed multiple liver abscesses and sepsis caused by lactobacilli after the percutaneous intratumoral injection of ethanol for hepatocellular carcinoma  we diagnosed the liver abscess at an early stage because of a the finding of gas on ultrasound and computed tomography  blood cultures grew gram positive rods  which were of the lactobacillus species  the patient responded to the administration of antibiotics  and his hepatic tumors have not recurred in the 7 months since treatment  this is the first report of liver abscess following percutaneous ethanol injection therapy  
class1	ofloxacin treatment of chlamydia pneumoniae  strain twar  lower respiratory tract infections  purpose  limited data suggest that tetracycline or erythromycin is the antibiotic of choice for treating chlamydia pneumoniae infection  but they are not always effective or well tolerated  because the fluoroquinolone ofloxacin is effective for chlamydia trachomatis infections  we investigated its role in treating c  pneumoniae infections  patients and methods  eighty seven patients were enrolled in a randomized trial of antibiotic therapy for acute lower respiratory tract infections  the patients were randomly assigned to oral treatment with either ofloxacin  400 mg twice a day  or erythromycin  400 mg four times a day  for 10 days  frozen acute and convalescent serologic specimens were tested for twar antibody by microimmunofluorescence  susceptibility testing of c  pneumoniae to ofloxacin was also performed  results  four patients who received ofloxacin were retrospectively identified as having c  pneumoniae pneumonia  two  or bronchitis  two   within 2 weeks of starting ofloxacin therapy  all were cured or markedly improved  the minimum inhibitory concentrations of ofloxacin for three previously isolated clinical strains of c  pneumoniae were determined to be 1 0 to 2 0 micrograms ml  well within the achievable serum levels  3 to 5 micrograms ml  with ofloxacin therapy  conclusion  ofloxacin may be an effective alternative antibiotic treatment for c  pneumoniae respiratory infections  
class1	determinants of condom use among french heterosexuals with multiple partners  in september 1988  a sample of french individuals between 18 and 49 years of age  who reported more than one sexual partner in the past six months and who considered themselves heterosexuals  n   1088   were interviewed at home about risk perception of human immunodeficiency virus  hiv  transmission  sexual behavior  and condom use  systematic or occasional use of condoms during the previous 12 months was reported by 46 9 percent of respondents  among condom users  38 7 percent declared they had never used condoms before the last 12 months  fear of acquired immunodeficiency syndrome  aids  rather than contraception being the main motivation of these recent users  multivariate analysis indicates that voluntary testing for hiv  average or more than average fear of sexually transmitted diseases  stds   and knowledge of hiv carrier in personal relations are associated with condom use  
class1	increased septic complications with three drug sequential immunosuppression for cadaver renal transplants  in 152 renal transplant recipients  the results of immunosuppression with three drug sequential  minnesota antilymphocyte globulin  prednisone  azathioprine  and cyclosporine  immunosuppression  n   107  were compared with those of a two drug sequential protocol  minnesota antilymphocyte globulin  prednisone  and cyclosporine  that excluded azathioprine  n   45   the study groups were comparable by age  sex  etiology of renal failure  incidence of diabetes  and degree of hla matching  patient survival at 1 year was not significantly different in the two groups  two drug  93  versus three drug  86   p   0 19   one year graft survival was superior in the two drug group  two drug  93  versus three drug  75   p   0 02   analysis of primary transplants only  n   116  yielded the same results  during the first year  the serum creatinine level remained stable in both groups  as expected  the three drug therapy group had significantly more bacterial and viral infections  for low risk primary cadaveric renal transplants  two drug sequential immunosuppression is superior  
class1	outpatient percutaneous central venous access in cancer patients  a 1 year experience of percutaneous subclavian catheterization in outpatients with cancer was reviewed to document reliability  safety  and cost  there were 763 catheter insertions attempted with prospective documentation of complications in 664 consecutive patients  catheter insertion was successful in 722 attempts  95    there were only 13 pneumothoraces  2    thirty catheters required repositioning  4    the average catheter duration was 191 days  range  0 to 892 days   fifty six catheters  8   were removed because of suspected infection  documented catheter sepsis occurred in 21 patients  3    catheter site infection occurred in 8 patients  1    thus  only 0 22 infections per catheter year occurred during this 382 catheter year experience  the estimated cost of catheter insertion was  562  which is one third the estimated cost for tunneled catheters   1 403  and for reservoir devices   1 738   in our experience  percutaneous subclavian catheterization is a reliable  cost effective method compared with tunneled or reservoir devices  with an equivalent incidence of catheter related infections  the cornerstone of our success with this program is a staff dedicated to catheter care and intensive patient education  in centers where a large number of patients require central venous access  percutaneous catheterization should be the technique of choice  
class1	severe anemia is an important negative predictor for survival with disseminated mycobacterium avium intracellulare in acquired immunodeficiency syndrome  published erratum appears in am rev respir dis 1991 feb 143 2  451  disseminated mycobacterium avium intracellulare  mai  in patients with the acquired immunodeficiency syndrome  aids  is usually unresponsive to antimycobacterial therapy  we examined clinical and laboratory characteristics of mai organisms and their relationship to the length of survival  we studied factors influencing survival and compared these in 76 patients with aids with and without mai  serum levels of p24 antigen and erythropoietin  and cd4 positive helper t lymphocytes in blood were assessed in 36 additional patients with various clinical stages of hiv infection  in patients with mai infection  survival was significantly related only to total lymphocyte count  hematocrit  platelet count  and sex  of these  hematocrit and total lymphocyte count were the only linear predictors of survival  anemia was significantly more profound in patients with aids and mai than in the other patients  this anemia in patients with mai could not be ascribed to increased peripheral destruction of red cells  deficient nutritional factors  or erythropoietin production  hiv viral or bacterial load  or a general effect on other blood elements such as neutrophils or platelets  the influence of mai on survival in patients with aids did depend upon whether the mai occurred as an index infection or was preceded by other opportunistic infections  patients with other preceding opportunistic infection lived for a much shorter duration from the time of diagnosis of mai  
class1	risk factors for staphylococcus aureus nosocomial pneumonia in critically ill patients  staphylococcus aureus nosocomial pneumonia has become an important infection not only because of an apparently increasing incidence but also because of its high mortality rate  a total of 50 episodes of nosocomial pneumonia in critically ill patients in which etiologic diagnosis was well established were prospectively followed in a medical surgical intensive care unit  icu   s  aureus was isolated in a total of 13 episodes  in the univariate analysis the variables significantly associated with s  aureus nosocomial pneumonia were below 25 yr of age  coma  nonuse of corticosteroids  and antecedent trauma  a step forward logistic regression analysis defined only coma as significantly influencing the risk of developing s  aureus nosocomial pneumonia  we suggest that antimicrobial drugs active against s  aureus must be included in the initial empirical antimicrobial regimen for treating nosocomial pneumonia in patients with coma  the identification of factors influencing the etiology and the possibility of earlier effective antimicrobial treatment may represent a further step in the control of nosocomial pneumonia in critically ill patients by improving its prognosis  
class1	a rat model of prolonged pulmonary infection due to nontypable haemophilus influenzae  pulmonary colonization and infection with nontypable  unencapsulated  haemophilus influenzae  nthi  occurs commonly in the setting of chronic lung diseases  because the study of nthi pulmonary infection in animal models has been limited by the rapid clearance of organisms  a model of persistent pulmonary infection was developed  groups of rats were inoculated by transtracheal instillation of viable nthi suspended in broth or semisolid agar  some rats had received hexamethylphosphoramide  hmp  in drinking water before inoculation to cause respiratory epithelial mucosal damage  groups of animals were sacrificed serially  lungs were cultured quantitatively and their gross and microscopic anatomy examined  nthi was recovered in small quantities from few broth inoculated rats after the first day of infection and in none after day 7  in contrast  nthi was recovered from the majority of animals and in greater amounts through 2 wk after agar borne inoculation  hmp pretreatment further enhanced recovery through 4 wk after inoculation with an agar vehicle  the pulmonary inflammatory reaction was brief in broth inoculated rats  the longer persistence of gross and histologic changes seen in agar infected lungs paralleled the enhanced recovery of nthi  abscess formation occurred at 7 to 14 days in some agar inoculated animals  thus pulmonary inoculation of nthi in a viscous vehicle resulted in perpetuation of infection and inflammatory response  and previous damage to respiratory mucosal epithelium induced by hmp further enhanced such infection  
class1	disseminated conidiobolus infection with endocarditis in a cocaine abuser  a crack cocaine abuser developed disseminated infection caused by a species of conidiobolus not known to cause disease in vertebrates  the fungus gained entry via skin abrasions on the lower extremities  spread through the hematogenous route  and caused endocarditis  there was evidence of fungal infection in the lungs  heart  kidneys  skeletal muscles  and brain  an additional complication was extensive rhabdomyolysis  with a marked elevation of creatine kinase of up to 1 2 million u l  
class1	tuberculous meningitis  short course of chemotherapy  in march 1986  we began a 6 month short course trial of therapy for tuberculous meningitis  in which 28 patients were analyzed  the diagnosis was based on the following cerebrospinal fluid test results  in 53 5  of the cases  mycobacterium tuberculosis was identified by direct smear  in 57   culture in lowenstein jensen medium was positive  in 83 3   the detection of anti bacille calmette guerin  bcg  antibodies by enzyme linked immunosorbent assay was positive  and in 74   the dosification of adenosine deaminase activity was positive  in addition  in 21 4  of the cases  the diagnosis was established by means of autopsy findings  moreover  the diagnosis was supported by bacteriological analyses from another tissue or body fluids  despite the administration of an antituberculous therapy  32 4  of the patients died  all of the decreased had reached the last stage of the disease by the beginning of treatment  sixteen percent of the patients who survived after more than 18 months of follow up after therapy had ended suffered neurological sequelae  with the 6 month therapeutic regimen  the morbidity mortality is similar to that found in the longer course therapies  the latter regimen is therefore thought to be a good and acceptable therapeutic option for the treatment of tuberculous meningitis  
class1	acquired childhood aphasia  outcome 1 year after onset  the effects of the variables age at onset  cause  severity and bilaterality of lesion  and type of aphasia on course and outcome were investigated in a group of 28 aphasic children  analysis of spontaneous speech and tests of auditory verbal comprehension were used to determine the presence of aphasia  the severity of the cerebral lesion was assessed using a rating scale for computed tomographic scans  most of the children had not recovered completely 1 year after onset  recovery was significantly different according to etiological categories  complete recovery was seen in the majority of traumatic cases  
class1	cumulative aids incidence and altered mortality from bacterial infections  to determine whether populations with high cumulative incidence of acquired immunodeficiency syndrome  aids  experienced increased deaths from sepsis  central nervous system abscess  or endocarditis  new jersey aids patients were grouped according to their age  sex  race  and residence specific cumulative incidence of aids since the onset of the aids epidemic  between 1980 and 1986  among 25 44 year olds in the highest cumulative incidence group for aids  sepsis mortality increased from 3 3 to 15 2 deaths 100 000 year  an increase of 11 9 deaths 100 000 year  95  confidence interval  6 9  17 0  deaths 100 000 year   mortality from central nervous system abscesses increased from zero to 1 7  0 1  3 2  deaths 100 000 year  and mortality from endocarditis increased from 0 8 deaths 100 000 year to 2 4 deaths 100 000 year  an increase of 1 6   0 5  3 7  deaths 100 000 year  age matched new jersey patient populations with low cumulative incidence of aids did not sustain a similar increase  the hiv disease associated increase in sepsis mortality among young populations represents a new component of the substantial increase in u s  sepsis mortality that occurred over the last two decades  but was previously limited to older populations  
class1	patterns of bacterial infection in calves implanted with artificial hearts  device related infection is one of the most serious potential consequences of total artificial heart  tah  implantation  this complication must be addressed before the full potential benefit of these devices  especially fully implantable devices  can be realized  a review of research reports and clinical data was conducted to ascertain if similarities existed between the patterns of infection reported in human tah recipients and those seen in the experimental animal models  infection was reported in approximately 57  of the human tah recipients and approximately 47  of the implanted animals  implant periods ranged from 1 620 days for the humans  and 32 287 days for the animals  the spectrum of organisms isolated from both groups were similar  with a high proportion of infections caused by pseudomonas aeruginosa and staphylococcus epidermidis  in addition  numerous isolates of enterobacter and enterococci were obtained from the animals  positive blood cultures have often been observed in animals within 2 4 weeks following implantation of the devices  the similarities noted in this review suggest that the calf may be an appropriate animal model in which to study the pathogenesis of tah related infection  
class1	peritoneal macrophage beta 2 microglobulin production and bacterial peritonitis in capd patients  to evaluate the role of bacterial peritonitis in peritoneal macrophage  pm  beta 2 microglobulin  b2m  production  and its relationship with pm interleukin 1  il 1  and leukotriene b4  ltb4  release  the authors studied 20 capd patients  10 with peritonitis   1  in vivo plasma and peritoneal dialysis effluent  pde  b2m  il 1  and ltb4 levels  2  in vitro b2m  il 1  and ltb4 release by pm  values were compared with those seen in the plasma or with peripheral blood monocytes of 30 hemodialysis  hd  patients  10 treated with cuprophan  cu   10 with polyacrylonitrile  pan   and 10 with cellulose acetate  ca    results showed that in capd patients with bacterial peritonitis b2m  il 1 and ltb4 concentrations in the pde were significantly higher than those seen in capd patients without peritonitis  or in the plasma of hd patients treated with pan or ca  but were similar to those seen in hd patients treated with cu  at the same time  in vitro pm from capd patients with bacterial peritonitis produced more b2m  il 1  and ltb4  than did pm from capd patients without peritonitis  or peripheral blood monocytes from hd patients treated with pan or ca  the authors conclude that in capd patients  bacterial peritonitis is able to induce pm b2m production  probably via a cytokine mediated process  which may be analogous to what occurs with peripheral blood monocytes of hd patients treated with cu  
class1	prevention of infection in a porous tracheal prosthesis by omental wrapping  the ideal tracheal prosthesis has to permit complete incorporation by epithelialization of the luminal surface  this is not possible with the currently available impermeable solid silicone tube  the authors developed a reinforced  porous polyurethane tubular prosthesis which has the potential for complete incorporation  however  because these prostheses are implanted in a contamined area such as the airway  they all become infected  in order to prevent infection  the authors evaluated the effect of omental wrapping in guinea pigs  the authors  tubular prosthesis was implanted subcutaneously in the abdominal area with the ends open to the air  ten prostheses were wrapped with omentum and 10 prostheses were not  in 4 weeks  all control prostheses were infected and marsupialized  all the wrapped prostheses remained in place and were macroscopically not infected  microscopically  all wrapped prostheses were well vascularized and were incorporated by granulation tissue  which did not occur in the prostheses of the control group  from these results the authors conclude that omental wrapping would be an effective way to prevent infection of porous tracheal prostheses in an open to the air situation  and allow rapid tissue ingrowth and incorporation in the host  
class1	the role of indium labelled leukocyte imaging in pyrexia of unknown origin  indium 111 labeled white blood cell scanning is often used in the investigation of pyrexia of unknown origin  puo  to locate an otherwise occult source of sepsis  from a series of 166 white blood cell studies performed for sepsis  28 cases of true puo were identified and reviewed  the sensitivity was 60  and specificity 70   with a positive predictive value of 38  and negative predictive value of 90   only 11  of studies revealed a pyogenic cause for puo  these results are discussed and the potential role of gallium scanning in puo is raised  
class1	surgical presentation of kawasaki disease  mucocutaneous lymph node syndrome   five patients with kawasaki disease  mucocutaneous lymph node syndrome  are reported whose varied presentations included acute abdominal pain  peripheral arterial aneurysms  digital gangrene and sterile pyuria and whose presenting pathology ranged from hydrops of the gallbladder to enteric pseudo obstruction  as the complications of the disease can usually be managed without resort to surgery  which is associated with a mortality rate of up to 25 per cent  the recognition of kawasaki disease will prevent hazardous and unnecessary laparotomy  
class1	new isotopic technique for detecting prosthetic arterial graft infection  99mtc hexametazime labelled leucocyte imaging  early and accurate detection of prosthetic arterial graft infection is important because this serious complication of vascular surgery carries high morbidity and mortality rates  this report describes the use of a new method of isotopic imaging to detect graft infection using 99mtc hexametazime labelled leucocytes  seventeen patients with potentially infected arterial grafts were imaged in addition to routine investigations but were managed according to our normal surgical practice  99mtc imaging was positive in eight patients with proven graft infection and falsely positive in one patient with a groin haematoma  89 per cent specificity   there were no false negatives  100 per cent sensitivity  after an average follow up of 6 months  range 3 9 months   this technique has proved a reliable and rapid method of confirming graft infection  
class1	post cannulation radial artery aneurysm  a rare complication  the following case report describes an expanding aneurysmal dilatation of the radial artery which developed 17 days following cannulation  possible causes of this complication are  abnormal state of the vessel wall  multiple attempts at cannulation  and haematoma or infection at cannulation site  other major and minor sequelae following arterial cannulation are reviewed  
class1	widespread dermatophyte infections that mimic collagen vascular disease  this article reports the cases of two patients in whom a widespread dermatophyte infection mimicked the cutaneous lesions of their underlying collagen vascular disease  griseofulvin may be associated with an increased incidence of adverse cutaneous reactions in patients with systemic lupus erythematosus  one patient with systemic lupus erythematosus developed erythema multiforme after taking griseofulvin  
class1	parents  vs physicians  utilities  values  for clinical outcomes in potentially bacteremic children  our previous analyses of decision strategies in children 3 24 months with acute onset fever greater than or equal to 39 degrees c and no evident bacterial focus of infection indicated that the risks of routine blood cultures  the unnecessary hospitalization and treatment of children who clear their bacteremia spontaneously  outweigh its benefits  the prevention of a few cases with major infectious sequelae   because those analyses were based on parents  values for beneficial and adverse clinical outcomes  we wished to examine whether those values differed in physicians and  if so  whether the differences were sufficient to change the results of the decision analysis  using a pre tested linear analog utility  value  scale  we evaluated eight potential clinical outcomes in potentially bacteremic children by surveying 121 parents of healthy 3 24 month old children attending a private pediatric group practice and 57 attending physicians of a tertiary care children s hospital emergency room  utilities were based on a 0 1 normalization  where 0 is the utility of the worst outcome  meningitis or other major bacterial infection  plus venipuncture   and 1 the utility of the best outcome  complete recovery without venipuncture or hospitalization   and were analyzed using a recently developed statistical model of utility  the majority of parents and physicians combined the imputed components of the outcomes  disease  pain of venipuncture  and stress of hospitalization  in a nonlinear fashion  parents assigned substantially lower utility  i e  greater disutility  to venipuncture  minor infection  and hospitalization than did physicians  and these utilities were even lower in parents with other children at home  
class1	low gastric acid as a risk factor for cholera transmission  application of a new non invasive gastric acid field test  although gastric acid is thought to be an important host defense against certain enteric infections  field studies of the role of gastric acid in preventing enteric infections have been hampered by the lack of a suitable non invasive test  because low gastric acid output  gao  is an established risk factor for cholera  we assessed after validation  whether a new non invasive test which estimates gao by measuring breath hydrogen excess after ingestion of magnesium and a stimulant of gastric acid secretion  could discriminate between persons at high and at low risk of developing cholera  fifteen age matched pairs  participants in the field trial of two oral cholera vaccines in rural bangladesh  were tested  in each pair the  case  was a person who had recovered from severe cholera at least 6 months before testing and the  control  was a person who resided in the home of a cholera patient but remained uninfected  the stimulated breath hydrogen was higher in controls  median hydrogen excess   369 mumol 80 min  than in cases  median hydrogen excess   150 mumol 80 min   p less than 0 05  and was higher in controls in 12 out of 15 pairs  the results  which are consistent with past invasive assessments of the association between hypochlorhydria and cholera  suggest that this non invasive test may be useful in evaluating gao in epidemiological field studies  
class1	tampon absorbency  composition and oxygen content and risk of toxic shock syndrome  tampon use has been identified as a major risk factor for toxic shock syndrome  although the etiologic role of tampons is not clearly understood  two epidemiologic studies conducted to date have reported an association between tampon absorbency and risk of toxic shock syndrome  this finding is not corroborated by laboratory studies  however  which have suggested that absorbency may be a marker for other characteristics that create an environment conductive to the elaboration of toxic shock syndrome toxin 1  we used data from the previously reported tri state study to estimate simultaneously the effects of tampon oxygen content  absorbency and chemical composition  although the data are sparse  oxygen content was more strongly associated with risk of toxic shock syndrome than either absorbency or chemical composition  the results suggest that it may be possible to develop a highly absorbent tampon that is not associated with a high risk of toxic shock syndrome  
class1	castanospermine vs  its 6 o butanoyl analog  a comparison of toxicity and antiviral activity in vitro and in vivo  inhibitors of glycoprotein processing  such as castanospermine  1 6 7 8 tetrahydroxyoctahydroindolizine   have been shown previously to inhibit human immunodeficiency virus type 1  hiv 1  with acceptable toxicity in cultured human cells  in prior experiments  we have tested the toxicity and antiviral efficacy of castanospermine in mice infected with the rauscher murine leukemia virus  rlv   when compared with 3  azido 3  deoxythymidine  azt  zidovudine   castanospermine was less effective and more toxic  since the 6 o butanoyl analog of castanospermine was previously found to have a more favorable activity profile than the parent compound against hiv 1 in cultured cells  we compared the antiviral efficacy of both compounds in parallel in vitro and in vivo in the rlv system  plaque formation in the xc assay was inhibited with a 50  inhibitory concentration  ic50  of 2 4 microm for the 6 o butanoyl analog of castanospermine  as compared to 9 microm for castanospermine  for both compounds  concentrations resulting in significant cytotoxicity were about ten times higher  both compounds significantly decreased hiv 1 env induced syncytium formation in a novel in vitro assay  in rlv exposed mice  the 6 o butanoyl analog showed no advantage over the parent compound  both curves for toxicity as well as antiviral efficacy were super imposable  we conclude that the 6 o butanoyl analog of castanospermine as well as castanospermine itself are active antiviral agents in mice and that prolonged oral administration is tolerable  however  in comparison to azt  their antiviral activity profiles are less favorable  
class1	prevention of a false diagnosis of sexually acquired reactive arthritis by synovial lymphocyte responses  three cases are reported in which a diagnosis of sexually acquired reactive arthritis might have been made erroneously from the history  but the enteric origin of the reactive arthritis was evident from synovial lymphocyte responses  the importance of making the correct diagnosis and the avoidance of unwarranted spousal dysharmony is stressed  
class1	pyogenic sacroiliitis in a rural population  we describe 10 cases of pyogenic sacroiliitis occurring in a rural population  seven were male and 3 were female with a mean age of 22 4 years  none was a recent intravenous drug abuser  five patients had a history of recent pelvic trauma  99mtechnetium scintiscans revealed increased sacroiliac  si  joint uptake in 8 of 8 cases  blood cultures were positive in 60  of patients  staphylococcus aureus was isolated in 7 cases from blood and or si aspirates and hemophilus influenzae type b in one case  nine of 10 patients recovered completely  one underwent arthrodesis for recurrent si pain without evidence of relapse of infection  median followup was 18 months  
class1	sternocostoclavicular hyperostosis  two cases with differing dermatologic syndromes  sternocostoclavicular hyperostosis is a rare rheumatic condition characterized by ossification and erosion of the clavicle and the first rib  that has been shown to be associated with pustular skin lesions  we present 2 cases  one of which had features of pustulosis palmaris et plantaris and the other dissecting cellulitis of the scalp  although the dermatologic manifestations differ  both cases have rheumatologic and roentgenographic features diagnostic of sternocostoclavicular hyperostosis  
class1	yersinia enterocolitica tenosynovitis  the first case  we describe a case of tenosynovitis of tibialis posterior due to yersinia enterocolitica occurring after injury by a plant thorn in a 55 year old man  the illness was chronic with 2 recurrences in spite of antibiotic treatment  full recovery was obtained only after surgical intervention  our patient s chronic course was fostered by the persistence of thorn fragments in the infected area and the exceptionally pathogenic character of the isolated colony of yersinia  
class1	septic streptococcus milleri spondylodiscitis  we describe 2 patients presenting lumbar spondylitis due to streptococcus milleri  in both cases origin was related to preexistent intestinal pathology  surgical drainage of a collection of pus was necessary in one case  longterm antibiotic therapy led to full recovery  despite confused nomenclature streptococcus milleri must be considered a serious pathogen mainly associated with purulent infection with osteoarticular affinity  
class1	development and potential use of antibody directed against lipopolysaccharide for the treatment of gram negative bacterial sepsis  gram negative bacterial sepsis remains a major cause of lethality in hospitalized patients  despite routine therapy consisting of antimicrobial agents  hemodynamic monitoring and fluid resuscitation  and metabolic support  because a large body of evidence supports the concept that gram negative bacterial lipopolysaccharide  endotoxin  lps  is responsible for many of the direct and host mediator induced deleterious effects  recent work has been centered on the development and use of anti lps antibody preparations in order to ameliorate lethality  both polyclonal and monoclonal antibody preparations directed against the common deep core lipid a region of lps are cross reactive in vitro and cross protective in vivo against a wide range of challenge organisms and lps  and preliminary clinical trials indicate that a reduction in lethality may be possible  the precise endotoxin epitope against which antibody should be directed in order to maximize protection  however  has not been established  this modality most probably will become a standard form of adjunctive therapy within the next several years for the treatment of gram negative bacterial sepsis  
class1	the systemic septic response  concepts of pathogenesis  following resuscitation from shock  the clinical phase of persistent hypermetabolism is entered from which a substantial number of patients transcend into progressive organ failure and expire  the available epidemiologic  physiologic  and metabolic data are consistent with the position that a persistent degree of microcirculatory hypoxia  although it may be present in amounts that are below the sensitivity of current detection systems  becomes an increasingly less important etiologic factor as the organ failure disease progresses  rather  aerobic metabolism appears to be the dominant mechanism of meeting the increased work loads and energy demands  there is an increasing body of evidence that cytokine release systemically  and increased cell cell interaction through cytokines and prostanoids locally  may alter not only parenchymal function in the proximity of these mononuclear cells  but organ function at distant sites  if this latter hypothesis continues to be substantiated  it implies that the underlying cell and organ dysfunction may indeed be reversible if appropriate counter regulatory mechanisms could be developed and the appropriate timing of their application understood  
class1	altered ca2  homeostasis and functional correlates in hepatocytes and adipocytes in endotoxemia and sepsis  decreased cytosolic  ca2   and impaired ca2  release in response to an ip3 challenge are among perturbations in hepatocyte ca2  homeostasis associated with endotoxemia and sepsis  these changes are consistent with the accompanying alterations in appropriate physiologic functions  e g   activation of glycogen phosphorylase and gluconeogenesis  mediated by  ca2  c and defective phosphorylation of relevant enzymes  attenuation of ip3 binding to the subcellular fractions that are imputed to be targets of ip3 and a decrease in the size of the ip3 sensitive pool of releasable ca2  are underlying components of the mechanism of the reduced ca2  release upon ip3 stimulation and its metabolic sequelae  et treatment leads to a significant increase in ca2  associated with the cell surface compartment of adipocytes  a reduction in 45ca2  uptake by endoplasmic reticulum and higher cytosolic  ca2   under basal conditions and upon acth stimulation than that observed in cells of control rats  the reduced 45ca2  uptake is also manifest in adipocytes of septic rats  alterations in adipocyte metabolism induced by et include increased oxidation of glucose to co2  an insulin like effect  and increased lipolysis upon ne and acth stimulation  
class1	aberrations in post trauma monocyte  mo  subpopulation  role in septic shock syndrome  appearance of increased proportions of monocytes bearing the 72kd fcri  receptor for igg correlated to aberrant monocyte  mo  functions  depressed immune functions  and poor clinical outcome  the trauma patients  fcri  mo subpopulation produced the majority of their elevated il 6  tnf alpha  tgf beta  and pge2  igg stimulation of patients  mo through fcri not only stimulated tnf alpha  il 6  and pge2 levels  but also greatly augmented the levels of these monokines produced after subsequent bacterial challenge  post trauma increased il 6 levels can lead to polyclonal b cell activation and high levels of circulating  nonspecific igg as seen in trauma patients  this nonspecific igg triggers the fcri on the increased numbers of fcri  mo leading to ever increasing monokine levels  il 4 was found to downregulate patients  fcri  mo production of mediators  the cycle of altered cytokine levels  increased fcri  mo numbers  elevated igg  and augmented triggering of fcri  mo may be broken by addition of il 4  
class2	abnormal differentiation of human papillomavirus induced laryngeal papillomas  we studied the proliferation and differentiation of human laryngeal papillomas  which are benign tumors induced by human papillomaviruses  immunofluorescent stains of tissues for a number of differentiation specific proteins showed abnormal differentiation  papilloma tissue fragments in vitro showed a slightly decreased fraction of proliferating cells that incorporated tritiated thymidine and a markedly reduced incorporation of tritiated uridine when compared with normal tissue  we propose that papillomavirus infection results in normal basal cell proliferation but abnormal terminal differentiation and that this abnormality significantly contributes to the hyperplasia of the papillomas  
class2	laser photodynamic therapy for papilloma viral lesions  photodynamic therapy was tested for its therapeutic efficacy in eradicating rabbit papilloma warts  the wild type viral warts suspension was used to induce treatable papilloma warts in the cutaneous tissue of dutch belted rabbits  the photosensitizing agents used intravenously were photofrin ii at 10 mg kg of body weight and chlorin e6 monoethylene diamine monohydrochloric acid  chlorin e6 med hcl  at 1 mg kg of body weight  the lasers used were an argon dye laser at 628 and 655 nm and a gold vapor laser at 628 nm  the irradiances of 25 to 180 mw cm2 were applied topically with an end on lens optical fiber with total radiant doses of 7 5 to 54 j cm2  photofrin ii and the argon dye laser at the highest light dosage  54 j cm2  and chlorin e6 monoethylene diamine monohydrochloride administered 2 hours before argon dye laser irradiation at 655 nm at the highest light dosage  54 j cm2  produced wart regression  total wart regression without recurrence was achieved with photofrin ii and the gold vapor laser at all light dosages  the difference observed between the argon dye laser and the gold vapor laser might be explained by the pulsed nature of the gold vapor laser  with its high peak powers  some 5000 x the average measured light dose  in this model  the smaller  less cornified lesions were more effectively treated with photodynamic therapy  
class2	influenza infection and diabetes mellitus  case for annual vaccination  herein  epidemiological data on influenza pneumonia and mortality  results of clinical studies  and the outcome of influenza vaccination trials are reviewed  all excess mortality studies that specify for underlying disease list diabetes as one of the major risk factors  during influenza epidemics  death rates among patients with diabetes mellitus may increase by 5 15   diabetes mellitus is also mentioned as a risk factor in most clinical studies  making up 3 14  of the patients studied  even in recent studies  diabetes mellitus is only preceded as a risk factor by cardiovascular disease and chronic pulmonary disorders  to what extent cardiovascular disease and old age contribute to the increased influenza mortality and morbidity in diabetic patients remains unclear  the influence of epidemic influenza on the incidence of diabetic acidosis in combination with an impaired immune response to both staphylococcus aureus and the influenza virus suggests that diabetes mellitus itself is the main risk factor  it is concluded that all patients with diabetes mellitus should receive annual vaccinations and that  in official recommendations  patients with diabetes mellitus should be mentioned as a separate risk group  whole virus vaccines are preferred over subunit vaccines  
class2	disseminated cutaneous herpes zoster following cardiac surgery  our case report describes disseminated cutaneous herpes zoster in the early post operative period following cardiac surgery with cardiopulmonary bypass  this has not been reported previously in the absence of immunosuppressive therapy  despite associated neurologic and respiratory impairment  our patient was treated successfully with intravenous acyclovir and subsequently discharged  
class2	oligoclonal t cell receptor gene rearrangements in blood lymphocytes of patients with acute epstein barr virus induced infectious mononucleosis  gene rearrangement studies were performed on blood lymphocytes from eight patients with acute epstein barr virus induced infectious mononucleosis  the diagnosis in each case was based on characteristic clinical  hematologic  and serologic findings  the blood lymphocytes in each patient consisted predominantly of cd8  t cells  ebv dna was detected in seven patients by southern blot analysis  ebv bam hi w probe  bam hi   a germline configuration was found for the immunoglobulin heavy and light chain genes  jh probe  bam hi and eco ri  c kappa probe  bam hi  and c lambda probe  eco ri   t cell receptor gene rearrangements were detected with j gamma and j beta 1   2 probes  using a j gamma probe with two different restriction enzymes  bgl ii and eco ri   the blood from each patient showed several bands corresponding to the polyclonal pattern previously described in the blood of normal individuals  using j beta 1   2 probes with two different restriction enzymes  bgl ii and bam hi   each case showed from 3 to about 12 extragermline bands of varying intensity and in different locations from case to case  in addition  each case showed relative deletion of the j beta 1 germline band  this oligoclonal pattern of t cell receptor gene rearrangements has not been previously reported in benign or malignant t cell populations  
class2	cutaneous lesions of disseminated histoplasmosis in human immunodeficiency virus infected patients  disseminated histoplasmosis is being diagnosed more frequently in persons infected with the human immunodeficiency virus and is often the initial manifestation of the acquired immunodeficiency syndrome  aids   disease related cutaneous features of hiv associated disseminated histoplasmosis are defined as mucocutaneous lesions from which fungal organisms were either cultured or demonstrated histopathologically  we report four hiv seropositive patients with disseminated histoplasmosis who had culture positive skin or oral lesions of histoplasmosis and review the specific cutaneous manifestations of hiv associated disseminated histoplasmosis  including our patients  disease related skin and or mucosal lesions were present in 11  of patients  26  of 239  with hiv associated disseminated histoplasmosis  the possibility of disseminated histoplasmosis should be considered in all hiv infected persons and in persons with aids risk factors who have fever  weight loss  hepatosplenomegaly  and new cutaneous lesions  an early skin or mucosal biopsy specimen for crushed tissue preparation  histologic evaluation  and fungal culture is a simple  rapid diagnostic procedure  
class2	itraconazole in opportunistic mycoses  cryptococcosis and aspergillosis  striking results were obtained with oral itraconazole therapy in two opportunistic mycoses  of 28 patients with cryptococcal meningitis  18 achieved complete responses  including 16 of 24 patients with acquired immunodeficiency syndrome  other manifestations of cryptococcosis were similarly responsive  in aspergillosis 12 of 15 patients responded  including 8 of 10 immunocompromised hosts  these patients included those with invasive pulmonary disease  4 5   skeletal disease  2 2   pleural disease  1 2   and pericardial  sinus  mastoid  hepatosplenic  or nail disease  1 1   these results with itraconazole compare favorably to conventional  parenteral  therapy  and toxicity was minimal  this suggests that comparative trials are now in order  
class2	itraconazole therapy in aspergillosis  study in 49 patients  itraconazole  200 to 400 mg once daily  was administered to 49 patients with different types of aspergillosis  pulmonary aspergilloma  14 patients   chronic necrotizing pulmonary aspergillosis  14   and invasive aspergillosis  21   itraconazole was prescribed alone or in combination or after treatment with amphotericin b and flucytosine  of 14 aspergilloma patients  2 were cured and 8 had symptomatic improvement  in chronic necrotizing pulmonary aspergillosis  7 of 14 patients were cured and 6 improved significantly  in invasive aspergillosis treatment failed in 6 patients and 15 were cured  itraconazole can be an alternative to amphotericin b in the treatment of invasive aspergillosis and chronic necrotizing pulmonary aspergillosis  in aspergilloma itraconazole may be useful in inoperable cases  
class2	assessing the risk of occupational acquisition of the human immunodeficiency virus  implications for hospital policy  in determining infection control policy  it is essential to quantitatively assess the risk of transmission of human immunodeficiency virus  hiv  to health care workers and their families  the risk should be placed in perspective by comparing it with other occupational hazards  the risk of seroconversion from a needlestick injury can be calculated from the probability of a needlestick occurrence  the probability that the source patient is infected  and the probability of seroconversion  given an exposure  the risk of seroconversion due to drawing 1000 blood specimens from seropositive patients is between 86 and 470 in 100 000  the risk to surgeons from performing 25 operations on infected patients is approximately 272 in 100 000  the risk of fatal injury in the course of one year s work on a louisiana oil rig is between 188 and 283 per 100 000  
class2	cytomegalovirus induced osteomyelitis in a patient with the acquired immunodeficiency syndrome  a 43 year old man with aids had a periodontal abscess  no fever  and normal findings on funduscopic examination  three months later  the abscess area was debrided  and histologic examination of the tissue revealed osteomyelitis of the mandible  within the area of osteomyelitis were numerous cells with inclusions typical of cytomegalovirus  cmv  infected cells  funduscopic examination at that time revealed extensive cmv retinitis  osteomyelitis should be added to the list of infections caused by cmv in patients with aids  
class2	risk factors for white matter changes detected by magnetic resonance imaging in the elderly  we found increased age  p   0 001  and history or evidence of stroke  p   0 016  to be significant independent multivariate predictors of the presence and severity of leukoencephalopathy on magnetic resonance imaging brain scans in a mixed population of 35 elderly psychiatric patients and 25 neurologically healthy elderly volunteers  these results suggest that subcortical ischemia  as well as age related changes that may not be vascular in origin  contribute to the emergence of periventricular and other deep white matter hyperintensities that are commonly seen on the magnetic resonance imaging brain scans of older adults  
class2	isolation of measles virus in primary rhesus monkey cells from a child with acute interstitial pneumonia who cytologically had giant cell pneumonia without a rash  the isolation of measles virus in primary rhesus monkey kidney cells  prmk  in patients with documented giant cell pneumonia who have presented without a rash is limited  the diagnosis usually is made by cytologic examination of nasal or bronchial secretions in which characteristic multinucleated giant cells with intranuclear and intracytoplasmic inclusion bodies are observed  the diagnosis of giant cell pneumonia has been associated with measles virus but not exclusively  canine distemper  herpes group viruses  and parainfluenza infections have been associated with these cells  in addition  vitamin a deficiency also has been cytologically associated with multinucleated giant cells  the authors describe the isolation of measles virus from bronchial washing and sputum in prmk cells at 4 days from an 11 year old child with acute interstitial pneumonia who was in remission for acute lymphocytic leukemia  classic cytopathologic effect  cpe  consisting of syncytial and hole formation on the prmk monolayer was apparent  in addition  a foamy appearance of the monolayer was noted in an otherwise clean lot of monkey cells  confirmatory testing with measles antibody of the infected areas of the monolayer by indirect immunofluorescence  ifa  was positive for measles antigen and negative for mumps  parainfluenza  types i  ii  and iii  and influenza a and b virus  serologic studies for measles antibody revealed an ifa igg titer of greater than 1 10 240  and an igm titer of 1 128  cytologic examination of the same bronchial fluid revealed the typical giant cells with characteristic inclusions associated with measles virus  because this disease usually is severe  and often fatal  prompt recognition of this virus is essential  not only to the patient  who can be treated with immunoglobulin and or antiviral therapy  but also to prevent the spread of the virus to other patients and medical personnel  these findings also support direct evidence for the etiologic role of measles virus in giant cell pneumonia that has been detected either histologically or cytologically and in tissue culture at autopsy  
class2	disseminated  nonmeningeal gastrointestinal cryptococcal infection in an hiv negative patient  gastrointestinal cryptococcosis is extremely rare  especially in patients with no involvement of the central nervous system  we describe a 63 yr old man undergoing prednisone therapy for chronic hepatitis and cirrhosis who presented with peritonitis  colitis  and skin lesions  pathological studies revealed necrosis and numerous cryptococcal organisms in the colon  omentum  and skin  and cultures yielded cryptococcus neoformans  the patient died of multisystem organ failure following emergency exploratory surgery performed when he had onset of symptoms of a bowel perforation after an endoscopic biopsy  clinicians should be aware that gastrointestinal cryptococcosis can occur in the absence of infection of the central nervous system or lungs  and that it may affect relatively healthy patients who are immunocompromised because of splenectomy  chronic liver disease  or steroid therapy  
class2	sexually transmitted diseases and human immunodeficiency virus infection among women with pelvic inflammatory disease  both human immunodeficiency virus infections and pelvic inflammatory diseases are sexually acquired illnesses of great consequence to women  this study was undertaken to determine if women hospitalized with pelvic inflammatory disease  in a community endemic for human immunodeficiency virus  were at high risk to be infected with human immunodeficiency virus and if human immunodeficiency virus infections altered their hospital course  one hundred ten women hospitalized with pelvic inflammatory disease in brooklyn  in a hospital in which 2  of parturients are human immunodeficiency virus seropositive  agreed to human immunodeficiency virus testing  15  13 6   were found to be seropositive  seropositive women were significantly more likely to have an admission white blood cell count less than 10 000 mm3  p   0 001   human immunodeficiency virus seropositivity was not associated with a higher frequency of other sexually transmitted diseases although there was a trend toward more cases of syphilis among human immunodeficiency virus infected women  similarly  although there was no significant difference in rates of operative intervention  26 6  among seropositive and 8 4  among seronegative  p   0 058   there was a trend toward more surgery among those who were human immunodeficiency virus infected  women hospitalized with pelvic inflammatory disease  in a community endemic for human immunodeficiency virus  are at high risk for human immunodeficiency virus infection  more research is needed to verify a trend toward more refractory infections among human immunodeficiency virus infected women  
class2	high infectious morbidity in pregnant women with insulin dependent diabetes  an understated complication  patients with insulin dependent diabetes are prone to infection  possibly related to poor metabolic control  relative immune deficiency exists in pregnancy  we hypothesized that pregnant patients with insulin dependent diabetes are at an increased risk for infection and that infection is related to poor glycemic control  we matched 65 pregnant women with insulin dependent diabetes to 65 nondiabetic pregnant controls  at least one episode of infection before delivery occurred in 83  of the women with insulin dependent diabetes  26  in control group   the rate of postpartum infection was five times higher in the group with insulin dependent diabetes and they were susceptible to more kinds of infections  although there was no overall difference among the indices of glycemic control  hemoglobin a1 obtained before the infection was higher than during infection  we conclude that a high rate of infection exists in pregnant women with diabetes  infection and poor glycemic control may be associated  but it is unclear whether improvement in metabolic control will reduce this high infection rate  
class2	the use of in situ hybridization to show human papillomavirus deoxyribonucleic acid in metastatic cancer cells within lymph nodes  southern blot hybridization has been used to identify human papillomavirus types in both primary tumors and lymph node metastases  however  this technique requires fresh frozen tissue and is incapable of localizing deoxyribonucleic acid sequences to specific cell types in the tumor sample  in contrast  in situ hybridization precisely locates viral sequences within tumor cells while preserving cellular architecture  further  in situ hybridization requires only small samples of formalin fixed  paraffin embedded tissues  five lymph nodes  from four patients  containing metastatic cervical squamous tumor cells  identified with hematoxylin and eosinophil staining  were analyzed with in situ hybridization techniques with human papillomavirus type 16 deoxyribonucleic acid probes labeled with sulfur 35  the primary cervical cancer from all four patients had been shown to contain human papillomavirus type 16 sequences by southern blot  three specimens from two patients clearly showed the presence of human papillomavirus type 16 sequences within the nuclei of metastatic tumor cells  whereas two specimens were nondiagnostic most likely as a result of the small volume of cancer relative to the size of the lymph node  this information indicates that it is the tumor cells themselves that contain viral deoxyribonucleic acid and provides additional evidence linking human papillomavirus with cervical carcinogenesis  
class2	rapidly progressive outer retinal necrosis in the acquired immunodeficiency syndrome two patients  both seropositive for the human immunodeficiency virus  developed rapidly progressive retinal necrosis associated with a systemic herpes zoster infection  the retinitis in these patients was characterized by primary involvement of the outer retina  with sparing of the inner retina and retinal vasculature until late in the disease process  a rapidly progressive course  poor response to intravenous acyclovir  and development of rhegmatogenous retinal detachment  in one of the patients  the retinitis was initially multifocal  electron microscopy of a retinal biopsy specimen from one of the patients demonstrated virus particles consistent with a herpesvirus  and polymerase chain reaction disclosed herpesvirus in a retinal biopsy specimen of the other patient  this entity may represent a distinct form of acute retinal necrosis that is seen in immunocompromised individuals  
class2	perturbation of differentiated functions during viral infection in vivo  in vivo relationship of host genes and lymphocytic choriomeningitis virus to growth hormone deficiency  retarded growth and disordered glucose metabolism secondary to growth hormone  gh  deficiency are associated with persistent lymphocytic choriomeningitis virus  lcmv  infection of gh producing cells in the anterior lobe of the pituitary gland  infected c3h st mice  which are h 2k haplotype  become gh deficient  and lcmv replicates in most  more than 90   of their gh producing cells  in contrast  balb wehi and swr j mice  which are h 2d and h 2q  respectively  do not develop this gh deficiency  and less than 20  of their gh producing cells are infected by virus  yet all three strains infected at birth with lcmv strain armstrong  arm  carry equivalent amounts of virus in their blood  brain  heart  kidney  liver  spleen  and thymus throughout life  of five additional h 2k murine strains tested  c3h hej and cba n mice develop this gh like disorder  whereas neither akr j  b10 br  nor balb kae mice do  indicating that the h 2k haplotype does not control the gh susceptibility  furthermore c3h sw mice  which have the h 2b haplotype on the c3h background  develop the disease  again negating any correlation with h 2k but inferring that the c3h background is responsible  one half of the hybrid offspring produced by crossing the c3h st gh deficient strain with balb wehi resistant mice develop the disease  but the trait is not sex linked  f1 hybrid backcrosses with the susceptible c3h st parental strain or resistant balb wehi strain indicate the involvement of more than two genes  hence the development of a gh deficiency by lcmv infected c3h st mice is not linked to the mhc haplotype  is not sex linked  and is not due to a dominant gene  multiple genes are involved and these are related to c3h background  
class2	central airway obstruction due to cytomegalovirus induced necrotizing tracheitis in a patient with aids  cytomegalovirus  cmv  infection in patients with the acquired immunodeficiency syndrome  aids  can present as either disseminated disease  pneumonitis  retinitis  gastroenteritis  neuropathy  or a subclinical infection  we report a patient whose initial manifestation of cmv infection was severe central airways obstruction due to necrotizing tracheitis  at bronchoscopy  the lesion appeared deeply ulcerated  distinctly different from previously described airway lesions in patients with aids  mucosal biopsies showed characteristic intranuclear and intracytoplasmic inclusions and cultures yielded only cmv  the patient responded partially to ganciclovir  steroids  and antibiotics against suspected anaerobic superinfection but died as a result of central nervous system disease believed due to toxoplasmosis or lymphoma  cmv infection of the upper airway should be considered in the patient with aids presenting with atypical cough or stridor and ulcerated endobronchial lesions  
class2	spontaneous splenic rupture following infectious mononucleosis  four cases of spontaneous splenic rupture after infectious mononucleosis  im  have been treated at this institution since 1978  the condition is rare  occurring in 0 1 0 5 per cent of patients with proven infectious mononucleosis  splenectomy is considered the treatment of choice for these patients  however  because recent trends in the management of traumatic splenic rupture are moving towards nonoperative treatment with selected patients  a similar approach has been considered for the patient with spontaneous splenic rupture following im  the major reason for avoiding splenectomy is the increased incidence of sepsis in splenectomized patients  yet  splenic rupture is accompanied by hemorrhage and the risks associated with blood transfusion for ongoing hemorrhage are of similar magnitude as those of sepsis following splenectomy  in addition  the grossly abnormal spleens seen at operation tend to include large  contained hematomas that may also be prone to rupture  therefore  operative management still appears to be the preferred treatment for spontaneous splenic rupture following im  splenectomy is curative  safe  and obviates the need for transfusion  extended hospitalization  and activity restriction  
class2	suppression of herpes simplex virus type 1 reactivation from latency by      9    z  2  hydroxymethyl cyclohexyl methyl  guanine  l 653 180  in vitro  latent herpes simplex virus type 1  hsv 1  infection was induced in human embryonic lung cells in vitro by using a combination of viral replication inhibitors and elevated temperature  under reactivating conditions  superinfection by human cytomegalovirus or temperature manipulation   a nonantiviral thymidine kinase inhibitor  l 653 180  was found to suppress or delay reactivation of hsv 1 from latently infected human embryonic lung cells  l 653 180 alone or in combination with interferon was ineffective as a primary or acute viral replication inhibitor and was unable to induce latent hsv 1 infection in cell culture  these data suggest that initial or acute virus replication and replication resulting from reactivation from latency are separate events  
class2	treatment of adult chickenpox with oral acyclovir  thirty one late adolescents and adults with varicella were studied  patients identified within 72 hours of varicella exanthem were offered open treatment with acyclovir  4 g d   and those patients identified after 72 hours of exanthem were followed up but not treated  twenty two patients were treated with acyclovir  nine patients were not treated  no severe complications occurred in any of the 31 patients  minor complications  including prolonged fever  localized secondary infections  persistent cough  and prolonged fatigue were more frequent in the untreated group  if the acyclovir therapy was begun within the first 24 hours of varicella exanthem  then the rash and clinical illness were dramatically lessened  treatment with oral acyclovir should be considered for varicella in adults who are identified within the first 24 hours of exanthem  
class2	sensitivity and specificity of various morphological features of cervical condylomas  an in situ hybridization study  fifty seven cervical biopsy specimens or endocervical curettings showing condyloma  changes suggestive of condyloma  or no changes of condyloma were analyzed for presence of nuclear atypia  nuclear enlargement and irregularity in superficial epithelium   presence of multinucleated cells  and presence of perinuclear cytoplasmic clearing in superficial squamous epithelium  the findings were correlated with results of in situ hybridization with biotin labeled human papillomavirus dna probes  moderate nuclear atypia was significantly more specific than perinuclear cytoplasmic clearing and 100  sensitive for predicting cases positive for human papillomavirus  of the various morphological features analyzed  perinuclear cytoplasmic clearing had the lowest specificity for predicting positive results on in situ hybridization  
class2	no evidence for human t cell leukemia virus type i or human t cell leukemia virus type ii infection in patients with multiple sclerosis  the involvement of human t cell leukemia viruses  htlvs  in the pathogenesis of 18 hungarian patients with multiple sclerosis was investigated  no antibody to htlvs could be detected in any of the patients  furthermore  using polymerase chain reaction under highly sensitive conditions  neither htlv i dna nor htlv ii dna could be noted in peripheral blood lymphocytes of the patients  our data do not support a causal association of htlv i or htlv ii with multiple sclerosis  
class2	failure to detect human t cell leukemia virus related sequences in multiple sclerosis blood  we tested 11 patients with multiple sclerosis for the presence of human t cell leukemia virus type i  htlv i   or type ii  htlv ii  related sequences  dna from blood mononuclear cells was analyzed by the polymerase chain reaction utilizing three different oligonucleotide primer pairs  two of these primer pairs detect sequences shared between htlv i and htlv ii in either p24  gag protein  or in p21  env transmembrane protein  the third primer pair was synthesized based on regions in the pol gene where amino acid sequences are conserved between htlv i  htlv ii  and the related bovine leukemia virus  the multiple sclerosis samples were consistently negative while appropriate control samples were positive  we conclude that viruses related to htlv i  htlv ii  or bovine leukemia virus are not present in the blood of patients with multiple sclerosis and  therefore  that htlv bovine leukemia virus related viruses are not likely to be involved in the pathogenesis of multiple sclerosis  
class2	characterization of a macrophage tropic hiv strain that does not alter macrophage cytokine production yet protects macrophages from superinfection by vesicular stomatitis virus  macrophages  unlike cd4  t cells  can be productively infected by human immunodeficiency virus  hiv  without prior cellular activation  cytopathic infection ensues without the induction of tumor necrosis factor alpha  tnf alpha   interleukin 1 beta  il 1 beta   interleukin 6  il 6   or tissue factor genes  in detailed studies on tnf alpha  hiv infection did not affect the regulation of tnf alpha in response to bacterial lipopolysaccharide  in an effort to examine the interferon responsiveness of hiv infected macrophages  the cells were challenged with vesicular stomatitis virus  vsv  with or without interferon pretreatment  surprisingly  hiv infected macrophages were completely resistant to vsv induced lysis even in the absence of interferon  however  no interferon was detected in the supernatants of these infected cells  the resistance of hiv infected macrophages to superinfection with vsv indicates a previously undescribed effect of hiv upon macrophage cellular metabolism  
class2	role of the monocyte macrophage in influenza virus infection of lymphocytes  implications for hiv infection  knowledge of the pathogenesis of viruses which are less virulent than human immunodeficiency virus  hiv  may provide valuable insights into the pathogenesis of hiv infection  influenza virus  an enveloped rna virus  infects monocyte macrophages  although the infection is brief and abortive  isolated purified lymphocytes are completely resistant to infection  in contrast  mixtures of lymphocytes and macrophages can synthesize all virus proteins  infection requires physical association of monocyte macrophages and lymphocytes in  clusters   these studies with influenza virus suggest that the pathogenesis of virus infections in mixed cell cultures may be very different from that observed in purified cell populations  and they suggest that similar studies should be performed with hiv  
class2	hiv 1 infection of lung alveolar fibroblasts and macrophages in humans  we have studied the infected cell populations in the lungs of four human immunodeficiency virus type 1  hiv 1  seropositive patients suffering from lymphocytic alveolitis or lymphocytic interstitial pneumonitis  adherent cells were obtained by bronchoalveolar lavage  bal  and were analyzed by various technical approaches  the cells considered here were alveolar macrophages and fibroblasts  and could be clearly identified morphologically and by the expression of specific cell surface markers using monoclonal antibodies  the presence of hiv 1 in both of these cell types was established by serological  virological  and molecular procedures  our results show that alveolar macrophages and fibroblasts are naturally infected in the lungs of hiv  patients  both cell types express the cd4 receptor molecule  in contrast to skin fibroblasts which are negative  alveolar macrophages and fibroblasts thus may act as eventual hiv 1 reservoirs in vivo  and are probably involved in the induction of inflammatory reactions because they are targets for cd8 cytotoxic t lymphocytes  ctl   
class2	antibody enhanced infection of monocytes as the pathogenetic mechanism for severe dengue illness  antibody dependent enhancement of certain virus infections can occur in cells expressing fc receptors  this mechanism plays an important pathogenetic role in the development of complications associated with dengue virus infection  including dengue hemorrhagic infection and dengue shock syndrome  the virulence of the virus  characterized by the ability to infect fc receptor bearing monocytes also influences the development of these severe illnesses  
class2	chickenpox chorioretinitis  chickenpox infection in an adult was complicated by peripheral chorioretinitis and treated with oral acyclovir  similarities of this case to the recently proposed mild type of acute retinal necrosis syndrome are discussed  
class2	wegener s granulomatosis presenting during first trimester of pregnancy  we describe a case of wegener s granulomatosis in a lady who presented acutely with pulmonary haemorrhage  fever and breathlessness during her early pregnancy  she responded well to aggressive medical treatment  
class2	an anonymous seroprevalence survey of hiv infection among pregnant women in british columbia and the yukon territory we performed an anonymous seroprevalence survey of human immunodeficiency virus  hiv  type 1 infection through hiv antibody testing of blood samples from 22 512 women aged 15 to 44 years receiving prenatal care in british columbia and the yukon territory from mar  15 to sept  30  1989  of the samples six were confirmed to be hiv positive  this yielded a crude overall seroprevalence rate of 2 7 per 10 000 pregnant women  95  confidence interval  ci  1 0 to 5 8   all of the positive samples were from women 20 to 29 years of age  four were from vancouver  one was from victoria  and one was from elsewhere  the highest seroprevalence rates were among women aged 15 to 29 years in vancouver and victoria  7 2 and 9 4 per 10 000 pregnant women respectively   thus  1 in 1300 pregnant women in that age group in the metropolitan areas of british columbia was hiv positive  application of seroprevalence rates to the total female population in british columbia and the yukon territory revealed that as many as 401 women had hiv infection in 1989  our estimates likely represent the minimum  as a subset of women of childbearing age pregnant women are likely at lowest risk of hiv infection  and so the true number of women 15 to 44 years of age with hiv infection is probably several times higher  our study has provided a baseline assessment and will be repeated annually to analyse trends in hiv seroprevalence among pregnant women in british columbia and the yukon territory  
class2	undiagnosed tuberculosis in patients with human immunodeficiency virus infection we describe the clinical features of 11 patients with human immunodeficiency virus infection in whom tuberculosis was undiagnosed and untreated prior to death  most patients  9 of 11  had pulmonary complaints and 8 of 11 had roentgenographic findings suggestive of tuberculosis  hilar or mediastinal adenopathy  pleural effusion  apical infiltrate or miliary pattern   despite these findings  tuberculin skin tests were not performed in any of the patients  acid fast smears of sputum were obtained in three cases and bronchoscopy performed in only four  reflecting the low index of suspicion for tuberculosis  pneumocystis carinii pneumonia was the presumptive diagnosis in nine cases but was confirmed in only one case  autopsy revealed tuberculosis as the cause of death in four patients  of the seven patients who did not undergo autopsy  disseminated tuberculosis  manifest by mycobacteremia  was the only life threatening illness identified and probably contributed to death  increased awareness of the clinical and roentgenographic features of tuberculosis in hiv infected patients  combined with more intensive use of acid fast smears and tuberculin skin testing  are necessary in order to decrease mortality from this treatable complication of hiv infection  
class2	pulmonary manifestations of disseminated cryptococcosis in patients with aids  forty eight patients with disseminated cryptococcosis and aids were retrospectively studied to define the pulmonary manifestations  cryptococcus neoformans  cn  was first isolated from a pulmonary site in 12 patients  disseminated disease was subsequently documented in all these patients  symptoms and roentgenographic manifestations  normal  nodular circumscribed infiltrates  pleural effusions  lobar consolidation  were diverse  interstitial infiltrates predicted the presence of another opportunistic lung infection besides cryptococcosis in five patients  three untreated and two treated patients   infectious causes other than cryptococcosis were established by culture and clinical course in five of the ten patients who developed chest roentgenographic abnormalities during amphotericin b therapy  endobronchial abnormalities were identified in four patients at bronchoscopy  bronchoalveolar lavage  9 9  and pleural fluid  3 3  cultures were sensitive tests for detection of pulmonary involvement with cn  
class2	infection of mice with lactate dehydrogenase elevating virus destroys the subpopulation of kupffer cells involved in receptor mediated endocytosis of lactate dehydrogenase and other enzymes  in previous experiments in rats  we have shown that the rapid plasma clearance of a number of clinically important enzymes is due to receptor mediated endocytosis by kupffer cells and other resident macrophages  others have shown that infection of mice with lactate dehydrogenase elevating virus  a virus that proliferates in macrophages  leads to reduced plasma elimination of these enzymes  this paper integrates these two sets of experiments  plasma elimination of intravenously injected  radioactively labeled lactate dehydrogenase m4 and mitochondrial malate dehydrogenase in mice was shown to be caused in part by uptake in liver  spleen and bone  uptake of lactate dehydrogenase m4 by these tissues was  to a large extent  saturable and the two dehydrogenases competitively inhibited each other s clearance  these results suggest that  also in mice  these enzymes are partly cleared from plasma by endocytosis by way of a common receptor on cells  probably macrophages  from liver  spleen and bone marrow  morphometrical data showed that normal mouse liver contains 23 x 10 6  kupffer cells cm3  this number was reduced to about 30  of that of controls 24 hr after infection of mice with lactate dehydrogenase elevating virus but returned to normal within the next 9 days  the saturable component of uptake of lactate dehydrogenase m4 by liver  spleen and bone had disappeared 24 hr after infection with the virus  and did not return after the kupffer cell population had recovered  our findings suggest that lactate dehydrogenase m4 is  to a large extent  removed from the circulation by way of a receptor on a subpopulation of macrophages that is permissive for replication of lactate dehydrogenase elevating virus  
class2	transfusion risks  hepatitis remains the most serious transfusion risk  in terms of incidence and severity  transfusion associated aids  hemolytic reactions  trali  and anaphylaxis are severe problems that occur relatively rarely  while febrile reactions and mild allergic reactions are common but not serious  the key to avoiding all these complications is autotransfusion  see the article  autologous transfusion  in this issue   although intraoperative scavenging became available in many centers in the united states in the 1980s  it is hoped that pre deposit autotransfusion will also become widely utilized in the next decade  
class2	chronic encephalitis caused by leukoencephalopathy  as mentioned previously  both ms and pml are demyelinating conditions of the cns and pose diagnostic difficulties in their differentiation because of similarities in their clinical findings  however  certain features unique to each of these diseases are helpful in clinical diagnosis  ms  unlike pml  is a disease of unknown cause  polygenetic influences in combination with exposure to an environmental agent and immune mediated factors may be operative in the pathogenesis of ms  age of onset peaks in the third to fourth decades with a predominance in women  as contrasted with pml  which peaks in the fifth to sixth decades in most non aids associated cases with a slight predominance in men  ms is more prevalent in areas farther from the equator  north america  europe  australia  and new zealand  common initial symptoms seen in ms include bilateral limb weakness  with the legs being affected twice as often as the arms   hyperreflexia  spasticity  optic neuritis  diplopia  incoordination  and paresthesias   paresthesias are typically found in the lower limbs in a symmetric pattern  but may follow no obvious anatomic distribution and often do not correspond to the distribution of sensory symptoms  vibration and position sense are more frequently disturbed than pain and temperature   intellectual impairment and mental deterioration are uncommon early in ms  whereas they are a more frequent initial presentation in pml  in addition  the presence of speech impairment and monoparesis or hemiparesis with homonymous hemianopsia is more suggestive of pml  brain stem involvement is infrequent  
class2	sensitivity of digoxigenin and biotin labelled probes for detection of human papillomavirus by in situ hybridisation  the sensitivity of digoxigenin and biotin labelled dna probes for the detection of human papillomavirus  hpv  by dot blotting and in situ hybridisation was compared in tissues from cervical  laryngeal  and anogenital neoplasia  probes were either labelled with digoxigenin by the random primer technique and detected with anti digoxigenin antibody  or labelled with biotin by nick translation and detected with streptavidin  both methods having a common final visualisation procedure using alkaline phosphatase  digoxigenin labelled probes proved two to 10 fold more sensitive by quantitative dot blotting and four fold more sensitive in detecting hpv 16 dna in a series of 31 anal carcinomas  compared with biotinylated probes  the digoxigenin method also produced less non specific background staining of tissue sections than biotin labelled probes  it is concluded that digoxigenin dna labelling and detection provides a simple  reliable  and efficient alternative to the use of biotin or radioactive isotopes for the detection of hpv dna by in situ hybridisation  digoxigenin labelled probes also offer the possibility of double labelling in situ hybridisation procedures when used with biotin labelled probes to provide simultaneous identification of different dna sequences  
class2	in situ hybridisation with digoxigenin labelled dna probes for detection of viral genomes  the applicability of a recently developed non radioactive dna labelling and detection method  which uses the digoxigenin  dig  enzyme linked immunosorbent assay  elisa  system  for the detection of viral infections in pathology specimens by in situ hybridisation  was examined  its efficacy was compared with that of biotin and radioisotope labelling methods  three cases of progressive multifocal leucoencephalopathy  two of verruca vulgaris  and seven cases of laryngeal papilloma were studied  the sensitivity of the dig labelled probe was almost the same as that of a 35s labelled probe in the dot blot hybridisation test  using in situ hybridisation with 35s labelled and dig labelled probes  the levels of the hybridised signals detected were similar  the biotin labelled probe was less sensitive  particularly in the cases of laryngeal papilloma  the dig labelling and detection method was highly sensitive and applicable to the detection of viral infection by ish  and is preferable to a radiolabelled probe  especially when in situ hybridisation is done in the pathology laboratory  
class2	application of 1 nm gold probes on paraffin wax sections for in situ hybridisation histochemistry  an in situ hybridisation technique that uses 1 nm immunogold reagents and silver enhancement was devised to detect biotinylated dna viral probes in formalin fixed  paraffin wax sections of human cervix  dna probes labelled with biotin 11 deoxyuridine triphosphate were detected after hybridisation to nucleic acid sequences by an antibiotin antibody  followed by a gold labelled secondary antibody  silver enhancement then permitted visualisation of the signal at the light microscopic level  the method was reliable and produced less background staining than previously described methods  the signal could be enhanced by epi polarisation microscopy  furthermore  biotinylated dna probes may be detected directly by a 1 nm gold labelled goat antibiotin antibody without loss of labelling intensity  and this may be preferable to the longer two layer technique  previously described  
class2	use of immunoelectron microscopy to show ebola virus during the 1989 united states epizootic  a filovirus  serologically related to ebola virus  was detected by  post embedment  immunoelectron microscopical examination of ma 104 cells  these had been infected by inoculation with serum samples obtained during the 1989 epizootic in cynomolgus monkeys  macaca fascicularis   imported from the philippines and maintained at reston  virginia  usa  a primate holding facility  the immunoelectron microscopy method  when used in conjunction with standard transmission electron microscopy  tem  of infected cells  provided consistent results and was simple to perform in this epizootic  it is concluded that immunoelectron microscopy is potentially useful in the direct immunological diagnosis of ebola and related filoviral infections  such as marburg  in clinical samples obtained from those with acute infection  
class2	immunocytochemical analysis of lymph node aspirates in patients with human immunodeficiency virus infection  thirty four patients positive for human immunodeficiency virus  hiv  who had lymphadenopathy were investigated using fine needle aspiration  cytological analysis included immunocytochemical investigation with the alkaline phosphatase antialkaline phosphatase  apaap  method  all patients had confirmation of cytological diagnosis by lymph node biopsy  fifteen aspirates with follicular hyperplasia were evaluated  eleven patients showed b cell predominance  the b cell population did not show light chain restriction  ten patients with b cell non hodgkin s lymphoma  five with burkitt s lymphoma and five with b cell immunoblastic lymphoma  were investigated  nine out of 10 cases were monoclonal with respect to their light chain determinants  only one case with burkitt s lymphoma with partial lymph node metastasis did not show light chain restriction  the cytological diagnosis included two mycobacterial infections and four cystic lesions  histological investigation was necessary to diagnose the extent of lymph node disease caused by kaposi s sarcoma  these findings indicate that the immunocytological investigation of lymph node aspirates is useful for evaluating lymphadenopathy in hiv positive patients  
class2	cutaneous horn of the penis  its association with squamous cell carcinoma and hpv 16 infection  cutaneous horns of the penis are rare  including this case  only 19 cases have been reported in the english language literature  in 37  of the reported cases a malignant tumor was found beneath the cutaneous horn  our case is remarkable because a stage i squamous cell carcinoma developed on the shaft of the penis of a neonatally circumcised man  human genital carcinoma resulting from a multifactorial process in which  promoting  papillomavirus is an integral element is being increasingly reported  we review the relationship of circumcision to genital human papillomavirus infection and their synergism in the development of squamous cell carcinoma  
class2	widespread flat warts associated with human papillomavirus type 5  a cutaneous manifestation of human immunodeficiency virus infection  numerous flat and tinea versicolor like warts developed on the face  trunk  and upper extremities of a 10 year old boy with human immunodeficiency virus infection  nucleic acid analysis of involved skin revealed human papillomavirus type 5  which has sometimes been associated with epidermodysplasia verruciformis  this human papillomavirus type has also been described in patients with common variable immunodeficiency and dyskeratosis congenita and in renal allograft recipients  human immunodeficiency virus infection should be added to the list of immune related disorders that predispose to widespread flat warts  
class2	pharmacokinetics of indium 111 labeled antimyosin monoclonal antibody in murine experimental viral myocarditis  the pharmacokinetics of indium 111 labeled antimyosin monoclonal antibody fab were investigated with use of murine experimental viral myocarditis as a model  the biodistribution of indium 111 labeled antimyosin antibody fab on days 3  5  7  14  21 and 28 after encephalomyocarditis virus inoculation demonstrated that myocardial uptake increased significantly on days 5  7 and 14  maximum on day 7  in infected versus uninfected mice  p less than 0 001   in vivo kinetics in infected mice on day 7 demonstrated that the heart to blood ratio reached a maximum 48 h after the intravenous administration of indium 111 labeled antimyosin fab  which was considered to be the optimal time for scintigraphy  the scintigraphic images obtained with indium 111 labeled antimyosin fab demonstrated positive uptake in the cardiac lesion in infected mice  the pathologic study demonstrated that myocardial uptake correlated well with pathologic grades of myocardial necrosis  high performance liquid chromatography revealed the presence of an antigen antibody complex in the circulation of infected mice after the injection of indium 111 labeled antimyosin fab  this antigen bound to indium 111 labeled antimyosin fab in the circulation might be whole myosin and this complex may decrease myocardial uptake and increase liver uptake  it is concluded that indium 111 labeled antimyosin monoclonal antibody fab accumulates selectively in damaged heart tissue in mice with acute myocarditis and that indium 111 labeled antimyosin fab scintigraphy may be a useful method for the visualization of acute myocarditis  
class2	the role of antihistamines in otitis  chronic and recurrent otitis media can manifest as otitis media with effusion  both infection and eustachian tube obstruction  eto  have been found to play an important role in its pathogenesis  eto can be demonstrated during both early  and late phase reactions in patients with allergic rhinitis after intranasal challenge with an allergen  intranasal challenge with either histamine or prostaglandin d2 also provokes eto  with the latter mediator perhaps more potent than the former  middle ear effusions from patients with chronic or recurrent otitis media have been found to contain dramatically increased concentrations of histamine relative to the concentrations in their plasma  the development of nasal and eustachian tube obstruction in allergic rhinitis patients has been prevented by pretreatment with an antihistamine plus decongestant before intranasal challenge with pollen allergen  investigations are currently under way to assess the effect of antihistamine pretreatment on nasal and eustachian tube obstruction in patients undergoing intranasal histamine challenge  
class2	immunology of aids related to psoriasis  the association of severe psoriasis with hiv infection  which dysregulates and destroys the human immune system  supports the hypothesis that psoriasis is an immunologically mediated disease  psoriasis and kaposi s sarcoma share angiogenesis as basic early findings and could both be caused by differential cytokine expression or responsiveness  aids and research models including transgenic mice offer new models in which to study the role of the immune system and specific gene products in the pathogenesis of psoriasis and other skin diseases  
class2	the role of human immunodeficiency virus infection in pneumococcal bacteremia in san francisco residents  human immunodeficiency virus  hiv  is an important risk factor for invasive pneumococcal disease  but information on clinical course and infecting serotypes is limited  to help develop strategies to reduce the morbidity due to invasive pneumococcal disease  episodes of pneumococcal bacteremia were identified by retrospective review of microbiology records  november 1983 november 1987  at 10 san francisco hospitals and  for patients 20 55 years old living in san francisco  hiv antibody status was determined by review of medical records  pneumococcal isolates from one hospital were serotyped  of 294 patients with pneumococcal bacteremia identified  32  11   had aids at the time pneumococcal bacteremia was diagnosed and another 43  15   were hiv infected but did not have aids  12 hiv infected patients developed aids after the episode of pneumococcal bacteremia  the rate of pneumococcal bacteremia in aids patients was estimated to be 9 4 1000 patient years  serotypes of 27  82   of 33 pneumococcal isolates from hiv infected patients and 107  90   from 119 patients without known hiv infection were among the 23 serotypes included in the currently available polysaccharide vaccine  the rate of pneumococcal bacteremia is approximately 100 fold greater in aids patients in san francisco than rates reported before the aids epidemic  but more than half the episodes of pneumococcal bacteremia in hiv infected patients occurred in patients without aids  data on pneumococcal serotypes causing invasive disease in hiv infected patients suggest that the current pneumococcal vaccine  if effective in this population  could provide significant protection against pneumococcal disease  
class2	use of polymerase chain reaction for successful identification of asymptomatic genital infection with herpes simplex virus in pregnant women at delivery  the polymerase chain reaction was adapted to the amplification of a herpes simplex virus  hsv  dna sequence  common to hsv types 1 and 2  hsv 1  hsv 2   the amplified product was detectable by ethidium bromide staining or southern hybridization of gels and by dot hybridization  the hsv polymerase chain reaction detected hsv dna in samples obtained from eight patients with genital lesions from which hsv 2 was isolated in tissue culture and from four patients with labial lesions from which hsv 1 was isolated  the hsv polymerase chain reaction identified hsv in clinical specimens obtained from 11 women who had asymptomatic genital hsv infections at delivery  none of 11 samples obtained at delivery from women who had antibodies to hsv 2  but whose delivery cultures were negative  were positive by polymerase chain reaction and no false positive reactions were obtained when the reaction mixture contained human cell dna or varicella zoster virus  cytomegalovirus  epstein barr virus  or human papillomavirus dna  
class2	measles antibody  reevaluation of protective titers  a school blood drive before a measles outbreak permitted correlation of preexposure measles antibody titers with clinical protection using the plaque reduction neutralization  prn  test and an eia  of 9 donors with detectable preexposure prn titer less than or equal to 120  8 met the clinical criteria for measles  7 seroconfirmed  compared with none of 71 with preexposure prn titers greater than 120  p less than  0001   seven of 11 donors with preexposure prn titers of 216 874 had a greater than or equal to 4 fold rise in antibody titer  mean  43 fold  compared with none of 7 with a preexposure prn titer greater than or equal to 1052  p less than  02   of 37 noncases with preexposure prn titer less than 1052  26  70   reported one or more symptoms compared with 11  31   of 35 donors with preexposure prn titers greater than or equal to 1052  p less than  002   by eia  no case had detectable preexposure antibody  the preexposure geometric mean titer of asymptomatic donors  220  was not significantly higher than that of symptomatic donors who did not meet the clinical criteria for measles  153   p    10   the study suggests that prn titers less than or equal to 120 were not protective against measles disease and illness without rash due to measles may occur in persons with prn titers above this level  
class2	measles incidence  vaccine efficacy  and mortality in two urban african areas with high vaccination coverage  measles incidence  vaccine efficacy  and mortality were examined prospectively in two districts in bissau where vaccine coverage for children aged 12 23 months was 81   bandim 1  and 61   bandim 2   there was little difference in cumulative measles incidence before 9 months of age  6 1  and 7 6   respectively   between 9 months and 2 years of age  however  6 1  contracted measles in bandim 1 and 13 7  in bandim 2  even adjusting for vaccination status  incidence was significantly higher in bandim 2  relative risk 1 6  p    04   even though 95  of the children had measles antibodies after vaccination  vaccine efficacy was not more than 68   95  confidence interval  ci  39  84   and was unrelated to age at vaccination  unvaccinated children had a mortality hazard ratio of 3 0 compared with vaccinated children  p    002   indicating a protective efficacy against death of 66   ci 32  83   of measles vaccination  these data suggest that it will be necessary to vaccinate before age 9 months to control measles in hyperendemic urban african areas  
class2	evaluation of wc3 rotavirus vaccine and correlates of protection in healthy infants  the safety  immunogenicity  and efficacy of wc3 rotavirus vaccine was evaluated in a double blind  placebo controlled trial of healthy infants 2 12 months of age  103 received one dose of vaccine and 103 received placebo  vaccination appeared to be safe and induced an antibody response  wc3 neutralizing antibody  in 97  of vaccinees  only 9  9   of these  however  produced antibody to human rotavirus serotypes  at least 7 of the 9 were naturally infected before vaccination  neither the number of symptomatic episodes of rotavirus diarrhea  21 vs 25  nor the number of moderate to severe rotavirus illnesses  9 vs  15  was significantly different in vaccine or placebo recipients  respectively  during a predominantly serotype 1 rotavirus season  a slight but significant decrease in mean symptom score was detected in vaccine recipients  despite an overall lack of efficacy  protection could be correlated to previous rotavirus infection  high levels of wc3 neutralizing antibody  and preexisting  maternal  serotype 1 neutralizing antibody with a titer greater than or equal to 30  
class2	coccidioidomycosis in human immunodeficiency virus infected patients  coccidioidomycosis is at best a complicated fungal infection  often it is life threatening  coccidioidomycosis is confined epidemiologically to the southwestern region of the usa  and most cases have occurred in that area  particularly in arizona  however  we have seen several cases in san francisco in patients with only a history of travel to endemic areas  in part because of its regional distribution  information about the clinical presentation  diagnosis  and treatment of patients with coccidioidomycosis has lagged behind information about other  more commonly encountered aids associated opportunistic infections  drs  galgiani and ampel have probably had the largest single experience with coccidioidomycosis in individuals infected with the human immunodeficiency virus  these specialists share their experience and make recommendations as to how these complicated conditions should be approached  
class2	quantitative detection of brain aberrations in human immunodeficiency virus type 1 infected individuals by magnetic resonance imaging  the brains of 65 individuals with antibodies to human immunodeficiency virus type 1  hiv 1   20 hiv 1 seronegative homosexual men  and 75 heterosexual controls were examined by a quantitative magnetic resonance imaging technique  a white matter aberration was detected most frequently in patients with aids related complex  arc  or aids  but also in asymptomatic hiv 1 seropositive persons and in hiv 1 seronegative homosexual men  of whom two of three tested were reactive for hiv 1 dna by polymerase chain reaction  the aberration was not found in the control group  brain atrophy was mainly confined to patients with arc or aids  the brain lesions correlated with the presence of hiv 1 in cerebrospinal fluid and with elevated levels of beta 2 microglobulin and neopterin  the most pronounced brain aberrations were in patients with aids dementia complex  these findings indicate that brain aberrations may occur in persons in the early stages of hiv 1 infection  although to no greater extent than in hiv 1 seronegative homosexual men  the occurrence of pronounced brain lesions seems to be associated with the presence of an advanced immunodeficiency  
class2	distribution and specific identification of papillomavirus major capsid protein epitopes by immunocytochemistry and epitope scanning of synthetic peptides  monoclonal  mabs  and polyclonal antibodies were produced against the major capsid protein of detergent disrupted  purified bovine papillomavirus type 1  bpv 1   the precise locations of the corresponding epitopes were identified by the reactivity of mabs and selected polyclonal antibodies with synthetic  overlapping  hexameric peptides corresponding with 95  of the bpv 1 major capsid protein  the topography of these epitopes was determined by reactivity of antibodies with intact  conformational and nonconformational surface epitopes  and disrupted  external or internal nonconformational epitopes  bpv 1 virions  the distribution of epitopes in various papillomaviruses of 13 different species was determined by reactivity of the mabs and polyclonal sera with productively infected  formalin fixed papillomas  fibropapillomas  and fibromas  epitope scanning  using mabs and polyclonal antisera  resulted in the precise location of bpv 1 hexameric epitopes that could be correlated with their topography on the capsid and distribution in papillomatous lesions of various species  
class2	occurrence of groups a and b of respiratory syncytial virus over 15 years  associated epidemiologic and clinical characteristics in hospitalized and ambulatory children  over 15 years respiratory syncytial virus  rsv  isolates from 1209 hospitalized and ambulatory children were examined for strain group and in a subset for subgroup to determine the associated epidemiologic and clinical characteristics  three patterns of yearly outbreaks existed   1  strong predominance of group a strains  9 years with 83  100  a strains    2  relatively equal proportions of group a and b strains  4 years   and  3  strong predominance of group b strains  78  85   in 2 years  separated by a decade  the first pattern of highly dominant a strains occurred in cycles of 1 or 2 consecutive years with a single intervening year in which b strains were greater than or equal to 40  of the isolates  subgroups a1 and a2 predominated  while b2  3  and 4 occurred almost equally  a greater clinical severity for group a strains was suggested by children with group a infections requiring intensive care significantly more often  15 4 vs  8 3   p    008   further  strongly dominant a strain years were associated with higher proportions of rsv admissions requiring intensive care  16 6  vs  5 5   p less than  01   strains of subgroups a2 and b4 were more frequently found in hospitalized patients and a1 in outpatients  and the 2 years with the highest rates of intensive care admissions were those in which subgroup a2 dominated  
class2	effect of vaccination on serotype specific antibody responses in infants administered wc3 bovine rotavirus before or after a natural rotavirus infection  in an evaluation of wc3 bovine rotavirus  serotype 6  vaccine in infants  some subjects experienced a natural serotype 1 rotavirus infection before vaccination and others after  therefore  the effects of both wc3 and natural rotavirus strains as either primary or boosting immunogens on serotype specific neutralizing antibody responses could be determined  after primary natural infection  symptomatic or asymptomatic   neutralizing antibody titers were highest to serotype 1 but were consistently high to serotype 3  and low titers  greater than or equal to 20  to serotypes 2 and 4 were often detected  previous vaccination with wc3 had little effect on the magnitude of these responses  in contrast  subjects infected with serotype 1 strains before vaccination experienced large  average  12 fold  rises in neutralizing antibody to human serotypes 1 4 when vaccinated with wc3  thus  although wc3 and the natural strains are distinct serotypes  their epitopes were sufficiently similar that reinfection with wc3 could boost neutralizing antibody titers to human serotypes in subjects primed by a previous natural infection  
class2	pichinde virus infection in strain 13 guniea pigs reduces intestinal protein reflection coefficient with compensation  pichinde virus inoculation into strain 13 guinea pigs is a model with features reputed to be similar to hemorrhagic fever in humans  although the infection is lethal by day 13 19  guinea pigs of approximately 600 g do not show edema or effusions  this raises the questions of whether capillary damage is present in such infected animals and  if it is  why edema is absent  the effects of pichinide virus on protein transport across jejunal capillaries were examined in 38 normal and 7 infected strain 13 guinea pigs 12 days after inoculation  the latter lost 20 3  body weight but maintained normal blood pressure  serum protein concentration  and jejunal lymph flow  however  their protein solvent drag reflection coefficient  sigma  was reduced to  52      03  mean     se  from  73      02  2p less than  001   while permeability surface area product was not changed  in the absence of gross edema or effusions  pichinde virus infected guinea pigs demonstrated a leaky gut capillary wall to protein compatible with an increase in pore size or large pore number less than sufficient to change permeability surface area product  compensatory mechanisms that prevent edema at this stage are efficient and may include reduced capillary pressure or some degree of capillary flow stasis  
class2	seroprevalence of human t cell leukemia viruses in selected populations of homosexual men  this study sought to define the seroprevalence of human t cell leukemia virus  htlv  types i and ii in selected populations of homosexual men  serum specimens were screened for antibodies to htlv and to human immunodeficiency virus  hiv  by enzyme immunoassay  successive testing of specimens with positive results was done by western blotting and radioimmunoprecipitation assay  ripa  and then by polymerase chain reaction  pcr  assay on available peripheral blood mononuclear cells  pbmc   of 1290 specimens  only 4 had antibodies against htlv confirmed by ripa  pcr analysis of dna from pbmc from two subjects showed one to be htlv i and the other to be htlv ii  both men also had hiv antibodies  these results demonstrate a lower seroprevalence rate for htlv than some previous studies and emphasize the need for specific confirmatory tests  
class2	confocal microscopic detection of human immunodeficiency virus rna producing cells  a central anomaly in the pathogenesis of aids is that few actively infected cd4  cells  1 in 10 4  10 5  have been detected in the peripheral blood  even though dramatic depletion  often greater than 90   of cd4  cells is the hallmark of disease progression  a sensitive  35s based human immunodeficiency virus  hiv  rna in situ hybridization technique was coupled with a new detection method  confocal laser scanning microscopy  to examine transcriptionally active hiv infected cells from individuals at different disease stages  in 35 symptomatic hiv infected individuals  aids and aids related complex   an average of 1 in 350 mononuclear cells produced hiv rna  in contrast  in an asymptomatic group of 30 individuals  an average of 1 in 2000 mononuclear cells produced hiv rna  these data  obtained using this improved detection method  suggest there are more hiv rna producing cells in hiv infected individuals than previously reported  in addition  increased numbers of hiv transcribing cells were found to correlate with declining clinical condition as assessed by karnofsky performance score  these data suggest that viremia per se may account for the pathologic consequences in hiv infection  
class2	rotavirus specific antibody response in saliva of infants with rotavirus diarrhea  the reliability of saliva as an indicator of rotavirus infection was assessed among 15 infants  3 12 months  with rotaviral and 15 with nonrotaviral diarrhea  paired salivary samples collected during acute and convalescent phases were tested for rotavirus specific iga and igm by an elisa  the sensitivity of iga or igm alone to predict infection was 53 3  and 46 6   respectively  used in conjunction  the sensitivity rose to 80   it seems that infants with rotaviral diarrhea mount mucosal antibody responses as reflected in their saliva  possibly salivary antibodies could be used to evaluate vaccine  take  in rotavirus vaccine trials  
class2	infectious mononucleosis complicated by lingual tonsillitis  although upper airway obstruction and superimposed infection are well known complications of infectious mononucleosis  lingual tonsillitis in this context has not been mentioned in the literature  we describe a case of acute bacterial lingual tonsillitis with airway obstruction complicating infectious mononucleosis  the role of the base of tongue region in the pathophysiology of infectious mononucleosis is discussed  
class2	adult immunization in a network of family practice residency programs  a substantial proportion of morbidity and mortality associated with vaccine preventable diseases occurs among adults  teaching residents about disease prevention is mandated in the curriculum guidelines for family practice programs  a cooperative study among the kansas city family practice residency programs was begun to look at immunization behaviors in these teaching programs  a retrospective audit of medical records and a prospective survey of residents and faculty were performed  from the medical records of 400 patients seen for health maintenance examinations  the frequency of tetanus diphtheria immunizations recorded was 4 75   the pooled immunization rate recorded for pneumococcal vaccine was 25   and for influenza vaccine  24   although 93  of respondents knew patients need tetanus diphtheria immunization every 10 years  on a written questionnaire giving clinical examples  they were less likely to elect to immunize older patients eligible for tetanus diphtheria vaccine  the following immunization criteria were listed by respondents  for pneumococcal vaccine  age over 65 years  86    for influenza vaccine  age over 65 years  85    chronic diseases  69    residence in a chronic care facility  7    and being a health care worker  28    educational interventions stressing the appropriate criteria and involvement of the patient are planned at the separate programs  
class2	psychological functioning in a cohort of gay men at risk for aids  a three year descriptive study  this study describes the mental health of a large cohort of gay men participating in the chicago multicenter aids cohort study coping and change study  six biannual questionnaires were self administered between 1984 and 1988  general mental health was determined by the hopkins symptom checklist  hscl   an abbreviated version of the center for epidemiologic study depression scale  cesd 5  and an adapted diagnostic interview schedule  dis  question also measured depression  suicidal ideation was assessed by one question in the hscl  aids specific distress was determined by three subscales specifically developed for this study  while mean hscl and cesd 5 scores were stable during the observational period  aids specific distress increased over time  the hscl scores for the cohort were somewhat elevated above general population norms but considerably below psychiatric outpatient norms  fewer than 12  of the men reported elevated hscl or cesd 5 scores three or more times  a self reported episode of depression of two weeks or more  measured by the dis screening question  was experienced by 40 1  of the sample  suicidal ideation was reported on three or more visits by 18 8  of the men  the younger members of this cohort exhibit greater general and aids specific distress  income was inversely associated with general distress  hiv seropositive participants had generally higher aids specific distress scores than those who were seronegative  but their scores were equivalent on the hscl and cesd 5  
class2	implementation of preventive services in an hmo practice  practice does not conform to guidelines unless the guidelines are specifically implemented and performance is monitored  several examples of implementation in one health maintenance organization  hmo  are given  these include immunization for influenza and follow up of positive screening tests for colorectal and cervical cancer  each implementation effort has required the development of systems  which in this hmo are automated  several issues influencing implementation are discussed  including resource constraints and priorities for the allocation of new resources  developers cannot expect that their guidelines will be incorporated into clinical practice  they must foster specific implementation plans  
class2	adult immunizations  are they worth the trouble  there are good data to recommend routine use of vaccines against measles  rubella  tetanus  influenza  and pneumococcal infections in adults  an adolescent or an adult born after 1956 is considered to be susceptible to measles unless he or she has received two doses of live measles vaccine or has suffered a physician diagnosed case of measles  tetanus is largely a disease of the elderly  and there is a universal need for immunizations with tetanus toxoid  influenza continues to be a major public health problem  and influenza vaccine should be given annually to the elderly and to those at high risk  the efficacy of pneumococcal vaccine in american adults is still being debated  results from case control studies show that the vaccine is about 60  effective in reducing the incidence of disease due to vaccine related strains  its use in the elderly and in those at higher risk for pneumococcal infection is recommended  
class2	early ribavirin treatment of respiratory syncytial viral infection in high risk children  a 3 year prospective  blinded  multicenter study was done to assess the efficacy of early ribavirin intervention in mild respiratory syncytial virus illness in children with bronchopulmonary dysplasia or with congenital heart disease  a cohort of 178 children younger than 36 months of age with bronchopulmonary dysplasia or congenital heart disease were followed  forty seven infants whose respiratory syncytial virus infection resulted in mild symptoms of less than or equal to 72 hours  duration received ribavirin  n   20  or water placebo aerosol  n   27  either in a hospital or at home  outcome measures included respiratory and analog score  room air oxygen  saturation  and oxygen flow needed to maintain saturation at greater than or equal to 91   no difference in age  gender  family size  passive smoking  baseline oxygen saturations in room air  or duration of symptoms before treatment was found between groups  after 3 days of therapy  ribavirin produced a greater rate of improvement of analog scores  p   less than or equal to 0 001   lower oxygen requirements  p   0 01   and higher oxygen saturation  p   0 01   respiratory scores and total hospital days did not differ significantly between the groups  treatment failure occurred in 2 of 20 children  10   in the ribavirin group versus 5 of 27 children  18   in the placebo group  a nonsignificant difference  no child required assisted ventilation or had an adverse reaction  we conclude that early ribavirin therapy may help to reduce morbidity from respiratory syncytial virus infection in high risk young children  
class2	urinary retention due to sacral myeloradiculitis  a clinical and neurophysiological study  we report 5 cases of sacral myeloradiculitis presenting with transient urinary retention  neurophysiological testing  including bulbocavernosus reflex  pudendal evoked response and external anal sphincter electromyography  was performed  parasympathetic pelvic nerves  pudendal nerves as well as the spinal cord seem to be involved to various degrees in this infrequent disorder  
class2	type specific antigens for serological discrimination of htlv i and htlv ii infection  55 htlv i  human t cell lymphotropic virus  and 45 htlv ii carriers  confirmed by htlv type specific polymerase chain reaction  pcr   were distinguished by western blot assays with recombinant htlv i or ii envelope glycoproteins  recombinant protein  rp  b1 contains aminoacids 166 201 from htlv i exterior glycoprotein gp46 and was reactive with htlv i samples only  rp iib  which contains aminoacids 96 235 from htlv ii exterior glycoprotein gp52  was reactive with all htlv ii samples  39 patients  86 6   had high reactivity by densitometry  of 55 htlv i samples  35  65 5   had antibody reactivity to rp iib  but only 1  1 8   had high reactivity by densitometry  rp b1 and iib western blot assays may replace the pcr test in diagnosis of htlv infection  
class2	cytomegalovirus and rasmussen s encephalitis in situ hybridisation with a biotinylated cytomegalovirus  cmv  dna probe was done on brain biopsy specimens from 10 patients with rasmussen s encephalitis  re  and 46 age matched control patients with other neurological diseases  all 10 patients with re had intractable epilepsy and focal neurological deficits  and there was perivascular cuffing  microglial nodules  astrogliosis  and neuronal loss  cmv genomic material was demonstrated in 7 of the 10 patients with re  in neurons  astrocytes  oligodendrocytes  and endothelial cells  and in 2 of the 46 control patients  probes for herpes simplex virus and hepatitis b virus were negative in all patients and in fibroblast controls  the results suggest that cmv is a likely cause of rasmussen s encephalitis  
class2	primary central nervous system lymphoma in patients with and without the acquired immune deficiency syndrome  a retrospective analysis and review of the literature  twenty two cases of pcl were reviewed  in which 9 patients had aids and 13 did not  a review of the literature identified 247 cases of aids related pcl  differences between patients with aids and immunocompetent pcl were noted in our series  aids related pcl when compared to non aids pcl in our series has the following notable clinical features  1  significantly younger age at presentation  median age 34 versus 59 years  2  significantly higher incidence of b symptoms  44  versus 8   3  worse median performance status at presentation  3 versus 1  and  4  shorter median survival  3 versus 10 months  differences in performance status and survival  however  were not significant  aids related pcl is further characterized by frequent  44   ring enhancing mass lesions on head ct scan  a finding that makes it clinically difficult to distinguish from toxoplasmosis  median survival appears to be improved in the absence of opportunistic infection at time of diagnosis of pcl  6 versus 2 months  the therapeutic approach to patients with pcl  with and without aids  is variable  combined modality therapy may improve the survival in patients with non aids pcl  therapy for patients with aids related pcl is tailored to the status of the individual and it is  therefore  difficult to make comparisons to non aids pcl patients  aids patients are often too ill to tolerate aggressive surgery or systemic treatment and in this instance  radiotherapy alone may be an acceptable alternative  nonetheless  overall survival for patients with aids related and non aids pcl remains poor  
class2	use of single fiber emg and macro emg in study of reinnervation  the use of single fiber emg and macro emg in studies of reinnervation is discussed  sfemg gives information about changes in the topography of the motor unit and in function of transmission in terminal nerve  motor endplate and muscle fiber  dynamics of reinnervation may be studied with this technique  the amount of reinnervation is obtained from macro emg studies  the capacity for reinnervation is discussed for a few conditions as well as factors that limit the reinnervation process  
class2	the agent of bacillary angiomatosis  an approach to the identification of uncultured pathogens background  bacillary angiomatosis is an infectious disease causing proliferation of small blood vessels in the skin and visceral organs of patients with human immunodeficiency virus infection and other immunocompromised hosts  the agent is often visualized in tissue sections of lesions with warthin starry staining  but the bacillus has not been successfully cultured or identified  this bacillus may also cause cat scratch disease  methods  in attempting to identify this organism  we used the polymerase chain reaction  we used oligonucleotide primers complementary to the 16s ribosomal rna genes of eubacteria to amplify 16s ribosomal gene fragments directly from tissue samples of bacillary angiomatosis  the dna sequence of these fragments was determined and analyzed for phylogenetic relatedness to other known organisms  normal tissues were studied in parallel  results  tissue from three unrelated patients with bacillary angiomatosis yielded a unique 16s gene sequence  a sequence obtained from a fourth patient with bacillary angiomatosis differed from the sequence found in the other three patients at only 4 of 241 base positions  no related 16s gene fragment was detected in the normal tissues  these 16s sequences associated with bacillary angiomatosis belong to a previously uncharacterized microorganism  most closely related to rochalimaea quintana  conclusions  the cause of bacillary angiomatosis is a previously uncharacterized rickettsia like organism  closely related to r  quintana  this method for the identification of an uncultured pathogen may be applicable to other infectious diseases of unknown cause  
class2	clinical and pathological features of bacillary peliosis hepatis in association with human immunodeficiency virus infection background  peliosis hepatis is characterized by cystic  blood filled spaces in the liver and is seen in patients with chronic infections or advanced cancer and as a consequence of therapy with anabolic steroids  cutaneous bacillary angiomatosis is a bacterial infection that occurs in patients with human immunodeficiency virus  hiv  infection  its histologic appearance is that of a pseudoneoplastic vascular proliferation  methods  we studied liver tissue from eight hiv infected patients with peliosis hepatis  two of whom also had cutaneous bacillary angiomatosis  for comparison we examined tissue from four patients who had peliosis hepatis without hiv infection  tissues were examined histologically on routine sections and with special stains and electron microscopy  results  the histologic features seen in peliosis hepatis associated with hiv infection  but not in the four cases unrelated to hiv infection  were myxoid stroma and clumps of a granular purple material that on warthin starry staining and electron microscopy proved to be bacilli  the bacilli  which could not be cultured  were morphologically identical to those found in the skin lesions of cutaneous bacillary angiomatosis  the clinical courses of two of the patients with this  bacillary peliosis hepatis  indicate that it responds to antibiotic treatment  conclusions  hiv associated bacillary peliosis hepatis is an unusual  treatable opportunistic infection  probably caused by the same organism that causes cutaneous bacillary angiomatosis  our failure to find bacilli in non hiv associated cases implies that other pathogenetic mechanisms may also be responsible for peliosis hepatis  
class2	a newly recognized fastidious gram negative pathogen as a cause of fever and bacteremia background  we identified a motile  curved  gram negative bacillus as the cause of persistent fever and bacteremia in two patients with symptomatic human immunodeficiency virus infection  the same organism was subsequently recovered from a bone marrow transplant recipient with septicemia and from two immunocompetent persons with week long febrile illnesses  all the patients recovered after antimicrobial therapy  methods and results  primary cultures of blood processed by centrifugation after blood cell lysis yielded adherent  white  iridescent  morphologically heterogeneous colonies in 5 to 15 days  subcultures grew in four days on chocolate  charcoal yeast extract  or blood agar  the organisms stained weakly with safranin and were not acid fast  fluorescent antibody tests for legionella and francisella were negative  biochemical reactivity was minimal and difficult to ascertain  agar dilution testing revealed in vitro susceptibility to most antimicrobial agents tested  the cellular fatty acid composition of the isolates was similar  resembling that of rochalimaea quintana or brucella species  but not helicobacter pylori or species of campylobacter or legionella  as resolved by gel electrophoresis  cell membrane preparations of all isolates contained similar proteins  with patterns that differed from that of r  quintana  patterns of digestion of dna from all isolates by ecorv restriction endonuclease were virtually identical and also differed from that of r  quintana  on immunodiffusion  serum from one convalescent patient produced a line of identity with sonicates of all five isolates  conclusions  this pathogen may have been unidentified until now because of its slow growth  broad susceptibility to antimicrobial agents  and possible requirement of blood cell lysis for recovery in culture  it should be sought as a cause of unexplained fever  especially in persons with defective cell mediated immunity  
class2	circulating cd8  cytotoxic t lymphocytes specific for htlv i px in patients with htlv i associated neurological disease  the human t lymphotropic virus type i  htlv i   the first human retrovirus to be characterized  is associated with adult t cell leukaemia and a chronic progressive disease of the central nervous system termed tropical spastic paraparesis  or htlv i associated myelopathy  only 1  of individuals infected with htlv i develop clinical disease however  the various manifestations of an htlv i infection may be related to differences in the genetic backgrounds of individuals  infection with variant strains of htlv i  differences in viral tropism or host immune response to the virus  whereas the humoral response to htlv i is well characterized  little is known about the human cellular immune response  such as the production of cytotoxic t lymphocytes  here we report the presence of high levels of circulating htlv i specific cytotoxic t lymphocytes in patients with htlv i associated neurological disease but not in htlv i seropositive individuals without neurological involvement  these cytotoxic t lymphocytes are cd8   hla class i  restricted and predominantly recognize the htlv i gene products encoded in the regulatory region px  these findings suggest that htlv i specific cytotoxic t lymphocytes may contribute to the pathogenesis of associated neurological disorders associated with htlv i  
class2	the myelodysplastic syndromes  case report and review  the myelodysplastic syndromes are a heterogenous group of hematologic disorders of myeloid progenitor cells  oral manifestations may be among the first signs and often reflect degrees of neutropenia or neutrophil dysfunction  a patient with persistent herpes labialis and severe oral mucosal ulceration in myelodysplastic syndrome is reported  the features of myelodysplasia are reviewed and their oral manifestations and significance to dental management outlined  
class2	diagnosis of oral hairy leukoplakia by ultrastructural examination of exfoliative cytologic specimens  lingual exfoliative cytologic specimens  scrapings  were obtained from 18 patients positive for human immunodeficiency virus with clinical oral hairy leukoplakia  buccal mucosal scrapings were obtained from 12 of these patients  the specimens were processed for examination by transmission electron microscopy  tem   sixteen  89   of the lingual specimens revealed infection of keratinocytes by herpes type virus  there was no evidence of virus infection in the 12 buccal mucosal scrapings  fungal hyphae were seen by tem in 14  78   of the lingual scrapings and two  17   of the buccal scrapings  one exfoliative specimen and two biopsy specimens were stained for epstein barr virus dna with a dna probe  the demonstration of herpes type virions by tem in keratinocytes from a lesion clinically suspected to be hairy leukoplakia provides direct  objective diagnosis  furthermore  use of exfoliative cytologic specimens provides a clinically simple  noninvasive technique  
class2	nosocomial bacteremias in measles  the purpose of this study was to determine whether nosocomial bacteremias occurred more frequently in patients admitted with severe measles compared with general pediatric admissions  in a retrospective survey of 977 blood culture reports during a 4 year period  1985 to 1988  the incidence of nosocomial bacteremias in patients with measles was found to be on the average of 3 37 100 admissions year  approximately 6 times that of general pediatric patients  0 57   gram negative organisms  predominantly klebsiella and salmonella species  accounted for 86 5  of all isolates from measles patients  with 23  of these being multiply antibiotic resistant  all the isolates from the general patients were fully susceptible to antibiotics  the duration of hospitalization was more than doubled in both groups of affected patients  the onset of hospital acquired bacteremias occurred on an average of 11 2 days after admission in the patients with measles and 20 5 days in the general patients  our findings revealed that nosocomial bacteremias occurred with greater frequency in patients with measles and contributed to the morbidity of these patients  
class2	clinical features of adenovirus enteritis  a review of 127 cases  we retrospectively analyzed the clinical features of 127 hospitalized pediatric patients whose fecal samples were positive for adenovirus  ad  by electron microscopy during an 18 month period  serotyping results obtained by microneutralization tests and restriction endonuclease analysis were available for 105 of 127 cases  there were 69 males and 58 females and 94  of patients were less than 4 years of age  the average body temperature was 38 degrees c rectal  range  36 2 40 8 degrees c  with an average duration of fever of 1 6 days  the average duration of clinical illness was 8 8 days  range  1 to 32 days   although ad 40 and ad 41 were isolated in the majority of cases  59 of 105  56    ad 31 was associated with 18 of 105 cases  17    of the 18 cases associated with ad 31  14 were nosocomial and associated with diarrhea  our survey confirms the importance of fastidious enteric ad in infantile diarrhea  ad 40  ad 41  and suggests that ad 31 produces a clinical syndrome indistinguishable from that caused by ad 40 and ad 41  the occurrence of ad enteritis in patients admitted for unrelated illnesses well after initial hospitalization suggests that ad is also an important cause of nosocomial enteritis in our hospital  
class2	study design considerations for ribavirin  efficacy studies  five placebo controlled double blind studies  each including approximately 30 subjects  have addressed the question of the effect of aerosolized ribavirin on the course of rsv lower respiratory infection in infancy  the fact that each was able to establish a beneficial effect despite the small number of subjects studied is convincing evidence that such an effect exists  the studies from rochester using oximetry and an analog illness severity scale indicate that this effect is both statistically significant and clinically relevant  these tools are reliable and easily applicable measures for multicenter studies when illness severity is selected as an outcome measure  characteristics that should be taken into consideration when assigning experimental groups include age  sex  a history of prematurity or underlying conditions and arterial oxygen saturation  future studies will address additional questions about the efficacy of ribavirin  such as its role in critically ill children  the economic benefits of its use in terms of duration of hospitalization  the usefulness of early treatment of rsv disease in high risk infants  and the impact of treatment on long term consequences of rsv infection  these studies may require outcome variables and subject selection strategies different from those used in earlier studies  
class2	transbronchial biopsies in children after heart lung transplantation  sixty transbronchial biopsies have been performed in eight children after heart lung transplantation  the selection of fiber optic bronchoscope or a small  4 mm  30 cm  rigid bronchoscope was made according to the size of endotracheal tube required at surgery  if the endotracheal tube was size 7 5 or greater  a fiber optic bronchoscope was used  whereas if the endotracheal tube size was below 7  a rigid bronchoscope was used  for the diagnosis of lung rejection  the histology of biopsies revealed a sensitivity of 91  and specificity of 69   similar to the result in adults   the histology also distinguished lung infection from rejection  complications included three pneumothoraces and two clinically significant episodes of hemorrhage  one of which led to a cardiorespiratory arrest  which may have been caused by hypoxia  as a result  arterial oxygen saturation is now monitored during the procedure using a pulse oximeter  
class2	a rhesus monkey model for sexual transmission of a papillomavirus isolated from a squamous cell carcinoma  recently we molecularly cloned and characterized a papillomavirus from a lymph node metastasis of a primary penile carcinoma found in a rhesus monkey  this virus species  rhesus papillomavirus type 1  rhpv 1   is similar to oncogenic human papillomaviruses  hpvs   such as hpv 16 or hpv 18  in that the rhpv 1 dna was found to be integrated in the tumor cell dna  to compare the sexual transmission and oncogenic nature of rhpv 1 with these hpvs  we undertook an extensive retrospective study of a group of rhesus monkeys whose sexual mating and offspring histories were known  these animals had mated directly with the index male mentioned above or were secondarily exposed to this virus through intermediate sexual partners  this study combines cytological  histopathological  and several complementary hybridization and dna amplification techniques on multiple tissue samples to demonstrate the sexually transmitted nature of rhpv 1  the oncogenic potential of rhpv 1 is suggested in several of the infected animals by the presence of various degrees of neoplasia including squamous cell cancer of the cervix  
class2	interferon system and natural killer cell activity in myasthenia gravis  the autoimmune response in myasthenia gravis is well characterized  but little is known about the mechanisms initiating it  we have studied the interferon system and natural killer cell activity in 25 patients with myasthenia gravis and compared them to 68 healthy subjects and 96 patients with acute viral infections  forty four per cent of patients had circulating interferon  greater than 16 mu ml   and in a similar proportion their peripheral blood mononuclear cells were in an antiviral state  i e   showed low levels of viral replication when infected by vesicular stomatitis virus  spontaneous in vitro interferon production by patients  peripheral blood mononuclear cells was also common  greater than 10 mu ml  32 per cent   while the response to the alpha interferon inducer poly i c was lower than expected  possibly reflecting the already high state of activation of the interferon system  these results were essentially similar to those obtained in patients with viral illnesses and differed significantly from healthy controls  in many myasthenia gravis patients  16 of 22  73 per cent   a markedly deficient natural killer cell activity was found  with a median cytotoxicity of 6 5 per cent compared to 29 per cent in healthy subjects  p less than 0 005   thus  many patients with myasthenia gravis have evidence of an activated interferon system and defective natural killer cell activity  suggesting an occult viral infection or reflecting nonspecific stimulation which may nevertheless contribute to the pathogenesis of the autoimmune response  
class2	bacterial tracheitis  report of eight new cases and review  bacterial tracheitis  previously referred to as nondiphtheritic laryngitis with marked exudate  was commonly discussed in pediatric textbooks before 1940  it seemed to disappear as a clinical entity after that time  but it has been recorded with increasing frequency in the pediatric literature since 1979  we describe eight new cases and review 110 previously described cases  the clinical course consists of a prodromal upper respiratory illness with stridor  fever  and a variable degree of respiratory distress  unlike patients with croup  patients with bacterial tracheitis do not respond to aerosolized racemic epinephrine  most patients require endotracheal intubation  some require tracheostomy  reported complications include pneumonia  pneumothorax  formation of pseudomembranes  toxic shock syndrome  and cardiopulmonary arrest  bacterial tracheitis is a secondary bacterial infection following a primary viral respiratory infection  the most common preceding viral infection is parainfluenza  staphylococcus aureus and haemophilus influenzae are the predominant causes of bacterial tracheitis  secondary bacterial infection may occur as a result of tracheal mucosal injury or impairment of normal phagocytic function due to viral infection  
class2	early treatment with acyclovir for varicella pneumonia in otherwise healthy adults  retrospective controlled study and review  the effect of early acyclovir therapy on the course of varicella pneumonia in previously healthy adults was assessed  medical records from five university affiliated medical centers were retrospectively reviewed  included were all immunocompetent adults with a clinical diagnosis of primary varicella  a chest radiograph consistent with varicella pneumonia  and an arterial blood gas measurement indicating significant hypoxia  of the 38 patients who met the study criteria  11 had had a course of intravenous acyclovir initiated within the first 36 hours of hospitalization  the mean time from admission to initiation of therapy in this early treatment group was 9 6 hours  the group that received early acyclovir treatment had a lower mean temperature beginning on the fifth day of hospitalization  37 0 degrees c vs  37 7 degrees c  p    011  and a lower mean respiratory rate beginning on the sixth day of hospitalization  21 vs  28 respirations per minute  p    004   early acyclovir therapy also resulted in a significant improvement in oxygenation beginning on the sixth day of hospitalization in patients with follow up arterial blood gas measurements  p    035   thus  early institution of acyclovir therapy is associated with reduction in fever and tachypnea and improvement in oxygenation in otherwise healthy adults with varicella pneumonia  
class2	tropical neuromyelopathies and retroviruses  a review  debilitating disorders of the nervous system have a relatively high prevalence in the tropics  a geographic region that is often deficient in specialists in the fields of neurology and epidemiology  during world war ii  attention was called to a possible nutritional origin for most of these diseases  recently  however  human t lymphotropic virus type i  htlv i   formerly linked only to a rare form of leukemia  adult t cell leukemia   has been associated with a spastic paraplegia observed mostly in tropical areas and referred to as tropical spastic paraparesis  this entity is also observed in nontropical areas endemic for htlv i  including japan  south america  and the southern united states  viruses of the htlv family are being associated increasingly with pathology in humans  the pathogenesis of htlv i associated tropical spastic paraparesis remains to be understood  however  future research is expected to favor a multidisciplinary approach  with exciting potential insights derived from the fields of neurology  immunology  and infectious diseases  the aim of this review is to summarize contemporary research related to the viral etiology of this clinical entity  
class2	measles in israel  the west bank  and gaza  continuing incidence and the case for a new eradication strategy  measles continues to occur in epidemic waves in israel  gaza  and the west bank  causing morbidity and mortality  in israel  immunization of infants against measles began in 1967  and 90  had been immunized by the mid 1980s  in gaza and the west bank  where immunization of infants against measles began in 1973 and 1976  respectively  the immunization rate reached 75  in the late 1970s and increased to greater than 90  in the 1980s  measles epidemics  which previously had occurred in 5  to 7 year cycles  occurred every 2 4 years in the 1980s and affected individuals who were older than those affected in previous years  israel s commitment to eradicating measles by 1992 will require a substantially expanded immunization program in comparison with the traditional program that requires immunization of infants alone  the benefits of several alternative immunization strategies considerably exceed their costs  a new  two dose immunization will be needed as a minimal strategy  and a campaign for administering booster doses to school aged children may be required as well to achieve control and eradication of measles  measles is a serious but preventable public health problem  appropriate strategies must be devised by national and international public health officials to control the disease in developing and developed countries  
class2	impact of cytomegalovirus infection on organ transplant recipients  cytomegalovirus  cmv  is the single most important infectious agent affecting recipients of organ transplants  with at least two thirds of these patients having cmv infection 1 4 months after transplantation  latently infected allografts are the major exogenous source of cmv infection in transplant recipients  although leukocyte containing blood products can also transmit the virus  three patterns of cmv infection are recognized  primary infection  reactivation infection  and superinfection  primary infection has the greatest clinical impact  the clinical effects of cmv infection include infectious disease syndromes such as pneumonia and chorioretinitis  an immunosuppressed state that predisposes to potentially lethal opportunistic infection  and the initiation of a process that can result in allograft injury  progress has been made in controlling cmv infection  hyperimmune anti cmv globulin and certain antiviral drugs appear promising for prophylaxis  and the combination of hyperimmunoglobulin and ganciclovir appears promising for therapy  
class2	syphilis  human immunodeficiency virus infection  and targeting prevention  to examine the interaction between syphilis and human immunodeficiency virus type 1  hiv 1  infection in oklahoma  we conducted an unlinked hiv seroprevalence survey using serum specimens submitted to the oklahoma state department of health for serologic test for syphilis  of specimens with positive results from fluorescent treponemal antibody absorption test  fta abs   6 3  were hiv 1 seropositive compared to 0 8  of those that had negative results from fta abs  among specimens positive for syphilis  hiv 1 seropositivity was found almost exclusively among those from persons 20 to 39 years of age and more often among those from men than those from women  9 9  vs 1 3    of syphilis positive specimens from 20  to 39 year old men  17 6  were hiv 1 seropositive  in oklahoma  an area with a relatively low overall prevalence of hiv 1 infection  targeting prevention efforts to young adults who test positive for syphilis should be an efficient way to reach some persons at high risk for hiv 1 infection  
class2	ocular disease associated with epstein barr virus infection  epstein barr virus  ebv  is a ubiquitous dna virus of the herpesvirus genus with a high prevalence rate for antibody  about 90   in the adult population  it is the most common causative agent of infectious mononucleosis syndrome  during recent years an increasing number of ocular disease entities have been reported to be linked to ebv infection  these entities include oculoglandular syndrome  conjunctivitis  dry eye  keratitis  uveitis  choroiditis  retinitis  papillitis and ophthalmoplegia  while ebv specific serologic tests can now document recent and past primary infection with ebv and also identify patients manifesting atypical immunologic reactions to ebv  the lack of an animal model  the absence of clear cut response to therapy and the paucity of documentation by culture render the pathogenesis uncertain or the association questionable in many of these cases  
class2	american blood donors seropositive for human t lymphotropic virus types i ii exhibit normal lymphocyte subsets  recent reports have demonstrated that some lymphocyte subsets are abnormal in japanese blood donors who are seropositive for human t lymphotropic virus type i  htlv i   to determine if similar changes characterize american blood donors who are seropositive for htlv i ii  lymphocyte subsets were measured in 42 htlv seropositive and 42 htlv seronegative blood donors  the seronegative individuals were matched by age  race  and gender to the seropositive individuals  peripheral blood mononuclear cells were treated with a panel of 12 monoclonal antibody pairs and then analyzed by two color flow cytometry  no significant differences were observed between the seropositive and seronegative groups with respect to the absolute number of circulating lymphocytes or the percentages of lymphocytes belonging to the subsets assessed  these subsets included b  t  cd4  and cd8 cells and subpopulations of cd4 and cd8 cells defined by the coexpression of markers that appear  cd25  hla dr  cd38  or disappear  leu 8  cd45ra  after activation  these findings indicate that htlv seropositive persons in the american blood donor pool do not exhibit the lymphocyte subset alterations reported for htlv i seropositive blood donors in japan  
class2	efficiency of white cell filtration and a freeze thaw procedure for removal of hiv infected cells from blood  strategies for diminishing the risk of blood transfusion associated transmission of hiv 1 were evaluated  hiv 1 infected peripheral blood mononuclear cells were added to blood that was subsequently filtered by using different white cell  wbc  filters  cellulose acetate and polyester   the average log reduction of infected cells with polyester filters was at least 2 5 as measured by id50 titration and polymerase chain reaction  in two wbc filtration experiments with blood from seropositive donors diluted 1 4 with seronegative blood  log reductions of 2 4 and greater than 2 5 were observed  no cell free virus was retained by the filter used  a freeze thaw procedure applied to hiv 1 contaminated blood resulted in a minimal log reduction  these results indicate that the reduction of hiv 1 infectivity as a result of filtration is mainly due to the removal of hiv 1 infected wbcs  and that complete removal of infected wbcs cannot be achieved by the current filtration or freeze thaw procedures  however  the development of filters with enhanced ability to remove  possibly infected  wbcs may have the added benefit of improving the safety of donor blood  especially in multiply transfused patients  
class2	measles update  the incidence of measles in the united states dramatically increased in the 1980s  from a low of 1 497 cases in 1983 to over 17 000 cases in 1989  family physicians can help reverse this trend by following the revised immunization schedule  which includes a measles mumps rubella  mmr  booster for preschool age children  new guidelines also recommend that either the two dose mmr schedule or serologic evidence of immunity be required for all persons entering college or employed in the medical field  immunization policies for physician s offices should ensure that all office staff have acquired measles immunity and that a triage policy separating patients with rash from those with other illnesses is utilized  mild upper respiratory illness  a history of seizures  nonanaphylactic egg allergy and asymptomatic human immunodeficiency virus infection are not contraindications to measles vaccine  all cases of measles should be reported to the local health department  
class2	hiv disease  a review for the family physician  part ii  secondary infections  malignancy and experimental therapy  the first part of this two part article included recommendations for the initial evaluation of patients suspected of having hiv infection  the centers for disease control s classification scheme for hiv disease and current recommendations for the use of zidovudine  in this second part  secondary infections and malignancy are reviewed  and various experimental therapies are briefly discussed  
class2	comparison of southern transfer hybridization and dot filter hybridization for detection of cervical human papillomavirus infection with types 6  11  16  18  31  33  and 35  a commercial dot filter hybridization kit  virapap kit  was compared with southern transfer hybridization for the detection of seven types of human papillomavirus  hpv  in cervical specimens from 450 consecutive females attending a sexually transmitted diseases clinic  in comparison with southern transfer hybridization  performed with the same probes used in the dot filter kit  the sensitivity  specificity  and positive and negative predictive values of dot filter hybridization were 90   94   74   and 98   respectively  among patients with cervical cytologic dysplasia  hpv dna was detected in 44  by dot filter hybridization and in 35  by southern transfer hybridization  although 26  of specimens positive by dot filter hybridization were not confirmed by southern transfer hybridization  cervical dysplasia was detected in 5  25   of 20 with hpv dna detected by dot filter hybridization alone  compared with 25  8   of those with no definitive evidence of hpv by either method  p   0 009  and with 16  30   of 53 with hpv dna detected by both methods  p   0 7   the kappa statistic for interobserver and intraobserver reproducibility for interpretation of blots was similar for the two methods  the dot filter hybridization method evaluated appears to be a satisfactory alternative to southern transfer hybridization for detection of hpv dna  
class2	pregnancy outcomes among mothers infected with human immunodeficiency virus and uninfected control subjects  between june 26  1985  and feb  24  1989  101 seropositive pregnant women and 129 seronegative pregnant women from the same prenatal clinics in brooklyn and the bronx were recruited into a prospective study of human immunodeficiency virus infection in pregnant women and their offspring  this report details the course of pregnancy and short term neonatal outcomes of 91 seropositive women and 126 seronegative women who gave birth during the study period  seropositive mothers were significantly more likely to have sexually transmitted diseases  17 6  vs 7 1   p   0 017  and medical complications  43 0  vs 25   p   0 006  during pregnancy  no other obstetric complications  e  g   chorioamnionitis  endometritis  toxemia  or placental problems  were associated with serologic status  after controlling for confounding variables  drug use  tobacco use  age of mother  and clinic   we found that the mother s serologic status was not significantly associated with birth weight  gestational age  head circumference  or apgar scores among live infants  for example  after adjustment on confounders we found that children born to seropositive mothers weighed about 7 gm more than children of seronegative mothers  95  confidence interval   180 to 194 gm   we conclude that in this population human immunodeficiency virus infection has little demonstrable impact on the status at birth of live neonates  
class2	extensive vulvar and vaginal varicella necessitating abdominal delivery  maternal varicella occurs in fewer than five per 10 000 pregnancies in the united states  a case is reported in which markedly painful  extensive vulvar and vaginal ulcers prevented cervical examination  and cesarean section was performed with the patient under general anesthesia  
class2	modeling the impact of breast feeding by hiv infected women on child survival  published erratum appears in am j public health 1991 may 81 5  658 9  this study models the survival outcomes of children born to hiv infected  human immunodeficiency virus  women who are breast fed  bottle fed  and wet nursed  it is estimated that  given the relative risk of alternatives to maternal milk in developing countries  the probability of hiv transmission via breast milk would need to be at least  12 in a community with an under five child mortality rate from non hiv causes of 100 1000 live births and at least  27 in a community with a rate of 200 1000 before alternative feeding practices should be recommended even to the known hiv infected mother who has an available feeding alternative with a relative risk of 2 1  while such a low relative risk may be achievable with wet nursing  most studies report a relative risk of at least 3 1 for bottle feeding  a sensitivity analysis is conducted around the relative risk of child mortality from non hiv causes associated with different feeding practices  while the critical transmission rate does not vary significantly with a rate of false positives as high as 20 percent on the hiv screening test  the critical transmission rate is very sensitive to the availability of hiv screening  in communities where the hiv prevalence rate among mothers reaches 40 percent  breast feeding should still be recommended in the absence of hiv screening unless hiv transmission via breast milk surpasses 30 percent  
class2	hiv seroconversion in two homosexual men after receptive oral intercourse with ejaculation  implications for counseling concerning safe sexual practices  seroconversion for hiv antibody occurred in two homosexual men who reported no anal intercourse for greater than or equal to 5 years and multiple episodes of receptive oral intercourse with ejaculation  neither man reported intravenous drug use or receipt of blood products  the last antibody negative specimen was also negative by the polymerase chain reaction and p24 antigen assays  all sexually active persons should be clearly counselled that receptive oral intercourse with ejaculation carries a potential risk of hiv transmission  
class2	human t cell lymphotropic virus infection in guaymi indians from panama  preliminary studies found that 9  of guaymi indians from bocas del toro province have antibody to human t cell lymphotropic virus  htlv i ii   the present study enrolled 317  21  of the population  guaymi indians from changuinola  the capital of bocas del toro province and 333  70  of the population  from canquintu  an isolated rural village  demographic information and family relationships were ascertained and subjects were screened for neurologic diseases  serum specimens were screened by an enzyme linked immunosorbent assay for htlv i ii antibody and positives were confirmed according to u s  public health service criteria  twenty five  8   guaymi residing in changuinola and 7  2 1   from canquintu were confirmed seropositive  in changuinola  antibody was virtually limited to residents greater than or equal to 15 years of age  24  16   of 153  and rates were slightly higher in males than in females  in canquintu  antibody rates did not increase significantly with age and appeared higher in females than in males  in changuinola  there was no evidence for household clustering of infection  in contrast  htlv antibody among canquintu residents clustered significantly by household  htlv associated neurologic disease was not detected in either population  the atypical seroepidemiology observed in both locations might be explained if the virus endemic to the guaymi differed from htlv i previously described in the caribbean basin and japan  
class2	high incidence of viral hepatitis among american missionaries in africa  protestant missionaries  n   360  serving in sub saharan africa between 1967 1984 were studied to determine the risk of hepatitis a virus  hav  and hepatitis b virus  hbv  infection  personnel were serologically screened for antibody to both the hepatitis a virus  anti hav  and the surface antigen to the hepatitis b virus  anti hbs  prior to departure  periodically during service abroad  and upon completion of their african tour  rates of seroconversion were used as measures of the incidence of infection  prior to service  16  of the staff had anti hav and 3  had anti hbs  post service rates were 42  and 26   respectively  over 90  of the staff with greater than 20 years of service were seropositive for anti hav  for both viruses  the infection rate was highest during the first 1 2 years of service  when 28  of those susceptible to hav and 11  of those susceptible to hbv became infected  over the next decade  the median annual attack rate was 5 4  for hav and 4 2  for hbv  differences in the missionary hbv infection rate among the various african nations served tended to reflect differences in the magnitude of chronic hbv carriage among indigenous population groups  we conclude that missionaries to sub saharan africa are at enhanced risk of both hav and hbv infection  and that all should receive passive immunization with immune globulin and active immunization with hepatitis b vaccine  
class2	association of acute colonic pseudo obstruction  ogilvie s syndrome  with herpes zoster  ogilvie s syndrome  or acute pseudo obstruction of the colon is characterized by massive distension of the colon in the absence of organic distal obstruction  the syndrome is associated with various unrelated and  most often  extra abdominal causes  an association between ogilvie s syndrome and herpes zoster has been reported only once  by ceccese et al  in 1985  we present a second such case  this patient did not show evidence of any active illness other than the involvement of the t10 dermatome by herpes zoster  the patient s symptoms of colonic obstruction subsided with resolution of the zosteriform rash  
class2	infection with human immunodeficiency virus type 1  hiv 1  among recipients of antibody positive blood donations objective  to assess the incidence of human immunodeficiency virus type 1 hiv 1  transmission by antibody  anti hiv 1  positive blood components  and to determine the immunologic and clinical course in hiv 1 infected recipients  design and subjects  we retrospectively tested approximately 200 000 donor blood component specimens stored in late 1984 and 1985 for anti hiv 1  and we contacted recipients of positive specimens to determine their serologic status  they were compared with both recipients of hiv 1 negative transfusions and healthy  untransfused  controls  subjects were seen at 3  to 6 month intervals for up to 4 years for clinical and immunologic evaluations  measurements and main results  of 133 recipients  9 had other possible exposures  excluding these cases  111 of 124  89 5   were anti hiv 1 positive  95  ci  84 1  to 94 5    the recipient s sex  age  underlying condition  and type of component did not influence infection rates  the cumulative risk for developing the acquired immunodeficiency syndrome  aids  within 38 months after transfusion was 13   ci  7 5  to 21 6    at 36     3 months after the index transfusion  seropositive recipients had lower counts of cd2 cdw26   cd4   cd4 cd29   and cd4 cd45ra subsets and more cd8 i2  lymphocytes than did recipients of anti hiv 1 negative transfusions  the cd4  and cd2 cdw26 subsets changed the most rapidly  the absolute cd8  count remained normal  conclusions  transfusion of anti hiv 1 positive blood infected 90  of recipients  the rate of progression to aids within the first 38 months after infection was similar to that reported for homosexual men and hemophiliacs  although most lymphocyte subset counts changed over time  cd8  counts were constant  
class2	delayed endolymphatic hydrops and its relationship to meniere s disease  delayed endolymphatic hydrops  eh  can be characterized as having ipsilateral and contralateral types  they are similar in that both have early and late phases of otologic symptoms and that the early phase is a profound hearing loss in one ear  the late phases differ  however  in that the ipsilateral type develops the symptoms of eh  episodic vertigo  in the deaf ear and the contralateral type develops the symptoms of eh  fluctuating hearing loss and or episodic vertigo  in the hearing ear  in more than half the cases of both types of delayed eh  the profound hearing losses in the early phase are simply discovered to be present in early childhood without a known time of onset  the temporal bones of two patients with contralateral delayed eh show pathologic changes in the deaf ears that are similar to those known to occur in mumps and measles labyrinthitis  whereas the pathologic changes in the hearing ears are similar to those known to occur in meniere s disease  these observations support the proposition that meniere s disease may occur as a delayed sequela of inner ear damage sustained during an attack of subclinical viral labyrinthitis occurring in childhood  
class2	characterization of the dermal infiltrate in human immunodeficiency virus infected patients with psoriasis  we investigated the dermal inflammatory cell infiltrates of psoriatic lesions from nine human immunodeficiency virus infected patients and nine age   sex   and site matched control specimens  the study was retrospective and observer blinded  t lymphocytes were quantitated using uchl 1  a pan t cell monoclonal antibody  and plasma cell number was estimated in hematoxylin eosin stained sections  differences in both variables reached statistical significance  there were fewer t cells and the number of plasma cells was significantly higher in specimens from the human immunodeficiency virus positive individuals in comparison with control specimens  as plasma cells are readily identified on hematoxylin eosin stained sections  their presence in skin biopsy specimens from psoriatic leisons should arouse suspicion of human immunodeficiency virus infection  the depletion of helper inducer t lymphocytes by the human immunodeficiency virus may promote the presence of plasma cells in cutaneous inflammatory infiltrates  
class2	sulfadiazine crystalluria revisited  the treatment of toxoplasma encephalitis in patients with acquired immunodeficiency syndrome  toxoplasma gondii encephalitis is an important opportunistic infection in the acquired immunodeficiency syndrome  estimated to occur in 20 000 to 40 000 patients with acquired immunodeficiency syndrome in the united states by 1991  the combination of sulfadiazine and pyrimethamine is regarded as the treatment of choice  acute renal failure due to crystal deposition in the urinary tract was well described 30 to 40 years ago and is likely to resurface as a clinical entity if appropriate prophylactic measures are not taken  we describe two cases of sulfadiazine induced crystalluria and renal failure in patients with acquired immunodeficiency syndrome  review the pertinent literature  and discuss the pathogenesis  recommendations are made for the prophylaxis and treatment of sulfadiazine related renal toxic reaction  physicians using this  new  drug must be aware of the potential danger of sulfonamide induced injury to the urinary tract  
class2	retrovirus from human t cell leukemia virus type i associated myelopathy is the same strain as a prototype human t cell leukemia virus type i  a retrovirus was isolated from a t cell line that was established from lymphocytes in the cerebrospinal fluid of a patient with human t cell leukemia virus type i associated myelopathy  ham   and its genome was sequenced  the nucleotide sequence of the 3  half of the total genome was identical in 99 5  of the nucleotides to that of the prototype human t cell leukemia virus type i that was derived from a patient with adult t cell leukemia  these results indicate that the same retrovirus human t cell leukemia virus type i is associated with both a neurological disease  ham  and a lymphoproliferative disease  adult t cell leukemia  
class2	silent infections with human immunodeficiency virus type 1 are highly unlikely in multitransfused seronegative hemophiliacs  we used the polymerase chain reaction  pcr  to determine the frequency of silent human immunodeficiency virus type 1  hiv 1  infections in seronegative high risk individuals with hemophilia who had been exposed to contaminated blood products more than 3 years previously  in a cross sectional study of a cohort of 57 prospectively followed seronegative hemophiliacs who received multiple transfusions before 1986  hiv 1 proviral dna was found transiently in only one patient  these data suggest that the rate of hiv infection among high risk antibody negative individuals with hemophilia is very low to absent  in the range of 0  to 2   these findings should provide considerable reassurance to seronegative persons with hemophilia and their sexual partners  
class2	predominance of polymorphonuclear leukocytes in cerebrospinal fluid of aids patients with cytomegalovirus polyradiculomyelitis  cytomegalovirus  cmv  polyradiculomyelitis was diagnosed in 4 of 241 consecutive neurologically assessed human immunodeficiency virus type  hiv 1  seropositive patients  cmv related neurologic disease was suspected on clinical grounds and was subsequently confirmed by cmv culture from cerebrospinal fluid  csf  and or cmv in situ hybridization on specific specimens  all four patients showed csf pleocytosis with predominance of polymorphonuclear leukocytes  pmns   retrospective analysis of the results of csf examination  performed in 143 of 241 patients with neurologic symptoms  showed pleocytosis in 58 of 143 patients  predominance of pmns was found in seven patients  including the four with cmv polyradiculomyelitis  it is concluded that in hiv 1 seropositive patients with a clinical diagnosis of polyradiculomyelitis  a predominance of pmns in csf could be an indication that the condition is cmv related  this should lead to early diagnosis and institution of specific antiviral therapy  
class2	acute syphilitic posterior placoid chorioretinitis  six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large  placoid  yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas  all eyes had vitreitis  all of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining  five patients had mucocutaneous lesions typical of secondary syphilis  all five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions  the ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis  modification of the host response to syphilis by human immune deficiency virus  hiv  infection may be partly responsible for this peculiar fundus picture  three of the four patients tested positive for hiv  
class2	mapping of herpes simplex virus 1 neurovirulence to gamma 134 5  a gene nonessential for growth in culture  the gene designated gamma 134 5 maps in the inverted repeats flanking the long unique sequence of herpes simplex virus 1  hsv 1  dna  and therefore it is present in two copies per genome  this gene is not essential for viral growth in cell culture  four recombinant viruses were genetically engineered to test the function of this gene  these were  i  a virus from which both copies of the gene were deleted   ii  a virus containing a stop codon in both copies of the gene   iii  a virus containing after the first codon an insert encoding a 16 amino acid epitope known to react with a specific monoclonal antibody  and  iv  a virus in which the deleted sequences were restored  the viruses from which the gene was deleted or which carried stop codons were avirulent on intracerebral inoculation of mice  the virus with the gene tagged by the sequence encoding the epitope was moderately virulent  whereas the restored virus reacquired the phenotype of the parent virus  significant amounts of virus were recovered only from brains of animals inoculated with virulent viruses  inasmuch as the product of the gamma 134 5 gene extended the host range of the virus by enabling it to replicate and destroy brain cells  it is a viral neurovirulence factor  
class2	infectious mononucleosis in older adults  infectious mononucleosis as a manifestation of primary epstein barr virus infection occurs uncommonly in adults over age 40  while fever is almost universal  older patients with the disease often present without lymphadenopathy  pharyngitis  splenomegaly  lymphocytosis or atypical lymphocytes  jaundice and hepatomegaly occur more commonly in older patients than in adolescents and create diagnostic confusion  often  infectious mononucleosis in this age group is confused with lymphoma  leukemia or biliary obstruction  or is classified as  fever of unknown origin    
class2	primary lymphoma of the central nervous system in two children with acquired immune deficiency syndrome  postmortem examination disclosed central nervous system non hodgkin s lymphoma in two children who died of acquired immune deficiency syndrome  aids  at 6 and 14 months of age  respectively  systemic signs of lymphoma were not present  the b cell origin and clonality of the neoplastic cells were established by immunohistochemistry in one case and by molecular analysis of immunoglobulin gene rearrangement in the other  moreover  in the latter case the neoplastic cells were characterized by the presence of a single episomal ebv genome  according to these data  the monoclonal b cell proliferation occurred after ebv infection  thus suggesting a possible pathogenetic role of ebv in the early stages of lymphomagenesis  
class2	idiopathic sudden sensorineural hearing loss and postnatal viral labyrinthitis  a statistical comparison of temporal bone findings  although the cause of idiopathic sudden sensorineural hearing loss remains uncertain  a viral origin has been suggested in many cases on the basis of anamnestic microbiologic and pathologic data  twenty two temporal bone specimens from 18 patients who during life suffered a sudden partial or complete sensorineural hearing loss were studied  on the basis of clinical data  these cases were assigned to one of three diagnostic categories  and the temporal bones were studied by light microscopy and serial section analysis  the implications of the histopathologic findings for the pathogenesis of idiopathic sudden sensorineural hearing loss are discussed  
class2	lymphomatoid granulomatosis presenting as ulcerodestructive gastrointestinal tract lesions in patients with human immunodeficiency virus infection  a new association  we describe cases of severe odynophagia  extensive oral ulcerations  and bowel perforation in patients with human immunodeficiency virus infection that were caused by lymphomatoid granulomatosis  such presentations in human immunodeficiency virus infected individuals are usually ascribed to other causes and may be incorrectly treated on an empiric basis  in addition  deep tissue specimens obtained at the margin of ulcerative lesions are often necessary for definitive diagnosis  we review our limited treatment experience with zidovudine  interferon alfa  and h2 blockers in our patients  based on the markedly increased frequency in which lymphomatoid granulomatosis is being diagnosed at our institution in the post human immunodeficiency virus era  we postulated an association between these two entities  
class2	disseminated strongyloidiasis with central nervous system involvement diagnosed antemortem in a patient with acquired immunodeficiency syndrome and burkitts lymphoma  a 45 year old man presented with central nervous system involvement as the initial manifestation of disseminated infection with strongyloides stercoralis  several concurrent clinical factors contributed to this event  all related to the patient s immunosuppression  including high grade lymphoma  corticosteroid therapy  and acquired immunodeficiency syndrome  this is only the third case of cns involvement in disseminated strongyloidiasis diagnosed antemortem  
class2	does prematurity alter the course of respiratory syncytial virus infection  we compared previously healthy prematurely born infants with full term infants hospitalized with respiratory syncytial virus  rsv  infection to evaluate the role of prematurity on the clinical course of the illness  during a 5 yr period  1984 to 1989   484 previously healthy patients were admitted to the hospital with rsv infection  no differences were found in the presenting symptoms of respiratory distress  cough  fever or shock  although the premature group was more likely to present with apnea  p less than  001   chest roentgenograms revealed that premature infants had a higher incidence of atelectasis infiltrate and hyperinflation  p less than  05   premature infants had longer hospital stays as well as a higher physiologic stability index and therapeutic intervention score  p less than  001   they were also more likely to receive supplemental oxygen  icu admission  mechanical ventilation  and nothing by mouth status  p less than  001   we conclude that premature birth increases the risk of more severe and prolonged rsv disease  
class2	tracheal stenosis and failure to wean from mechanical ventilation due to herpetic tracheitis  a 64 year old man with chronic obstructive pulmonary disease presented with pneumococcal pneumonia that progressed to respiratory failure within one week  requiring mechanical ventilation  despite a low minute ventilation and clear chest roentgenogram  multiple weaning attempts failed  bronchoscopy revealed significant narrowing of the distal trachea with erythema  edema  and ulceration of the mucosa  cytology of tracheal washings was consistent with herpes simplex virus  and the patient was successfully extubated following treatment with intravenous acyclovir  bronchoscopy following acyclovir therapy demonstrated resolution of the inflammation and narrowing  herpetic tracheitis is a rarely recognized reversible cause of tracheal stenosis  especially in a nonimmunocompromised patient  it should be suspected in patients without an obvious cause of failure to wean from mechanical ventilation  and can be successfully treated with acyclovir  
class2	herpes simplex virus hepatitis in pregnancy  two patients successfully treated with acyclovir  two cases of herpes simplex virus hepatitis in pregnancy are presented  each case was characterized by extremely high serum aminotransferase levels with minimal bilirubin elevation  in both cases  liver biopsy was instrumental in arriving at the diagnosis  in addition  computed tomography showed a radiographic appearance of the liver not characteristically seen in other hepatic disorders of pregnancy  a high index of suspicion in the second case led to early recognition and treatment  despite the presence of fulminant liver failure and evidence of herpes encephalitis in the other case  institution of therapy with acyclovir was associated with complete recovery in both patients  the present cases are compared and contrasted with the literature  the incidence of two cases within a 6 month period suggests that herpes simplex virus hepatitis in pregnancy may occur more frequently than previously reported  
class2	gastrointestinal motor dysfunction in acquired selective cholinergic dysautonomia associated with infectious mononucleosis  this report documents the disturbance in gastrointestinal motor function in a patient with selective cholinergic dysautonomia that occurred following acute infectious mononucleosis  apart from the gut  other organs affected included the pupils  sweat glands  lacrimal and salivary glands  and urinary bladder  autonomic function tests showed the preservation of sympathetic adrenergic functions in contrast to the generalized involvement of postganglionic parasympathetic and sympathetic cholinergic nerves  including denervation hypersensitivity of the pupil and urinary bladder to exogenous cholinergic agonists  cardiac and abdominal vagal responses were abnormal  colon myenteric plexus ganglion cells were normal by morphological and immunohistochemical studies  suggesting that the selective cholinergic dysautonomia was the most likely pathophysiologic process responsible for the observed motility disorder  this study documents the occurrence of selective cholinergic dysautonomia following a viral illness  the importance of the extrinsic neural control on the motor function of the gastrointestinal tract  and the usefulness of combined motility and autonomic function testing in the evaluation of patients with symptoms suggestive of gut dysmotility  
class2	hepatic fibrin ring granulomas in a patient with hepatitis a  hepatic fibrin ring granulomas were found in a 30 year old patient with serologically confirmed hepatitis a  other causes associated with the presence of fibrin ring granulomas in the liver  such as hodgkin s and non hodgkin s lymphoma  cytomegalovirus infection  visceral leishmaniasis  and consumption of allopurinol  were ruled out  it is suggested that hepatitis a must be included in the differential diagnosis of a patient with hepatic fibrin ring granulomas  
class2	are stressful life events risk factors for herpes zoster  to determine if psychologically stressful life events are risk factors for herpes zoster  we conducted a case control study of zoster and self reported recent negative life events and major changes in spousal relationships  the subjects were 101 healthy community dwelling cases of zoster and 101 healthy controls matched for age  sex  and race and generated by random digit dialing  the geriatric scale of recent life events was administered to case and control subjects  and additional questions were asked regarding the perception of the life event  the results showed that case subjects experienced negative life events significantly more often than subjects in the control groups in the 2 months before zoster onset by analysis of discordant pairs  26 versus 10  odds ratio 2 60  95  confidence interval  ci  1 13  6 27  p    012   3 months before  29 versus 11  odds ratio 2 64  95  ci 1 20  6 04  p    007   or 6 months before  35 versus 16  odds ratio 2 00  95  ci 1 04  3 93  p    012   the mean number of total life events was significantly higher in cases at 6 months before zoster  case means   2 64  control means   1 82  p    008   but there were no significant differences at 2  3  or 12 months before  there were no significant differences between case subjects and control subjects for spousal events  or any given single life event  in conclusion  we found that whereas patients with herpes zoster experienced the same kinds of life events in the year preceding the illness as did control subjects  recent events perceived as stressful were significantly more common among patients with zoster  
class2	human immunodeficiency virus and the primary care physician  as the scope and size of the human immunodeficiency virus  hiv  epidemic grows  the primary care physician will need to assume a greater role  a knowledge of hiv risk factors and the ability to perform pretest and posttest counseling for hiv testing is essential  counseling patients on hiv risk reduction should be part of the hiv risk interview  an understanding of the benefits and contraindications of testing  as well as a respect for the impact of testing  is important  all hiv seropositive individuals should undergo a complete history and review of symptoms as soon as test results are known  judicious use of laboratory testing  including monitoring of cd4 cell counts  is recommended  pneumocystis carinii prophylaxis and zidovudine therapy should be offered to patients with appropriately low cd4 counts  
class2	immunopathology and viral reactivation  a general theory of schizophrenia  a theory is proposed that explains a broad range of clinical manifestations in schizophrenia  it is a heuristic device for organizing research in the neuroimmunology and virology of schizophrenia  this approach is different from other immune and viral theories of schizophrenia and defines testable hypotheses for further theory refinement or rejection  defective alpha interferon  aifn  regulation resulting in excessive effect is postulated to cause schizophrenia  the role of aifn in the regulation of development and its induction within the brain by the reactivation of viruses that are commonly present in the normal central nervous system  cns  are the primary pathophysiological mechanisms  biological properties of aifn include neural excitation  opiate and adrenocorticotropic hormone activity  and inhibition of cellular proliferation and differentiation  psychosis results from in situ viral stimulation of aifn production in the cns of a vulnerable host having defective regulation of either sensitivity or production  negative symptoms result from aifn effects on cns development and the behavioral toxicity of aifn  biological developmental abnormalities  gender differences in severity  and decline in psychotic symptoms with age are discussed in the context of the theory  research strategies and specific testable hypotheses are presented  
class2	chancroid and the role of genital ulcer disease in the spread of human retroviruses  chancroid is the most prevalent form of genital ulcer disease in developing countries and is undergoing a resurgence in industrialized countries  as a result of a nonspecificity of the clinical findings  the etiologic diagnosis of genital ulcer disease requires laboratory support  genital ulcer disease is a risk factor for the transmission of human retroviral infections  an understanding of this interaction is emerging and will impact on the treatment and control programs for the agents causing genital ulcer disease  
class2	human papillomavirus infections of the genital tract  infection of the genital tract by hpv is a sexually transmitted disease of increasing prevalence  the association of hpv infection with genital tract malignancies is of great concern  and further studies are needed to clarify this association  few investigators believe at this time that proof of a direct causative role exists for hpv in these cancers  but indirect evidence of such a role is abundant  there are many clinical forms of hpv infection of the genital tract  and few clinicians can easily recognize them all  treatment of condyloma acuminatum is difficult and frustrating  cryotherapy with liquid nitrogen is the safest and most effective therapy for most forms of condyloma acuminatum  recurrence of condyloma acuminatum is common with all presently used forms of therapy  probably owing to latent hpv infection in normal appearing skin  no form of treatment is ideal for all forms of condyloma acuminatum  but without continued efforts to find better therapeutic modalities and preventative measures  the epidemic of genital hpv infection will continue unchecked  
class2	the emergence of hepatitis b as a sexually transmitted disease  in the united states  approximately 300 000 cases of hepatitis b virus infection occur annually  and heterosexual activity is one of the most commonly reported risk factors for acquiring disease  until the number of infections transmitted through heterosexual contact can be reduced through hepatitis b vaccination  there is little chance of controlling this infection  
class2	epidemiology of human immunodeficiency virus infection in women in the united states  from 1981 to 1989  the number of women with hiv infection and acquired immunodeficiency syndrome  aids  increased rapidly  most women were infected through intravenous drug use or sexual contact with an infected man  most children were infected through mother to infant transmission during pregnancy or delivery  available data suggest that the rapid increase in the number of women with aids will continue for at least the next few years  
class2	primary care of women infected with the human immunodeficiency virus  aids is the leading cause of death among women aged 25 to 34 years in new york city  gynecologic care should be directed toward early identification and aggressive treatment of infectious and neoplastic processes that may take a more fulminant course in immunosuppressed women  dealing with women s contraceptive needs highlights the problem of preventing sexually transmitted diseases through contraceptive technology  public health policies and recommendations will be of no avail without an educated and supportive medical community  
class2	isolation of human t cell lymphotropic virus type 2 from guaymi indians in panama  human t lymphotropic virus type i  htlv i  is associated with adult t cell leukemia lymphoma and with a chronic degenerative myelopathy  however  another major type of htlv  htlv ii  has been isolated only sporadically  and little is known of disease associations  transmission routes  and risk factors for htlv ii infection  recent studies indicate that a high percentage of certain groups of i v  drug users and blood donors are infected with htlv ii  seroepidemiologic studies have found an elevated rate of seroreactivity to htlv among guaymi indians from bocas del toro province  panama  to identify the cause of seroreactivity among this unique population we used htlv ii specific polymerase chain reaction techniques to detect htlv genetic sequences from blood leukocytes of three seropositive guaymi indians  the htlv ii primer amplified polymerase chain reaction products from two of these subjects were partially sequenced and matched published htlv ii nucleotide sequences in both p24 gag  94  of 107 bases  and pol  98  of 112 bases  regions  a cd4  t lymphocyte line established from one of these same subjects produced htlv ii specific proteins when tested in antigen capture and immunoblot assays  as well as mature htlv particles  the demonstration of htlv ii infection in this geographically and culturally isolated central american indian population without typical risk factors for htlv infection suggests that htlv ii infection is endemic in this population and provides an important clue to potential natural reservoir for this virus  
class2	immunological studies of the basis for the apathogenicity of simian immunodeficiency virus from african green monkeys  potential reasons for the lack of pathogenicity of the simian immunodeficiency virus sivagm in its natural host  the african green monkey  agm  cercopithecus aethiops   were investigated with respect to immunological mechanisms  the functional immune response of monkeys to infection was similar  though not identical  to that of humans to infection with human immunodeficiency virus type 1  hiv 1   in the sera of infected animals  neutralizing antibodies were found to be low or absent  and in particular there was no neutralization of the various isolates by homologous sera  there was no detectable antibody complement cytotoxicity  though agm sera were able to initiate antibody dependent cellular cytolysis of infected cells in the presence of healthy effector peripheral blood lymphocytes  as in the human hiv system  macrophages from agms are readily infected by sivagm  two possibly important differences between the agm sivagm system and the human hiv system are  i  the low immune response of the agms to the core protein of sivagm and  ii  the significantly lower inhibitory effect of sivagm proteins on the proliferation of agm lymphocytes  
class2	granulomatous pneumocystis carinii pneumonia in a patient with the acquired immunodeficiency syndrome  a patient with an unusual granulomatous response to infection with pneumocystis carinii is described  the diagnosis was made by open lung biopsy after two negative bronchoalveolar lavages  
class2	bronchoalveolar lavage via a modified stomach tube in intubated patients with the acquired immunodeficiency syndrome and diffuse pneumonia  a simple non bronchoscopic bronchoalveolar lavage method was used in 30 patients with the acquired immunodeficiency syndrome undergoing assisted ventilation for respiratory failure  a modified argyle levin stomach tube was passed via the endotracheal tube and lavage performed  the lavage was well tolerated and performed quickly and easily  required little training  and had a high degree of sensitivity  73   a diagnosis in 22 of the 30 cases   
class2	current report  hiv  aids at the crossroads  a report from the 1990 international conference on aids  san francisco  major scientific and clinical breakthroughs in hiv disease are rarely saved for the international conference on aids  nevertheless  this conference provides an opportunity for experts  providers  and patients to gain new information  exchange ideas  and assess progress  the conference is also a public forum for political and social discussion and serves as a barometer of scientific and social trends as well  this year s conference featured refinements in clinical care  a deeper understanding of the epidemiologic trends  and a public awareness of the many political aspects of the aids epidemic  contributions from family physicians and other primary care providers about problems they face and the family aspects of hiv need still greater prominence and exposure  hopefully family physicians will use their expertise and report at future international conferences  
class2	the incidence of myocarditis in endomyocardial biopsy samples from patients with congestive heart failure  we present the combined experience of three yugoslavian cardiovascular centers in the application of endomyocardial biopsy for the diagnosis of myocarditis in patients who present clinically with congestive heart failure  the study group comprised 107 patients  mean age  40 8 years  range  19 to 61 years   on the basis of patient history and diagnostic tests  the following clinical diagnoses were established  dilated cardiomyopathy  85   myocarditis  16   and alcohol induced heart disease  6   emb samples were taken from the left ventricle  95  or both ventricles  12  by use of a king s college bioptome  with a mean of 3 2 samples per patient  histologic evidence of myocarditis was noted in 10 of 85 patients  12   with a clinical diagnosis of dilated cardiomyopathy  in 2 of 6 patients  33   with alcohol induced heart disease  and in 12 of 16 patients  75   with a clinical diagnosis of myocarditis  there was confirmation of the clinically suspected diagnosis in 63  of cases  a change of diagnosis based on histology in 15  of cases  and nonspecific findings in 22   however  useful information was obtained in 78  of the cases  and there was a 22  incidence of histologically proven myocarditis for the entire group  our results indicate that endomyocardial biopsy is beneficial in determining the true incidence of myocarditis in patients with a clinical presentation of dilated cardiomyopathy  
class2	effect of delayed captopril therapy on left ventricular mass and myonecrosis during acute coxsackievirus murine myocarditis  the effect of captopril on coxsackievirus b3 murine myocarditis was investigated  thirty two  3 week old mice were infected with coxsackievirus b3 on day 0 of the study  then randomized into a placebo group or a captopril group starting on day 3 of infection  on day 9 of infection  the mice were put to death  hearts were weighed and processed for light microscopic examination  heart weight was 125     19 mg in the control group versus 102     14 mg in the captopril group  p less than 0 0003   amount of necrosis as a percentage of left ventricular section was 3 5   2 0  to 7 5   in the placebo group versus 2 0   0 0  to 5 0   in the captopril group  p less than 0 01   the amount of dystrophic calcification was 5 0   0 0  to 27 5   in the placebo group versus 1 3   0 0  to 20 0   in the captopril group  p less than 0 01   the extent of the histopathologic involvement by planimetry was 10 2  in the placebo group versus 5 4  in the captopril group  p   0 052   we conclude that captopril is beneficial in decreasing left ventricular mass and the amount of myocardial necrosis and calcification in the short term in the murine myocarditis model  
class2	central retinal artery obstruction in herpes zoster ophthalmicus and cerebral vasculopathy  we present a case of acute central retinal artery obstruction in association with herpes zoster ophthalmicus and delayed cerebral vasculopathy  retinal vascular obstruction is rare in zoster  and its occurrence during postherpetic cerebral vasculopathy has not been reported previously to our knowledge  the syndrome of delayed cerebral vasculopathy is discussed as is its possible relationship to central retinal artery obstruction  
class2	central nervous system vasculitis after chickenpox  cause or coincidence  a 7 5 year old boy  known to have a seizure disorder  presented with an infarct in the left middle cerebral artery territory  10 weeks after severe chickenpox  immunofluorescent antibody titre to the varicella zoster virus in the cerebrospinal fluid was 1 32  cerebral angiography showed evidence of focal vasculitis  he presented again seven months later with an acute exacerbation of seizures  magnetic resonance imaging of the brain showed an old posterior extension of the infarct  but a repeated angiography demonstrated an improvement in the vasculitic process  cerebrospinal fluid antibody titre was again 1 32  although this may have been an unfortunate coincidence  a possible association between chickenpox and vasculitis  similar to that reported with herpes zoster  and with potentially significant clinical implications  should be considered  as a definite proof can be obtained only by a brain biopsy  however  which is generally not indicated in such cases  only additional clinical reports can lead to delineation of this association as a definite entity  
class2	continued need for pneumococcal prophylaxis after splenectomy two children died from pneumococcal infection five and eight years after splenectomy  pneumococcal vaccination had not been given to either child  when the infection developed both children were not taking prophylactic penicillin  vaccination and daily penicillin reduce the incidence of this complication and therefore we strongly recommend that both of these measures are continued indefinitely  
class2	five year prospective study of hiv infection in the edinburgh haemophiliac cohort objective  to identify measures of immune state that reflect the course of hiv related disease in order to predict deterioration of symptoms and assess response to treatment  design  five year longitudinal clinical and laboratory study  setting  regional haemophilia centre  university virology laboratory  and medical research council laboratory  patients  32 patients with haemophilia a exposed to a single batch of hiv contaminated factor viii concentrate from the scottish national blood transfusion service in 1984 who were followed up regularly in edinburgh  31  or abroad  one   main outcome measures  counts of circulating t cell subsets  cd4 and cd8   plasma beta 2 microglobulin  neopterin  and iga concentrations  and delayed type hypersensitivity to multiple skin test antigens  results  18 patients who seroconverted after exposure had received significantly more contaminated factor viii than the 14 who did not  mean 43  range 9 109  v 15  3 30  phials  p less than 0 01   the two groups were not distinguishable by other criteria before exposure  the group that seroconverted subsequently showed a progressive fall in mean circulating cd4 lymphocytes and an increase in plasma beta 2 microglobulin and neopterin concentrations  from 1987 patients in this group also showed an increase in mean circulating cd8 lymphocytes and in plasma iga concentration  neither of which was seen in patients who did not seroconvert  patients with hiv antibody who developed centers for disease control category iv symptoms within five years after infection showed more extreme changes in all measures  except cd8 lymphocyte count  than those whose symptoms remained in categories ii and iii  skin test reactivity declined to barely detectable levels in all patients positive for hiv antibody  conclusions  serial estimates of circulating cd4 lymphocytes and of plasma beta 2 microglobulin concentration are the most reliable measures of disease progression  of these  beta 2 microglobulin concentration seems to be the better predictor of impending serious symptoms  high iga concentrations reflect rather than predict disease state  individual variation in most measures is such that a wide range of measurements should be used in assessing the effects of trial treatment in hiv infected patients without symptoms  
class2	causes  diagnosis  and treatment of pharyngitis  pharyngitis is a common disease of the respiratory tract that can be caused by several different viruses and bacterial organisms  clinically speaking  the most important causative agent is group a streptococcus  streptococcus pyogenes   although rare  postpharyngitis complications arise as a result of disease caused almost exclusively by group a streptococcus  because group a streptococcal pharyngitis usually responds well to antimicrobial treatment  it is important to diagnose it  penicillin  erythromycin  and peroral first generation cephalosporins have been documented to be effective  in addition to group a streptococcus  c  pneumoniae and m  pneumoniae have also been detected in patients with pharyngitis  the possibility of diagnosing these organisms is limited at the present  clinical surveys are still needed  moreover  to evaluate the effect of antimicrobial treatment on the disease caused by these organisms  although routine viral diagnostic methods do not help primary care physicians in treating patients with pharyngitis  information on bacteria and viruses in the immediate environment could prove to be of great help in daily clinical work  
class2	increasing incidence of varicella hospitalizations in united states army and navy personnel  are today s teenagers more susceptible  should recruits be vaccinated  hospital records for 10 687 united states army and navy adult varicella  chickenpox  admissions were reviewed  annual hospital admission rates for varicella increased more than fourfold in the active duty army during 1980 to 1988 and more than 18 fold among active duty navy enlisted personnel during 1975 to 1988  fifty seven percent of varicella admissions occurred in the most junior military members  aged 17 to 20  more than half of the total varicella admissions occurred in personnel with less than a year of military service  multivariate analysis of the navy data confirmed increasing time related trends of risk  suggesting a national temporal trend of increased varicella susceptibility in us teenagers and young adults  administering a safe and effective varicella vaccine to army and navy recruits could prevent more than 7260 hospital bed days during the first year of use  
class2	a routine tool for detection and assessment of epidemics of influenza like syndromes in france  a regression model for the nonepidemic level of influenza like syndrome has been estimated from the 55 200 cases collected between october 1984 and august 1988 using the french communicable diseases computer network  the start of a major epidemic in 1988 89 was detected early  the size of the epidemic  for the entire country  was estimated at approximately 4 3 million cases  the excess cost of sick leave  among those of working age  was estimated at  86 million  
class2	increased septic complications with three drug sequential immunosuppression for cadaver renal transplants  in 152 renal transplant recipients  the results of immunosuppression with three drug sequential  minnesota antilymphocyte globulin  prednisone  azathioprine  and cyclosporine  immunosuppression  n   107  were compared with those of a two drug sequential protocol  minnesota antilymphocyte globulin  prednisone  and cyclosporine  that excluded azathioprine  n   45   the study groups were comparable by age  sex  etiology of renal failure  incidence of diabetes  and degree of hla matching  patient survival at 1 year was not significantly different in the two groups  two drug  93  versus three drug  86   p   0 19   one year graft survival was superior in the two drug group  two drug  93  versus three drug  75   p   0 02   analysis of primary transplants only  n   116  yielded the same results  during the first year  the serum creatinine level remained stable in both groups  as expected  the three drug therapy group had significantly more bacterial and viral infections  for low risk primary cadaveric renal transplants  two drug sequential immunosuppression is superior  
class2	cerebrospinal fluid neopterin in human immunodeficiency virus type 1 infection  we evaluated cerebrospinal fluid  csf  concentrations of neopterin  a putative marker of activated macrophages  in 97 subjects infected with human immunodeficiency virus type 1 who had a spectrum of neurological complications  the highest csf neopterin concentrations occurred in those with neurological opportunistic infections  primary central nervous systems lymphoma  and acquired immunodeficiency syndrome  aids  dementia complex  in general  the csf concentration of neopterin was independent of csf cell count and blood brain barrier disruption to albumin  in the patients with aids dementia complex  csf neopterin concentrations correlated with severity of disease and decreased in conjunction with clinical improvement following treatment with zidovudine  these results suggest that csf neopterin  although not disease specific  may be useful as a surrogate marker for the presence of aids dementia complex and its response to antiviral therapy  
class2	an hiv 1 and hiv 2 cross reactive cytotoxic t cell epitope  the hla b27 restricted hiv gag cytotoxic t lymphocyte  ctl  epitope  265 279  is highly conserved amongst hiv 1 isolates  only one  hiv 1eli  having a single amino acid substitution  over the same region hiv 2 differs by five amino acids  as a broadly cross protective aids vaccine should protect against infection from all isolates of hiv 1 and hiv 2  we tested ctl specific for the hiv 1 265 279 epitope with peptide analogues from hiv 1eli  hiv 2 and two simian immunodeficiency virus  siv  isolates  and with recombinant vaccinia viruses expressing the respective gag genes  to determine whether there was any cross reactivity for this ctl epitope  ctl from the hiv 1 infected donor could recognize the hiv 1eli peptide  the hiv 2 peptide and recombinant vaccinia virus infected target and one of the two siv peptide treated targets  epitopes that exhibit such cross reactivity may be valuable in vaccine design  
class2	response of mononuclear cells from hiv infected patients to b cell mitogens  correlation with immunological and clinical features of disease progression  proliferation of mononuclear cells from hiv seropositive patients to b cell mitogens was studied in the absence and presence of mixed lymphocyte culture supernatants  mlc sup   the results show   1  patients  responses to b cell mitogens overlap with normal responses but are  on average  consistently lower than normal   2  the addition of mlc sup increases the proliferative responses to t cell independent mitogens  but does not bring patient s responses up to control levels   3  hiv positive patients in all clinical categories have decreased responses to b cell mitogens  although some patients with aids centers for disease control  cdc  group ivc and ivd have the lowest responses  asymptomatic  cdc group ii  and aids related complex  arc  cdc groups iii iva and ivb  patients also show significant defects   4  the same patients were recategorized using an immunological staging system  those patients with more normal immunohematological parameters have significantly greater responses to mitogens compared with patients with more abnormal immunological parameters  the data suggest that immunological staging could provide more information than clinical classification with respect to the underlying immunopathogenic events occurring in hiv infection  
class2	aids following mother to child transmission of hiv 2  mother to child infection with hiv 2 is thought to be rare  and there have been few previous reports of transmission by this route  reports of morbidity associated with hiv 2 infection in children are also rare  we describe eight children born to mothers who were infected with hiv 2  five developed aids  and three were still seropositive at 17 49 months of age  the only apparent route of hiv 2 transmission was from mother to child  except for one child who had been transfused  three of the children with aids died  all having decreased cd4  lymphocytes and mitogen responses  further studies are needed to determine the prevalence and natural history of mother to child transmission of hiv 2  
class2	an analysis of the economic impact of hiv infection among patients at mama yemo hospital  kinshasa  zaire  in a prospective study of adult admissions to the department of internal medicine at mama yemo hospital  kinshasa  zaire in late 1988  129 women and 122 men were screened for hiv infection  fifty per cent were found to be seropositive  with half of the seropositives meeting the world health organization  who  clinical aids definition  the hiv seropositives had a mortality rate of 50   which was significantly higher  p   0 004  than the 30  mortality rate seen in the seronegative group  direct costs during hospitalization did not differ   60 30 for hiv seropositives   56 50 for hiv seronegatives   but pre hospitalization expenses were significantly higher in the hiv seropositive group   170 for hiv seropositives   110 for hiv seronegatives   years of productive life lost due to death were also significantly higher for hiv seropositives versus hiv seronegatives  30 6 versus 21 3 years  p   0 0007   and 73  of the premature mortality in the study population was attributable to hiv infection  
class2	a semiquantitative microassay for measurement of relative number of blood mononuclear cells infected with human immunodeficiency virus  a simple semiquantitative microassay was developed for the measurement of relative number of infected peripheral blood mononuclear cells  pbmc  from individuals infected with human immunodeficiency virus  hiv   the assay is based on cocultivation of serially diluted pbmc of a seropositive person with phytohemagglutinin stimulated normal pbmc  the microassay has comparable sensitivity with the standard virus culture method in detecting positive hiv cultures  since the microassay uses only 2 3 x 10 5  patients  pbmc  the assay is also most suitable for hiv isolation from hiv infected infants or from aids patients with extremely low t cell counts  the microassay can also be used to measure antiviral effects of a drug on persistent hiv infection in vitro  because the microassay measures the relative number of infected pbmc  it can be readily used for following the quantitative antiviral effect of a drug in a clinical trial  
class2	cumulative aids incidence and altered mortality from bacterial infections  to determine whether populations with high cumulative incidence of acquired immunodeficiency syndrome  aids  experienced increased deaths from sepsis  central nervous system abscess  or endocarditis  new jersey aids patients were grouped according to their age  sex  race  and residence specific cumulative incidence of aids since the onset of the aids epidemic  between 1980 and 1986  among 25 44 year olds in the highest cumulative incidence group for aids  sepsis mortality increased from 3 3 to 15 2 deaths 100 000 year  an increase of 11 9 deaths 100 000 year  95  confidence interval  6 9  17 0  deaths 100 000 year   mortality from central nervous system abscesses increased from zero to 1 7  0 1  3 2  deaths 100 000 year  and mortality from endocarditis increased from 0 8 deaths 100 000 year to 2 4 deaths 100 000 year  an increase of 1 6   0 5  3 7  deaths 100 000 year  age matched new jersey patient populations with low cumulative incidence of aids did not sustain a similar increase  the hiv disease associated increase in sepsis mortality among young populations represents a new component of the substantial increase in u s  sepsis mortality that occurred over the last two decades  but was previously limited to older populations  
class2	complications of tenckhoff catheters post removal  complications due to tenckhoff catheters can occur at prolonged intervals after their removal  from january 1979 to october 1989  431 patients at our center began continuous ambulatory peritoneal dialysis  capd   278 of whom subsequently transferred to another form of renal replacement therapy  we identified 12 patients  4 3  or 12 278  with post removal catheter complications  there were 14 post removal complications  two each in two patients  and one in each of 12 others  the mean time to complication was 541     143 days  27 2 040   in 71   10 14  of the complications  an abscess was found at the site of the previously removed tenckhoff catheter  in 29   4 14  of the complications  foreign body material consistent with a retained cuff was recovered  documentation at the time of tenckhoff catheter removal should include a statement regarding the presence of the tenckhoff catheter cuffs  and patients with retained cuffs should be monitored closely for the development of abscesses or other complications  immunocompromised patients are at high risk for these complications  
class2	cerebrospinal norepinephrine concentrations and the duration of epidural analgesia this study was performed to determine whether the addition of norepinephrine to local anaesthetics prolongs epidural analgesia in man  in addition  cerebrospinal fluid norepinephrine  ne  concentrations were measured  in the first part of the study  epidural catheters were inserted in 14 patients before herniotomy  mepivacaine  1 5 per cent  0 35 ml kg 1   was administered and norepinephrine  5 micrograms ml 1  was added in seven patients  the duration of anaesthesia was prolonged from 54     11 min to 83     12 min  p less than 0 05  and csf ne concentrations increased from 68     12 pg ml 1 to 336     85 pg ml 1 in the ne group  p less than 0 01   in the second part  eight patients with herpetic neuralgia received epidural analgesia at the fourth to eighth thoracic interspace  using bupivacaine 0 25 per cent  with and without ne  the csf ne concentrations in this group were greater than in the surgical patients before operation and increased from 254     58 to 406     58 pg ml 1 30 min after administration of bupivacaine with ne  the duration of pain relief was prolonged with ne  these results suggest that adding ne to local anaesthetics prolongs epidural analgesia  moreover  ne concentrations in surgical patients increased to levels similar to those found in patients suffering from herpetic analgesia  this suggests that the increase of csf ne in chronic pain states has an antinociceptive effect  
class2	a phase i study of recombinant human interferon alpha 2a or human lymphoblastoid interferon alpha n1 and concomitant zidovudine in patients with aids related kaposi s sarcoma  to determine the safety  maximum tolerated dose  and preliminary efficacy of concomitant interferon alpha and zidovudine therapy in aids related kaposi s sarcoma  ks   56 patients with biopsy proven ks and documented human immunodeficiency virus type 1  hiv  infection were enrolled into a phase i study  interferon alpha was given intramuscularly at a dose of 9  18  or 27 mu once a day and zidovudine was administered as 100 or 200 mg every 4 h for 8 weeks followed by a 48 week maintenance period  the major toxicities were anemia  neutropenia  and hepatotoxicity  neutropenia was dose limiting with 1 200 mg of zidovudine day and the lowest dose of interferon alpha  9 mu day   hepatotoxicity was dose limiting with 27 mu of interferon and 600 mg of zidovudine day  cumulative dose related anemia or neutropenia was not seen during long term follow up  the maximum tolerated doses for the combination were defined as 18 mu daily for interferon alpha and 600 mg daily for zidovudine  variable changes in cd4 lymphocytes occurred during the first 8 weeks of therapy  at higher doses of the combination  sustained increases in median cd4 lymphocyte numbers were noted  p less than 0 001   in hiv antigenemic patients  progressive antigen suppression was seen with increasing doses of the combination  p less than 0 005   the overall antitumor response rate was 47   tumor regression was associated with better survival benefits  p less than 0 001  and a pretreatment cd4 cell count greater than or equal to 200 cells mm3  p   0 01   in conclusion  intermediate doses of interferon alpha and lower doses of zidovudine appear to be relatively well tolerated and associated with disease improvement  including survival benefits  
class2	cd4  monocyte counts in persons with hiv 1 infection  an early increase is followed by a progressive decline  in this study  we asked whether there is a difference in the number of cd4  and cd4  peripheral blood monocytes as cd4  t cells decrease during hiv mediated immunodeficiency  monocytes and t cells from 90 hiv positive and 43 hiv negative persons were analyzed by flow cytometry  the 90 hiv positive patients represented the entire spectrum of cd4  t cell counts  we report that as cd4  t cells decrease  the number of cd4  monocytes decrease in parallel  moreover  significantly higher cd4  monocyte counts were observed in persons with early stage hiv disease  i e   greater than 800 cd4  t cells mm3  than in hiv negative persons with greater than 800 cd4  t cells mm3  potential implications of these findings are discussed  
class2	cigarette smoking  a modifier of human immunodeficiency virus type 1 infection  two hundred and two homosexual men enrolled in a prospective cohort study of aids risk were assessed for differences in the occurrence and progression of human immunodeficiency virus type 1  hiv 1  infection with respect to cigarette smoking  among subjects who were initially seronegative  smokers were more likely than nonsmokers to become hiv 1 seropositive  p   0 03   after seroconversion  serum beta 2 microglobulin and cd4  lymphocyte levels were elevated in cigarette smokers relative to nonsmokers  p   0 02 for both comparisons   but both of these differences disappeared within 2 years  there was no detectable difference in the risk of aids or pneumocystis carinii pneumonia with respect to smoking  our data suggest that cigarette smoking may alter the immune response to hiv 1 infection  but it appears to have no marked effect on clinical outcome  they also suggest that cigarette smoking may be a surrogate marker for continued high risk sexual behavior in homosexual men  
class2	rectourethral fistula caused by kaposi s sarcoma  a 35 year old man with the acquired immunodeficiency syndrome related complex was evaluated for a persistent urethral discharge  pneumaturia and watery diarrhea  radiographic and endoscopic procedures established the diagnosis of a rectourethral fistula  perineal exploration and excision of the fistula revealed the pathological diagnosis of kaposi s sarcoma  the differential diagnosis of an acquired rectourethral fistula and the significance of kaposi s sarcoma are discussed  
class3	endoscopic cholangiopancreatography in hepatic clonorchiasis  a follow up study  cholangiographic changes of the biliary system in 16 patients with proven hepatic clonorchiasis  diagnosed by positive stool or bile ova isolates  were studied  all patients presented with epigastric pain  other symptoms included jaundice in 31   5 of 16  and fever in 12 5   2 of 16   praziquantel given at 25 mg kg for three doses in 1 day were administered  three consecutive stool tests were performed 3 months after treatment and were negative in 87 5   14 of 16   ercp studies were repeated at a mean interval of 31 6 months  range  8 to 69 months   measurements of the bile ducts on retrograde cholangiograms before and after treatment were compared using the paired student s t test  filling defects and blunting of the terminal bile ducts seen on the initial cholangiogram  interpreted as the presence of adult worms  disappeared after treatment  however  there was no significant change between pre  and post treatment measurement of bile duct caliber  bile duct dilation  irregularities  and ductal proliferation persisted despite eradication of the parasite  
class3	cardiac echinococcosis  the diagnostic value of computed tomography scanning  the diagnosis of cardiac hydatid disease is a difficult one  conventional and specific cardiac investigations are not pathognomonic of this disease  in this report  the diagnostic value of computed tomography  ct  scanning was prospectively investigated in seven patients  in five patients  the diagnosis was confirmed surgically  the ct information obtained correlated accurately to the operative findings  in all the patients  ct densities of the lesions were measured and were found to coincide with values of mean ct densities of hydatid cysts elsewhere in the body  the capability of measuring tissue densities is unique to ct scanning and have been emphasized in this report  
class3	impact of mass treatment of onchocerciasis with ivermectin on the transmission of infection  onchocerciasis is a major blinding disease that  until recently  has been essentially untreatable  ivermectin is a safe and effective drug for the mass treatment of onchocerciasis and when used on an individual basis  it reduces the ability of the treated person to transmit onchocerca volvulus infection  in the present study  the effect of community based ivermectin treatment on the degree of transmission within the community was assessed by determining the incidence of new infection in children  ivermectin was distributed annually on three occasions to the eligible members of a population of approximately 14 000 people living on a rubber plantation in a forest area endemic for onchocerciasis  after 2 years  the prevalence of infection in 5 year old children decreased by 21   the annual incidence in an uninfected cohort of children decreased by 35  and  after age specific adjustment  the reduction in incidence in 7  to 12 year old children was 45   thus  community based distribution of ivermectin led to a significant reduction in incidence of new infection  these findings suggest that ivermectin can be important in reducing the transmission of onchocerciasis  
class3	disseminated strongyloidiasis in aids and non aids immunocompromised hosts  diagnosis by sputum and bronchoalveolar lavage  in conclusion  disseminated strongyloidiasis is a fatal disease that commonly affects the lungs  the disease should be suspected in an immunocompromised host who came from an area endemic for s stercoralis even years before the onset of symptoms or in patients with unexplained gram negative bacteremia or meningitis  treatment should be started promptly and should be maintained for a long time  
class3	cerebral cysticercosis  we studied 143 cases of cerebral cysticercosis over a 30 year period  in 46 there was hydrocephalus due to cysts obstructing the cerebrospinal fluid pathways  with signs of hydrocephalus and cerebellar dysfunction  in 97 there were cysts in the cerebral parenchyma  causing symptoms of intracranial hypertension alone in 22 cases  with additional neurological deficits in the remainder  before 1980 diagnosis was made by pneumoencephalography and ventriculography  but since then it has mostly been done by computed tomography  in 28 cases scanned  typical abnormalities were present in 25  complement fixation tests were positive in serum in 74  of cases and in cerebrospinal fluid in 73   and the enzyme linked immunosorbent assay test was positive in serum in 90  and in cerebrospinal fluid in 92   treatment of cases with hydrocephalus was by removal of the cysts at craniotomy  with placement of a shunt where necessary  intracranial hypertension caused by parenchymal cysts was treated with steroids and osmotic agents  if possible  in resistant cases subtemporal decompression was needed  unilateral in 55 cases and bilateral in eight  mortality in the acute stage was 11   with a further 20  at follow up  
class3	pleuropulmonary manifestations of hepatic amebiasis pleuropulmonary manifestations of hepatic amebiasis occurred in 30 patients  18  60   presented with at least 1 pulmonary complaint and 10  33   had multiple pulmonary symptoms  in 14 patients  47    abnormalities were found on examination of the chest  in 16 chest roentgenograms  53    there was at least 1 abnormality  right sided pleural effusion  9 patients  and elevated right hemidiaphragm  8 patients  were the most common  all patients were treated with metronidazole  flagyl  and had resolution of the amebic liver abscess and pulmonary disease  pleuropulmonary disease is a common complication of amebic liver abscess  the clinical presentation and chest roentgenograms are virtually diagnostic and obviate the need for invasive procedures to confirm the diagnosis  pleuropulmonary disease resolves with amebicidal treatment of the hepatic abscess  
class3	ascariasis  ascaris lumbricoides is the most common helminth to infect humans  infection occurs when contaminated soil containing mature eggs is swallowed  clinically  infection ranges from the asymptomatic carrier state to life threatening pulmonary disease or intestinal obstruction  diagnosis is most frequently established by identification of the eggs in stool specimens  treatment with antiparasitic drugs is effective in preventing serious complications and eradicating the parasite from all members of the household  
class3	toxoplasmic chorioretinitis and hepatic granulomas  a 71 yr old male presented with a 2 month history of fever  malaise  and weight loss  physical exam revealed chorioretinitis  laboratory studies were notable for elevated levels of alkaline phosphatase  gamma glutamyl transpeptidase  aspartate transaminase  and alanine transaminase  immunoglobulin g antibody to toxoplasma gondii was positive to a dilution of 1 4096  whereas serologic studies for hepatitis a virus  hepatitis b virus  cytomegalovirus  epstein barr virus  human immunodeficiency virus  brucella  and tularemia were negative  a percutaneous biopsy of the liver revealed hepatic granulomas  culture of the biopsy specimen was negative for growth of mycobacteria or fungi  spontaneous improvement in clinical and laboratory parameters occurred over a 4 month period  
class3	high infectious morbidity in pregnant women with insulin dependent diabetes  an understated complication  patients with insulin dependent diabetes are prone to infection  possibly related to poor metabolic control  relative immune deficiency exists in pregnancy  we hypothesized that pregnant patients with insulin dependent diabetes are at an increased risk for infection and that infection is related to poor glycemic control  we matched 65 pregnant women with insulin dependent diabetes to 65 nondiabetic pregnant controls  at least one episode of infection before delivery occurred in 83  of the women with insulin dependent diabetes  26  in control group   the rate of postpartum infection was five times higher in the group with insulin dependent diabetes and they were susceptible to more kinds of infections  although there was no overall difference among the indices of glycemic control  hemoglobin a1 obtained before the infection was higher than during infection  we conclude that a high rate of infection exists in pregnant women with diabetes  infection and poor glycemic control may be associated  but it is unclear whether improvement in metabolic control will reduce this high infection rate  
class3	successful medical management of acanthamoeba keratitis seven patients with documented acanthamoeba keratitis were treated with prolonged and intensive triple antiamoebic therapy consisting of topical neomycin polymyxin b gramicidin  propamidine isethionate 0 1   and miconazole nitrate 1   additionally  five patients were treated with topical corticosteroids  six of seven patients were cured of acanthamoeba keratitis with medical therapy alone  one patient required therapeutic penetrating keratoplasty to eradicate the infection  two patients underwent penetrating keratoplasty to improve their vision after medical therapy  our series differs from previous reports in that triple antiamoebic therapy was used in all seven patients and was successful in both early and advanced cases of acanthamoeba keratitis  prolonged and intensive topical therapy with these three antiamoebic drugs may be an effective mode of therapy for acanthamoeba keratitis  
class3	humoral and cell mediated immune responses to the plasmodium falciparum antigens pf155 resa and cs protein  seasonal variations in a population recently reexposed to endemic malaria  resurgence of falciparum malaria occurred in the central highlands of madagascar in the 1980s and the disease is currently hyperendemic  we determined the humoral and cellular responses to synthetic peptides reproducing the repeat sequences of 2 major plasmodium falciparum antigens  the pf155 resa and the circumsporozoite  cs  protein  blood samples from 83 subjects living in a rural community near antananarivo were obtained at the beginning and the end of the transmission season  at enrollment  40 subjects presenting with and 43 without blood parasites had similar t cell proliferative response and antibody level to all antigens tested  however  p  falciparum infected individuals exhibited a decrease in the absolute number of t lymphocytes  due to a diminished number of cd8  and natural killer lymphocytes  the number of cd4  cells was similar in both groups  in the overall population  45  of subjects had a t cell response to at least 1 resa peptide  29 35  responding to a given peptide  and 35  to the cs protein peptide  thirty two percent of the donors presented with resa antibodies and 23  had cs protein antibodies  after 20 weeks  at the end of the transmission season  cellular proliferative responses to all antigens markedly decreased as evidenced by a decrease of both the number of responders and mean stimulation indexes  humoral response to resa  as detected by erythrocyte membrane immunofluorescence  number of responders and mean antibody titers  markedly increased  humoral responses to the cs protein and resa peptides were similar  
class3	in vitro growth inhibition of plasmodium falciparum by sera from different regions of the philippines  sera from different malaria endemic regions of the republic of the philippines were compared for their ability to inhibit growth of plasmodium falciparum in vitro  dialyzed serum was added to synchronous cultures containing schizonts for either the total 48 hr test period or only the last 24 hr in order to analyze the effects on erythrocytic invasion and intraerythrocytic growth  respectively  reduction in 3h hypoxanthine uptake was used to determine the percent of inhibition compared to nonimmune serum  one hundred seventy sera from mindanao and palawan in the south  the centrally located island of mindoro  and luzon in the north  were tested against 4 p  falciparum strains from the philippines and 1 from africa  indirect fluorescent antibody titers were not predictive of inhibition  inhibition of merozoite invasion rather than intraerythrocytic parasite growth is suggested by this study  generally  sera were more inhibitory to parasite strains from the same geographical area than to those from more remote areas  
class3	comparison of active and passive case detection of cutaneous leishmaniasis in guatemala  to estimate the degree to which passive case detection underestimates the true incidence of cutaneous leishmaniasis in guatemala  we compared data from the passive surveillance system of the guatemalan ministry of health with a cross sectional population based survey of cutaneous leishmaniasis in guatemala  of the 2 938 persons interviewed  143  5   reported having had cutaneous leishmaniasis at some time in the past  37  1 3   reported the onset of infection in the 12 months before the survey  31  1 1   had active infections  and 16  0 5   had parasitologically confirmed infections  calculated on the basis of these reports and the estimated population of the endemic area  the total number of new cases in the leishmaniasis endemic area in the 12 months before the survey was approximately 2 574  during the same 12 month period  ministry of health data based on passive surveillance listed 64 cases of cutaneous leishmaniasis  in guatemala  incidence estimates based on passive surveillance may underestimate the occurrence of cutaneous leishmaniasis by as much as a factor of 40  
class3	diffuse cutaneous leishmaniasis acquired in peru  a case of diffuse cutaneous leishmaniasis  dcl  acquired in peru is described  the causative agent was leishmania mexicana amazonensis as determined by isoenzyme analysis and species specific monoclonal antibody binding characteristics  histological examination of biopsy material showed a large number of intracellular and extracellular amastigotes and few lymphocytes  treatment with meglumine antimoniate  glucantime  administered iv at a dosage of 20 mg antimony kg body weight day for 60 days resulted in visible improvement of the lesions  but not in clinical or parasitological cure  
class3	a comparison of host responses of the mongolian jird to infections of brugia malayi and b  pahangi  host responses of jirds receiving a single subcutaneous inoculation of subperiodic brugia malayi were compared with those of jirds similarly infected with b  pahangi  parasite burdens  lymphatic lesion severity  granulomatous reactivity  antibody responses to parasite antigens  and complete blood cell counts were assessed at 60 and 150 days post inoculation  at 60 days post inoculation  percentages of adults recovered at necropsy and lymphatic lesion severity were greater in b  pahangi infected jirds  at 150 days post inoculation  lesion severity and percentages of worms recovered were similar in both infections  no significant differences were noted in either infection in reactivity to homologous or heterologous parasite antigens in any parameter measured  similarities in the kinetics of the inflammatory reactivities of the 2 infections suggest that previous observations made in the jird b  pahangi model could be utilized in designing studies using b  malayi  further  the more marked lesion severity observed in b  pahangi infected jirds and the relative ease of maintaining b  pahangi in the laboratory support the continued use of this system as a conceptual model for the study of lymphatic lesion pathogenesis  
class3	transmission indices of loa loa in the chaillu mountains  congo  a longitudinal entomological survey of the vectors of loiasis was conducted in the missama area  lekoumou region  in the congo from september 1987 to august 1989  the principal catching site was a palm grove surrounded by forest 3 km from the village  landing biting densities of chrysops were measured by standardized fly catches lasting 11 hr carried out twice a month  vector landing densities were also assessed in the bantu and pygmy villages and in the fields  populations of chrysops from the palm grove were examined 6 times a month for infection with the infective stage of loa loa  chrysops silacea was the predominate vector except at the beginning of the rainy season  when c  dimidiata was the prevailing species  chrysops were caught throughout rainy season  from october to june  the host seeking activity of c  silacea was greatest in the middle of this season  february   but occurred sooner  october  for c  dimidiata  the following variables associated with transmission were calculated from our observations in the palm grove  the first figure corresponds to the first year of the study and the figure in parentheses corresponds to the second year   it was calculated that 2 658  2 185  c  silacea and 1 412  1 182  c  dimidiata could bite a person in the palm grove per year  including an average of 14 4  12 7  infective c  silacea and 9 8  7 2  infective c  dimidiata  the percentage of all dissected flies with third stage larvae in the head and the mean number of larvae in the head infective fly were 0 57  and 10 1     6 8 for c  silacea and 0 66  and 11 2     6 5 for c  dimidiata  respectively  the estimated annual transmission potentials were 171 1  102 9  for c  silacea and 116 1  73 8  for c  dimidiata  in the palm grove  transmission was ensured by 2 effective vectors during the rainy season  october to may   although the annual biting rate for both species was twice as low in the village as in the forest  our data suggest that effective transmission occurs there also  
class3	in vivo assessment of antimicrobial agents against toxoplasma gondii by quantification of parasites in the blood  lungs  and brain of infected mice  the in vivo effects of antimicrobial agents against toxoplasma gondii were evaluated in mice that were infected intraperitoneally with 10 4  tachyzoites of the rh strain by determination of survival rates and study of the kinetics of growth of t  gondii in infected mice  at various intervals after infection  subcultures of serial dilutions of blood  lung  and brain homogenates were performed in fibroblast tissue cultures for determination of parasitic loads  pyrimethamine  18 5 mg kg per day   sulfadiazine  375 mg kg per day   and clindamycin  300 mg kg per day  were administered for 10 days from day 1 or day 4 after infection  untreated control mice died within 9 days and showed early and predominant lung involvement  all mice treated with sulfadiazine administered from day 1 survived and were apparently healthy  parasitic loads decreased early after treatment  but a relapse was observed 5 days after the cessation of therapy  when pyrimethamine was administered from day 1  7 of 11 mice died within 25 days  by determination of parasitic loads  the effect of pyrimethamine was only demonstrable from day 6  and a relapse was constantly observed after the cessation of therapy  when pyrimethamine and sulfadiazine were administered in combination  100  of mice survived  when therapy was started at day 1  parasites remained undetectable  in mice treated from day 4  parasites were eradicated by day 8 but infection relapsed 8 days after the cessation of therapy  all mice treated with clindamycin from day 1 or day 4 died within 10 days  but parasitemia was always undetectable  
class3	intraoperative bronchial aspiration of ruptured pulmonary hydatid cysts  ruptured pulmonary hydatid cysts are seen clinically and radiologically as persistent cavitary lesions of the lung  bronchi opening into the pericyst cavity allow for discharge of fluid matter but not the escape of solid remnants of the collapsed parasite  operative manipulation of the involved lung in the course of surgical management of chronic ruptured pulmonary hydatids can force fragments of the laminated membrane or small daughter cysts into the bronchial tree  such extruded solid fragments lodge in bronchi of the same or opposite lung with resulting acute obstruction of airways  intraoperative bronchial aspiration of hydatid material was seen in 7 patients with ruptured hydatid cysts of the lung  either primary or secondary to transdiaphragmatic extension of liver hydatids  the first clinical sign can be unexplained difficulty in ventilation  effective management consists of prompt exposure of the stem bronchus on the operative side  with bronchotomy for suction retrieval of escaped solid fragments of the parasite  
class3	an immunofluorescence study of cerebral malaria  a correlation with histopathology  histopathologic and immunopathologic features of cerebral malaria have been defined in a study of six autopsy cases with severe plasmodium falciparum infection  in five cases  immunofluorescent studies demonstrated intense deposition of p falciparum antigen  igg  and fibrin in cerebral vessels associated with the histopathologic finding of hemorrhage in the white matter of cerebrum and cerebellum regardless of the presence of parasitized erythrocytes in the cerebral vessels  immunofluorescent study also demonstrated the extravascular deposits of p falciparum granular antigen associated with acute inflammatory lesion in cerebral tissue in one case  these findings suggested that the immunopathogenic mechanism may in some way play a role in the pathogenesis of cerebral malaria  
class3	in vitro rosetting  cytoadherence  and microagglutination properties of plasmodium falciparum infected erythrocytes from gambian and tanzanian patients  to understand the molecular mechanisms that lead to sequestration of red blood cells infected with mature stages of plasmodium falciparum and to examine the relevance of earlier studies on adherence properties of laboratory derived p falciparum parasites to the natural parasite population  we analyzed gambian and tanzanian isolates for in vitro cytoadherence and antibody mediated microagglutination  eighteen cryopreserved isolates of ring stage parasites were cultured for 20 to 30 hours in vitro  in the patients original erythrocytes  to the trophozoite and schizont stage  all parasites were positive in the microagglutination assay with at least one of four african hyperimmune sera  in a rosetting assay  only 2 of the 18 isolates were strongly positive  35  and 41  of parasitized erythrocytes with more than two uninfected cells bound   thirteen isolates showed either intermediate  5  to 18   or low  less than 5   rosetting while three isolates did not form rosettes  infected cell binding of the different isolates to immobilized cd36 or thrombospondin  or c32 melanoma cells correlated with the percentage of mature parasites in the blood samples  r    932 for cd36  r    946 for thrombospondin  and r    881 for c32 melanoma cells   there was a high correlation between binding to cd36 and thrombospondin  r    982   the extent of infected cell rosetting with uninfected cells in these blood samples was not correlated with these other receptor properties  we also observed coexpression of rosetting and cytoadherence receptors on the same parasitized erythrocytes  
class3	mefloquine kinetics in cured and recrudescent patients with acute falciparum malaria and in healthy volunteers  mefloquine pharmacokinetics were compared in a randomized clinical trial in thailand among patients with malaria and healthy volunteers  a single oral dose of 1500 mg mefloquine hydrochloride was administered to 11 patients and 5 volunteers and 750 mg was given to 16 patients and 5 volunteers  efficacy was 82  for 1500 mg and 63  for 750 mg  in cured patients taking 750 mg mefloquine  peak plasma drug concentration  cmax  and area under the plasma concentration time curve  auc  were significantly greater than in the patients for whom treatment failed  p less than 0 0005 and p less than 0 01  respectively   and plasma mefloquine levels were significantly higher from 8 hours to 18 days after treatment  mefloquine auc was reduced and variable in the presence of diarrhea  compared with noninfected volunteers  clinically ill patients displayed a delayed time to reach peak concentration  p less than 0 01  and significantly higher mefloquine plasma levels in the first 2 days after administration of either the 750 mg or the 1500 mg dose  mefloquine auc was similar in patients with malaria and healthy volunteers  because plasma levels increased in temporal relationship with clinical illness  mefloquine volume of distribution or clearance  or both  was reduced during the acute phase of illness  
class3	hemoptysis in a 49 year old man  an unusual presentation of a sporadic disease  although amebiasis is prevalent in tropical and subtropical areas  it occurs sporadically in the united states  pleuropulmonary involvement is seen in about 20 percent of the patients with amebic liver abscesses  we describe a patient with pleuropulmonary amebiasis who complained of hemoptysis but had no gastrointestinal symptoms  this rather unusual presentation caused a considerable delay in securing the diagnosis  
class3	variceal sclerosis in schistosomotic patients  a 5 year follow up study  to assess the therapeutic possibilities of injection sclerosis in schistosomotic portal hypertension  a 5 year prospective study was conducted in northeast brazil  where this parasitosis is endemic  fifty patients undergoing endoscopy for upper gastrointestinal hemorrhage from rupture of esophageal varices from july through december 1981 were chosen for the study  the 32 consenting patients were submitted to injection sclerotherapy paravariceally  using ethanolamine oleate  the 18 refusing to participate were assigned to the control group  the incidence of rebleeding was 28 1  in the former and 44 5  in the latter  a difference which was not statistically significant  fisher s test  p   0 375   mortality from rupture of esophageal varices was 3 1  in the sclerotherapy group and 27 7  in the control group  a statistically significant difference  fischer s test  p   0 017   since sclerotherapy markedly improved the long term survival rate of the patients  this procedure is advocated for the treatment of esophageal varices in cases of portal hypertension due to schistosomiasis  
class3	transfusion risks  hepatitis remains the most serious transfusion risk  in terms of incidence and severity  transfusion associated aids  hemolytic reactions  trali  and anaphylaxis are severe problems that occur relatively rarely  while febrile reactions and mild allergic reactions are common but not serious  the key to avoiding all these complications is autotransfusion  see the article  autologous transfusion  in this issue   although intraoperative scavenging became available in many centers in the united states in the 1980s  it is hoped that pre deposit autotransfusion will also become widely utilized in the next decade  
class3	circulating immune complex associated parasite antigens in human onchocerciasis  this study identified and characterized parasite antigens in sera from humans infected with onchocerca volvulus  immune complexes were precipitated from human sera with polyethylene glycol and analyzed by immunoblot with rabbit antibodies to o  volvulus  a 23 kda parasite antigen was detected in sera from 17 of 23 nigerian onchocerciasis patients and 5 of 10 endemic controls  other parasite antigens with apparent molecular masses of 62  66  and 70 kda were less consistently observed  these antigens were not present in nigerian or us nonendemic control sera  in sera from patients with various other parasitic infections  or in sera from us patients with autoimmune diseases  biochemical studies indicated that these antigens are nonglycosylated acidic proteins that do not contain phosphorylcholine  these antigens may be useful as targets for improved diagnostic tests for onchocerciasis based on parasite antigen detection  
class3	bacterial infections in patients with visceral leishmaniasis  bacterial infections are often seen in patients with visceral leishmaniasis  to determine the incidence of such infection and the more common infectious agents  30 consecutive patients with visceral leishmaniasis were followed throughout hospitalization  there were 24 episodes of bacterial infection in 18 patients  60    the incidence of bacterial infections in these patients was 22 2 1000 days of admission  the proportion of patients becoming infected by time was significantly greater in the visceral leishmaniasis group than in controls  p less than  01   the skin  respiratory tract  and middle ear were the most common sites of infection  and pseudomonas aeruginosa and staphylococcus aureus were the most common agents  low grade virulence bacteria  e g   serratia and providencia species  were also isolated from some cases  bacterial infections  mainly nosocomial  in patients with visceral leishmaniasis tend to be severe and can cause death  when bacterial infection is suspected in these patients  empiric antibiotic therapy should be started immediately  including coverage for p  aeruginosa and s  aureus  after appropriate diagnostic procedures are taken  
class3	diagnosis of intestinal amebiasis using salivary iga antibody detection  this investigation sought to determine whether detection of salivary iga antibodies to entamoeba histolytica could identify intestinal amebic infections among 223 school children  four groups of children were identified through coproparasitoscopic examination  e  histolytica as other parasites only  20    and parasite free  25    the diagnostic accuracy of salivary iga antibodies to an e  histolytica membrane extract was 91 5   sensitivity  85   specificity  98    maintaining high predictive value at different prevalences  also  a positive correlation  r    753  p less than  001  was observed between fecal e  histolytica membrane antigen levels and salivary iga antibody activity  measurement of iga antibodies in saliva may be useful in diagnosing intestinal infections with e  histolytica within a wide range of prevalences  moreover  sampling of saliva may be a useful non invasive test for immunoepidemiologic surveys  
class3	effects of albendazole on echinococcus multilocularis infection in the mongolian jird  albendazole chemotherapy of larval echinococcus multilocularis was studied in the mongolian jird by administration of medicated feed at various concentrations and durations  the effects were evaluated by comparison of treated and control groups in terms of host mortality  larval metastases to the lungs  and final weight and histologic appearance of larval tissue  viability of larval tissue at necropsy of each animal was tested by inoculation into two noninfected jirds  albendazole medicated feed  0 05  0 10   significantly inhibited larval growth  other effects of the drug included larval degeneration and necrosis  inhibition of protoscolex formation  decreased pulmonary metastases  and reduced mortality of hosts  adverse effects on the parasite correlated significantly with serum albendazole metabolite levels and duration of therapy  however  serum albendazole levels in jirds equal to or exceeding concentrations achieved in humans receiving daily doses of 10 mg kg of body weight did not kill the parasite  
class3	dexamethasone increases plasma levels of albendazole  therapy of neurocysticercosis with cysticidal drugs is frequently complicated by the exacerbation of symptoms that follows the inflammation triggered by the acute destruction of cysticerci  treatment of such adverse reactions with dexamethasone is highly effective  however  it has been shown that dexamethasone lowers the plasma levels of praziquantel  thus reducing its cysticidal efficacy  we measured plasma levels of albendazole  another strong cysticidal drug  when dexamethasone was given simultaneously  we found that dexamethasone increased the plasma levels of albendazole by about 50   p less than 0 002   hence  it seems that cysticercosis and the ensuing inflammation can be treated simultaneously with albendazole and dexamethasone without diminishing the efficacy of the cysticidal drug  
class3	toxoplasmosis of the conus medullaris in a patient with hemophilia a associated aids  case report  toxoplasma gondii has been reported to be the most common cause of focal brain lesions in patients with acquired immunodeficiency syndrome  aids   a case of intramedullary toxoplasmosis of the conus medullaris is reported in a patient with hemophilia a associated aids  the diagnosis is discussed  with particular emphasis on the magnetic resonance imaging appearance  
class3	cerebral malaria in children cerebral malaria is a rapidly progressive encephalopathy with up to 50  mortality  a cardinal feature is the massing of red cells containing mature plasmodium falciparum within the cerebral capillaries  adhesion of these parasitised red cells to endothelium  an event which may initiate cerebral malaria  is being studied at the molecular level  however  the relevance of these studies to the pathophysiology and treatment of human cerebral malaria is uncertain  although chloroquine is still widely used to treat falciparum malaria  resistance has spread to most of the endemic zone  quinine is emerging as the only effective treatment for cerebral malaria  though resistance to this drug threatens to become a problem  alternative drugs are urgently needed  
class3	hiv disease  a review for the family physician  part ii  secondary infections  malignancy and experimental therapy  the first part of this two part article included recommendations for the initial evaluation of patients suspected of having hiv infection  the centers for disease control s classification scheme for hiv disease and current recommendations for the use of zidovudine  in this second part  secondary infections and malignancy are reviewed  and various experimental therapies are briefly discussed  
class3	detection of congenital toxoplasmosis by chorionic villus sampling and early amniocentesis  we describe a strategy used in this case to detect congenital toxoplasmosis early in pregnancy  combination of chorionic villus sampling and early amniocentesis with an in vitro cell culture technique makes prenatal diagnosis of congenital toxoplasmosis possible from the end of the first trimester of pregnancy  
class3	variations in malaria transmission rates are not related to anopheline survivorship per feeding cycle  anopheline survivorship  vectorial capacity  and mosquito infection probability estimates from mosquito infection rates were determined 4 times in 1 year in a papua new guinea village  estimates of survivorship over the length of the extrinsic incubation period differed significantly during the year  however  survivorship per feeding cycle  individual mosquito vectorial capacity  and mosquito infection probability did not vary significantly  estimates of these parameters were then compared to estimates of survivorship  individual vectorial capacity  and mosquito infection probability in mosquito populations in other villages in the study area  since survivorship per feeding cycle did not vary significantly among the mosquito populations in these villages  changes in malaria transmission potential can be better gauged from estimates of survivorship over the length of the extrinsic incubation period  however  as measurements of relative inoculation rates are easier to perform and have been related to parasite prevalences in children in this area  estimates of inoculation rates are a preferred option for estimating malaria transmission in the madang area of papua new guinea  
class3	geographical distribution of plasmodium falciparum erythrocyte rosetting and frequency of rosetting antibodies in human sera  uninfected erythrocytes bind spontaneously to those infected with certain strains of plasmodium falciparum  this is known as spontaneous erythrocyte rosetting  we have studied the occurrence and frequency of rosetting in 75 fresh patient isolates and have identified rosetting strains from africa  south america  and asia  rosetting was present in 49  of the isolates tested  the frequency of rosetting red blood cells  rbc  in individual isolates was 0 75  when scored during the first cycle of in vitro growth  rosetting antibodies were found in 15 out of 73  21   liberian sera as measured by disruption of rosettes in vitro  however  antibodies able to inhibit cd36 dependent cytoadherence of p  falciparum infected rbc were not detected in these sera  erythrocyte rosetting is a geographically widespread phenomenon  rosetting antibodies seem to be induced by natural infection and the molecular mechanism of rosette formation seems distinct from that of endothelial cytoadherence  
class3	studies in owl monkeys leading to the development of a synthetic vaccine against the asexual blood stages of plasmodium falciparum  during the development of a synthetic vaccine for human use against the asexual blood stages of plasmodium falciparum  monkey trials were performed to assess safety  immunogenicity  and protectivity  we determined the minimal infective dose of the p  falciparum fvo strain  the kinetics of the immune response induced by vaccination with the synthetic peptide mixture  s7   s12   s17  or the synthetic hybrid polymeric protein spf66  and the induction of protective immunity against the experimental challenge with 2 p  falciparum strains  a clear boosting effect was observed  determined by the increased antibody titers against synthetic peptides s7  s12  s17  and spf66  and by improvement in the protective immune response against the challenge  these studies suggest that either the peptide mixture or the synthetic hybrid polymeric protein are excellent choices for the development of a vaccine against p  falciparum  
class3	immunization of owl monkeys with a combination of plasmodium falciparum asexual blood stage synthetic peptide antigens  a mixture of 3 synthetic peptides  35 1  55 1  and 83 1  corresponding to portions of the 35 kda  55 kda  and 83 kda proteins from the asexual blood stages of plasmodium falciparum and a polymer of a syntheic peptide incorporating the 3 individual peptides  spf66  were tested as candidate malaria vaccine antigens in aotus nancymai  monkeys were immunized with combinations of the 3 peptides from 2 separate sources  centers for disease control  cdc   atlanta  ga or colombia  or with the synthetic polymer  animals immunized with a combination of the 3 peptides from cdc had higher antibody titers to the 35 1 and 55 1 peptides than to the 83 1 peptide  monkeys immunized with a combination of the 3 peptides produced in colombia developed higher levels of antibody to the 55 1 than to the 83 1 and 35 1 peptides  animals immunized with the polymer produced detectable antibodies to the 55 1 peptide alone  following challenge with p  falciparum  no differences were observed between the 3 vaccine groups and 2 control groups with respect to the number of animals with parasitemias greater than or equal to 10   the inconsistency of serologic response to all 3 peptides in these animals contrasted with previous trials performed in colombia where the monkeys developed high antibody titers against the 3 peptides and were protected against the experimental infection  
class3	ultrasonographical investigations of onchocerciasis in liberia  the efficiency of ultrasonography  us  for the diagnosis and clinical characterization of onchocerciasis was evaluated  us was performed on 120 probands in liberia  ninety two patients had generalized onchocerciasis  21 patients suffered from the chronic hyperreactive form of onchocerciasis  sowda   and 7 probands served as controls  patients were examined by us with linear  7 5 mhz and 5 mhz  and sector  3 5 mhz  scanners  us results were evaluated by examination of extirpated nodules  the us structure of nodules revealed a typical pattern consisting of a homogeneous echogenicity with small echodense particles and a lateral acoustic shadow  and differentiation from lymph nodes  lipoma  or fibroma was achieved  within the onchocercomata  calcifications or fluid were identified  regarding the estimation of the worm burden  it is important to note that in 24 patients  additional nodules not previously palpated were found by us  also  the number of worm centers in palpable conglomerate nodules were determined more exactly by us than by palpation  in 4 of 16 sowda patients  impalpable nodules were found by us  in 13 patients with positive microfilaria counts  no nodules could be detected  the highly characteristic ultrasonographical pattern of onchocercomata may serve as a basis for further us investigations in onchocerciasis  
class3	plasmodium falciparum infected anopheles stephensi inconsistently transmit malaria to humans  malaria was transmitted to only 5 of 10 volunteers bitten by 1 2 anopheles stephensi carrying sporozoites of the 3d7 clone of the nf54 strain of plasmodium falciparum in their salivary glands  parasites were detectable by culture in blood taken 7 10 days following exposure and by thick blood film 14 16 5 days after exposure  infectivity did not correlate with the numbers of sporozoites in the salivary glands  
class3	quantitative in vitro drug potency and drug susceptibility evaluation of leishmania ssp  from patients unresponsive to pentavalent antimony therapy  quantitative in vitro drug sensitivity of 32 leishmania isolates  16 from patients failing pentavalent antimony  sbv  therapy  was determined using a radiorespirometric microtechnique  ram   of 30 isolates with histories  22  73   ram tests agreed with patient history  the remaining 8  27   did not  there was no difference in ram drug sensitivity  clinical correlation between 15 isolates tested blindly and 15 with known clinical history  4 did not agree with clinical history in both   test sensitivity appeared to be limited only by the sensitivity of the leishmania to sbv and could be detected at 2 micrograms ml sb  about 10  of serum drug level   an isolate from a patient with untreated self healing cutaneous disease was drug resistant  using ram  parasite drug sensitivity can be quantified apart from patient physiologic and immunologic variables intrinsic to clinical data  potency differed a maximum of 100   weight  sb weight  sb  among drug lots and also between glucantime and pentostam  potency changes between drug lots were not explainable based on sb content or test to test variability  this microtest offers a rapid method for evaluating the drug sensitivity of patient isolates and for determining of the activity of pentavalent antimonials and other candidate anti leishmanials prior to the initiation of therapy  
class3	parasite antigenemia in untreated and treated lymphatic filarial infections  to evaluate the merit of antigen detection assays as a tool to monitor the efficacy of chemotherapy for lymphatic filariasis  we serially measured antigen levels in sera from jirds infected with brugia malayi and from humans with bancroftian filariasis  antigenemia was detected in all animals with parasitologically proven infection and was present in jirds with prepatent or occult filariasis  antigen levels correlated with worm burdens  and progressively declined in drug cured animals  treatment with diethylcarbamazine  dec  triggered a transient increase in serum levels of filarial antigens bearing the epitope recognized by the monoclonal antibody hc 11  all patients with bancroftian filariasis became amicrofilaremic within one week after dec treatment  antigenemia levels slowly declined over a period of several months in all but one treated individual  forty two months after treatment  progressively rising antigen levels are present in 10 patients  six of these remain amicrofilaremic  in the other 4  elevated antigenemia levels preceded or were detected at the same time as recurrent parasitemia  periodic monitoring of antigenemia levels after treatment of patients with lymphatic filariasis can be used to identify individuals who are likely to develop recurrent microfilaremia before the parasites become detectable in blood samples  thereby allowing timely retreatment  
class3	selective breeding of dogs for segregation of limb edema from microfilaremia as clinical manifestations of brugia infections  three generations of beagles were monitored for microfilaremia  mf  and clinical disease during repeated infection with brugia pahangi and were selectively bred for offspring manifesting limb edema and low or amicrofilaremia  a high microfilaremic female mated to a high microfilaremic male produced 7 pups  6 of which maintained mf greater than 1 000 ml for greater than 2 years after 5 monthly infections of 10 infective larvae each  an uninfected female mated to another high mf male produced 5 pups  4 of which did not exceed 1 000 mf ml 7 months after initiation of the repeating infection regimen  1 of these remained amicrofilaremic after 2 additional challenges  neither the parents nor the offspring from these matings manifested chronic limb edema  two matings were conducted with offspring from the microfilaremic female by breeding siblings with the lowest mf and breeding siblings with the highest mf  the high mf siblings produced 4 5 offspring manifesting chronic limb edema  greater than or equal to 7 months duration  and either no mf  in 2 dogs  or less than 100 mf ml after the repeating infection regimen  the lower mf siblings produced 5 offspring  all with greater than 1 000 mf ml 6 months after the initiation of the repeating infection regimen  none manifested edema  comparisons of igg antibody levels  specific for extracts of adult worms  showed no consistent differences between these 2 litters of dogs that could be associated with limb edema or mf when monitored for 16 months  however  the onset of lymph node enlargement was much earlier in the group of dogs manifesting limb edema than in the other litter  
class3	physical activity  opportunity for reinfection  and sibling history of heart disease as risk factors for chagas  cardiopathy  a case control study was conducted to examine whether physical activity  sibling history of heart disease  hhd   and length of residence in an area endemic for chagas  disease were associated with the risk of developing chagas  cardiopathy  two hundred forty seven cases of chagas  heart disease and 345 seropositive subjects with normal ecg  controls  were selected in a population survey in goiania  brazil  prevalence ratios for exposure variables were estimated for cases in relation to controls and for subgroups of seropositives with selected ecg abnormalities in relation to controls  increasing age and male sex were consistently and significantly related to an increased risk of ecg abnormalities  hhd was significantly associated with ecg alterations in 3 of the 5 comparison subgroups  any ecg alteration  right bundle branch block  and left anterior hemiblock   no association was found between length of residence in an area endemic  physical activity  and ecg abnormalities  a sample of 529 seronegative subjects were also examined and the interaction between exposure variables and seropositivity was tested to assess whether the associations found were specific for seropositives  males were at greater risk of any ecg alteration and left anterior hemiblock in relation to females if they were seropositive  an increasing risk of ventricular premature beats with age was clearer for seropositive than for seronegative subjects  subjects with hhd were at an increased risk of ecg abnormalities and this was greater in those with a positive serological test  p less than 0 05   the findings suggest a possible geographical clustering or a familial aggregation of cases of chagas  heart disease  
class3	efficacy and toxicity of sodium stibogluconate for mucosal leishmaniasis  objective  to determine the efficacy and toxicity of the world health organization s  who  recommended treatment for mucosal leishmaniasis  antimony  20 mg kg body weight per day for 28 days  design  open trial with 12 month follow up  setting  inpatient unit of a regional referral hospital in a developing country  patients  twenty nine consecutive eligible patients with culture confirmed infection of the mucosa with leishmania species who were otherwise healthy  eight patients  28   had mild to moderate disease  confined to the nasal mucosa   twenty one patients  72   had severe disease  including the oropharynx as well as the nasal mucosa   intervention  antimony  20 mg kg body weight intravenously every day for 28 days  patients received antimony in the form of sodium stibogluconate  measurements and main results  initial results of therapy were as follows  63 of 72 lesions  88   healed or markedly improved  all lesions were culture negative for parasites  and 18 of 29 patients  62   showed complete clinical and parasitologic cure of all lesions  by the 12 month follow up examinations  however  37 lesions had recurred  8 new lesions had appeared  and only 8 patients  30   showed clinical cure of all lesions  of the 8 patients with mild to moderate disease  6 were cured compared with only 2 of the 21 patients with severe disease  side effects of this treatment regimen included t wave inversion on electrocardiogram  4 patients   abnormal liver function tests  10 patients   and musculoskeletal pain  24 patients   no side effects occurred during week 1 of therapy  conclusions  the only recommended treatment for mucosal leishmaniasis is ineffective in patients with severe disease  the acceptable toxicity of the regimen suggests that longer courses of therapy with antimony  or that trials with other antileishmanial agents alone or combined with antimony be evaluated as initial therapy for this disease  
class3	acute renal failure in obstructive jaundice in cholangiocarcinoma  this study was aimed at defining the natural history of renal failure in obstructive jaundice due to cholangiocarcinoma  which is an important health problem in northeastern thailand  sixty four patients among a total of 130 patients with obstructive jaundice secondary to cholangiocarcinoma who developed acute renal failure were studied retrospectively  analysis was made with respect to clinical features  laboratory findings  and outcome  the development of renal failure before surgery was observed in all patients  it was nonoliguric in 80  and was associated with severe jaundice  gram negative infection  42    hypotension  31    hypoproteinemia  30    hyponatremia  56    and hypokalemia  63    the mean duration of renal failure was 2 weeks  all patients underwent surgery for the relief of jaundice  seventy seven percent of the patients survived and had recovery of renal function after the relief of jaundice  twenty three percent of the patients died of infection  clinical data highlight the higher serum bilirubin levels and the frequent occurrence of hyponatremia  hypokalemia  and hypotension in renal failure  their possible roles in contributing to the development of renal failure are discussed  
class3	sulfadiazine crystalluria revisited  the treatment of toxoplasma encephalitis in patients with acquired immunodeficiency syndrome  toxoplasma gondii encephalitis is an important opportunistic infection in the acquired immunodeficiency syndrome  estimated to occur in 20 000 to 40 000 patients with acquired immunodeficiency syndrome in the united states by 1991  the combination of sulfadiazine and pyrimethamine is regarded as the treatment of choice  acute renal failure due to crystal deposition in the urinary tract was well described 30 to 40 years ago and is likely to resurface as a clinical entity if appropriate prophylactic measures are not taken  we describe two cases of sulfadiazine induced crystalluria and renal failure in patients with acquired immunodeficiency syndrome  review the pertinent literature  and discuss the pathogenesis  recommendations are made for the prophylaxis and treatment of sulfadiazine related renal toxic reaction  physicians using this  new  drug must be aware of the potential danger of sulfonamide induced injury to the urinary tract  
class3	lindane  kwell  induced aplastic anemia  numerous toxic exposures have been implicated in causing aplastic anemia  thirteen cases of aplastic anemia and 5 cases of other blood dyscrasias  eg  red blood cell aplasia and thrombocytopenia  associated with lindane  have been reported in the literature  however  aplastic anemia secondary to the scabicidal product  lindane  kwell   has not been documented  to our knowledge  we present the case of a 21 year old man with a diagnosis of aplastic anemia  known prolonged exposure to lindane  and documented elevated serum lindane levels  his clinical course is described as well as various defects are explored for the aplasia  
class3	pathophysiological insights into the cardiomyopathy of chagas  disease  the evidence gained from both human and animal studies of chronic chagasic cardiomyopathy suggests that the disease occurs as a consequence of several discrete and progressive pathophysiological processes occurring after infection  the ultimate expression of which depends on a host of unidentified factors  collectively  the infection associated events compromise microvasculature function and result in hypoperfusion  with consequences indistinguishable from those observed in other  nonparasitological cardiomyopathic diseases secondary to hypoperfusion  therefore  chronic chagasic cardiomyopathy may share similar pathophysiological abnormalities with other chronic congestive cardiomyopathic states  
class3	longitudinal study of lesions of the posterior segment in onchocerciasis  onchocerciasis is a major cause of blindness  and much of the blindness due to onchocerciasis is caused by chorioretinitis  little is known about the progression of lesions in the posterior segment in either untreated or treated disease  the authors studied the progression of onchocercal chorioretinitis in 57 patients from 1 to 3 years  changes were documented from detailed ocular examinations  fundus photographs  and fluorescein angiograms  and included live intraretinal microfilariae  intraretinal hemorrhages  cotton wool opacities  intraretinal pigment  white and shiny intraretinal deposits  retinal pigment epithelial window defects  and atrophy  depigmentation at the edge of chorioretinal scarring progressed at a rate of up to 200 microns per year  ivermectin or mebendazole treatment did not appear to alter the progress of depigmentation at the edge of chorioretinal scars  these observations suggest that onchocercal chorioretinitis is associated with early changes in the retina and retinal pigment epithelium  and that disease in the posterior segment may progress rapidly  
class3	toxoplasma gondii retinochoroiditis and optic neuritis in acquired immune deficiency syndrome  report of a case  a 29 year old man with acquired immune deficiency syndrome  aids  was found to have a retinochoroiditis and optic neuritis of his left eye  results of fundus examination showed inflammatory and hemorrhagic retinal lesions consistent with retinitis due to cytomegalovirus infection  a computed tomographic  ct  scan demonstrated enlargement of the optic nerve  the eye was enucleated and results of histopathologic examination showed retinal necrosis with underlying choroiditis and an optic neuritis  numerous encysted toxoplasma gondii organisms were present in the retina and tachyzoites were present in the optic nerve  to the authors  knowledge this is the second histologically documented case of toxoplasma optic neuritis in a patient with aids  
class3	concomitant neurocysticercosis and brucellosis  a young mexican woman had headache and left arm weakness develop shortly after immigrating to the united states  a solitary cerebral cysticercus was found at surgery  but  instead of the expected finding of clear fluid  the cyst contained pus from which brucella melitensis was cultured  although the patient had no signs or symptoms suggestive of brucellosis  agglutination studies revealed igm and igg antibodies consistent with active brucellosis  clinicians should be alert to the possibility of multiple infections in immigrants from countries where parasites and bacteria that are uncommon in the united states are endemic  
class3	disseminated strongyloidiasis with central nervous system involvement diagnosed antemortem in a patient with acquired immunodeficiency syndrome and burkitts lymphoma  a 45 year old man presented with central nervous system involvement as the initial manifestation of disseminated infection with strongyloides stercoralis  several concurrent clinical factors contributed to this event  all related to the patient s immunosuppression  including high grade lymphoma  corticosteroid therapy  and acquired immunodeficiency syndrome  this is only the third case of cns involvement in disseminated strongyloidiasis diagnosed antemortem  
class3	echinococcus infestation of the biceps brachii  a case report  echinococcus is a genus of tapeworm endemic in certain parts of the world but found only rarely in the united states  an extremely unusual case of an intramuscular infestation involving an extremity occurred in a 41 year old man  since the infestation closely resembled a soft tissue tumor on clinical and roentgenographic examination  the patient was treated with an incisional biopsy of the mass  which consisted of a cystic cavity filled with clear fluid  the diagnosis of an echinococcus cyst was made only after permanent section analysis revealed numerous scoleces within the cyst lining  the patient was asymptomatic six months after cyst excision but still remains at risk for recurrence of the infestation  the present report serves to alert the reader to this rare but potentially fatal condition  preoperative diagnosis is imperative to avoid inadvertant rupture of a hydatid cyst  which releases viable scoleces into the systemic circulation and may precipitate an anaphylactic reaction  
class3	phrenomediastinal echinococcosis  a patient with the rare presentation of posterior mediastinal echinococcosis is reported  magnetic resonance imaging  mr  demonstrated the extension of a primary retroperitoneal cyst into the posterior mediastinum which was subsequently confirmed surgically to be of echinococcal origin  such a case of phrenomediastinal echinococcosis has been described only once before in literature  
class3	epidemiology of epilepsy in guaymi indians from bocas del toro province  republic of panama  this cross sectional study was conducted to describe the epidemiology of epilepsy in guaymi indians residing in changuinola  a small town on panama s caribbean coast near costa rica  we randomly selected households and attempted to enroll all residents aged less than or equal to 1 year  337 eligible subjects agreed to participate  93  response rate   we administered a standard neurologic disease screening examination to all subjects and  if any abnormality was found  we administered a standard neurologic evaluation  we detected 19 cases of active epilepsy  the mean age at onset was 12 years  and generalized tonic clonic seizures were the most common diagnosis  10 of 19  53    the prevalence of active epilepsy among caribbean coastal guaymi  57 1000  is considerably greater than that in lower class panama city populations  22 1000  or in other parts of the world  to identify risk factors for epilepsy  we collected epidemiologic data and serum  for cysticercus antibody  from subjects with active epilepsy and from 44 age sex matched controls  significantly more cases  47   than controls  6   had other family members with epilepsy  relative risk  rr   14   44  of cases and 13  of controls reported a history of febrile seizures during childhood  rr   6   
class3	light microscopic diagnosis of human microsporidiosis and variable response to octreotide  microsporida are protozoan parasites that have recently been identified as a cause of human disease in immunocompromised patients  because of their small size  they have been recognized primarily by electron microscopy  this has limited the study of their prevalence  incidence  and association with large volume diarrhea  the present report describes two cases of enterocytozoon bieneusi infection of the small intestine in patients with intractable diarrhea in whom the diagnosis was made by light microscopy and confirmed by electron microscopy  both patients were treated with octreotide  and one had a good response  
class3	b cell responses to paramyosin  isotypic analysis and epitope mapping of filarial paramyosin in patients with onchocerciasis  to examine the fine specificity of the human immune response to filarial paramyosin  the antigenicity of an expressed rcdna  2 55 kb  of dirofilaria immitis paramyosin was detailed by elisa  using sera from patients infected with onchocerca volvulus  we analyzed both the entire paramyosin molecule and six subcloned fragments for their igg  igg subclasses  and ige responses  patients from both guatemala  64  positive  and ghana  100  positive  reacted to paramyosin with specific igg levels above normal controls  although there was no anti paramyosin subclass restriction common to all patients  the igg3 response in the ghananians was significantly greater than that of guatemalans  p less than 0 001   ige anti paramyosin responses showed positive correlations with igg2  p less than 0 001   igg4  p less than 0 002   and igg1  p less than 0 04  responses  epitope mapping using the igg response to the six subclones demonstrated preferential recognition of the amino terminal end of the molecule  nucleotides 1 to 360   igg2 reactivity was clearly localized to the most amino terminal 120 amino acids  and the igg4 antibodies recognized amino acids immediately adjacent to this fragment  these studies examining the fine specificity of anti filarial immune reactions should provide a method for understanding how parasites either evade or induce host immune responses  
class3	eosinophilic meningitis  cause of a chronic pain syndrome  three tourists developed eosinophilic meningitis after visiting the fijian islands  two had a severe and long lasting illness with chronic intractable pain  in one patient electrophysiological studies and mri scan of the brain were abnormal and provided evidence of both radicular and cerebral parenchymal involvement by the most likely causative agent  angiostrongylus cantonensis  
class3	the  nuisance  sexually transmitted diseases  molluscum contagiosum  scabies  and crab lice  although molluscum contagiosum  scabies  and infestation by crab lice do not carry the requirements of partner notification or other long term consequences  they are among the most commonly reported sexually transmitted disease  molluscum contagiosum is a benign viral infection of the skin epidermal layer  most often transmitted by intimate skin to skin contact  the lesions often resolve spontaneously over time  but patient discomfort or social reasons may require destructive removal of the lesions  scabies is caused by the sarcoptes scabiei mite  the victims continually itch  especially at night  and often seek over the counter topical remedies before seeing a clinician  once a correct diagnosis is made  successful resolution of this disease and its itching can be achieved  head and pubic lice account for most of the more than three million cases of louse infestation treated in the united states each year  symptoms of infestation generally include itching that leads to scratching  erythema  irritation  and inflammation  a careful diagnosis followed by disinfection  symptomatic treatment  and psychologic support should result in a complete cure with no long term effects  
class3	identification of toxoplasma gondii in paraffin embedded sections by the polymerase chain reaction  we used the polymerase chain reaction to amplify dna fragments specific to toxoplasma gondii  the sensitivity of the technique allowed for the detection of as few as ten cultured t  gondii tachyzoites  we applied the same amplification technique to deparaffinized ocular sections from two cases of ocular toxoplasmosis  although toxoplasmic cysts could only be seen in one eye by optical microscopy  polymerase chain reaction allowed the identification of the parasite in both cases  our study indicates the feasibility of a sensitive dna based assay to complement pathologic studies of an ocular parasitic disease  
class3	acanthamoeba keratitis associated with disposable contact lenses  two patients developed acanthamoeba keratitis associated with the use of disposable extended wear hydrogel contact lenses  both patients removed  irrigated  and reinserted the contact lenses without disinfecting them  one patient wore the lenses on a daily basis  rinsed the lenses in tap water  stored them overnight  and discarded them weekly  both infections were treated successfully  in a third patient  acanthamoeba species was cultured from two pairs of disposable lenses that had been stored in cases rinsed with well water  potential benefits from disposable contact lens wear are negated when patients do not comply with a continuous wearing schedule  
class3	visceral leishmaniasis in a scottish child  a scottish girl acquired visceral leishmaniasis  kala azar  while on holiday in majorca  she presented with the infection  six months later  in scotland  because of inexperience with the disease and a degree of scepticism unnecessary investigations were carried out resulting in a delay in treatment  
class3	human cerebral malaria  association with erythrocyte rosetting and lack of anti rosetting antibodies  plasmodium falciparum isolates from 24 gambian children with cerebral malaria and 57 children with mild forms of the disease were assessed for their ability to form erythrocyte rosettes  all isolates from the children with cerebral malaria were able to form rosettes  whereas those from children with mild forms of the disease did not form rosettes  or had a significantly lower rosetting rate  plasma of children with cerebral malaria lacked anti rosetting activity  whereas plasma of children with mild disease could often disrupt rosettes in vitro  a monoclonal antibody to p falciparum histidine rich protein  pfhrp1 kp kahrp  disrupted rosettes of many of the isolates in vitro indicating that the rosetting ligand is relatively conserved compared with ligands associated with endothelial cytoadherence  the findings strongly support the hypothesis that erythrocyte rosetting contributes to the pathogenesis of cerebral malaria and suggest that anti rosetting antibodies protect against cerebral disease  
class3	pregnancy outcome after inadvertent ivermectin treatment during community based distribution  ivermectin is the drug of choice for community based treatment of onchocerciasis  since pregnancy testing during mass distribution campaigns is not feasible  the safety of ivermectin in pregnancy must be established  during a 3 year study  ivermectin was distributed to the population of a rubber plantation  14 000 people  in liberia  only 31  of women were aware of their pregnancy status during the first month  it was calculated that about half of women in the first trimester of pregnancy are likely to be treated inadvertently  203 children born to women inadvertently treated during pregnancy were identified  in this limited sample  there was no significant difference in birth defects between treated and untreated mothers in the same population or compared with a reference population  children of treated and untreated mothers showed no difference in developmental status or disease patterns  further surveillance is necessary  however  since no major effects of ivermectin on pregnancy outcome were detected  there seems no need to change existing strategies of ivermectin distribution  
class3	activated eosinophils increase vascular permeability and resistance in isolated perfused rat lungs the effects of eosinophils activated with phorbol myristate acetate  pma  on isolated perfused rat lungs were examined  eosinophils were obtained from lungs of rats infected with toxocara canis by bronchoalveolar lavage  incubated with pma  and administered to an isolated perfused rat lung preparation  vascular endothelial permeability was assessed by measuring the capillary filtration coefficient  kf c  in the perfused lungs  in lungs receiving either no eosinophils  control  or nonactivated eosinophils  there were no changes in pulmonary hemodynamics or kf c  however  in lungs receiving 2 x 10 6  eosinophils activated with pma  there was a transient 4 8 fold increase in pulmonary vascular resistance that peaked at 30 min  primarily due to the constriction of small arteries and veins  after the initial pressor response  kf c was increased to 7 5 times control at 130 min and resulted in marked lung edema  increased wet dry weight ratios  and edema on histologic examination  pulmonary arterial pressure and kf c responses were dose related for eosinophil numbers between 1 x 10 6  and 4 x 10 6  cells  peak airway pressure  paw  during constant tidal volume ventilation also increased in lungs receiving activated eosinophils compared to the control and nonactivated eosinophil groups  these findings indicate that activated eosinophils are potent effector cells and can cause pulmonary vasoconstriction  bronchoconstriction  and vascular endothelial injury without widespread plugging of capillaries by aggregated eosinophils  
class4	abnormal differentiation of human papillomavirus induced laryngeal papillomas  we studied the proliferation and differentiation of human laryngeal papillomas  which are benign tumors induced by human papillomaviruses  immunofluorescent stains of tissues for a number of differentiation specific proteins showed abnormal differentiation  papilloma tissue fragments in vitro showed a slightly decreased fraction of proliferating cells that incorporated tritiated thymidine and a markedly reduced incorporation of tritiated uridine when compared with normal tissue  we propose that papillomavirus infection results in normal basal cell proliferation but abnormal terminal differentiation and that this abnormality significantly contributes to the hyperplasia of the papillomas  
class4	cisplatin fluorouracil interaction in a squamous cell carcinoma xenograft  patients with squamous cell carcinoma of the head and neck are treated with cisplatin and fluorouracil according to a schedule based on the findings of clinical studies  a similar schedule showed a supra additive effect in the treatment of xenografted human squamous cell carcinoma of the head and neck  we sought to ascertain whether this schedule was optimal  a single intraperitoneal injection of cisplatin  7 5 mg kg  was combined with three injections of fluorouracil given during a 24 hour period  total dose  150 or 80 mg kg  before  during  or after cisplatin administration  the combined effect of cisplatin and fluorouracil on tumor growth and toxic effects was schedule dependent  consideration of both toxic effects and tumor growth inhibition  as assessed by reduction of the area under the growth curve  the optimal administration interval was found to be fluorouracil given 3 days after cisplatin administration  
class4	hla class i and class ii antigen expression on squamous cell carcinoma of the head and neck  we compared human major histocompatibility  hla  class i and class ii antigen expression on squamous cell carcinoma of the head and neck with that on normal mucosa  frozen sections of a consecutive series of 30 squamous cell carcinomas were stained with the monoclonal antibodies w6 32  class i  and anti dr  class ii  using an immunoperoxidase technique  normal mucosa showed class i and class ii expression in the basal layers only  class i expression on tumors was diffuse in 87   patchy in 10   and scattered in 3   class ii expression on tumors was diffuse in 20   patchy in 53   scattered in 20   and absent in 7   patterns of expression did not correlate significantly with clinical parameters  including survival  except that class ii diffuse and patchy patterns were found to correlate with more poorly differentiated tumors  
class4	computed tomography of metastatic cervical lymph nodes  a clinical  computed tomographic  pathologic correlative study  a retrospective comparative study of 63 neck dissections was undertaken to evaluate further the accuracy of high resolution computed tomography  ct  in the detection of nodal metastases  as previous studies have indicated a trend toward the superiority of ct scanning over palpation  the respective values of neck examination  ct scanning  and histopathologic examination were assessed in 51 patients with head and neck cancer who underwent a total of 63 neck dissections  the overall agreement between clinical examination findings and histopathologic findings was 92  vs 81  for ct scanning  a retrospective analysis of the ct findings failed to reveal greater accuracy  we found nodes measuring 10 mm or more with central low density always to be malignant  because ct scanning seems to offer little advantage over palpation in the nonirradiated neck  it should not be regarded as an essential tool in the staging of nodal disease  after radiation therapy  as neck dissection is only performed because of clinical or radiologic suspicion  ct scanning is of utmost importance  
class4	pseudocyst of the auricle  case report and world literature review we treated a patient with pseudocyst of the auricle and reviewed the 113 cases previously published in the world literature  pseudocyst of the auricle is an asymptomatic  noninflammatory cystic swelling that involves the anthelix of the ear  results from an accumulation of fluid within an unlined intracartilaginous cavity  and occurs predominantly in men  93  of patients   characteristically  only one ear is involved  87  of patients   and the lesion is usually located within the scaphoid or triangular fossa of the anthelix  previous trauma to the involved ear is uncommon  the diagnosis may be suggested by the clinical features  and analysis of the aspirated cystic fluid and or histologic examination of a lesional biopsy specimen will confirm the diagnosis  therapeutic intervention that maintains the architecture of the patient s external ear should be used in the treatment of this benign condition  
class4	multiple intracranial mucoceles associated with phaeohyphomycosis of the paranasal sinuses  the purpose of this article is to alert clinicians to a new pathogenic fungus of the paranasal sinuses called exserohilum rostratum  exserohilum species are one of the etiologic agents of phaeohyphomycosis  a constellation of entities caused by dematiaceous fungi  this class of fungal sinus infection has emerged only in the past decade  it occurs primarily in immunocompetent individuals and produces a tenacious  progressive pansinusitis  to our knowledge  this study describes the first case of multiple intracranial mucoceles secondary to e rostratum  the diagnostic workup includes computed tomography and magnetic resonance imaging followed by direct microscopic examination of tissue biopsy specimens  a craniotomy followed by a bilateral external ethmoidectomy was necessary for complete extirpation of the infected mucoceles  aggressive surgical management of this mycotic infection is described  
class4	osteoma of the middle ear  report of a case  osteomas of the middle ear are rare  we report a case of a 7 year old boy with osteoma originating from the pyramidal eminence  combined with congenital cholesteatoma  the osteoma and cholesteatoma were successfully removed by tympanomastoidectomy  the long process of the incus and the superstructure of the stapes disappeared  the body of the incus was sculpted and used as a columella  histopathologically  the osteoma was much the same as an external auditory canal osteoma  the possibility of a primary congenital origin of this neoplasm is suggested  
class4	transoesophageal echocardiography improves the diagnostic value of cardiac ultrasound in patients with carcinoid heart disease  transthoracic and transoesophageal cardiac echocardiography and doppler investigations were performed in 31 consecutive patients with malignant midgut carcinoid tumours  the transoesophageal images allowed measurement of the thickness of the atrioventricular valve leaflets and the superficial wall layers on the cavity side of both atria  the mean thickness of the anterior tricuspid leaflet was significantly greater than that of the mitral valve  a difference not seen in a control group of age matched patients without carcinoid tumours and with normal cardiac ultrasound findings  in addition  the edges of the tricuspid leaflets were thickened giving them a clubbed appearance  tricuspid incompetence was detected transoesophageally in 71  of the patients with carcinoid compared with 57  by transthoracic investigation  the inner layer of the right atrial wall in the carcinoid patients was significantly thicker than that of the left atrium and that of both atria in the controls  furthermore  patients with other signs of severe carcinoid heart disease had significantly thicker mean right atrial luminal wall layer than those with less or no signs of right heart disease  transoesophageal cardiac ultrasound investigation improved the diagnostic accuracy and seemed to show the structural changes typical of carcinoid heart disease established by histopathological investigations  
class4	skin exudate levels of interleukin 6  interleukin 1 and other cytokines in mycosis fungoides  the role of locally released cytokines in inducing lymphocyte activation and infiltration in the skin lesions of mycosis fungoides has been investigated  the levels of selected cytokines were measured in chamber fluid samples from lesional and control skin  biologically active interleukin 6 was significantly elevated in lesional samples and a recombinant form of this cytokine was shown to induce lymphocyte migration in an in vitro assay  biologically active interleukin 1 was detected in all control chamber fluid samples  significantly reduced levels of this cytokine were present in lesional samples  which may be the result of the release of preformed material  interleukin 2 and tumour necrosis factor activity  and gamma interferon and granulocyte macrophage colony stimulating factor immunoreactivity  were not detectable in any of the samples  interleukins 1 and 6 may play a role in the pathogenesis of the lesional lymphocyte infiltrates in mycosis fungoides  
class4	invasive migration of epidemic kaposi s sarcoma cells in vitro  kaposi s sarcoma  ks  is a low grade malignant neoplasm which shows invasive growth and often occurs in immunosuppressed patients with the acquired immune deficiency syndrome  aids  epidemic ks   it is also found in elderly men where it is usually limited to the skin  classic ks   the present study investigated the chemotaxis and invasive migration of epidemic ks cells in vitro and compared them to cells grown from classic ks lesions and to fibroblasts  epidemic ks cells demonstrated invasive migration through reconstituted basement membrane  matrigel  as well as through interstitial connective tissue  collagen i  in early passages  whereas fibroblasts did not invade either barrier  epidemic ks cells in late passages did not show any invasive migration  following pretreatment with tumour necrosis factor alpha  tnf alpha  there was no enhanced migration through the matrigel and collagen i for epidemic ks cells  whereas classic ks cells showed an increased migration through the type i collagen barrier  
class4	lymphokine activated killer  lak  cell activity in b and t chronic lymphoid leukemia  defective lak generation and reduced susceptibility of the leukemic cells to allogeneic and autologous lak effectors  the capacity to generate lymphokine activated killer  lak  cells and the susceptibility of the neoplastic cells to both allogeneic and autologous lak effectors were studied in b and t chronic lymphoproliferative disorders  while in b cell chronic lymphocytic leukemia  b cll  the depressed natural killer function could be restored after a 7 day incubation with recombinant interleukin  il 2   b cll mononuclear cells showed a reduced lak activity compared with normal lak cells  furthermore  in all but 1 of the 20 b cll samples tested the leukemic cells were totally resistant to autologous lak effectors  in most cases the leukemic cells were also resistant to normal allogeneic lak cells  competition experiments demonstrated that the patients  lak cells  as well as normal lak effectors  were capable of recognizing b cll cells  pointing  therefore  to a postbinding cytolytic defect  in hairy cell leukemia  hcl  an overall reduced lak activity against allogeneic targets was documented  but  at variance from b cll  hairy cells were often susceptible to the lytic effect of normal lak cells  and in half of the cases tested the neoplastic population was also sensitive in an autologous system  similarly to b cll  in the great majority of t chronic lymphoproliferative disorders studied  the pathologic cells were resistant to normal and autologous lak effectors and a defective lak generation was found  these results demonstrate that in most b and t chronic leukemias the lak function is defective and  when inducible  does not appear directed against the leukemic population  the possibility of exploiting an immunotherapeutic approach with il 2 lak cells in the management of chronic lymphoproliferative disorders does not gain support by these findings  
class4	distinct characteristics of lymphokine activated killer  lak  cells derived from patients with b cell chronic lymphocytic leukemia  b cll   a factor in b cll serum promotes natural killer cell like lak cell growth  we show that lymphokine activated killer  lak  cell precursors derived from patients with b cell chronic lymphocytic leukemia  b cll  and cultured in the presence of recombinant interleukin 2 and normal human serum  nhs   develop into primarily nk cell like  cd 57   lak cells  whereas identically prepared lak cell precursors from normal subjects develop into mainly t cell like  cd 3   cd 8   lak cells  b cll lak cells exhibited greater proliferative capacity than did normal lak cells  when normal lak cells were grown in b cll serum instead of nhs  their proliferation increased  nk cell levels also increased to those found in b cll lak cells  suggesting that b cll serum contains a factor that promotes nk cell like growth  lak cells derived from normal or b cll patients demonstrated similar lytic activity toward k562 and raji cells  growth in b cll serum did not reduce their lytic potential  thus  the altered phenotype and growth exhibited by b cll lak cells and normal lak cells grown in b cll serum does not lead to abnormalities in their cytolytic functions  we propose instead that the predominance of nk like cells in b cll lak cell populations and the presence of an nk cell like growth factor in b cll serum reflect abnormalities related to nk cell mediated b cell regulation  ie  either inhibition of normal b cell growth and or growth stimulation of the leukemic clone in b cll  
class4	a new monoclonal antibody  ch f42  recognizes a cd7  subset of normal t lymphocytes and circulating malignant cells in adult t cell lymphoma leukemia and sezary syndrome  we describe a new rat immunoglobulin m monoclonal antibody  ch f42  that recognizes a subset  1 5  to 8   of normal peripheral blood t lymphocytes  the phenotype of these cells was determined  using dual color immunofluorescence  to be cd2   cd3   cd4   cd5   cd7   cd8   they do not express t cell activation markers  and are positive for uchl1  cd45ro   but negative for 2h4  cd45ra   the antigen was expressed on circulating malignant cells in sezary syndrome  four of four cases  and adult t cell lymphoma leukemia  atll   four of six cases  and negative in a variety of other hematologic malignancies tested  these included chronic and acute lymphoid leukemias of b and t lineage  together with chronic and acute myeloid leukemias  however  normal ch f42  cells do not display any of the ultrastructural features associated with sezary or atll cells  the marked similarities between these conditions together with the shared expression of an otherwise very restricted surface antigen  ch f42  provide strong evidence for the existence of a common normal counterpart  preliminary characterization studies of the antigen  which is also expressed by k562 and jurkat cells  suggest the ch f42 antigen is an o linked  sialated glycan on a glycoprotein  
class4	characterization of a factor dependent acute leukemia cell line with translocation  3 3  q21 q26   a strictly factor dependent cell line  ucsd aml1  was established from a patient with the syndrome of multilineage acute leukemia with high platelets  the patient s cells and the cell line karyotype were 45 xx  7 t 3 3  q21 q26   typical of the syndrome of acute leukemia with high platelets  the cell line expresses cd34  cd7  tdt  and myeloid  cd13  cd14  cd33  and megakaryocyte platelet  cd36  cd41  cd42b  cdw49b  antigens  in short term culture  ucsd aml1 cells proliferate in response to interleukin 3  il 3   il 4  il 6  macrophage colony stimulating factor  m csf   and granulocyte macrophage csf  gm csf   but not il 1  il 2  il 5  or g csf  in long term culture  proliferation can be sustained by gm csf  il 6  or m csf  when maintained in gm csf  a small percentage of cells form multinucleated megakaryocyte like giant cells  culture with gm csf combined with il 6  but not with il 6 alone  increased giant cell formation fourfold to sevenfold  il 6 alone or in combination with gm csf increased expression of platelet related antigens  in contrast  culture with phorbol ester induced formation of macrophage like cells  ucsd aml1 is the first human acute nonlymphocytic leukemia cell line established from a patient with an acute leukemia syndrome associated with a specific chromosome abnormality  
class4	expression of transcobalamin ii receptors by human leukemia k562 and hl 60 cells  plasma membrane receptors for the serum cobalamin binding protein transcobalamin ii  tcii  were identified on human leukemia k562 and hl 60 cells using immunoaffinity purified human tcii labeled with  57co cyanocobalamin  the bmax values for tcii receptors on proliferating k562 and hl 60 cells were 4 500 and 2 700 per cell  respectively  corresponding dissociation constants  kd  were 8 0 x 10  11  mol l and 9 0 x 10  11  mol l  rabbit tcii also bound to k562 and hl 60 cells but with slightly reduced affinities  calcium was required for the binding of transcobalamin ii to k562 cells  brief treatment of these cells with trypsin resulted in almost total loss of surface binding activity  after removal of trypsin  surface receptors for tcii slowly reappeared  reaching pretrypsin treatment densities only after 24 hours  reappearance of receptors was blocked by cycloheximide  tcii receptor densities on k562 and hl 60 cells correlated inversely with the concentration of cobalamin in the culture medium  this suggests that intracellular stores of cobalamin may affect the expression of transcobalamin receptors  nonproliferating stationary phase k562 cells had low tcii receptor densities  less than 1 200 receptors cell   however  the density of tcii receptors increased substantially when cells were subcultured in fresh medium  up regulation of receptor expression coincided with increased 3h thymidine incorporation  which preceded the resumption of cellular proliferation as measured by cell density  in the presence of cytosine arabinoside  which induces erythroid differentiation  k562 cells down regulated expression of tcii receptors  when hl 60 cells were subcultured in fresh medium containing dimethysulfoxide to induce granulocytic differentiation  the up regulation of tcii receptors was suppressed  this event occurred well before a diminution of 3h thymidine incorporation and cessation of proliferation  thus  changes in the regulation of expression of tcii receptors correlate with both the proliferative and differentiation status of cells  
class4	genotypic characterization of centrocytic lymphoma  frequent rearrangement of the chromosome 11 bcl 1 locus  centrocytic lymphomas are defined in the kiel classification as b cell lymphomas composed exclusively of cells resembling cleaved follicular center cells  fcc   these lymphomas have been shown to be histologically  immunophenotypically  and clinically distinct from other cleaved fcc lymphomas  dna from 18 centrocytic lymphomas  14 patients  was analyzed using southern blotting and probes for immunoglobulin heavy  jh  and kappa light chain  jk  joining gene  t cell receptor beta chain constant gene  cb   bcl 1  bcl 2  and c myc gene rearrangements  all of the lymphomas had jh and jk rearrangements  confirming their b cell origin  none of the specimens had detectable cb  bcl 2  or c myc rearrangements  however  4 of 14 patients  28 6   had rearrangement of the chromosome 11 bcl 1 locus  therefore  centrocytic lymphomas are genotypically distinguishable from the majority of other small cleaved fcc lymphomas by their lack of demonstrable bcl 2 rearrangements  this supports the distinct nature of centrocytic lymphomas and suggests the lack of importance for the putative oncogene bcl 2 in these cases  furthermore  the frequent rearrangement of bcl 1 suggests a possible role for this locus in the pathogenesis of at least some centrocytic lymphomas  
class4	biology and clinical significance of cytogenetic abnormalities in childhood acute lymphoblastic leukemia  virtually all cases of childhood all have chromosomal abnormalities and half contain translocations  which are nearly equally divided between random and nonrandom rearrangements  nonrandom chromosomal abnormalities have been correlated with leukemic cell lineage  the degree of cell differentiation  and the specific gene involved at the molecular level  many cytogenetic findings have prognostic significance  however  the adverse influence of certain changes  including most chromosomal translocations  may in fact be offset by the greater cytoreductive effects of intensified therapy  table 4 summarizes the relation of selected karyotypic findings to treatment outcome in patients treated on contemporary protocols  among all of the chromosomal abnormalities identified in childhood all  hyperdiploidy greater than 50 has been associated with the most favorable prognosis  at the opposite end of the spectrum  the treatment outcome for patients with classical ph  or hypodiploid all is very poor even in programs of intensive chemotherapy  alternative treatment such as bone marrow transplantation should be considered for such patients  cases with the t 4 11  q21 q23  also have a very poor clinical outcome  but the adverse prognosis may be limited to the infant or adolescent age groups  the prognostic significance of other nonrandom translocations  such as t 1 19  q23 p13  and several other abnormalities  needs to be further assessed in larger numbers of patients  finally  as more is learned about the molecular pathology underlying these rearrangements  it may be possible to develop new therapeutic agents that are specifically targeted to interfere with the aberrant gene products expressed by human leukemic cells  
class4	effects of recombinant human interleukin 3 on human hematopoietic progenitor and precursor cells in vivo  dna synthesis rates and concentrations of bone marrow  bm  and peripheral blood  pb  progenitor cells were studied in 22 patients treated with recombinant human interleukin 3  rhil3  as part of a clinical phase i ii study  recombinant hil3 at doses of 60 to 500 micrograms m2 was administered by subcutaneous bolus injection for 15 days to 13 patients with solid tumors and preserved hematopoietic function and to nine patients with bone marrow failure  including five with myelodysplastic syndromes  following treatment with rhil3  the percentage of actively cycling bm erythroid  bfu e  and multilineage  cfu gemm  progenitors in patients with preserved hematopoietic function increased from 16  to 36   p less than  05  and from 10  to 40   p less than  01   respectively  the dna synthesis rates of early and late granulocyte macrophage progenitor cells increased from 11  to 26   cfu gm day 14  p less than  02  and from 13  to 30   cfu gm day 7  p less than  05   there was an increase in bm cellularity from 37  to 58   and of the myeloid to erythroid ratio from 1 4 to 3 2  while the concentration of marrow progenitors on a per cell basis was unchanged or slightly decreased  the frequencies of blast cells in the bm were unchanged  mean levels of pb cfu gm day 14 and cfu gemm were 100  and 72  above baseline values after 7 days of rhil3 but only 25  and 28  above initial levels at the end of treatment  peripheral blood bfu e were reduced in the majority of patients with normal marrow after both 7 and 15 days of rhil3  no augmentation of circulating bfu e and cfu gemm was seen in 5 patients with mds who had few or no pb bfu e or cfu gemm initially  total leukocyte  neutrophil  and eosinophil counts increased significantly  p less than  01  in 21 of 22 patients with a peak response after a median of 13 days of rhil3  while a small increase in reticulocytes was not accompanied by an elevation of the hemoglobin or hematocrit  platelet counts increased by 50  in patients with preserved marrow function  thus  rhil3 induces a multilineage response in vivo  apparently by stimulating proliferation of multipotential and lineage restricted progenitors  it remains to be determined whether this is due to direct or indirect effects on the progenitor cells  
class4	the pharmacokinetics of plasminogen activator inhibitor 1 in the rabbit  the pharmacokinetics of the activated and latent forms of plasminogen activator inhibitor 1  pai 1  isolated from ht1080 fibrosarcoma cells  ht1080 pai 1  and a nonglycosylated form of human pai 1 isolated from a yeast expression system  rpai 1  were followed in the rabbit  as assessed by an immunologic assay specific for human pai 1  guanidine hci activated ht1080 pai 1 and rpai 1 entered the total plasma volume following intravenous bolus administration and exhibited a biphasic clearance pattern  the t1 2s of ht1080 pai 1 for the initial and beta phases equalled 6 0 and 24 8 minutes  respectively  the t1 2s of rpai 1 for the initial and beta phases equalled 8 8 and 34 0 minutes  respectively  similar results were obtained by measuring pai 1 activity in plasma and with trace amounts of 125i rpai 1  suggesting that the above pharmacokinetic behavior could also apply to endogenous pai 1  the liver was the main site of rpai 1 clearance  unactivated  latent pai 1 exhibited a very different pharmacokinetic profile  over 80  of latent rpai 1 cleared from the circulation within 10 minutes  t1 2   1 7 minutes   the difference in clearance behavior between activated and latent pai 1 may be related to the ability of activated pai 1  but not latent pai 1  to rapidly form high molecular weight complexes with plasma binding factors which were observed in vitro and in vivo  because pai 1 could potentially tilt the fibrinolytic balance toward a prothrombotic state  its rapid clearance may represent an important control mechanism governing the circulating levels of this key component of the fibrinolytic pathway  
class4	survival of premenopausal women with metastatic breast cancer  long term follow up of eastern cooperative group and cancer and leukemia group b studies  in premenopausal women with metastatic breast cancer  differences in survival curves early during follow up can be misleading  the authors therefore analyzed long term survival in 378 patients  entered in three randomized trials  started between 1973 and 1978  combined data from the three trials were used to increase the power for identifying prognostic variables  cancer and leukemia group b  calgb  trial 7382 randomized patients to oophorectomy plus either cyclophosphamide or combination chemotherapy or observation  eastern cooperative oncology group  ecog  2174 randomized patients who had not progressed 3 months after oophorectomy to combination chemotherapy or combination chemotherapy or observation  trial ecog 2177 randomized estrogen receptor  er  positive or er unknown patients to oophorectomy plus combination chemotherapy or immediate combination chemotherapy  and er negative patients were directly assigned to combination chemotherapy  hence er negative patients need not have been healthy enough to be randomized to oophorectomy  with only 14  of the patients still alive  median survival on the three studies was 30  24  and 28 months  the median survival of individual treatments changed noticeably in ecog 2174 and ecog 2177 with long term follow up  at this time there are no differences in survival between randomized regimens in any of the three trials  in a multivariate model  factors associated with significantly poorer survival were visceral dominant disease  nodal metastases  breast metastases  age younger than 45 years  er negativity  and not receiving chemotherapy immediately after oophorectomy  this treatment difference was thus not due to imbalances in the prognostic variables used in the model  but it may be due to imbalances of unknown prognostic factors or differences in patient selection  
class4	analysis of bladder carcinoma by subsite  cystoscopic location may have prognostic value  nine hundred fourteen cases of carcinoma of the urinary bladder registered from 1977 to 1988 with the kansas state tumor registry were evaluated by subsite for differences in grade  histology  sex  age at diagnosis  and survival  only initial occurrences of carcinoma were included  carcinoma of the lateral walls accounted for 37 1   the posterior wall  17 9   the trigone  12 6   the neck  11 1   the ureteric orifices  9 8   the dome  7 7   and the anterior wall  3 8   malignant neoplasms occurring in the neck of the bladder had a significantly poorer prognosis by survival analysis  p less than 0 05   malignancies of the dome were found to present as higher grade lesions  p   0 00003   and carcinoma of the ureteric orifices and lateral walls tended to be of lower grade  p   0 02 and p   0 05  respectively   carcinomas of the anterior wall and dome occurred in a more elderly population  mean ages  75 6 and 73 9 years  respectively   and carcinomas of the trigone and ureteric orifices occurred in a younger group  mean ages  68 3 and 67 5 years  respectively   on histologic evaluation the trigone gave rise to more squamous cell carcinoma than expected  p   0 001  325  of expected   no distribution difference was noted among subsites with respect to sex  these data show significant differences among subsites of the urinary bladder with regard to survival  grade  histology  and age at diagnosis  
class4	the management of pseudomyxoma peritonei  the management of nine patients with pseudomyxoma peritonei was reviewed  aggressive surgical resection of tumor is the standard of treatment  with many patients requiring multiple laparotomies  chemotherapy  including the use of cisplatin is not effective  long term nutritional support provides a better quality of survival for select patients  
class4	chondrosarcoma of bone in children  chondrosarcoma of bone rarely occurs in children  this report analyzes the clinicopathologic features in a series of 47 patients with conventional chondrosarcoma who were less than 17 years of age  of the 47 cases  14 were from the mayo clinic files  and 33 were from our consultation files  most of the lesions occurred in the trunk and upper ends of the long bones  with the humerus being the most frequent skeletal site  twelve of the 47 tumors were secondary  the radiographic findings were the same as those seen in adult chondrosarcoma  pathologically  the tumors were low grade  en bloc resection is the treatment of choice because of the high incidence of local recurrence with lesser surgical margins  prognosis in childhood chondrosarcoma is no different from that in adult chondrosarcoma  none of the patients with follow up data had metastasis  
class4	cancer mortality in a higher income black population in new york state  comparison with rates in the united states as a whole  in the 1980 census the median family income among blacks in suffolk county  new york  i e    19 604  was much higher than that for american blacks as a whole  i e    12 618  and 94 1  of that for american whites  i e    20 840   but the proportion below the poverty level was still higher for suffolk county blacks than for american whites  observed numbers of deaths from 1979 to 1985 for total cancers and most cancer sites in suffolk county black men and women were not lower than expected on the basis of age specific and gender specific death rates for blacks in the us  although numbers of deaths from cervical cancer and prostate cancer were slightly lower than expected in suffolk county blacks versus american blacks  these numbers were still significantly greater than expected on the basis of death rates among american whites  age specific death rates for age groups 25 to 44 years to 55 to 64 years tended to be lower in suffolk county for lung cancers in black men but not for breast cancer in black women  specific cancer sites  which differ in the direction of the association between incidence and socioeconomic status  age  and gender must be considered in comparisons of cancer mortality by race and socioeconomic level  implications of the comparisons were discussed with regard to the goal of reducing racial differences in cancer death rates  
class4	immunocytochemical estrogen and progestin receptor assays in breast cancer with monoclonal antibodies  histopathologic  demographic  and biochemical correlations and relationship to endocrine response and survival  breast cancer specimens from 600 women were assayed for estrogen receptors  er  using an immunocytochemical assay  ica  employing the monoclonal antiestrophilin antibody h222 sp gamma  results showed significant correlation with biochemical er determinations as well as with tumor grade and menopausal status  in 449 cases  results of progesterone receptor assay by ica using the monoclonal anti pgr antibody kd 68  also correlated significantly with biochemical pgr measurements  the erica pgrica positivity was significantly more frequent in postmenopausal white women  colloid carcinomas were most likely to be erica positive and pgrica positive whereas medullary carcinomas were most often negative  in 47 patients with advanced mammary carcinoma  results of erica and pgrica were more closely related to endocrine response than those of er and pgr by dextran coated charcoal assay  dcc   in 339 women with stage i or stage ii breast cancer  erica was significantly associated with disease free survival  analysis by cox s proportional hazard model  however  showed pgrica to be the best predictor of survival and disease free survival in 197 women at the same stages of disease  these data indicate that ica is more predictive of prognosis than biochemical er and pgr  the ease of ica performance coupled with these results indicate that the method is an acceptable substitute for dcc in analyzing breast cancers for er pgr  
class4	teniposide  vm 26  and continuous infusion cytosine arabinoside for initial induction failure in childhood acute lymphoblastic leukemia  a pediatric oncology group pilot study  twenty six evaluable children with newly diagnosed acute lymphoblastic leukemia  all  who failed to achieve initial remission after receiving two to seven drugs for at least a 4 week period were given teniposide  vm 26  and continuous infusion cytosine arabinoside  ara c   twenty two received 150 mg m2 of vm 26 on days 1 and 2 with 100 mg 2 of ara c as a continuous infusion on days 1 through 5  a second shortened course was given on day 14 to eight patients who had evidence of some antileukemic effect or were clinically judged able to tolerate a second course  the last four patients received three daily doses of vm 26 and a 7 day infusion of ara c at the same daily dosages  twelve  48   achieved complete remission  cr  of all  there was a trend toward decreasing response rates with an increasing number of drugs used in the initial induction regimen  i e   five cr among seven patients with a prior two drug induction attempt  six cr among 14 patients with a prior three  to four drug induction attempt  and one cr among four patients with a prior five  to seven drug induction attempt  p   0 14   ten of 17 non t cell patients and two of nine t cell patients achieved remission  p   0 10   the median time required to achieve a complete remission from the initiation of treatment was 26 days  range  14 72 days   this period was shorter in those who required one course compared with those who required two induction courses  i e   25 days median vs  44 days median  toxicity was significant and due mainly to marrow aplasia and infection  one patient had severe prolonged vm 26 induced hypotension  of the 12 patients entering remission  two were removed for marrow transplant and one was removed due to parental request  in the remaining nine patients  median remission duration was only 2 months  range  1 18 months   all nine patients relapsed in the marrow  among the entire group of 26 patients  only one patient is alive and a long term event free survivor  after allogeneic marrow transplant   due to the current use of more aggressive initial induction regimens and the extremely poor prognosis in children who fail to achieve initial remission  more intensive regimens of continuation therapy or alternative therapies  such as bone marrow transplant  should be considered  
class4	association of disease free survival and percent of ideal dose in adjuvant breast chemotherapy  the relationship between percent of ideal dose and disease free survival was examined in 256 stage ii and iii patients who participated in a 2 year breast adjuvant chemotherapy trial consisting of cyclophosphamide  methotrexate  and 5 fluorouracil  cmf  given postoperatively  when analyzed analogously to previous work  the results confirmed a dose response relationship  that is  there appeared to be an improved disease free survival for patients receiving higher doses of adjuvant chemotherapy  the major criticism of such an analysis is its bias  this bias was addressed by considering only patients who were still receiving therapy at 6  12  and 24 months  then  the dose response relationship was no longer seen  although causality cannot be inferred  the apparent differences in disease free survival among the dose groups can be attributed to recurrences in the first 2 years among patients receiving lower doses of chemotherapy  
class4	doxorubicin for unresectable hepatocellular carcinoma  a prospective study on the addition of verapamil  a prospective study was conducted to assess the safety and efficacy of the addition of oral verapamil to intravenous adriamycin  doxorubicin  for the management of patients with unresectable hepatocellular carcinoma  hcc   all 28 patients studied had histologically verified disease  and cirrhosis was present in 20 of the 21 patients with adequate tissue sampling  the overall median survival was 57 days  chemotherapy was terminated in seven patients after one course of treatment  partial response and complete response were noted in four patients  19   and one patient  4 8    respectively  among the 21 patients evaluated  side effects related to the chemotherapy were present in all patients studied  death from fulminating sepsis occurred in three of the 13 patients with leukopenia  symptomatic myocardial dysfunction developed in one patient  the addition of verapamil apparently did not potentiate the tumoricidal effect of systemic adriamycin on hcc but probably did increase its complications  
class4	a phase i trial of cisplatin in hypertonic saline and escalating doses of 5 fluorouracil by continuous intravenous infusion in patients with advanced malignancies  thirty four patients with incurable solid tumors were treated in a phase i trial with a fixed dose of high dose cisplatin  cddp  administered in hypertonic saline and escalating doses of infusional 5 fluorouracil  5 fu   five treatment levels of 5 fu  ranging from 500 to 900 mg m2 day for 5 days  were studied  leukopenia  thrombocytopenia  and oral mucositis were the dose limiting toxicities encountered  nephrotoxicity was minimal  ototoxicity and peripheral neuropathies were rare and mild in this patient group  but most patients received only a small number of treatment cycles  diarrhea was not dose limiting  two complete responses  one non small cell lung cancer and one sweat gland carcinoma  were observed  no other major responses were noted  with the dose of cddp set at 35 mg m2 day for 5 consecutive days  the maximum tolerated dose  mtd  of a concurrent 5 day 5 fu infusion was found to be 900 mg m2 day  the recommended dosages for phase ii trials are 35 mg m2 day cddp and 800 mg m2 day 5 fu for 5 consecutive days  cancers of the lung  breast  gastrointestinal tract  and genitourinary tract would be reasonable targets for phase ii studies  
class4	treatment of advanced squamous cell carcinoma of the skin with cisplatin  5 fluorouracil  and bleomycin  the authors treated 14 patients with advanced squamous cell carcinoma  scc  of the skin or lip with one to four cycles of combination chemotherapy consisting of cisplatin by bolus injection  and 5 fluorouracil  5 fu  and bleomycin by continuous 5 day infusion  objective responses were seen in 11 of the 13 evaluable patients  84    four patients had a complete remission  30   and seven patients  a partial remission  54    local control after definitive complementary radiation and or surgical treatment was achieved in seven patients  toxic side effects was acceptable  they consisted of nausea and vomiting in all patients  transient skin changes  hematologic  grade 3 4  abnormalities in four patients  and pulmonary fibrosis in one elderly patient  these results show that this chemotherapy combination could play a role in reducing the tumor mass and in facilitating definitive treatment to obtain better functional and cosmetic results in advanced scc of the skin  
class4	effect of intraarterial versus intravenous cisplatin in addition to systemic doxorubicin  high dose methotrexate  and ifosfamide on histologic tumor response in osteosarcoma  study coss 86   in osteosarcoma  intraarterial  ia  administration of systemic treatment has been advocated to improve local tumor response preparing for  or even obviating  definitive surgery  because data from the literature did not unequivocally support the local superiority of ia infusion  a comparative study was started in 1986  preoperative chemotherapy consisted of 45 mg m2 of doxorubicin on days 1 and 2  12 g m2 of high dose methotrexate on days 15 and 22  and 3 g m2 of ifosfamide on days 29  30  50  and 51 followed on days 31 and 52 by intravenous  iv  versus ia tourniquet infusion of cisplatin  ddp   a strict randomization of patients was not feasible  a balanced distribution of risk factors was strived for by stratifying and allocating the appropriate patients centrally  the infusion time was prolonged from 1 to 5 hours in the iv group  and the ddp dose was reduced from 150 to 120 mg m2 in both arms when intolerable ototoxicity became apparent  a multivariate analysis was performed to exclude a bias on the response rates from risk factor distribution and from modifications of ddp infusion time and dosage  the overall fraction of histologic good responders  greater than 90  necrosis  was not found to be different after ia versus iv treatment  34 50  68   vs  41 59  69     intraarterial instead of iv use of ddp within an aggressive systemic treatment does not seem to improve the local tumor response  
class4	topographic classification  clinical characteristics  and diagnostic delay of cancer of the larynx hypopharynx in torino  italy  the case series of a population based case control study of laryngeal and hypopharyngeal cancers in torino  italy  included 281 men with clinical and anamnestic data  two hundred fifteen  28  and 38 cancers originated from the endolarynx  epilarynx  and hypopharynx  respectively  regions invaded by the tumor were divided into 26 subsites  a classification based on the number of invaded subsites was proposed  which agreed well with the t classification of the tnm system  cancers originating from the hypopharynx invaded more subsites than cancers from the endolarynx  and among the latter  supraglottic were more invasive than glottic lesions  the number of invaded subsites was strongly associated with nodal involvement  among symptoms at onset of disease and at diagnosis  patients with endolaryngeal lesions reported dysphonia and dyspnea more frequently  and patients with lesions from other regions had a higher prevalence of dysphagia  odynophagia  otalgia  and adenopathia  clinical and epidemiologic results of this study suggest considering the endolarynx  epilarynx  and hypopharynx as separate anatomic entities  diagnostic delay was not associated with tumor size and showed a negative trend with involvement of cervical lymph nodes  suggesting that stage at diagnosis is due to intrinsic differences in tumor aggressiveness  
class4	long term follow up of 24 patients undergoing radical resection for ampullary carcinoma  1953 to 1988  potentially curative radical pancreaticoduodenectomy for ampullary adenocarcinoma was performed in 24 patients over a 35 year period  the overall operative mortality was 12 5   actuarial survival rate at 5 years was 61      13 4 standard error of the mean  sem  and subsequently remained unchanged  in the same time period  21 patients underwent potentially curative radical pancreaticoduodenectomy for periampullary tumors of pancreatic origin  similar analysis showed an overall operative mortality of 23 8  and a survival rate at 5 years of 27      12 5 sem  the results of radical pancreaticoduodenectomy for ampullary carcinoma in the most recent years  1976 to 1988  were compared with those of former years  1953 to 1975   there were no statistically significant differences in the 5 year survival rate  however  the operative mortality decreased from 25  in the former period to 6 3  in the recent period  survival was dependent on nodal status  the 5 year survival rate was 78      11 5 sem in the absence of nodal metastasis versus 50      25 sem in the presence of regional nodal metastasis  these findings support the concept that radical pancreaticoduodenectomy offers a realistic probability for cure in a selected group of patients with carcinomas of the ampulla of vater  
class4	radiographic microcalcification and parenchymal patterns as indicators of histologic  high risk  benign breast disease  breast tissue from a forensic autopsy series of 486 women  15 to 98 years of age  was studied radiographically and by histologic sampling  prevalence of wolfe p2 dy parenchymal patterns decreased with age  radiographic nonvascular microcalcification and histologic presence of marked ductal epithelial hyperplasia and lobular microcalcification increased with age  both of these histologic parameters of increased risk for breast cancer correlated with the presence of radiographic microcalcification and wolfe p2 dy parenchymal pattern  the predictive value of the radiographic parameters for presence of  high risk  proliferative fibrocystic change increased with age  
class4	human papillomavirus type 16 associated with oral squamous carcinoma in a cardiac transplant recipient  human papillomavirus type 16  hpv 16  has been associated with a variety of squamous carcinomas  particularly those involving the anogenital tract  the authors report the development of an oropharyngeal carcinoma in a 43 year old man approximately 20 months after cardiac transplantation while he was on a maintenance regimen of cyclosporine a and prednisone  the carcinoma was resistant to treatment  and he died of complications related to metastatic disease 3 years posttransplantation  molecular biologic studies using nonisotopic labeled viral dna probes were done  in situ hybridization demonstrated the presence of hpv 16 dna in the tumor cells  dna dot blot analysis confirmed the presence of multiple copies of hpv 16 dna within the tumor cells and their absence from adjacent normal appearing tissue  southern blot analysis suggested that the hpv 16 dna was integrated into the tumor cell genome  with increasing recognition of the carcinogenicity of hpv type 16 infection  a role for this virus in the development of squamous cell malignancies in immunosuppressed organ transplant recipients is likely to be noted with increasing frequency  
class4	expression of ki 1 antigen  cd30  in mesenchymal tumors  expression of cd30 ki 1  antigen has long been considered to be restricted to activated lymphocytes and related tumors  however  expression of this antigen has also been detected in embryonal carcinomas  in nonembryonal carcinomas  in malignant melanomas  and even in some myeloid cell lines and macrophages at late stages of differentiation  in this study  using monoclonal antibody ki 1  expression of cd30 antigen was immunohistochemically examined in frozen sections of 28 benign and 63 malignant mesenchymal tumors  the authors found cd30 expressed in two of four leiomyomas  seven of 11 leiomysarcomas  one of six rhabdomyosarcomas  two of two aggressive fibromatoses  one of three fibrosarcomas  two of four synovial sarcomas  one giant cell tumors of tendon sheaths  all five malignant fibrous histiocytomas  all three osteosarcomas  one of three ewing s sarcomas  in a tumor cell subpopulation of two of ten malignant schwannomas  and in the schwann cell compartment of one of two ganglioneuromas tested  furthermore  cd30 was consistently expressed in the myoepithelial compartment of 13 fibroadenomas  however  all five lipomas  all seven liposarcomas  all three neuroblastomas  both ganglioneuroblastomas  both chondrosarcomas  and tumors of disputed origin tested were consistently cd30 negative  these findings indicate that  outside the lymphatic system  cd30 antigen is not restricted to epithelial neoplasms but may also be present in tumors of mesenchymal origin  the authors conclude that cd30 antigen  although having limited utility in the differential diagnosis of tumors of questionable histogenesis  may eventually define relevant subgroups within the main tumor categories  
class4	immunophenotypes in  classical  b cell chronic lymphocytic leukemia  correlation with normal cellular counterpart and clinical findings  this study evaluates the expression of a series of membrane antigens  normally expressed by b lymphocytes of the lymphocytic mantle and marginal zone  in 90 selected cases of  classical   mouse red blood cell receptor   cd20   cd5   surface immunoglobulin      b chronic lymphocytic leukemia  b cll  with the aim of contributing toward identifying the normal counterpart of b cll and any correlations between surface antigen pattern and certain clinical characteristics  clustered  cd23  25  39  40  27  1c  w75  and unclustered  nub1  7f7  kib3  monoclonal antibodies  moab  were tested  almost all cases showed high reactivity to cd23  27  w75  39  40  and nub1  expression of cd1c was very low and that of 7f7  kib3  and cd25 was variable  the reactivity of 7f7 and kib3 was strictly correlated  and they correlated individually with cd25  results show that the most frequent b cll phenotype  cd19   5   23   27   39   nub1   kib3      7f7      and cd25      corresponds to one or more cellular subsets in the mantle zone  no correlation was found between moab expression  surface immunoglobulin  sig  class or type  clinical stage  disease activity  or age at diagnosis  the only difference  statistically borderline  was the expression of 7f7 and kib3  in young versus old patients   this suggests that modulations in the expression of surface antigens do not affect the clinical behavior of the disease  
class4	significance of blasts in low cell count cerebrospinal fluid specimens from children with acute lymphoblastic leukemia  the purpose of this study was to determine whether the presence of more than 5  blasts in a differential count of cytocentrifuged cerebrospinal fluid  csf  with less than 6 leukocytes microliter was predictive of central nervous system  cns  relapse in children with acute lymphoblastic leukemia  all   a double concentrate method of cytocentrifuge preparation was used to analyze 4543 consecutive csf specimens from 349 children with all between january 1  1982  and september 30  1988  one hundred nine csf specimens from 58 evaluable children had less than 6 leukocytes microliter and more than 5  blasts on cytocentrifuge differential count  low cell count specimen with blasts  lcb    during the study period  25 of 332 evaluable children  7 5   had cns leukemic recurrence  in 22 of 25  88    the cns relapse was preceded by at least one abnormal low cell count csf specimen  one of 34 patients with a single lcb at diagnosis  3   had subsequent cns relapse compared with five of eight patients  62 5   with a single lcb during remission  p   0 0002   of 16 children with two or more lcb during remission  nine  56   had cns relapse defined by standard criteria  whereas six additional patients in this group were declared to be in cns relapse on the basis of their repetitive lcb  whether diagnosing cns recurrence earlier in its course based on a modification of the definition of cns leukemia will change the frequency of subsequent adverse events or make possible decreased intensity of cns retreatment remains to be determined  
class4	prognostic implication of ecto 5  nucleotidase activity in acute lymphoblastic leukemia  ecto 5  nucleotidase  5  n  activity was determined in 191 patients  71 children and 120 adults  with acute leukemia  elevated values for 5  n were registered in common acute lymphoblastic leukemia  all   but blast cells of t cell all  t all  and common all antigen negative non t all had low enzyme activity comparable with the values of acute non lymphocytic leukemia  dependence of remission duration on 5  n activity was analyzed in 74 adults with all  treated similarly in a prospective multicenter trial  the remission curves for all patients with 5  n activity lower than 10 nmol h x 10 6  cells were substantially and significantly better than those of patients with high activity  greater than 10 nmol h x 10 6  cells   this difference was also evident in the immunologic subclass common all  statistical evaluation showed that an interaction between immunologic subtype of the blast cells and their 5  n activity had prognostic significance for remission duration  in addition to the independent factor  initial age  this interaction was also prognostic for survival  
class4	sex hormone receptors in human thyroid tissues  the behavior of sex hormone receptors was studied in the cytosol of thyroid tissue samples in order to clarify the effects of sex hormones on diseases of the thyroid  androgen receptor  ar   estrogen receptor  er   and progesterone receptor  pgr  were assayed using the dextran coated charcoal  dcc  method and analyzed by the method of scatchard  androgen receptor  er  and pgr were negative in all of the cytosol prepared from normal thyroid tissues  however  the positive rates for the receptors in the neoplastic and nonneoplastic tissues were 22  for ar  29  for er  and 18  for pgr  especially  the incidence of er was significantly higher in neoplastic lesions than normal tissues  these data suggest that sex hormones  especially estrogen  may play a role in diseases of the thyroid  
class4	lewis system alterations in gastric carcinogenesis  alterations in the expression of type 1 blood group related antigens  lewis a and b  were examined immunohistochemically in 371 consecutives gastric biopsy and 80 surgical specimens from patients of gastric carcinoma  the abh and lewis phenotype and secretor status of the patients were correlated with histologic findings  an anomalous expression of lewis a antigen was found in 88 of 249 gastric biopsy specimens of lewis  a b   phenotype patients  the prevalence of this anomaly increased with the evolution of the premalignant process  in agreement with the commonly accepted model of gastric carcinogenesis  thus  anomalous lewis a antigen appeared in 66 6  of gastric dysplasia cases  in 64 6  of intestinal metaplasia  in 15 4  of atrophic gastritis  and in 7 4  of superficial gastritis  no alterations were found in subjects with normal gastric mucosa  forty seven of the 49 lewis  a b   phenotype gastric carcinoma patients showed antigenic alterations in tumor cells  anomalous lewis a antigen in 36 and loss of lewis antigens in 11   in 26 of these gastric specimens an anomalous lewis a antigen was present in areas of intestinal metaplasia and or dysplasia away from the area of neoplastic transformation  the expression of lewis a antigen in lewis  a b   phenotype patients is a frequent phenomenon in gastric neoplastic cells and could result from the blocked synthesis of lewis b antigen with accumulation of its precursors  these findings suggest that  during gastric carcinogenesis  antigenic alterations may precede neoplastic transformation  an anomalous lewis a antigen could constitute a significant index of severity of the histologic lesion and contribute to identifying high risk individuals  
class4	comparison of dna content in gastric cancer cells between primary lesions and lymph node metastases  cytophotomtric dna contents of tumor cells in primary lesions and the corresponding metastatic lymph nodes were compared in 61 cases of gastric cancer to determine whether the dna content remains stable during lymph node metastasis  the dna distribution patterns were grouped into three types  according to the proportion of aneuploid cell population  changes in dna patterns between primary and metastatic lesions were evident in 36 of 61 patients  59 0    in the remaining 25  41 0    the same dna distribution patterns were noted for both lesions  in 33 of these 36  dna pattern in the primary carcinoma was transformed into a more narrowly scattered one in the metastatic lesion of the lymph node  mean and modal values and the frequency of cells over tetraploid  4c  or hexaploid  6c  were significantly higher in the primary lesion compared with findings in the metastatic lesions  this reduction in dna content in the metastatic lesions was a more frequent occurrence in differentiated  18 of 23  than in undifferentiated adenocarcinoma  15 of 35   p less than 0 01   therefore  in primary lesions with a widely scattered dna ploidy  the tumor cells with a smaller dna ploidy frequently metastasized to lymph nodes  particularly in cases of a differentiated carcinoma  such observations may be pertinent in future designing of treatment protocols  
class4	a clinical and flow cytometric analysis of patients with nasopharyngeal cancer  abnormal cellular dna content  a hallmark of malignancy  is known to be an important prognostic factor in many human solid tumors  however  no data have been published on whether cellular dna content carries prognostic significance for patients with nasopharyngeal cancer  npc   archival  formalin fixed  paraffin embedded pathology specimens representing pretreatment tissue biopsies from 55 patients  41 men and 14 women  with npc were analyzed for cellular dna content in a retrospective fashion from 1968 to 1988  individual tumors were classified as either lymphoepithelioma  squamous cell  or anaplastic carcinoma  and were staged according to international union against cancer  uicc  criteria  all patients were treated with curative intent using a 4 to 6 mev linear accelerator to total doses ranging from 50 to 60 gy in 4 to 6 weeks  the overall 5 year actuarial survival for all 55 patients was 44 4   men  41   women  52    survival by t stage was as follows  t1  65   t2  51   t3  36   and t4  27   similarly  the 5 year survival rate declined as the bulk of nodal metastases increased  n0  62   n2  50   n3  37   and n1  25   patients who had anaplastic carcinoma had a 5 year survival of 73   those with lymphoepithelioma had a 60  survival  and those with squamous cell cancer  scc  had a 30  survival  there was a statistically significant difference in 5 year survival between patients with scc and those with nonkeratinizing histologies  p less than 0 05   in addition  there was a significant association between patients older than 40 years of age with scc and patients younger than 40 years of age with nonkeratinizing malignancies  p less than 0 01   of the 55 tumors successfully analyzed  22  40   were diploid and 33  60   were aneuploid  the mean coefficient of variation  cv  of all 55 samples was 6 17   there was no significant difference in 5 year survival between patients with diploid and those with aneuploid tumors  48  versus 42    furthermore  there was no statistically significant survival difference between aneuploid and diploid tumors within any one histologic subgroup  there was also no significant survival difference related to the dna index  the results indicate that the extent of local tumor spread is still the most important prognostic factor for patients treated with radiotherapy for npc  the data support the conclusion that patients with lymphoepithelioma and anaplastic carcinomas have a superior survival to patients with squamous cell carcinoma  abstract truncated at 400 words   
class4	mucinous adenocarcinoma of the submandibular gland  a rare tumor not easily classifiable among published histologic categories for salivary gland tumors is reported  the neoplasm developed within the submandibular gland of a 78 year old woman with invasion of the mandible and metastasis to regional lymph nodes  histopathologically  cuboidal cells possessing clear cytoplasm and displaced round nuclei proliferated and exhibited an adenomatous pattern  many cystic spaces surrounded by tumor cell strands were seen  mucus substance filled in the cystic spaces  and the tumor cells seemed mucus secreting  but neither epidermoid cells nor papillary appearance could be observed  electromicroscopically  numerous mucous droplets of low electron density were prominent in the cytoplasm  and the tumor cells had sparse irregular microvilli on the luminal surface  mucin histochemistry  including paradoxical concanavalin a staining  revealed that the tumor cells contained neutral and acid mucins  and these were identified as class ii and iii mucosubstances  no other neoplastic lesion  except recurrent metastatic neck nodes  has been detected 6 years after the first examination  and it seems that the tumor is a rare primary mucinous adenocarcinoma of the submandibular gland  
class4	the use of flow cytometry for the prognosis of stage ii adjuvant treated breast cancer patients  characterization of breast cancer cells by histology  flow cytometry  and steroid receptors was performed on 197 stage ii breast node positive cancer patients given adjuvant chemotherapy  plus tamoxifen for patients with positive hormone receptors  histologic and steroid receptor assays were performed using standard techniques  flow cytometric analysis was performed from paraffin embedded blocks obtained from the primary tumor  quality control studies on reproducibility  tissue heterogeneity  and analysis procedures have been included  of the 197 patients studied  aneuploidy was found in 102  52    the median  s value was 8  with a range of 0 4  to 38   our results demonstrated that number of positive nodes  receptor status  and grade were of prognostic value  cell cycle kinetic data were not of independent prognostic value in this series  however  ploidy could differentiate in prognosis in the receptor negative subgroup  patients with receptor negative tumors had a significantly better overall survival if the tumor was diploid in nature  cell kinetics was not significantly prognostic for either receptor subgroup  although patients with higher  s tended to have better relapse free and overall survival  this is in disagreement with other studies and may demonstrate that treatment has confounded our results and diminished the ability of flow cytometry data to help predict outcome  
class4	immunocytochemical characterization of lung tumors in fine needle aspiration  the use of cytokeratin monoclonal antibodies for the differential diagnosis of squamous cell carcinoma and adenocarcinoma  in the current study  immunocytochemical typing of intermediate filaments was used for a differential diagnosis of human lung tumors from transthoracic fine needle aspiration biopsies  tfnab   the authors have compared the cytologic diagnosis of 53 lung cancer cases with the immunofluorescence patterns obtained using a panel of monoclonal antibodies  five of which  kg 8 13  km 4 62  ks b 17  ks 8 12  kk 8 60  react with specific cytokeratin polypeptides and one with vimentin  vim 13 2   only in six of 23 samples cytologically diagnosed as squamous cell carcinoma did the immunocytochemical typing of cytokeratins  ictc  confirm the cytologic diagnosis  in seven cases some of the tumor cells stained positively with antibody ks b 17 specific for simple epithelial keratin  no  18   suggesting the presence of some cells of glandular origin  in ten additional cases the ictc was in conflict with the cytologic diagnosis of squamous cell carcinoma  i e   antibodies ks 8 12 and kk 8 60 were negative  and antibody ks b 17  positive  supporting a diagnosis of adenocarcinoma  in 14 of 18 cases cytologically diagnosed as adenocarcinoma  the ictc confirmed the diagnosis whereas in four cases additional presence of some squamous cells was noticed  the ictc labeling of cases cytologically diagnosed as undifferentiated and large cell carcinomas was similar to that of the group of adenocarcinomas  thus  the application of cytokeratin typing for tfnab samples seems to provide a vital complementation to routine cytologic study  especially for cases cytologically diagnosed as squamous carcinoma  
class4	comparison of the conventional method of lymph node staging with a comprehensive fat clearing method for gastric adenocarcinoma  discrepant results in long term survival between united states and japanese patients with resectable gastric adenocarcinoma may result from more accurate staging in the japanese series  the authors compared a comprehensive fat clearing method with the conventional pathology method of lymph node sampling in 11 patients undergoing curative gastrectomy and extended lymphadenectomy at their institution  comprehensive fat clearing doubled total lymph node counts  p less than 0 01   identified smaller lymph nodes  p less than 0 001   and identified more histologically involved nodes of significantly smaller size  p less than 0 001   comprehensive fat clearing pathologically upstaged 29  of the authors  eligible specimens  accurate pathologic staging is necessary when comparing japanese and united states survival data for resectable gastric adenocarcinomas  
class4	neuropeptide y and neuron specific enolase levels in benign and malignant pheochromocytomas  neuron specific enolase  nse  is the isoform of enolase  a glycolytic enzyme found in the neuroendocrine system  neuropeptide y  npy  is a peptide recently discovered in the peripheral and central nervous systems  serum nse and plasma npy levels have been reported to be increased in some patients with pheochromocytoma  the authors evaluated whether the measurement of these molecules could help to discriminate between benign and malignant forms of pheochromocytoma  the nse levels were normal in all patients with benign pheochromocytoma  n   13  and elevated in one half of those with malignant pheochromocytoma  n   13   plasma npy levels were on the average significantly higher in the malignant  177 1     38 9 pmol l  n   16  than in the benign forms of the disease  15 7     389 pmol l  n   24   however  there was no difference in the percentage of patients with elevated npy levels  these results show that determination of serum nse may be useful for distinguishing between malignant and benign pheochromocytoma  the measurement of plasma npy is not useful for differentiating the two kinds of tumors  
class4	flow cytometric dna ploidy analysis of synchronously occurring multiple malignant tumors of the female genital tract  in this study the authors applied flow cytometric dna ploidy analysis to multiple female genital tract malignant tumors in 43 patients  most of whom  n   37  had bilateral ovarian cancer  an algorithm was developed for calculation of the likelihood ratio of the probabilities that measured dna index differences between multiple tumor localizations within the same patient could be attributed to measurement variation or to true biologic dna content differences  the results of this statistical analysis show that in 72  of the cases  31 of 43  this probability ratio exceeded 1  because the probability that two independent tumors will have a near identical aneuploid dna content is very low  this finding supports a metastatic process rather than the occurrence of multiple primary tumors in these patients  thus  flow cytometric dna ploidy analysis can be helpful in the identification of metastatic disease in patients with multiple female genital tract malignant tumors  
class4	the relationship between bone morphogenetic protein and neoplastic bone diseases  the monoclonal antibody against bovine bone morphogenetic protein was used for demonstration of bone morphogenetic protein  bmp  in neoplastic bone diseases  the avidin biotin peroxidase complex method demonstrated that bmp mainly exists in the cytoplasm of tumor cells of osteosarcoma and chondrosarcoma  immunostaining showed that a majority of osteosarcomas and all of the chondrosarcoma cells contained a large quantity of bmp  conversely  none of the fibrosarcomas showed positive staining  thus  it was possible to differentiate osteosarcomas from fibrosarcomas by immunostaining  in fibrous dysplasia of bone  bmp was abundant in the fibrocellular tissue that had osteogenic activity  in contrast  fibrous tissue of ossifying fibroma showed weak positive staining  only the osteoblasts rimming the bone showed a positive reaction  immunostaining showed that bmp was also detected in other neoplastic bone diseases such as osteoma  chondroma  and other tumors  
class4	a newly established human osteosarcoma cell line with osteoblastic properties  a human osteosarcoma cell line  huo9  was established from a tumor that was heterotransplanted into athymic nude mice  antiserum against nude mouse spleen cells was added to the early passage cultures to eliminate the host fibroblastic cells  the cell line retained a high activity of liver bone kidney type alkaline phosphatase  alp  and secreted osteocalcin  i e   bone gamma carboxyglutamic acid containing protein  bgp   into the medium  the addition of 1 25 dihydroxyvitamin d3  1 25 oh 2d3  increased the alp activity as well as the level of bgp secreted into the medium  the alp of 1 25 oh 2d3 treated cells has the same inhibition characteristics to heat and amino acids as that of untreated cells  synthetic human parathyroid hormone stimulated the production of intracellular adenosine 3  5  cyclic monophosphate  camp  approximately 100 fold within five minutes  however  the stimulation was not observed with a synthetic human thyrocalcitonin  when huo9 cells were transplanted into the back of a nude mouse  a tumor with an abundant osteoid formation and mineralization was produced  the results indicate that the huo9 cell line expresses well differentiated osteoblastic phenotypes  huo9 is the first established human cell line to produce bgp  and it provides a useful model for the studies of osteoblasts and the regulatory mechanisms of bgp production  
class4	combined laminoplasty and posterolateral fusion for spinal canal surgery in children and adolescents  spinal deformities  especially kyphosis and instability  after laminectomy for tumors and other diseases  are major clinical problems  since 1981  combined laminoplasty and posterolateral fusion for the prevention of postlaminectomy spinal deformities was performed on eight male and two female patients aged two to 26 years  average  13 9 years   the follow up period was from six months to seven years and three months  average  three years and five months   two patients died six and ten months postoperatively because of brain metastases  astrocytoma  and lung metastases  neuroblastoma   respectively  good alignment with no instability of the cervical or thoracic spine was obtained for all patients  including the two who died  laminoplasty combined with posterolateral fusion was found to be very effective in preventing the development of spinal deformities after spinal canal surgery for spinal cord tumors or other diseases in children and adolescents  
class4	oncocytic glomus tumor of the trachea  an oncocytic variant of glomus tumor of the trachea occurred in a 47 year old woman  she experienced intermittent cough and hemoptysis for about three years  bronchoscopy and chest ct scan showed a small reddish polypoid tumor on the lower end of the trachea  bronchoscopic biopsy was carefully done and was diagnosed as oncocytoma  a wedge resection of the tumor was done  tumor cells were characterized by strongly eosinophilic granular cytoplasm on light microscopy and by numerous closely packed round or ovoid mitochondria with prominent tubular cristae on electron microscopy  they were arranged in a sheet around small vessels  as a result of which the biopsy diagnosis of oncocytoma was changed to oncocytic glomus tumor  to our knowledge  this is the first report of an oncocytic glomus tumor arising from the trachea  
class4	multicentric endobronchial granular cell myoblastoma  granular cell myoblastoma  gcm  is a rare benign neoplasm involving the tracheobronchial tree  it is believed to arise from the schwann cell  four cases of tracheobronchial gcm  all of which were multicentric  are presented and a conservative therapeutic approach is suggested  
class4	preoperative radiotherapy in operable rectal cancer  the effect of preoperative radiotherapy  31 5 gy in 3 5 weeks  in operable rectal cancer was examined with respect to resectability and prognosis after two surgical procedures  abdominoperineal resection  or low anterior resection  preoperative radiation did not influence the surgeon s selection of low anterior resection  which was similar  40 percent  in each group  radiation improved five year survival probability and decreased the incidence of local recurrence significantly after low anterior resection  in contrast  no improvement of treatment results was found in patients treated by abdominoperineal resection after radiotherapy  
class4	relationship between blood plasma prostaglandin e2 and liver and lung metastases in colorectal cancer  the relationship of prostaglandin e2  of which a large amount is produced in various neoplasms  and hematogenous distant metastases was investigated in a total of 44 colorectal cancer patients because of its varied pathophysiologic potentials  the authors found significantly high levels of pge2 in local venous blood draining the carcinoma and in peripheral blood in cases with liver or lung metastasis  as well as a significantly large amount of pge2 production in the carcinoma tissue  the results suggest that increased local blood pge2 could enhance the metastasis formation  and increased peripheral blood pge2 may be useful in the detection of such metastasis in colorectal cancer  
class4	palliative operations for colorectal cancer  a review of 96 consecutive patients who underwent palliative surgery for primary colorectal cancer was undertaken to clarify the value of palliation achieved with surgical treatment  the overall rate of postoperative mortality was 8 percent  8 of 96  and the overall rate of postoperative morbidity was 24 percent  23 of 96   the mortality rate was 5 percent  3 of 66  after resective surgery and 17 percent  5 of 30  after nonresective surgery  three deaths were related to the malignant disease  three were related to the intra abdominal infection  and two were related to formation of intestinocutaneous fistulas  of the 8 patients who died  1 had a tumor with local visceral involvement only and 7 had a tumor with more distant spread  median survival was 10 months for all patients  15 months for patients treated with resective surgery  and 7 months for nonresected patients  five patients  5 percent  have survived for longer than 5 years  the median relief of preoperative cancer symptoms was 4 months  4 months after resective surgery and 1 month after nonresective surgery   twenty five patients have undergone second surgery  it is concluded that palliative resective surgery for colorectal cancer can improve patient comfort with an acceptable postoperative mortality rate when cancer growth is localized and in favorable cases with more distant spread  whereas nonresective surgery fails to achieve symptom relief  
class4	rectal bleeding  patient delay in presentation  patient delay in presentation of rectal bleeding has been identified as a factor in delayed diagnosis among patients with colorectal cancer  the aim of this study was to identify demographic or psychological factors  or beliefs or behaviors related to delay in presentation of rectal bleeding  in 93 patients presenting with this symptom to their general practitioner  delay ranged from 0 to 249 days with a median of 7 days  27  29 percent  delayed more than 14 days  delay was unrelated to age  sex  ethnic origin  competence in english  length of schooling  social status  availability of social support  measured psychologic traits  and to the belief that the cause might be cancer  the proportions delaying more than 14 days were statistically significantly elevated among those who were not worried by the bleeding  47 percent delayed   those who did not regularly look at their feces or the toilet paper after use  37 percent   and those who took some other action before presenting to their general practitioner  43 percent   
class4	endosonography of pararectal lymph nodes  in vitro and in vivo evaluation  one hundred thirteen patients with carcinoma of the rectum were evaluated for lymph node metastases by endorectal ultrasound  with the use of 7 5 mhz and based on different echo patterns  two main groups of lymph nodes can be differentiated  hypoechoic and hyperechoic lymph nodes  compared with pathologic findings  hypoechoic lymph nodes represent metastases  whereas hyperechoic lymph nodes are visualized due to unspecific inflammation  lymph node metastases can be predicted with a sensitivity of 72 percent and inflammatory lymph nodes with a specificity of 83 percent  the physical basis of the differentiation of lymph nodes was assessed in vitro by the determination of ultrasound parameters  speed of sound  acoustic impedance  attenuation  and backscattered amplitude   the attenuation coefficient of benign lymph nodes  2 5 db  mhz x cm   is significantly higher than the mean value of lymph node metastases  1 3 db  mhz x cm    the results demonstrate that involved nodes can principally be differentiated from not involved nodes  micrometastases  mixed lymph nodes  and changing echo patterns within inflammatory nodes explain the accuracy rate of 78 percent  
class4	anorectal malignant melanoma in sweden  report of 49 patients  clinicopathologic features and prognosis of 49 patients with anal malignant melanoma were investigated in the total swedish population between 1970 and 1984  median age was 71 years  range  50 to 87 years   and there was a female predominance  31 females  18 males   the most common symptom at presentation was bleeding  the majority of tumors ranged between 2 and 5 cm in diameter and all invaded at least into the submucosa and or the lamina propria  at diagnosis  one third of the patients had either regional or distant metastasis with a median survival of 5 months  the remaining patients were surgically treated with curative intent  either by abdominoperineal resection  apr  or local excision  median survival was poor in both treatment groups  apr  12 months  local excision  13 months   most patients died with distant metastasis  our results confirm the opinion that apr offers no more curative potential than a more conservative surgical approach  however  tumor sizes were on average smaller in the group treated by local excision  this could indicate that  in the absence of known distant metastasis  radical surgery should be performed  particularly since local recurrences tended to be more common after a local excision  
class4	gastric dysrhythmias following pylorus preserving pancreaticoduodenectomy  possible mechanism for early delayed gastric emptying  transient delayed gastric emptying is reported as a frequent complication following pancreas preserving pancreaticoduodenectomy  ppw   we placed serosal electrodes on the stomach of a patient undergoing ppw  myoelectric recordings were obtained postoperatively and correlated with simultaneous radionuclide liquid gastric emptying studies  the patient developed early postoperative gastric atony  associated with frequent gastric dysrhythmias  these dysrhythmias may have been exacerbated by a perihepatic abscess  the gastric dysrhythmias correlated with alterations in liquid gastric emptying  gastric dysrhythmias may be a mechanism for gastric dysfunction in the early postoperative period  
class4	characterization and significance of sulfonylurea receptors  this study describes and characterizes a putative sulfonylurea receptor  the radioligand used was  3h glipizide  9 ci mmol   the beta cell plasma membranes were derived from a transplantable rat insulinoma generated by subcutaneous injection of rinm5f cells and purified by ultracentrifugation on a 15 55  sucrose gradient  specific binding of  3h glipizide to purified beta cell plasma membranes was determined to be maximal at temperatures of 4 23 degrees c  ph 7 3  and an incubation of 2 h  scatchard analysis indicated a single binding site with kd   7 nm and sulfonylurea binding of 0 93 pmol mg membrane protein  displacement of  3h glipizide from the purified beta cell plasma membranes by various sulfonylureas and their analogues correlated well with their known hypoglycemic and insulin releasing activities  various agents  including nutrients  agents affecting ca2  flux  gastrointestinal hormones  and pancreatic hormones  had no effect on  3h glipizide binding to the beta cell plasma membranes  putative sulfonylurea receptors on beta cell and brain cell plasma membranes have been reported by several groups of investigators  sulfonylurea binding to the beta cell is hypothesized to close an atp sensitive k  channel  which leads to depolarization of the membrane and activation of a voltage dependent ca2  channel  
class4	the effect of metoclopramide on ovarian responsiveness to gonadotropin administration in patients with severe polycystic ovarian syndrome  six patients with poor ovarian response to menotropin after pretreatment with a gonadotropin releasing hormone analog exhibited improved ovarian responsiveness when metoclopramide was added on days 3  5  and 7 of the cycle  this was evidenced by a higher number of leading follicles  4 4 versus 0 6   a higher mean of maximal serum 17 beta estradiol levels  560 versus 178 pg ml   a shorter duration of menotropin treatment  7 versus 11 days   and fewer ampules of menotropin used  20 versus 37 ampules cycle  in metoclopramide treated cycles as compared with control cycles  respectively  serum prolactin levels reached a maximum of 172 ng ml within 1 hour after metoclopramide administration and declined to normal range within 6 hours  these results suggest that intermittent increased prolactin secretion may augment ovarian response to gonadotropins  
class4	aromatase activity of human granulosa cells in patients with polycystic ovaries treated with dexamethasone  the effect of dexamethasone  dex   9 alpha fluro 16 alpha methyl prednisolone  on secretion of steroids by human granulosa luteinized cells was studied by culturing cells from mature follicles of women with polycystic ovarian disease and treated for infertility in the in vitro fertilization program  patients were treated with dex 0 5 mg d until the day of human chorionic gonadotropin administration  the cells were cultured for 24 hours in the presence of androstenedione  10  7 m   after incubating for 24 hours  the medium was replaced and the cells were incubated for an additional 24 hours  the medium was then harvested and assayed for estradiol  e2  and progesterone  p   results were compared with those of a control group who was not treated with dex  estradiol production by cells was significantly lower in the study group treated with dex  progesterone production was not influenced by dex  follicular fluid levels  e2  and androgens did not vary with dex treatment  whereas cortisol levels markedly decreased and p levels increased with the treatment  these findings suggest that glucocorticosteroids can directly influence granulosa luteinized cell function  
class4	pregnancy after in vitro fertilization in a patient with stage i endometrial carcinoma treated with progestins  a 35 year old woman with chronic anovulation and bilateral tubal disease was found during infertility evaluation to have grade i endometrial carcinoma confined to an endometrial polyp  she was treated with polypectomy and endometrial curettage followed by high dose progestagens for 6 months  endometrial curettage at 3 and 6 months of therapy indicated regression of the lesion and the patient subsequently achieved successful pregnancy with ivf  
class4	strong association between diabetes and displacement of mouse anti rat insulinoma cell monoclonal antibody by human serum in vitro  in an attempt to identify novel pancreatic beta cell surface antigens  mouse monoclonal antibodies  moabs  were raised against rat insulinoma  rin5f  cells with standard techniques  several clones were identified whose antibodies bound specifically to rin5f cells but not to other rat  mouse  and human target cells  each of these moabs was radiolabeled  and the specificity of binding of each moab was determined by the ability of excess cold homologous moab to displace the labeled moab  six rin5f cell specific moabs of different epitopic specificities were identified  the relevance of these beta cell epitopes to human insulin dependent diabetes  iddm  was demonstrated by the differential ability of human serums from control and diabetic children to displace the radiolabeled moabs from the rin5f cells  serums from 333 children without diabetes or a family history of diabetes and from 156 newly diagnosed iddm patients were tested  only one igm moab was specifically displaced by the iddm serums  i e   146 of 156  compared to serums from control children  i e   10 of 333  with immunofluorescence  the serum component responsible for the displacement of the mouse moab was identified as igg  most of the positive control serums were from children with active autoimmune thyroiditis  serums from children with other forms of glucose intolerance did not displace moab 1a2  there was no correlation between age and the degree of displacement of 1a2  thus  the displacement of 1a2 is a specific and sensitive marker of diabetes susceptibility easily applicable to mass screening  
class4	pancreatic secretory trypsin inhibitor stimulates the growth of rat pancreatic carcinoma cells  pancreatic secretory trypsin inhibitor was examined for growth promoting activity on five cell lines using standard cell culture techniques  one cell line  ar4 2j  derived from a rat pancreatic acinar cell carcinoma  responded with significantly increased incorporation of  3h thymidine and colony formation  pancreatic secretory trypsin inhibitor stimulated the incorporation of  3h thymidine in liquid culture  the maximal increase was 61     10  above control  p less than 0 001  and was seen at a concentration of 10  9  mol l  using a soft agarose clonogenic assay  pancreatic secretory trypsin inhibitor also consistently stimulated  3 assays  colony formation  the peak activity occurred at a concentration of 10  10  mol l which caused a 150     55   mean     se  p less than 0 05  increase above control  aprotinin had no effect on the growth of ar4 2j cells and pancreatic secretory trypsin inhibitor did not bind to the epidermal growth factor receptor  ar4 2j cells were shown to produce pancreatic secretory trypsin inhibitor  the study raises the possibility that pancreatic secretory trypsin inhibitor provides autocrine stimulation of tumor cell growth  
class4	immunochemical characterization and quantitative distribution of pancreatic stone protein in sera and pancreatic secretions in pancreatic disorders  a fluorometric immunoassay has been established to quantitate pancreatic stone protein providing a sensitivity for concentrations from 0 015 to 0 5 micrograms ml  when concentrations of pancreatic stone protein were determined from pancreatic secretions obtained either from patients suffering from chronic pancreatitis  n   31   including the calcifying forms  n   10    pancreatic cancer  n   22   or nonpancreatic diseases  n   17   no significant differences were found  in contrast  increased concentrations were found in serum samples from patients with chronic  39 66  and acute pancreatitis  16 20  compared with control patients  the differences between these diagnostic groups and controls were highly significant  p less than 0 0001  and independent of pancreatic enzyme activity  immunochemical analyses of serum pancreatic stone protein showed an isoelectric point  ph 9  similar to that reported for the pancreatic thread protein  with respect to recent communications  these data do not support the etiopathogenic role postulated for pancreatic stone protein in chronic pancreatitis and chronic calcifying pancreatitis by other investigators  
class4	endoscopic retrograde brush cytology  a new technique  endoscopic retrograde cholangiopancreatography has been shown to be a very valuable adjunct in the diagnosis of malignancy involving the biliary and or pancreatic ductal system  however  characteristic endoscopic retrograde cholangiopancreatography radiographic findings associated with malignant strictures are frequently not specific and cytological confirmation becomes essential for the diagnosis  unfortunately  the current overall diagnostic yield of positive cytology in such circumstances ranges from 18  56  depending on the technique  a new brush device has been designed which is uniquely adapted to pancreaticobiliary strictures of varying anatomical configurations  this study shows results using this new cytology brush in a series of 53 patients with pancreaticobiliary malignancy  a significant improvement in the cytological yield of tumor confirmation was obtained with a diagnostic sensitivity of 70  and specificity of 100  using the new brush technique  
class4	resolution of inferior vena cava syndrome after embolization of a hepatic adenoma  a 77 year old man presented with severe pruritus and massive lower body edema  computerized axial tomography of the abdomen showed a large hepatic mass compressing the inferior vena cava  and a liver biopsy specimen showed hepatic adenoma  embolization of vessels feeding the hepatic tumor resulted in complete resolution of pruritus and ascites  and clinical remission has persisted for 1 year following partial obliteration of tumor vasculature  angiographic ablation of tumor blood supply represents a nonoperative means for inducing clinical remission in patients with symptomatic hepatic adenoma who are at high surgical risk  
class4	misdiagnosis of the zollinger ellison syndrome due to hyperlipidemia  most authorities feel that diagnosis of the zollinger ellison syndrome is established when the serum gastrin level is greater than 1000 pg ml  1000 ng l  in a patient with gastric acid hypersecretion and clinical manifestations consistent with the diagnosis  a patient with recurrent peptic ulcer disease is reported who was thought to have had the zollinger ellison syndrome based on two serum gastrin level measurements greater than 1000 pg ml  1000 ng l   subsequent evaluation revealed the gastrin elevation to be spurious because the sample was hyperlipidemic  lipemic serum samples may yield falsely elevated serum gastrin determinations as determined by radioimmunoassay  
class4	late recurrence of a hepatocellular carcinoma in a patient with incomplete alagille syndrome  in this study  the case of a patient presenting a second hepatocellular carcinoma 13 years after resection of a first tumor of the same type is reported  in this case  etiological investigations remained negative  but an incomplete form of syndromatic alagille syndrome with paucity of bile ducts in the nontumoral tissue was detected and associated with nodular regenerative hyperplasia and foci of dysplasia  malignant transformation in alagille syndrome seems to be extremely rare  the fact that such tumors evolve very slowly could be an argument for partial hepatectomy and  if necessary  liver transplantation  
class4	endoscopic ultrasonography for the evaluation of smooth muscle tumors in the upper gastrointestinal tract  an experience with 42 cases  before surgery  12 patients with suspected leiomyoma and 12 patients with suspected leiomyosarcoma were studied by endoscopic ultrasonography  eus   computed tomography  ct   endoscopy  and barium swallow  the results were correlated with surgery and histology  ten leiomyomas  one benign gastric ulcer  one carcinoid metastasis  eight leiomyosarcomas  two leiomyoblastomas  one mucus secreting adenocarcinoma  and one bronchial carcinoma were diagnosed  eighteen additional patients suspected to have benign submucosal lesions by endoscopy and barium meal were treated non surgically  and studied by eus and ct  eus was superior to other imaging techniques in the detection  staging  and follow up of submucosal smooth muscle tumors because of clear imaging of the intramural abnormality and adjacent lymph nodes  
class4	endoscopic palliative intubation of the esophagus invaded by lung cancer  thirty two patients with esophageal involvement by lung cancer were managed by endoscopic intubation  in 22 patients with extrinsic esophageal strictures  the success rate of intubation was 91   and 82  were discharged with their dysphagia relieved and esophageal patency restored  the mean survival rate was 4 4 months  in 10 patients with esophago bronchial fistulas  3 had the fistulous tract obliterated and lived a mean of 5 months  this low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor associated stenosis  the overall morbidity rate was 28 1   18 8  perforation  6 3  hemorrhage  and 3 1  tracheal obstruction   the overall mortality rate was 18 8   although complications were more frequent than in primary esophageal tumors  endoscopic intubation was the only way to palliate this desperate condition and provided 66 6  of patients with relief of symptoms  nutritional improvement  and a mean survival time of 4 5 months  
class4	low diacylglycerol values in colonic adenomas and colorectal cancer  the biochemical events that make colonic epithelial cells proceed along the adenoma carcinoma sequence are not well understood  the phosphoinositol signal transduction pathway is involved in the regulation of cell growth and differentiation  to determine its role in colonic neoplasias we performed mass measurements of its second messenger sn 1 2 diacylglycerol in biopsy specimens from normal mucosa and neoplasias of the colon  normal colonic mucosa was also investigated in patients without colonic abnormalities  n   10   compared with pooled diacylglycerol values from five colonic sites  100    values in patients with a normal colon were highest in the ascending colon  120  5    p less than 0 05  and lowest in the rectum  81  5    p less than 0 01   absolute diacylglycerol values in patients with normal colons  2 62  0 16  nmol mg protein  were not significantly different from those found in the normal mucosa of patients with colorectal neoplasias  2 45  0 17  nmol mg protein   both colonic adenomas  n   15  and colorectal carcinomas  n   14  showed significantly decreased diacylglycerol values compared with the adjacent normal mucosa of each patient  72  4    p less than 0 001  and 71  4    p less than 0 001 respectively   the appreciable decrease in mass diacylglycerol values clearly distinguishes adenomas and carcinomas of the colon from the surrounding normal mucosa  this finding suggests that profound metabolic changes of the phosphoinositol signal transduction pathway occur early in the adenoma carcinoma sequence and may be important in colonic carcinogenesis  
class4	adult hepatic fibropolycystic disease presenting as obstructive jaundice  obstructive jaundice caused by compression of the common hepatic duct by a simple hepatic cyst in a 31 year old europid man is reported  the jaundice and duct compression resolved after percutaneous aspiration of the cyst under ultrasound direction and the patient has been well for 12 months  
class4	high grade dysplasia of the gastric mucosa  a marker for gastric carcinoma  the natural history of gastric epithelial dysplasia and its relation to gastric cancer are ill defined  a consecutive series of 40 patients with an initial diagnosis of gastric epithelial dysplasia based on examination of endoscopic biopsies has been reviewed to determine the clinical outcome and to evaluate a two tier histological grading system as a predictor of the risk of cancer  on review  only 20 of the 40 patients were considered to have true dysplasia  seven patients had low grade dysplasia and 13 had high grade dysplasia  of the 13 patients with high grade dysplasia  11  85   were found to have gastric cancer within 15 months  of the 10 patients with high grade dysplasia who underwent gastrectomy  six were found to have early gastric cancer  three had cancer invading into the muscularis propria  and none had lymph node metastases  high grade dysplasia is thus a marker of gastric cancer  moreover  the cancers associated with high grade dysplasia are usually pathologically favourable and curable  the finding  by an experienced pathologist  of high grade dysplasia in two separate sets of endoscopic biopsies is therefore an indication for radical surgical treatment  provided that the patient s age and general condition permit such an approach  
class4	growth of group a rotaviruses in a human liver cell line  recent observations in children with rotavirus gastroenteritis and in infant mice given rotavirus vaccine by oral administration suggest that this well known gastrointestinal pathogen may infect the liver  to examine this possibility  the susceptibility of hep g2 cells to infection with a variety of rotavirus strains was tested  these cells were used because they are considered to be well differentiated and exhibit many liver specific functions  the hep g2 cells supported the growth of the simian strain rhesus rotavirus  mmu 18006   a strain currently being used in vaccine trails  but did not support the growth of any human strain  d  ds1  price or st3   the rhesus rotavirus infection was cytopathic and resulted in release of lactate dehydrogenase  rhesus rotavirus growth in hep g2 cells displayed trypsin enhanced infectivity and was inhibited by pretreatment of cells with arthrobacter ureafaciens neuraminidase but not with neuraminidase from clostridium perfringens  hep g2 cells were also permissive for another simian strain  sa11   a bovine strain  uk  and single gene substitution reassortants containing vp7  the major outer capsid neutralization protein  from a human rotavirus strain and the remaining 10 genes from either rhesus rotavirus or uk  in general  uk and its reassortants produced lower levels of antigen than did rhesus rotavirus and its reassortants  hep g2 cells and other hepatic cell lines may prove to be useful tools to explore the hepatotropic potential of wild type rotaviruses and candidate vaccine strains  
class4	hbv dna sequences in tumor and nontumor tissue in a patient with the fibrolamellar variant of hepatocellular carcinoma  one patient with the fibrolamellar variant of hepatocellular carcinoma was found to be seropositive for hbsag and anti hbe  dna from tumor and nontumor areas of the liver was examined by molecular hybridization for hepatitis b virus dna sequences  undigested dna from the tumor gave a high molecular weight smear  and restriction enzyme analysis indicated a single instance of integration  nontumor liver tissue was analyzed from three separate areas  hepatitis b virus dna was detected in two of these  restriction enzyme digestion suggested they contained different sites of viral integration  as with the typical hepatitis b virus related hepatocellular carcinoma  analysis of hepatitis b virus dna from nontumorous liver yielded a different pattern of high molecular weight bands  indicating that the virus genome had integrated at different chromosomal locations than that seen in the tumor  the finding of integrated hepatitis b virus dna  especially in tumorous but also in nontumorous liver  would be consistent with an oncogenic role for hepatitis b virus in certain instances of fibrolamellar tumors and in the more typical hepatitis b virus related hepatocellular carcinoma  
class4	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  
class4	diagnostic value of brush cytology in the diagnosis of bile duct carcinoma  a study in 65 patients with bile duct strictures  malignant strictures of the extrahepatic bile ducts are difficult to distinguish from benign strictures  particularly in patients with primary sclerosing cholangitis  because attempts at diagnosing small cancers with fine needle aspiration biopsy are not possible in the absence of an associated mass lesion and because the sensitivity of exfoliative biliary cytology is controversial  brush cytology has been used as a potential means of establishing a specific diagnosis of bile duct carcinoma  herein we report our experience with this technique when performed on 65 patients over a 5 yr period  each had at least one brushing  thirty seven were found to have bile duct carcinoma and 28 were found to have benign strictures  of these 37  the first brushing was positive for malignancy in 15  40    whereas four  11   had cells suspected but not diagnostic of malignancy  thirteen patients with bile duct carcinoma whose initial brushings were negative for malignancy had second brushings  of these  five  38   had malignant cells  whereas three  24   yielded suspicious cells  three of the eight whose first two brushings were negative for malignancy were found to have malignant cells on the third brushing  in contrast  of the 28 patients with benign strictures  malignant cells were never found  however  in two patients  suspicious cells were reported with the first but not the second brushing  a single negative or suspicious cytological finding decreased the probability of bile duct carcinoma to 43   two and three sequential negative tests reduced the probability to 32  and 0   respectively  
class4	prognostic factors of hepatocellular carcinoma in the west  a multivariate analysis in 206 patients  to investigate the prognostic factors in western patients with hepatocellular carcinoma  206 patients with confirmed diagnoses of hepatocellular carcinoma were studied in terms of survival  all patients were diagnosed between 1983 and 1987  a multivariate survival analysis  cox regression model  using clinical  biochemical  ultrasonographical and pathological data obtained at diagnosis disclosed that bilirubin  p   0 0001   ascites  p   0 0001   toxic syndrome  defined by the presence of weight loss greater than 10  premorbid weight  malaise and anorexia   p   0 009   blood urea nitrogen  p   0 025   tumor size  p   0 001   gamma glutamyltranspeptidase  p   0 0006   age  p   0 0005   serum sodium  p   0 003  and presence of metastases  p   0 002  were independent predictors of survival  according to the contribution of each of these factors to the final model  a prognostic index was constructed allowing division of patients in different groups according to their relative risk of death  rrd   exp  age x 0 03   ascites x 0 8281   bun x 0 0137   serum sodium x   0 0538    gamma glutamyltranspeptidase x 0 0019   bilirubin x 0 0734   tumor size x 0 33   toxic syndrome x 0 4965   metastases x 0 55   these results facilitate the stratification of hepatocellular carcinoma patients to design and evaluate future controlled trials  
class4	review of hepatic imaging and a problem oriented approach to liver masses  we believe that imaging of the liver is complicated  the sporadic appearance of incidental benign lesions and variability in scanning techniques  equipment and artifacts add difficulties to the evaluation of liver masses  therefore we emphasize the need to define the problem for which the patient is being imaged  this information helps in choosing the procedure of choice and the technique needed to give the most expedient  accurate answer  this will also help apply the lowest risk and most cost efficient care  imaging algorithms vary depending on the suspected pathological conditions  dynamic bolus enhanced ct is the modality of choice in most situations  tc99m sulfur colloid liver spleen scans are helpful in patients with suspected fnh  and tc99m tagged rbc spect scans are recommended to confirm cavernous hemangiomas  cysts are easily confirmed by us  although mri is competitive with ct  it has not become a primary modality because of cost  availability  patient selection and variability of scanner capabilities among the many manufacturers and models  it is hard to predict what future development of imaging techniques will bring  many feel that significant advances have plateaued  time and money will more likely be concentrated on improving image resolution  speed of scanning and ability to transfer this information to sites outside of the radiology department  in addition to faster scanning  we expect to soon have available safe intravenous and enteric contrast agents for mri  certainly this will lead to a new round of investigations to compare mri with ct scanning  
class4	a surgical approach to the cervicothoracic spine  we describe a method for approaching the lower cervical and upper thoracic spine  the brachial plexus and related vessels  the method involves the elevation of the medial corner of the manubrium  the sternoclavicular joint  and the medial half of the clavicle on a pedicle of the sternomastoid muscle  we have used this exposure in 17 cases with few complications and good results  its successful performance requires high standards of anaesthesia  surgical technique and postoperative care  
class4	unusual haemostasis for an unusual tumour  catastrophic bleeding from a tactile neurofibroma affecting the thoracic vertebrae  case report  the symptomatology of a typical acute descending thoracic aorta dissection was imitated by profuse haemorrhage caused by a benign tumour composed almost exclusively of wagner meissner like tactile corpuscles and fatty tissue  the tumour caused extensive destruction of the bodies of the fifth and sixth thoracic vertebrae at the level of the vertebro costal articulation  emergency cross clamping of the descending aorta and haemostasis of the bleeding from osteal defects by tamponade with bone polymethyl methacrylate appeared the only way to control the life threatening haemorrhage  it seems that an intrathoracic tactile neurofibroma with a similar case history has not been reported till now  
class4	left ventricular fibroma  echocardiographic diagnosis and successful surgical excision in three cases  the management of three patients with left ventricular fibromas is outlined  all were asymptomatic children  routine chest radiography suggested cardiac masses  m mode and two dimensional echocardiography were valuable adjuncts to conventional angiography in assessing these children  electrocardiographic changes  present in all cases  were shown to regress postoperatively  we stress the importance of these noninvasive aids in the initial investigation and outline our operative methods of reconstruction  
class4	deletion of alu sequences in the fifth c sis intron in individuals with meningiomas  an abnormality in the c sis protooncogene was identified in leukocyte dna from members of a family predisposed to the development of meningioma  and was found to be associated with the development of the tumor in those individuals  molecular analysis of this abnormality demonstrated a deletion within the fifth intron of the c sis gene  the normal c sis gene has an alu sequence in this region which includes two perfect 130 nucleotide repeated sequences separated by 5 bp  the deleted c sis allele is missing precisely one copy of the 130 bp repeat and the intervening 5 bp  an identical deletion was also found in dna from 1 of 13 sporadic meningiomas  
class4	use of monoclonal antibody kp1 for identifying normal and neoplastic human mast cells  the monoclonal antibody kp1  cd68  was used to stain normal and neoplastic monocytes and macrophages in routinely processed  paraffin wax embedded tissue  mast cells also exhibited strong  consistent cytoplasmic immunoreactivity  light microscopic findings were corroborated by electron microscopical and immunocytochemical findings  the predominant sites of immunoreactivity were the specific intracytoplasmic granules of the mast cells  all mast cell subtypes  that is  normal and reactive mast cells  such as those in lymph nodes exhibiting chronic non specific lymphadenitis  and malignant or neoplastic mast cells in various types of mastocytosis  reacted with this antibody  this finding is of diagnostic importance  because mast cell proliferation could be mistaken for histiocyte proliferation  it also supports the hypothesis that mast cells derive from the bone marrow  
class4	testicular sex cord stromal tumour with granulosa cell differentiation  detection of steroid hormone receptors as a possible basis for tumour development and therapeutic management  a testicular sex cord stromal tumour with granulosa cell differentiation  typical of granulosa cell tumours of the adult type  was investigated immunohistologically on snap frozen and paraffin wax embedded material  the predominance of vimentin and the additional expression of cytokeratin subtypes 8 and 18  as well as the negative staining for epithelial membrane antigen  accorded with results previously reported  for ovarian granulosa cell tumours  the lack of expression of desmoplakin  however  was a distinctive feature  together with negative staining for leucocyte common antigen  the antigen pattern facilitates the differential diagnosis between granulosa cell tumour and undifferentiated carcinoma or gonadal lymphoma  although its suitability for differentiating within the group of gonadal stromal tumours seems to be limited  the small growth fraction  shown by the monoclonal antibody ki 67  is typical of the clinical behaviour of granulosa cell tumours  the expression of oestrogen and progesterone receptors  also recently found in testicular leydig cell tumours  may provoke new approaches to the management of testicular granulosa cell tumours  as well as a new hypothesis on the development of these tumours  
class4	upper gastrointestinal pathology in familial adenomatous polyposis  results from a prospective study of 102 patients  multiple gastric and duodenal biopsy specimens from 102 asymptomatic patients with familial adenomatous polyposis  taken during a prospective endoscopic screening programme were examined  one hundred patients had microscopic gastroduodenal pathology  often in the absence of macroscopic lesions  adenomas were found in 94 patients in the duodenum  in the second and third parts  hyperplasia of villous and crypt epithelium was also seen  sometimes in the absence of adenomas  this may be a precursor of neoplastic change  in the stomach fundic gland polyps were the commonest abnormality  seen microscopically in 44 patients  chronic antral gastritis was common in patients without fundic polyps  gastric adenomas were present in six patients  all of whom also had duodenal adenomas  if duodenal adenomas in familial adenomatous polyposis have a similar malignant potential to those in the colorectum sequential endoscopy and biopsy are necessary to detect cancer in these patients  
class4	effect of sample volume on yield of positive blood cultures from adult patients with haematological malignancy  six hundred and sixteen blood samples from patients with haematological malignancy were each distributed equally among three identical cells in a malthus microbiological growth analyser  the mean  sd  volumes inoculated into sets in which one  two  or three of the three bottles were positive were 37 7  10 1  ml  37 4  12 9  ml  and 37 7  10 5  ml  respectively  overall  clinically important organisms were isolated from one bottle only with 18 cultures  from two bottles only with 19 cultures  and from all three bottles in a set with 104 cultures  if the yield from a single bottle inoculated with a mean volume of 12 6 ml blood is taken as 100   the yield from 25 2 ml in two bottles was 110 7  and the yield from 37 7 ml in three bottles was 115 6   the increased yield from increased volume was considerably lower than that reported from unselected groups of patients  which suggests that the magnitude of bacteriaemia is greater in patients with neutropenia  the isolation of infecting organisms from the blood of patients with neutropenia is  however  particularly important in directing chemotherapy and consequently 45 ml blood samples from these patients continue to be requested  
class4	activation and inducer subset phenotype of the lymphocytic infiltrate around epidermally derived tumors  an in situ analysis of the mononuclear cell infiltrate found in association with a range of benign  premalignant  and malignant epidermal tumors is described  the predominant cell phenotype was that of the recently described immunoregulatory helper inducer t lymphocyte  a large number of lymphocytes expressed antigens associated with cellular activation  suggesting an ongoing immunologic response by the host against the tumor  although evidence of in situ proliferation of these cells was lacking  these findings suggest that the infiltrate found in association with cutaneous tumors does not represent passive accumulation of lymphocytes from the circulation but rather an active antitumor response  
class4	benign lymphangioendothelioma  we have studied eight cases of an acquired lymphatic endothelial lesion for which we propose the name  benign lymphangioendothelioma   the lesions developed as solitary  slowly extending  erythematous macules and plaques  usually occurring on the extremities or the shoulders in adolescents or adults  the characteristic histopathologic feature is permeation of the dermal collagen by flattened  endothelium lined channels and spaces  hemorrhage  iron deposition  and inflammation were not part of the lesion  ulex europaeus agglutinin i labeled the lesional endothelial cells consistently  but factor viii related antigen labeling was negative  this histologic pattern and the special studies suggested a lymphatic lesion  surgical excision  performed in six patients  was not followed by recurrence  
class4	absence of estrogen receptors in dysplastic nevi and malignant melanoma  benign nevi  dysplastic nevi  and primary and metastatic malignant melanomas were evaluated for the presence of sex hormone binding and estrogen receptor protein  we have confirmed the observation of ellis et al  that some pigmented lesions possess sex hormone binding proteins  we could not demonstrate a true estrogen receptor in any benign nevi  dysplastic nevi  primary melanomas  or metastatic melanomas  thus the ability to bind estrogen or progesterone does not correlate with the presence of a true estrogen receptor  lack of nuclear estrogen receptors suggests that the influence of estrogen on the pathophysiology of melanoma or of benign melanocytic nevi may not be significant  
class4	incidence of cutaneous t cell lymphoma and other rare skin cancers in a defined population  between 1970 and 1984 in rochester  minnesota  rare skin cancers developed in 15 local residents  cutaneous t cell lymphoma  six subjects   dermatofibrosarcoma protuberans  four   adenocarcinoma of sweat glands  two   merkel cell carcinoma  one   liposarcoma  one   and extramammary paget s disease  one   these cases were identified through a unique computerized retrieval system that is maintained at the mayo clinic for the population of rochester  minnesota  the annual incidences of these cancers in the rochester population were 0 9  0 5  0 3  0 2  0 2  and 0 2 per 100 000 residents  respectively  standardized to 1980 u s  population   to our knowledge  this is the first report of the incidences of these rare skin cancers in a well defined population  
class4	cutaneous surgery and the pregnant patient  cutaneous surgery in 34 pregnant women is described  the main indication for surgery was the diagnosis and or treatment of malignancy  surgery during the period of organogenesis  15 to 56 days  should be avoided when possible  patients should be positioned on the left side during the procedure to avoid the supine hypotensive syndrome  monitoring of the fetal heartbeat is desirable  local anesthetics  penicillin  and erythromycin are safe if used carefully  acetaminophen is the analgesic of choice  exposure to the sun should be avoided during the perioperative period  
class4	comparison of methods for checking surgical margins  surgical margins of a cutaneous neoplasm can be evaluated by various combinations of three major types of sections  vertical  perpendicular   horizontal  parallel   and oblique  mohs method   vertical sections may run transversely through tumor  breadloaf method   longitudinally through tumor  breadloaf cross method   or peripheral to the tumor  the peripheral  perimeter  sectioning methods are the only methods that can evaluate almost 100  of the margin  but they have the disadvantage of not showing the relationship of the tumor to its margin  which can be seen clearly with the vertical transverse sections  seven methods of checking surgical margins are compared and contrasted  none of these is judged to be perfect or best  
class4	years of potential life lost  another indicator of the impact of cutaneous malignant melanoma on society  years of potential life lost  ypll  is an indicator of premature mortality that complements traditional incidence and mortality rates and that facilitates comparisons among different cancers  we calculated ypll from cutaneous melanoma and 11 other cancers routinely recorded and tracked by surveillance  epidemiology and end results  seer   ypll from cutaneous melanoma ranked eighth for persons younger than 65 years of age and fourth for those 20 to 49 years of age  an average of 17 1 ypll per death were due to melanoma  one of the highest rates for adult onset cancers  the results of our study  the first to apply ypll to cutaneous melanoma  emphasize the disproportionate impact of this cancer on young and middle aged adults and reemphasize the importance of this cancer as a public health priority  
class4	trends in basal cell carcinoma  squamous cell carcinoma  and melanoma of the skin from 1973 through 1987  major increases have occurred in the incidence of basal cell carcinoma and squamous cell carcinoma of the skin  as well as in cutaneous malignant melanoma during the period 1973 through 1987 in british columbia  the greatest increases in basal and squamous cell carcinomas are on the head and neck  this indicates that exposure to sunlight is the major causative factor  the greatest increase in melanoma is on the trunk in men and on the lower limbs in women  the dramatic increases in nonmelanoma skin cancers in british columbia  a relatively low sunlight area  suggest that major prevention programs are needed in areas that are not considered  sunspots    
class4	pigmented bowen s disease arising from pigmented seborrheic keratoses  we report three cases of pigmented bowen s disease that clinically and histologically had features of seborrheic keratoses  we speculate about the mechanism of pigmentation in these lesions and suggest that they arise from pigmented seborrheic keratoses  
class4	the relationship of pemphigus to neoplasia  a statistically increased incidence of malignancy has been observed in patients with pemphigus  a review of the literature reveals 42 cases of nonthymic malignancies and 18 cases of thymic malignancies  a significant predominance of men  with mean age at onset of 50 years  was observed  pemphigus vulgaris is more common in patients with nonthymic neoplasms  whereas pemphigus foliaceus or pemphigus erythematosus and pemphigus vulgaris are equally common in patients with thymic neoplasms  lymphoreticular malignancies  especially kaposi s sarcoma  are most frequently observed  the majority of patients with nonthymic neoplasms have pemphigus before the detection of the malignancy and have a favorable 5 year survival rate after tumor resection  the majority of the patients with thymic neoplasms have a thymoma before the development of pemphigus  in some patients pemphigus develops after thymectomy and myasthenia gravis is often associated  overall  37 of the 60 patients  or 61   had a neoplasm of the immune system  
class4	proliferative mass found in the gingiva  the clinical course of peripheral ossifying fibroma is slow and the growth of most lesions is limited in size  usually up to 1 5 cm  complaints are rare unless the surface becomes ulcerated  or the lesion compromises oral function or esthetic appearance  treatment is surgical excision with close postoperative follow up  tooth extraction is seldom necessary  proper surgical intervention  which includes excision of reactive tissue down to periosteum  affords a low recurrence rate of 14  to 16   
class4	effect of gastric mucus on the uptake of the carcinogen mnng by gastric mucosal dna  in prostaglandin e2  pge2    pirenzepine   and indomethacin administered rats  the incorporation of n  methyl 3h  n  nitro n nitrosoguanidine   methyl 3h mnng  into gastric mucosal dna was measured quantitatively by liquid scintillation counting after intragastric instillation of  methyl 3h mnng  the amount of incorporation was 25 4     5 9 pmol mg dna in control rats  11 7     3 8 pmol mg dna in pge2 administered rats  6 2     5 6 pmol mg dna in pirenzepine administered rats  and 42 9     14 4 pmol mg dna in indomethacin administered rats  pge2 and pirenzepine significantly decreased the incorporation as compared with the control group  in contrast  indomethacin increased the incorporation  in addition  gastric mucosa of these drug treated rats was studied histochemically  pge2 and pirenzepine increased secretion of gastric mucus whereas indomethacin decreased it  it is possible that gastric mucus has a protective effect not only against ulcerogenic agents but also against carcinogens  it is considered that gastric mucus plays an important role in the defense mechanism against carcinogenesis  
class4	campylobacter pylori interactions with gastric cell tissue culture  many investigators have reported that gastric mucosal biopsies of patients with chronic gastritis and peptic ulcer disease show the presence of campylobacter pylori in a large majority of cases  histologic examinations of such tissues indicate a close approximation of c  pylori with gastric surface epithelial cells  a recent report has described both adherence and cell invasion of gastric cells by c  pylori  using a transmission electron microscope  we have examined the interaction between c  pylori  c  jejuni  and e  coli in vitro with a gastric cancer cell line  kato iii  our results indicate marked toxicity of e  coli and moderate toxicity of c  jejuni for kato iii cells  c  pylori had only a minor effect on tissue culture viability  c  pylori was found to have a strong association with the kato iii cell membranes and evidence of occasional cell invasion  both c  jejuni and e  coli showed no attachment or association with the kato iii cells  we interpret these findings as indicating that c  pylori may have a specific adhesion for gastric cells  
class4	pelvic pain  lessons from anatomy and physiology  pelvic pain is often a difficult differential diagnosis in the emergency department  for physiologic reasons  pain in the pelvis is difficult to localize to a specific organ  and pelvic peritonitis is hard to recognize  on the other hand  differences in types of pain can be very useful in arriving at a correct diagnosis  the clinician must learn to recognize superficial and deep somatic pain  and differentiate between various types of visceral pain which originate from inflammation  ischemia  or colic  a review of the anatomy and physiology of pelvic pain helps identify some of the problems as well as potential aids in approaching the patient with pelvic pain  
class4	hypointense renal cell carcinoma  mr imaging with pathologic correlation  in two pathologically documented cases of renal cell carcinoma  the appearance of the tumors at magnetic resonance  mr  imaging was markedly hypointense relative to normal renal parenchyma on both t1  and t2 weighted spin echo images  pathologic examination of both tumors revealed diffuse iron scattered throughout the tumors  the paramagnetic effect of the iron may account for this unusual hypointense appearance at spin echo imaging  independent of pulse sequence  
class4	rectal carcinoma  ct staging with water as contrast medium  computed tomography  ct  was used to study 42 patients with rectal carcinoma  water was used as a contrast medium for studying the local extent of tumor in all patients  scans were read prospectively without knowledge of the histologic staging and then compared with pathologic specimens  ct depicted the tumor in all patients  comparison of ct and histologic results  following the dukes classification  showed that disease was correctly staged as a in three of four patients  as b in eight of 12  as c in 15 of 17  and as d in nine of nine  overall  carcinoma was correctly staged with ct in 35 of 42 patients  diagnostic accuracy  83 3    the accuracy in the assessment of local invasion was 97 6   41 of 42   in the detection of lymph node involvement  the accuracy was 78 6   sensitivity  88   specificity  64 7    ct is recommended in the preoperative staging of rectal carcinoma and as an aid in choosing the appropriate therapy  the use of water enema and complete distention of the rectum are reliable techniques for improving the accuracy of ct in the assessment of local invasion by cancer  
class4	segmented turboflash  method for breath hold mr imaging of the liver with flexible contrast  a method called segmented turboflash imaging allows high resolution  multisection  short inversion time  ti  inversion recovery  stir   t1  or t2 weighted magnetic resonance  mr  studies of the liver to be completed within a breath hold interval  the method was applied in a phantom and in 19 patients with hepatic lesions  sequence comparisons were performed among segmented turboflash  single shot turboflash  t1 weighted gradient echo with ultrashort echo time  and t2 weighted spin echo  se  techniques  signal from fat and liver could be nulled with the segmented turboflash method  with tis of 10 and 300 msec  respectively  signal from these tissues could not be eliminated with the single shot approach  signal difference to noise ratios and contrast for the best segmented sequences were comparable with those of the best t2 weighted se and t1 weighted gradient echo techniques  it is concluded that it is feasible to obtain breath hold images with arbitrary tissue contrast by means of segmented turboflash imaging  the method may prove helpful for the detection and characterization of hepatic lesions and will likely have applications to other anatomic regions such as the chest and pelvis  
class4	effect of somatostatin analogue  octreotide  on blood flow to endocrine tumors metastatic to the liver  angiographic evaluation  the effect of an octapeptide analogue of somatostatin  octreotide  on tumor blood flow was evaluated with angiography in eight patients with hepatic endocrine tumors  one patient had primary intrahepatic gastrinoma  two patients had hepatic metastases from gastrinomas  two patients had vipomas  vasoactive intestinal polypeptide secreting tumor   and three patients had carcinoid tumors  octreotide caused a marked decrease in tumor blood flow in two patients with gastrinomas and two with vipomas  one patient could not be evaluated due to the lack of a tumor blush on a control angiogram  in patients with carcinoid tumors  octreotide caused a slight reduction in blood flow through the tumors in two patients  while there was no change in one patient  octreotide markedly decreased gastrin and gastric acid secretion in two of three patients with gastrinomas  lowered vip and stopped the diarrhea in patients with vipomas  and controlled symptoms in two of three patients with carcinoid tumors  the vasoactive effect of octreotide on hepatic endocrine tumors may be a direct action on tumor blood supply or secondary to inhibition of the endocrine tumor cell secretion and consequent decreased blood flow  
class4	direct interaction of a ligand for the erbb2 oncogene product with the egf receptor and p185erbb2  the erbb2 oncogene encodes a 185 kilodalton transmembrane protein whose sequence is similar to the epidermal growth factor receptor  egfr   a 30 kilodalton factor  gp30  secreted from mda mb 231 human breast cancer cells was shown to be a ligand for p185erbb2  an antibody to egfr abolished the tyrosine phosphorylation induced by egf and transforming growth factor alpha  tgf alpha  but only partially blocked that produced by gp30 in sk br 3 breast cancer cells  in two cell lines that overexpress erbb2 but do not expresss egfr  mda mb 453 breast cancer cells and a chinese hamster ovary cell line that had been transfected with erbb2   phosphorylation of p185erbb2 was induced only by gp30  the gp30 specifically inhibited the growth of cells that overexpressed p185erbb2  an antibody to egfr had no effect on the inhibition of sk br 3 cell colony formation obtained with gp30  thus  it appeared that gp30 interacted directly with the egfr and erbb2  direct binding of gp30 to p185erbb2 was confirmed by binding competition experiments  where gp30 was found to displace the p185erbb2 binding of a specific antibody to p185erbb2  the evidence described here suggests that gp30 is a ligand for p185erbb2  
class4	protection from chemotherapy induced alopecia in a rat model  alopecia  hair loss  is among the most distressing side effects of cancer chemotherapy  little progress has been made  however  in its prevention or treatment  partly because of the lack of suitable experimental model  in recent work on the treatment of myelogenous leukemia in the rat  the following observations were made   i  treatment of 8 day old rats with cytosine arabinoside consistently produced alopecia  and  ii  imuvert  a biologic response modifier derived from the bacterium serratia marcescens  uniformly produced complete protection against the alopecia  in subsequent experiments  both cyclophosphamide and doxorubicin also produced alopecia in this model  and the doxorubicin induced alopecia was prevented by treatment with imuvert  the potential relevance of these observations to chemotherapy induced alopecia in the clinical setting should be examined  
class4	molecular analysis of acute promyelocytic leukemia breakpoint cluster region on chromosome 17  acute promyelocytic leukemia  apl  fab m3  is characterized by a predominance of malignant promyelocytes that carry a reciprocal translocation between the long arms of chromosomes 15 and 17  t 15 17   q22 q11 2 q12   this translocation has become diagnostic for apl  as it is present in almost 100 percent of cases  a not i linking clone was used to detect this translocation initially on pulsed field gel electrophoresis and subsequently with conventional southern  dna  analysis  the breakpoints in ten apl cases examined were shown to cluster in a 12 kb region of chromosome 17  containing two cpg rich islands  the region is the first intron of the retinoic acid receptor alpha gene  rara   
class4	anxiety levels and cancer fear in patients admitted for elective operations  patients who are to have elective operations project varying degrees of anxiety  and many spontaneously express fear  without basis  that their operation involves a diagnosis of malignancy  to measure total  covert  and overt anxiety objectively  we gave the institute for personality and ability testing anxiety test to 125 consecutive patients admitted for elective general surgical procedures  a simple survey of cancer fear was also completed  chi square and fisher s exact test were used to compare categoric data  and linear regression and analysis of variance were used where appropriate  total anxiety scores were in the upper quartile compared to the general population  scores indicating fear of cancer were elevated in 75  of patients who had no history of or reason to suspect malignancy  covert anxiety scores correlated with cancer fear scores  and both significantly decreased as age increased  p less than  05   also  as age increased  the cancer fear scores decreased  p less than  002   obese patients had higher scores of cancer fear than all other patients  p less than  0001   
class4	acute promyelocytic leukemia  impact of hemorrhagic complications on response to induction chemotherapy and survival  from 1976 to 1989  21 adult patients with previously untreated acute promyelocytic leukemia were seen at the university of virginia hospital  we reviewed their cases retrospectively to determine the impact of hemorrhagic complications and other factors on treatment outcome  we observed a complete remission rate of 35   the median survival in complete responders was 15 months  evidence of disseminated intravascular coagulation was found in 13  62   of the 21 cases at diagnosis  fatal intracranial hemorrhage was the leading cause of death  occurring in eight  40   of the 20 patients evaluated  initial leukocyte count greater than 4 0 x 10 9  l and platelet count less than 20 x 10 9  l were significantly associated with an increased risk of intracranial hemorrhage  in patients with disseminated intravascular coagulation  the rate of intracranial hemorrhage was reduced by treatment with heparin  the high mortality of 40   8 20  due to intracranial hemorrhage during induction was a major contributor to the low complete remission rate of 35   7 20  in this series of consecutive unselected patients with newly diagnosed acute promyelocytic leukemia  
class4	carcinoma of the male breast  a review of 41 cases  we reviewed the cases of 41 consecutive men treated for breast carcinoma from 1950 through 1987 at vanderbilt university affiliated hospitals to examine controversies in and methods of therapy for this disease  twenty two patients  52   had stage i or ii lesions potentially curable by operative therapy  the overall 5 year survival rates were 100  for stage i  65  for stage ii  56  for stage iii  and 0  for stage iv  radical mastectomy offered no advantage over modified radical mastectomy in terms of survival or rate of recurrence  diagnosis at an early clinical stage and no finding of disease in axillary lymph nodes were important factors in survival in this series of patients  all tumors evaluated for hormone receptors were positive  although experience was limited  encouraging results were obtained with the use of tamoxifen citrate in adjuvant as well as palliative roles  with the exception of a predominance of centrally located lesions and a uniquely high frequency of positive hormone receptor status  carcinoma of the male breast appears biologically similar to the disease in women  and treatment should be guided by similar principles  
class4	malignant melanoma and pigmented lesions  a diagnostic and management dilemma  we document two cases of malignancy occurring at the site of partially removed benign nevi  because of the difficulty in clinical diagnosis and the uncertainty in its behavior  we propose that any recurring melanocytic nevus expanding beyond the original surgical scar be re excised and the specimen carefully analyzed to ensure complete removal  
class4	results of conservative surgery and radiation therapy for breast cancer  for stage i or ii breast cancer  conservative surgery and radiation therapy are as effective as modified radical or radical mastectomy  in most cases  cosmetic considerations and the availability of therapy are the primary concerns  the extent of a surgical resection less than a mastectomy has not been a subject of a randomized trial and is controversial  it appears that removal of a quadrant of the breast for small lesions is safe but excessive  using histologic findings in the biopsy as a guide  it may be possible to limit the breast resection to gross tumor removal for most patients while using wider resections for patients with an extensive intraductal component or for invasive lobular carcinoma  it also appears that excluding patients from breast conservation on the basis of positive margins on the first attempt at tumor excision may be unnecessarily restrictive  although patients with an extensive intraductal component or invasive lobular carcinoma should have negative margins  it appears that a patient with predominantly invasive ductal carcinoma can be treated without re excision if all gross tumor has been resected and there is no reason to suspect extensive microscopic disease  patients with indeterminate margins should have a re excision  axillary dissection provides prognostic information and prevents progression of the disease within the axilla  axillary dissections limited to level i will accurately identify a substantial number of patients who have pathologically positive but clinically negative nodes  when combined with radiation therapy to the axilla  a level i dissection results in a limited number of patients with progressive axillary disease  patients with pathologically positive axillas and patients at particularly high risk for systemic disease because of the extent of axillary node involvement can be identified by dissections of levels i and ii  radiation therapy can be avoided safely in patients who have pathologically negative axillas by level i and ii dissection  there appears to be no advantage to routine dissection of level iii lymph nodes  lymphedema of the arm and breast increases with more extensive dissections and with radiation therapy  
class4	role of mastectomy in breast cancer  the surgical management of breast cancer continues to evolve in an attempt to define the ideal line between therapeutic efficacy and morbidity  it is clear that breast cancer is a biologically heterogeneous group of diseases  and no single hypothesis explains its behavior  the surgical options proposed to the individual patient must draw from the experience of retrospective clinical studies and prospective randomized trials in an attempt to optimize the treatment plan  most patients without distant disease are eligible to consider mastectomy  which can accomplish excellent local control and significantly improve survival for earlier stages of disease  however  breast conservation remains an appropriate alternative for a carefully defined subset of patients  today  with early stage disease  no patient need leave the operating room without a breast  recent advances in reconstructive surgery make mastectomy with immediate reconstruction or limited resection plus axillary dissection with postoperative radiation therapy the two principal treatment choices available  future studies will focus on the integration of other treatment modalities  clinical research into the use of preoperative chemotherapy to downstage the disease to permit less extensive surgery is of interest  recent application of molecular biologic techniques such as oncogene analysis  cytogenetic studies  proliferative indices  and the highly sensitive detection of distant micrometastases using monoclonal antibodies may assist in the design of innovative approaches to surgery  radiation therapy  and systemic drug treatment  these advances show great promise for improving the quality of life and the cure rate for patients with breast cancer  today  surgical treatment options have evolved that fulfill some of the objectives outlined by dr  james ewing of memorial hospital some 50 years ago  his concerns about breast cancer remain as relevant today as they were half a century ago   i have drawn the impression that in dealing with mammary cancer  surgery meets with more peculiar difficulties and uncertainties than with almost any other form of the disease  the anatomical types are so numerous  the variations in clinical course so wide  the paths of dissemination so free and diverse  the difficulties of determining the actual conditions so complex  and the sacrifice of tissues so great  as to render impossible in the majority of cases a reasonably accurate adjustment of a means to an end    
class4	selection of breast preservation therapy for primary invasive breast carcinoma  breast preservation treatment for primary breast cancer should not be used for all women  women frequently excluded from consideration for such treatment or who choose not to have it may be elderly and not concerned about cosmetic appearance or live at a distance so that 6 weeks of daily trips to radiotherapy would be inconvenient or even impossible  also  if radiotherapeutic expertise or facilities are not available  a breast preservation program is difficult  in massachusetts  a full course of just over 6000 cgy  4500 cgy to the whole breast and a 1600 cgy local boost  costs roughly  6000  thus  breast preservation is more expensive than mastectomy even with reconstruction  as patients still frequently require a hospital admission with general anesthesia for an axillary dissection  although insurance policies cover such expenses  patients who do not have insurance or have inadequate coverage may find the extra expense of the breast preservation technique burdensome or impossible  women with a small breast and a proportionately large cancer may have an unsatisfactory cosmetic outcome after appropriate lumpectomy  the cosmetic result in such patients frequently cannot be predicted beforehand  this fact adds emphasis to the need for a two step process of lumpectomy and then re evaluation of the cosmetic outcome as well as pathologic features for decisions regarding breast preservation  finally  women may have strikingly different attitudes toward breast preservation than expected by the surgeon  for some women  the urge to preserve the breast is so strong that they will accept virtually any risk to achieve this option  whereas for other women  the constant anxiety about a recurrence or undergoing radiation therapy is traumatic enough that they readily accept mastectomy  in our referral surgical oncology practice  roughly 60  of patients are currently treated with breast preservation techniques  the remainder undergo mastectomy  with immediate reconstruction in approximately three fourths of the cases  the proportion of patients who elect to have breast preservation depends greatly on local medical customs and attitudes  the radiotherapeutic skills available  women s attitudes  which frequently are dependent on the local press and publicity  and the surgeon s interest and enthusiasm for such a program  there is no appropriate proportion of patients who should be treated by breast preservation techniques  but clearly  the proportion of patients so treated increases with experience  acceptability  publicity  and availability  thus  the selection of breast preserving therapy for individual patients is a result of an extraordinary array of factors that need to be considered in each patient  abstract truncated at 400 words   
class4	selection of therapy for stage iii breast cancer  locally advanced breast cancer is a heterogenous group including both operable and inoperable lesions  local surgery or radiation alone produces poor survival rates  indicating micrometastases at diagnosis  systemic chemotherapy as part of multimodality regimens has increased the length and rate of disease free survival  
class4	adjuvant chemotherapy of breast cancer  many women will not be cured of breast cancer by even the best early detection and surgical techniques because of micrometastases present at diagnosis  adjuvant therapy has extended the disease free interval for most patients and lengthens overall survival for many  combination chemotherapy has become the standard form of adjuvant treatment for premenopausal women with breast cancer and positive lymph nodes after primary therapy  with minimal toxicity  disease free and overall survival are improved  results are less impressive or less clear cut for postmenopausal women or any woman with negative lymph nodes  long term toxicities of adjuvant chemotherapy may include second malignancies and cardiac dysfunction  although these complications probably are rare  they must be considered seriously when weighing chemotherapy for patients in whom its benefits may be slight  innovations likely to become standard in adjuvant therapy decision making include risk assessment with new prognostic indicators  growth fraction  oncogene expression  and investigation of dose intensification using bone marrow growth factors and autologous stem cell support  
class4	adjuvant antiestrogen therapy for breast cancer  past  present  and future  laboratory investigations using animal models of breast cancer growth have indicated that the antiestrogenic compound tamoxifen is a tumoristatic agent  it is therefore effective in suppressing  rather than destroying  the breast tumor  its use as an adjuvant in breast cancer management has been successful  with a proportion of women benefiting from long periods of tamoxifen treatment  all the initial studies recruited postmenopausal women  but tamoxifen is now proposed for the treatment of premenopausal women for an extended time  naturally  there are many aspects of the toxicology of tamoxifen to consider  however  careful monitoring of clinical trials will determine the safety of the drug for the general patient population  
class4	management of local and regional recurrence after mastectomy or breast conserving treatment  locoregional failures after primary treatment for breast cancer include a diverse group of lesions that represent different categories of failures with various prognoses  although patients with chest wall recurrences and regional nodal failures after traditional radical surgery have a poor prognosis  many patients can still achieve a significant degree of palliation and even long term survival or cure with carefully orchestrated multimodal treatment  in patients who have breast failures after breast conservation surgery and radiation  long term salvage and cure can be achieved for the majority with prompt detection and appropriate treatment  which  like treatment for primary breast cancer  includes a consideration not only of local control but also of the risk of subsequent systemic failure and its need for treatment  
class4	reconstruction after mastectomy  advances in materials and techniques  especially those involving transposition of muscle and skin flaps  have made breast reconstruction possible for most women who undergo mastectomy for breast cancer  the availability of this option can alleviate the breast and chest wall deformity that results from virtually all local treatment of breast cancer  it is essential that the reconstruction surgeon be part of the breast cancer management team from the beginning of treatment planning and that this surgeon work closely with the general surgeon  medical oncologist  and radiation therapist as well as the adjunctive treatment team members  the patient s clinical status and the type of local treatment will be significant determinants of the reconstructive options  for women with stage i breast cancer  these decisions may be based largely on the oncologist s local and adjunctive therapy procedures and the woman s desire to proceed or delay  for women with systemic disease  all members of the breast management team may need to agree on the advisability and timing of reconstruction  central to all of the numerous decisions described in this paper regarding the timing  type  and extent of breast reconstruction is the primary goal of the entire team  the best possible management of the breast cancer itself  the promise of attractive  symmetric  and natural appearing breasts  complete with a symmetric nipple areolar complex  has eased somewhat the diminishment of self esteem and the threat to femininity that can accompany the loss of a breast  by lowering fear  the widely recognized availability of breast reconstruction may encourage more women to monitor their breasts and seek diagnosis of changes and may influence selection of the type of local treatment if cancer is detected  because of the psychological and cultural significance of the breast  the reconstructive surgeon must be particularly sensitive to the psychological and aesthetic expectations of the patient  even in those patients with metastases and limited life expectancy  breast reconstruction can enhance the quality of life  
class4	bilateral breast cancer  a second primary breast cancer in the opposite breast can be either synchronous or metachronous  the majority are metachronous  a woman who has had breast cancer has a fivefold increase in risk for a second breast cancer  additional risk factors include multifocal cancer  lobular carcinoma in situ  and an original cancer at an early age with long survival  lobular carcinoma in situ is predominantly a marker for the subsequent development of a second primary breast cancer  the incidence of synchronous bilateral cancer is approximately 1  to 2  and that of metachronous cancer 5  to 6   the cancer can be invasive or noninvasive  mammography has increased the number of synchronous cancers found but not the overall incidence  the incidence of invasive cancer detected by random biopsy of the opposite breast is not high enough to justify routine adoption of this procedure  the remaining breast must be followed for the remainder of the patient s life by physical examination and annual mammography  the treatment of the secondary primary breast cancer should be that appropriate for the stage of the disease  the prognosis for the woman with a second primary breast cancer is quite favorable and is dependent on the stage of both the first and the second cancer  
class4	breast cancer during pregnancy and lactation  breast cancer is the most frequently seen cancer in pregnancy and lactation  but the incidence is low  the disease being seen in approximately 0 03  of pregnancies  only 1  to 2  of breast cancer overall is diagnosed during pregnancy or lactation  there is no evidence to implicate pregnancy or lactation in either the etiology or the progression of breast cancer  careful breast examination early in the pregnancy is very important to find solid masses that require biopsy before breast engorgement hides them  therapeutic options vary  depending on the stage of disease and the stage of the pregnancy  operable disease in the first 6 to 7 months of the pregnancy should be treated by mastectomy  as irradiation is contraindicated  late in the pregnancy  a lumpectomy and axillary dissection can be done  with irradiation being delayed until after delivery  general anesthesia is safe if the usual precautions are taken to compensate for the physiologic changes induced by pregnancy  unfortunately  delay in diagnosis is common  and 70  to 89  of patients with operable primary lesions have positive axillary lymph nodes  late stage appears to be the only reason for the generally worse prognosis in these patients  as stage for stage  they have a course similar to that of nonpregnant patients  adjuvant chemotherapy can be considered late in the pregnancy but should usually be delayed until after delivery  in patients with locally advanced or metastatic cancer diagnosed early in the pregnancy  for whom both chemotherapy and radiation therapy would normally be recommended  consideration must be given to termination of the pregnancy  there is no evidence that termination of pregnancy improves the outlook for the patients  but it does permit standard aggressive therapy in advanced disease  
class4	male breast cancer  male breast cancer is uncommon but important  the diagnosis is easily made by breast biopsy  and patients are presenting earlier in the course of the disease than in the past  despite this  patients are often first seen with tumors that have metastasized to the axillary nodes  which markedly decreases the survival rate  therapy of localized disease includes simple excision  modified radical mastectomy  and radical mastectomy  but there is no consensus for which operation is appropriate  radiation therapy should be strongly considered in patients with metastases to the axillary nodes  but the role of adjuvant hormonal therapy or chemotherapy is unclear  for treatment of disseminated disease  tamoxifen seems to be replacing orchiectomy  the favorable response rate  especially in patients with estrogen receptor positive tumors  the lack of side effects  and the high level of patient acceptability make it an attractive therapeutic choice  
class4	clinical problems in follow up of patients after conservative surgery and radiotherapy  patients treated with conservative surgery and radiotherapy for early stage breast carcinoma are at risk of developing an ipsilateral breast recurrence for a long period  fortunately  few such patients present with an inoperable recurrence or simultaneous distant metastases  salvage rates are high and may be improved by early detection  although usually unambiguous  physical examination of the treated breast may reveal changes attributable to surgery and radiotherapy that can mimic a recurrent cancer  there also is substantial overlap in radiologic appearance between benign and malignant lesions  it may be necessary to perform a biopsy when there is a question of recurrence  careful life long follow up of patients thus is a critical part of their care  
class4	trends in primary breast cancer management  where are we going  the treatment of cancer during any period has been based not on the whim of a clinician but on the therapeutic consequences of the dominant biologic model of the disease  until the 1960s  the dominant model of breast cancer was of a disease that spread centrifugally along anatomic pathways  with time being the only determinant of prognosis  an alternative model  that of biologic determinism  posits that the outcomes of treatment are determined by the extent of microscopic dissemination that occurred before the tumor became detectable  this model  too  has flaws  and the author suggests that it is time for a kuhnian paradigm shift  breast cancer exhibits a heterogeneity of phenotypes resulting from one or perhaps two mutations  the multiple prognostic variables may be epiphenomena  expressing different degrees of amplification of a limited domain of the genome  
class4	prognostic indicators in invasive breast cancer  tumor size and axillary lymph node involvement are the primary determinants of clinical course for most patients  receptors for estrogen and progesterone are important additional prognostic factors for disease free survival  overall survival  survival time after initial disease recurrence  and the likelihood of response to hormonal therapy  histologic grading has merit as a prognostic factor  although poor reproducibility limits its broad application  promising data have been emerging from the use of flow cytometry to analyze dna content and proliferative rate  patients with aneuploid tumors are more likely to have a shorter survival time than patients with diploid tumors  a high s phase fraction also identifies a subset of patients at increased risk for early relapse  a combined index of ploidy and s phase may be a more useful guide  together  diploidy and low s phase identify a subgroup of node negative patients at very low risk for disease recurrence  a number of oncogenes have been identified in breast cancer  amplification of the her 2 neu gene or overexpression of the gene product may be an important prognostic indicator for node positive patients  
class4	broad spectrum penicillin as an adequate therapy for acute cholangitis  in a previous study of patients with acute cholecystitis  we demonstrated equal efficacy with a broad spectrum penicillin  piperacillin  and a penicillin plus amino glycoside combination  whether a single agent broad spectrum penicillin is adequate treatment for more severe infections  such as acute cholangitis  however  is still unclear  we  therefore  conducted a three center  prospective  randomized trial to determine whether or not a broad spectrum penicillin alone is adequate therapy for patients with acute cholangitis  during a 36 month period  96 patients with sepsis and biliary obstruction were randomly assigned to receive either piperacillin  n   49  or ampicillin plus tobramycin  n   47   the two groups receiving antibiotics were similar with respect to all clinical and laboratory parameters  the incidence of blood cultures with positive results  20 versus 21 per cent  and underlying malignant lesions  51 versus 62 per cent  was also similar between the two groups  the percentage of patients with a clinical cure or significant improvement was the same in the two groups  69 versus 70 per cent   however  there was a significant difference in the cure rate between patients with benign and malignant biliary obstructions  83 versus 59 per cent  p less than 0 01   no significant differences were noted between the two antibiotic groups with respect to drug toxicity  but patients with malignant conditions were more prone to antibiotic related toxicities  2 versus 19 per cent  p less than 0 05   these data suggest that outcome of treatment in patients with acute cholangitis is similar with either a broad spectrum penicillin or a penicillin plus aminoglycoside combination and is dependent upon the nature of the biliary obstruction  
class4	synchronous carcinoma of the colon and rectum  reports on the incidence of synchronous carcinoma of the colon and rectum have varied from 2 to 11 per cent  the variability is a result of a lack of uniformity in criteria of diagnosis  differences in the population studied and differences in time period used  in this study  we evaluated the incidence and distribution of synchronous lesions during a recent time period before the use of colonoscopy became widespread  we reviewed the records of all patients with newly diagnosed adenocarcinoma of the colon and rectum who were operated upon at our institution between 1976 and 1981  in a total group of 1 000 patients of which 52 per cent were men  there were 54 patients or 5 4 per cent who had synchronous carcinomas  the group of patients with synchronous carcinomas were older than the group with nonsynchronous carcinomas  72 4 versus 68 8 years   there was also a higher incidence of associated benign polyps in the group with synchronous carcinomas  70 versus 30 per cent for a nonsynchronous carcinomas   the anatomic distribution of carcinomas of the colon and rectum in the group with synchronous lesions  111 in total  revealed a higher percentage of carcinomas located on the right side  29 7 versus 22 5 per cent   although the difference did not reach statistical significance  synchronous carcinomas were located in nonadjacent segments of the colon in 37 per cent  there was no difference in stage between the groups with and without synchronous carcinomas  the preoperative identification of synchronous lesions by either colonoscopy or barium enema is important for the proper treatment of patients with carcinoma of the colon and rectum  failure to locate these tumors may lead to the demise of the patient  
class4	congenital dilatation of the bile duct in 100 instances and its relationship with anomalous junction  published erratum appears in surg gynecol obstet 1991 mar 172 3  246  congenital dilatation of the bile duct  cdbd  or choledochal cyst has been demonstrated to be associated with an anomalous junction of the pancreaticobiliary ductal system  multifarious clinical signs and symptoms of cdbd have been shown to be closely related with the presence of this anomalous junction  in the present study  100 instances of cdbd treated surgically at our institutions during a 30 year period were classified into two types according to the morphologic features of dilatation of the bile duct  there were 77 instances of the cystic type and 23 of the cylindric type  morphologic features of the lesion  clinical signs and symptoms and laboratory findings in these 100 instances were clinically analyzed  in almost all of the patients who were less than one year of age  the disease was of the cystic type and patients presented with either a palpable mass or jaundice as the main symptom  in patients more than one year of age  the disease was of either the cystic or cylindric type  a history of episodes of characteristic abdominal pain accompanied by elevated levels of serum amylase was present in 70 of the patients with the cystic type of disease and in all of the patients with the cylindric type  histologic sections from the patients showed glandular formation with chronic inflammation  possibly a result of refluxed activated pancreatic juice  in contrast  histologic sections from the remaining patients of all ages showed only thickening of the fibrous layer  thus  such variable morphologic features and clinical signs and symptoms in cdbd are highly dependent on two factors  the age at onset and the reflux of pancreatic juice into the bile duct through the common channel  
class4	carcinoma of the thyroglossal duct  a review of 39 instances of excision of a cyst of the thyroglossal duct performed at st  paul medical center  dallas  texas  revealed two patients with carcinoma of the thyroglossal duct  a review of the english literature yielded 146 instances of this uncommon tumor  eighty four per cent were papillary adenocarcinoma of thyroid type and 5 per cent were squamous cell carcinoma  the patients were from six to 81 years old with a 2 1 female to male ratio  metastatic disease to lymph nodes was noted in 11 per cent and invasion of overlying strap muscles was found in 4 per cent  carcinoma of the thyroid gland occurred in 14 per cent  preoperative diagnosis was rare  the sistrunk procedure is recommended for initial surgical therapy with further surgical or adjuvant therapy dependent on associated clinical findings  prognosis for carcinoma of the thyroglossal duct of thyroid type parallels that of carcinoma of the thyroid gland  
class4	surgical management of islet cell dysmaturation syndrome in young children  islet cell dysmaturation syndrome  icds  encompasses the causes of infantile hyperinsulinemic hypoglycemia histologically described as islet cell hyperplasia  pancreatic adenomatosis and nesidioblastosis  eleven infants underwent 14 pancreatic resections for icds from 1965 to 1990 at the university of california at los angeles medical center for severe hypoglycemia unresponsive to medical therapy  seizures were the presenting symptoms of hypoglycemia in eight infants  six patients had nesidioblastosis  four had islet cell hyperplasia and one patient had an adenoma with histologically normal pancreatic islet cells  four neonates underwent 80 per cent pancreatic resection  three with nesidioblastosis required reoperation  90 to 95 per cent resection   four older infants underwent 80 per cent pancreatic resection but required diazoxide for less than six months postoperatively  three infants underwent 90 to 95 per cent pancreatic resection  none have required reoperation or postoperative medications  all infants are normoglycemic without pancreatic exocrine insufficiency and none had postoperative complications  five infants had preoperative neurologic impairment  with three having severe retardation  all showed some improvement postoperatively  but only one infant now has normal findings on neurologic examination  early diagnosis and aggressive surgical resection should minimize neurologic complications of the icds  
class4	nonendoscopic percutaneous gastrostomy  tight peritoneal adherence of the stomach to the abdominal wall as a prerequisite of percutaneous gastrostomy can be achieved by a newly developed cannula  it serves for puncture and fixation of the gastric wall  thus  percutaneous gastrostomy can be established safely even in instances of an endoscopically nonaccessible stomach  further applications of the device for the purpose of intestinopexy and facilitation of endoscopic procedures are being evaluated  
class4	management of the pregnant patient with carcinoma of the breast  the diagnosis of carcinoma of the breast during pregnancy poses a challenging dilemma  although once regarded as incurable  recent reports reveal similar long term survival rates for pregnant and nonpregnant patients who have carcinoma of the breast  when referred to a surgeon  a pregnant woman with a suspicious mammary mass deserves an expedient histologic diagnosis  delay may jeopardize the chances of survival  once the diagnosis is established  pregnant patients should be treated in a manner similar to nonpregnant patients because there is no evidence that carcinoma of the breast in pregnant women is biologically different than carcinoma of the breast in other premenopausal women  fears of fetal exposure to radiation should not deter a physician from ordering appropriate preoperative diagnostic tests to stage the patients  operation may be performed safely when general anesthesia is administered and postoperative adjuvant therapy should be administered when necessary  the involvement of multiple subspecialties in the management of these patients is highly recommended  
class4	an unusual epidural  vascular spinal lipoma in a 3 year old child  a case report and review of the literature  epidural lipomas are usually benign tumors affecting the spinal cord  we report the unusual presentation of a cervicothoracic spinal lipoma associated with a cervical dysraphism in a young boy  diagnostic options using magnetic resonance imaging and gadolinium diethylenetriaminepentaacetic acid are discussed as a pathway to early diagnosis of these and other occult spinal lesions  
class4	neonatal intracranial teratomas  two neonates with intracranial teratomas presented with cranial enlargements a few weeks after birth  both cases underwent surgery  one died intraoperatively  the other is the longest known survivor  alive 7 years and 9 months after subtotal excision of a mature teratoma of the left sylvian fissure  previous operations have been relatively few and nearly all have been unsuccessful  size and favorable location may be the most important prognostic features regardless of the histologic classification as mature or immature  one of our cases demonstrates that even subtotal excision of a mature teratoma can result in long term survival  
class4	spinal extradural cavernous hemangioma  three cases of isolated spinal extradural cavernous hemangiomas are reported  two in the thoracic and one in the lumbar region  one of them manifested as acute cord compression  the other two as chronic progressive myelopathy or radiculopathy  a total excision or subtotal excision with irradiation was performed  all of them had good functional recovery  the clinical picture  radiological diagnosis  and optimal method of treatment are discussed  the relevant literature is reviewed  
class4	prospective evaluation of clinical and pathologic detection of axillary metastases in patients with carcinoma of the breast  complete axillary dissection was performed in 287 patients undergoing modified radical mastectomy between 1984 and 1987 to identify patterns of axillary node metastases  as well as discontinuous axillary node   skip   metastases  positive pathologic findings were compared with preoperative clinical examinations in 266 patients and showed only 60 cases  22 6   clinically suspicious for tumor  in contrast to 131  45 6   with pathologically confirmed positive lymph nodes  axillary contents were classified level i  ii  or iii based on their relationship to the pectoralis minor muscle  an average of 24 2 nodes was resected per patient  level i  10  level ii  8 1  and level iii  5 3   tumors ranged in size from 0 5 to 12 0 cm  mean  2 6 cm   and increasing tumor size was associated with an increased likelihood of positive nodes  the data on 204 patients with complete clinical and pathologic data show that of 119 patients with negative level i nodes a limited axillary dissection  level i only  would fail to identify 6 with positive level ii and 2 with positive level iii nodes  whereas of 85 patients with positive level i nodes limited axillary dissection would fail to identify 17 with positive level ii nodes  7 with positive level iii nodes  and 27 with positive levels ii and iii nodes  complete axillary dissection  levels i  ii  and iii  should be performed to stage patients accurately  as well as to remove tumor involved nodes and diminish local axillary recurrences  clinical examination of the axilla appears to be a poor means of identifying axillary metastatic cancer  
class4	short term tamoxifen plus chemotherapy  superior results in node positive breast cancer  three hundred eleven patients with node positive breast cancer were randomized to one of three adjuvant treatments  cyclophosphamide  cytoxan   methotrexate  and 5 fluorouracil  all of the above with tamoxifen citrate  or all of the above with tamoxifen and bacillus calmette guerin vaccination  local therapy for all patients was a modified radical mastectomy  estrogen receptors were measured on all primary tumors  patients were stratified by the number of positive nodes  one to three nodes and more than three nodes  and estrogen receptor value  less than 3 femtomole mg and greater than or equal to 3 femtomole mg   follow up is available  with a mean of 9 1 and maximum of 14 2 years  in this study the efficacy of short term tamoxifen is apparent over that of chemoimmunotherapy alone and continues to be significant with prolonged follow up  the addition of tamoxifen to chemoimmunotherapy significantly prolonged disease free survival among patients with estrogen receptor positive tumors who were postmenopausal  who had larger tumors  greater than 3 cm   or who had more extensive axillary node involvement  more than three nodes   tamoxifen improved overall survival for patients with estrogen receptor positive tumors larger than 3 cm  the addition of bacillus calmette guerin cytoxan  methotrexate  5 fluorouracil  and tamoxifen did not significantly alter disease free or overall survival  
class4	the diagnosis and definition of hepatic malignancies by use of arterial enhanced computerized tomographic scanning  axial computerized tomography is a useful tool in the evaluation of either primary or metastatic hepatic neoplasms  an adjunct to this technique is visceral arterial enhanced computerized tomography  aect   to determine the effectiveness of this modality  bolus intravenous enhanced computerized tomography scans and aect were compared and correlated to operative findings  fifty four consecutive patients were evaluated by aect and bolus intravenous enhanced computerized tomography over a 30 month period  may 1986 to august 1989  for suspected primary or metastatic hepatic malignancies  forty four patients  81   had hepatic lesions  fifty two percent  23 of 44 patients  of the metastatic tumors were from colonic or rectal primary lesions  and 20  were hepatocellular primary lesions  the remainder of the lesions were metastases from a variety of primary lesions  when studies were compared  34  of the patients  15 of 44 patients  differed in either the location or total number of lesions noted  the lesions of three of the 15 patients  20   were determined unresectable on the basis of aect  of the remaining patients  planned resections were revised in seven patients to either lesser or greater procedures  the number of lesions found at laparotomy equaled the number found by aect in all but two cases  aect caused no complications  aect improved our ability to identify and localize primary and metastatic lesions of the liver  this technique offers the advantage of preoperative definition of the hepatic arterial and portal venous anatomy  
class4	is dna ploidy of prognostic significance in stage i cutaneous melanoma  recent studies have suggested that the presence of dna aneuploidy in stage i cutaneous melanoma carries a poor prognosis  to see if our experience correlated with these reports  we used dna analysis by flow cytometry of propidium iodide stained nuclei disaggregated from formalin fixed paraffin embedded tissue of biopsy specimens to retrospectively study 55 patients who had cutaneous stage i melanomas  the patients had been treated from 1977 to 1987 with a mean follow up of 5 4 years  thirty nine  71   of the 55 histograms were diploid  and 16  29   of the histograms were aneuploid  dna content was significantly associated with other conventional prognostic factors  including growth pattern  ulceration  pathologic stage  tumor thickness  and clark s level  dna aneuploidy was significantly related to disease free survival and predicted a poorer prognosis  p less than 0 05   but when stratified for tumor thickness it lost significance  a multivariate discriminant function analysis of 12 factors in melanoma showed six factors to be independently significant in determining prognosis  dna content  p   0 034  ranked fifth in importance behind growth pattern  p less than 0 001   ulceration  p less than 0 001   thickness  p   0 001   and pathologic stage  p less than 0 005   dna content  although significantly associated with conventional prognostic factors and disease free survival  is not the best indicator of biologic behavior of melanomas in this study  further investigation into its usefulness is necessary before dna content can become a routine diagnostic modality in the work up of stage i cutaneous melanomas  
class4	long term results of surgical resection of locally advanced colorectal carcinoma  this study was undertaken to review the long term results of multivisceral resection of locally advanced colorectal carcinoma  between 1964 and 1980  1042 patients underwent exploratory surgery for colorectal cancer  of these  58 patients  5 5   underwent curative multivisceral resection for suspected contiguous invasion by the primary tumor  follow up was complete for all patients  the primary tumors were located in the rectum  38 patients   sigmoid  9 patients   left colon  6 patients   and right colon  5 patients   en bloc resection of other viscera included uterus  adnexa  bladder  vagina  small intestine  abdominal wall  liver  stomach  kidney  and ureter  the operative morbidity and mortality rates were 31  and 1 7   respectively  resection margins were free of tumor in 54 patients  in the four patients with tumor positive resection margins  recurrence of disease was evident between 8 and 22 weeks after surgery  mean survival time  8 2 months   carcinomatous invasion of the resected contiguous organ was confirmed in 49 patients  84    the mean survival time for patients without lymph node metastases was 100 7 months  but it was only 16 2 months  p less than 0 01  for patients with lymph node metastases  actuarial 5 year disease free survival rate for patients without lymph node metastases was 76   36 of 47 patients   none of the patients  0 of 11  with lymph node metastases survived for 5 years  three of 36 of the 5 year survivors experienced recurrence of disease before the seventh postoperative year  no cancer related deaths occurred between 7 and 25 years  these data suggest that survival in locally advanced colorectal carcinoma is more dependent on lymph node status than on the extent of local invasion  effective disease control associated with survival in the long term can be achieved by multivisceral resection  
class4	local recurrence after curative resection of colorectal adenocarcinoma  a total of 853 patients with 861 colorectal adenocarcinomas were operated on at our institution between 1965 and 1981  complete follow up information was obtained in all but six patients  99 4    and all available histologic slides were reviewed to determine pathologic stage and characteristics  six hundred fifty one patients  76 3   underwent a potentially curative procedure  and their operative mortality rate was 2 8   of the 627 patients available for analysis  50  8   had a local recurrence  the median time to local recurrence was 18 months  and only 16  of local recurrences were diagnosed 5 years after the original resection  median survival of patients with a local recurrence was 3 1 2 years from the original resection  and 16 patients  32   survived 5 years or longer  a multivariate logistic regression analysis was conducted to examine the influence of several clinical and pathologic characteristics on local recurrence among dukes  stages b and c adenocarcinomas  n   539  after exclusion of patients with synchronous tumors  n   8   postoperative deaths  n   18   loss to follow up  n   6   or incomplete data  n   11   this analysis revealed that the local recurrence rate was significantly related to depth of invasion  b1   c1   0   b2   c1   10   p less than 0 01   site of origin  right plus transverse colon   6   left plus rectosigmoid colon   10   rectum   12   p less than 0 05   and lymphatic or capillary microinvasion  absent  6   present  14   p less than 0 05   this analysis attempts to identify patients at high risk for development of local recurrent disease to select candidates for postoperative adjuvant therapy  
class4	follicular cell predominance in the cytologic examination of dominant thyroid nodules indicates a sixty percent incidence of neoplasia  the interpretation of aspiration cytologic smears that contain a predominance of follicular components often presents a dilemma to the clinician who is treating a patient who has a dominant thyroid nodule  especially when thyroid stimulating hormone suppression does not produce any significant involution of the dominant nodule  we reviewed a consecutive series of 555 fine needle aspiration cytologic examinations of dominant thyroid nodules  all specimens that contained colloid or follicular cells mixed with lymphocytes or hurthle cells were excluded from this review  additionally  nine aspirates contained degenerated follicular cells with insufficient material for cytologic diagnosis  the remaining 76 specimens contained a predominance of follicular cells  27 specimens were interpreted as containing  normal  follicular cells  and the remaining 49 specimens were read as  atypical  follicular cells  histopathologic examination of the resected specimens indicated a 60  incidence of neoplasia  30  carcinoma  30  adenoma  in which the aspiration cytologic study was interpreted as  normal  follicular cells  on the other hand  a 63  incidence of neoplasia  27  carcinoma  36  adenoma  occurred in which the cytologic study was read as  atypical   in conclusion  aspirates showing a predominance of follicular cells  whether  normal  or  atypical  indicate a 60  incidence of neoplasia in dominant thyroid nodules that do not decrease significantly in size with thyroid stimulating hormone suppression  
class4	management of recurrent malignant pleural effusion in the united kingdom  survey of clinical practice  malignant pleural effusions are often symptomatic and tend to recur after simple aspiration  pleurodesis may prevent recurrence of the effusion  many agents and techniques have been described  a questionnaire was sent to 448 clinicians in the united kingdom to determine how pleurodesis is performed in practice  there was a 56  overall response  with replies from 101 respiratory physicians  88 general physicians  29 thoracic surgeons  and 35 general surgeons  general surgeons saw few cases of malignant pleural effusion and rarely performed pleurodesis  a patient with recurrent malignant pleural effusion would usually be managed with pleurodesis by 76  76   respiratory physicians  26  30   general physicians  and 23  81   thoracic surgeons  a further 29  33   general physicians would refer such patients to another specialist  most medical pleurodesis were performed by junior staff  whereas consultant thoracic surgeons were more likely to be concerned with the procedure  all the thoracic surgeons used an intercostal tube drain  usually with suction  an intercostal tube drain was used routinely by only 54  54   of the respiratory physicians and 28  32   general physicians  thoracic surgeons preferred talc for pleurodesis whereas physicians most commonly used tetracycline  the variety of methods in use supports the need for randomised  controlled studies to determine the most effective technique of pleurodesis  
class4	pulmonary disease following intravesical bcg treatment  bacillus calmette guerin  bcg  is an attenuated strain of mycobacterium bovis that has been used in the treatment of malignant disease for over 20 years and for the treatment of bladder cancer since 1976  major complications of this treatment are infrequent  we report two cases of systemic illness with pulmonary manifestations after treatment with intravesical bcg  
class4	effective ultraviolet irradiation of platelet concentrates in teflon bags  several plastic materials used in blood storage were evaluated for their ability to transmit ultraviolet b  uvb  light  a plastic bag manufactured from sheets of transparent teflon efficiently  78 86   transmitted uvb light and was employed in subsequent functional studies of lymphocytes and platelets exposed to uvb light while contained in these bags  in vitro experiments showed a uvb dose dependent abrogation of lymphocyte responder and stimulator functions  with concurrent preservation of platelet aggregation responses  in a phase i pilot study  uvb treated platelet concentrates were administered to four bone marrow transplant recipients  adverse effects attributable to the transfusions were not observed  and patients showed clinically effective transfusion responses  no patient developed lymphocytotoxic hla or platelet antibodies  these studies suggest that platelets can be effectively irradiated with uvb light in a closed system  however  numerous variables  including container material  volume and composition of contents  steady exposure versus agitation  and exact uv wavelength  must be considered  
class4	management of stage a prostate cancer  transrectal ultrasonography has defined a new category of stage a disease  namely nonpalpable lesions diagnosed by needle biopsy  how this type relates to classic stage a disease is unclear  stage a1 carcinoma becomes clinically significant only in a distinct minority of patients  and even in this group  progression does not necessarily mean significant morbidity or death from prostate cancer  an aggressive approach is not justified  in contrast  stage a2 cancer is usually virulent  and aggressive therapy with curative intent is justified in patients of appropriate age and health  both radical prostatectomy and external irradiation appear to provide long term survival rates superior to those obtained with observation alone  but nearly 20  of these patients will die of cancer despite therapy  unfortunately  forecasting the outcome in an individual case is still not possible  and efforts to identify prognostic features must continue  in the meantime  emotional arguments in favor of the treatment of all discovered cancers must be suppressed by an informed and objective understanding of the natural history of nonpalpable prostate cancer and the potential impact of treatment  
class4	selection of patients with stage b prostate cancer for radical prostatectomy  there are several areas of concern in dealing with clinical stage b disease  first  understaging is common  second  recognition of extension into the seminal vesicles is important  third  the patient s predicted life expectancy must be taken into account  moreover  even clinically localized prostate cancer may have metastasized  and the need for surgical staging by lymph node dissection has been a significant factor in the authors  preference for radical retropubic rather than radical perineal prostatectomy  neither of the two serum markers in clinical use is an absolute predictor of stage  analysis of tumor ploidy may prove useful  and transrectal ultrasound warrants further study  in the elderly patient  the urologist certainly may elect to monitor the tumor without definitely deciding on operative versus conservative treatment  
class4	significance and treatment of positive margins or seminal vesicle invasion after radical prostatectomy  the periprostatic soft tissue involvement described in the older urologic literature differs from that now recognized  a much  earlier  pathologic stage c is being identified  apparent microscopic extension of the cancer to the margin of the specimen yields an approximately 25  risk of local recurrence  postoperative radiation apparently is effective in reducing this risk  and if patients are properly selected  such treatment is well tolerated  whether adjuvant radiation affects overall survival is not known  new observations on pathologic extension of the disease need to be refined  
class4	prostate specific antigen for staging prior to surgery and for early detection of recurrence after surgery  the exact usefulness of prostate specific antigen for staging before radical prostatectomy is still unclear  perhaps the marker s most exciting feature is its value in detecting residual disease after radical prostatectomy  the author also discusses the technical questions in testing and interpretation  
class4	local failure and related complications after definitive treatment of carcinoma of the prostate by irradiation or surgery  the authors review their institution s experience with the failure of definitive treatment to achieve local tumor control and with the distant dissemination and local morbidity associated with such failure  the causes of local failure are various  incomplete resection  implantation of spilled cells  and  possibly  selective implantation of circulating tumor cells in traumatized tissues after surgery and totally or partially resistant cells  new tumors  or radiologic misses after radiation  treatment of local failure may be prophylactic or therapeutic and differs depending on the stage of the disease  failure to control the tumor locally in the presence of distant metastases does not alter the length of survival  but it can profoundly affect the quality of survival  
class4	new concepts in the treatment of stage d1 adenocarcinoma of the prostate  stage d1 disease will be encountered in 20 per cent of patients by those who treat prostate cancer  there is marked heterogeneity among cancers discovered at this stage  with 5 year disease free survival rates ranging from 0 to 95 per cent  generally  when prostate cancer has escaped the confines of the gland  metastasis occurs  and widespread systemic disease prevails  any significant chance for long term cure will then depend on systemic therapy  from maturing data in retrospective reviews  preliminary data from prospective trials  and recent well conducted animal studies  chemotherapy and hormonal deprivation appear most effective when tumor volumes are the smallest  this evidence supports the removal of all cancer possible and the early institution of systemic treatment  caution must be exercised in extrapolating the aforementioned evidence to include cases of more extensive prostate cancer  i e   patients with bulky pelvic or retroperitoneal disease  distant metastasis  or significant elevation of serum markers   it is doubtful that  debulking  with removal of the prostate and lymph nodes will provide any justifiable advantages in these patients  whether removal of the prostate affords any local palliative benefit is an issue for debate  certainly  the primary tumor  if left untreated  will progress locally and cause symptoms necessitating further procedures in more than half these patients  whereas the incidence of local recurrence and the adverse effects of these recurrences in patients with d1 disease after radical prostatectomy and adjuvant therapy is less than 10 per cent  surgical refinements coupled with acceptably low morbidity now associated with radical prostatectomy have led some authors to endorse the palliative benefits of removing the primary tumor in selected patients  the purpose of this article is not to endorse or disparage the aggressive treatment of patients with stage d1 prostate cancer  the evidence suggests that if long term survival is the endpoint used to compare treatment groups  then to date no treatment option offers significant advantages  on the contrary  if progression rates or disease free survival are compared  then cytoreductive surgery and early systemic adjuvant treatment  testosterone deprivation or chemotherapy  provides significant advantages for selected patients with stage d1 disease  although ploidy analysis  receptor mapping  and oncogene assays are promising  today  there is no practical way to identify patients who will benefit most from multimodality treatment approaches  abstract truncated at 400 words   
class4	low incidence of asymptomatic brain metastases in patients with renal cell carcinoma  brain metastases from renal cell carcinoma are uncommon  the present study was undertaken to determine the value of routine computerized tomographic  ct  scanning of the brain in patients with renal cell carcinoma  a review of 106 patients with renal cell carcinoma who had undergone ct scan of the brain revealed brain metastases in only 13 2 percent  brain metastases were accompanied by central nervous system  cns  symptoms in 78 6 percent of patients  with headaches constituting the most common presenting symptom  64 3    brain metastases were detected in only 3 3 percent of patients who had no cns symptoms at the time of evaluation  it is concluded that ct scanning of the brain should be performed routinely only for those patients who report cns symptoms at the time of evaluation  
class4	is urethral sparing at cystectomy a safe procedure  urethrectomy is performed with cystectomy when the neoplasm is multifocal  at the bladder neck  or associated with carcinoma in situ  cis   the records of the most recent 20 patients treated by radical cystectomy at our institution were reviewed  in 50 percent of the cases  the extent of disease within the bladder was found to have been underestimated to the point that a urethral sparing operation  i e   to maintain urinary continence with an intestinal segment and an intact urethra  might have been dangerous  
class4	neodymium yag laser treatment of bladder hemangiomas  we present 3 cases of bladder hemangiomas  one single and two multiple  with a long term history of recurrent hematuria  treated with endoscopic neodymium yag  yttrium  aluminum  garnet  laser photocoagulation  and obtaining good results  
class4	squamous cell carcinoma antigen  ta 4  in penile carcinoma  ta 4 antigen  originally isolated from women with squamous cell carcinoma of the cervix  is elevated in the sera of patients with squamous cell carcinomas of several sites  including esophagus  lungs  and head and neck  in this study  we compared the serum levels of ta 4 in normal volunteers  patients with resected penile squamous cell carcinoma  and patients with metastatic penile squamous cell carcinoma  ta 4 values were elevated in 5 of 11 patients  45   who had metastatic disease  in 2  ta 4 was normal the first time metastasis was clinically detected but rose as the disease progressed  moreover  in 3 patients in whom serial determinations were made  serum ta 4 values correlated well with disease progression and response to treatment  we conclude that ta 4 values are elevated in some patients with metastatic squamous cell carcinoma of the penis and may become a useful marker for monitoring response to therapy  
class4	inverted papilloma of renal pelvis  flexible ureteroscopic diagnosis and treatment  a case is reported of inverted papilloma of the renal pelvis in a patient with previous transitional cell carcinoma of the bladder  the renal pelvic lesion was diagnosed and treated with a flexible ureteropyeloscope  although nephroureterectomy was avoided  the patient must be carefully followed endoscopically and radiographically for recurrence of lesions throughout the urinary tract  this case represents the first report of the endoscopic diagnosis and treatment of an inverted papilloma of the renal pelvis  it demonstrates the vast potential for endoscopic diagnosis  treatment  and surveillance throughout the urinary tract  
class4	improved early detection of recurrence in prostatic carcinoma following hormonal therapy  combined use of palpation and fine needle aspiration cytology  fifty nine hormonally treated prostatic carcinoma patients were prospectively followed by rectal examination and fine needle aspiration cytology at six month intervals for periods ranging from six to one hundred twenty months  median follow up 48 mos   the cytologic findings and clinical impressions were divided into four or five categories  respectively  ranging from benign to clearly malignant  cytologic material and clinical descriptions suitable for evaluation were available for 306 follow up examinations  of these  209 were cytologically benign  including 191 without and 18 with clinical evidence of malignancy   the remaining 97 examinations showed cytologic evidence of malignancy of which 50 were clinically apparent  51 5    while the correlation of clinical and cytologic findings was good  91 4   in cases with no evidence of disease activity  our findings indicate that many recurrences which are occult to clinical examination may be detected by cytologic examination  
class4	staging of ureteral transitional cell carcinoma by ct and mri  intravenous urography and retrograde pyelography are the primary radiologic studies for detecting ureteral carcinoma but give limited information regarding stage of disease  computed tomography  ct  and magnetic resonance imaging  mri  delineate the extent of ureteral carcinomas with a high degree of accuracy by depicting the periureteral fat and presence or absence of lymphadenopathy  in selected cases  ct and mri are valuable for assessing the presence or absence of tumor in a ureteral stump and for the differential diagnosis of ureteral obstruction  five cases of ureteral carcinoma and 2 cases of stump carcinoma are presented with preoperative ct and or mri evaluation and staging  
class4	uneventful delivery following series of successive treatments for virilized cushing syndrome due to adrenocortical carcinoma  a twenty one year old virilized woman with cushing syndrome due to a huge adrenocortical carcinoma was successively treated with trilostane  3 beta hydroxysteroid dehydrogenase inhibitor   subsequent adrenalectomy  and postoperative cis platinum  clinical or biochemical abnormalities peculiar to cushing syndrome gradually subsided  and three and one half years after the adrenal surgery  the patient delivered a normal female infant  this study points out some of the clinical and biochemical responses of each treatment  
class4	single polypoid cystitis cystica and glandularis presenting as benign bladder tumor  a case report of a ten year old boy with a benign polypoid bladder tumor is presented  the rarity of benign or malignant bladder tumors in children is reviewed  as well as the possible etiology of this unique lesion  
class4	transitional cell carcinomatous meningitis after m vac  methotrexate  vinblastine  doxorubicin  and cisplatin  chemotherapy  the m vac  methotrexate  vinblastine  doxorubicin  and cisplatin  regimen has been utilized at our two institutions to treat 17 patients with advanced stage transitional cell carcinoma of the bladder  we report 2 cases of carcinomatous meningitis resulting from metastatic transitional cell carcinoma which occurred in patients treated with m vac  review of the literature suggests that our experience with central nervous system metastases is not unique  and that treatment of advanced stage transitional cell carcinoma of the bladder with m vac may enhance the incidence of meningeal metastases  carcinomatous meningitis  although rare  is a rapidly fatal manifestation of metastatic transitional cell carcinoma if left untreated  however  prompt diagnosis and early aggressive therapy may result in palliation and stabilization of neurologic status  we review the pathophysiology  diagnosis  and treatment of transitional cell carcinomatous meningitis  
class4	selenium  nutritional  toxicologic  and clinical aspects despite the recent findings of environmental contamination  selenium toxicosis in humans is exceedingly rare in the united states  with the few known cases resulting from industrial accidents and an episode involving the ingestion of superpotent selenium supplements  chronic selenosis is essentially unheard of in this country because of the typical diversity of the american diet  nonetheless  because of the growing public interest in selenium as a dietary supplement and the occurrence of environmental selenium contamination  medical practitioners should be familiar with the nutritional  toxicologic  and clinical aspects of this trace element  
class4	apocrine mammary carcinoma  a clinicopathologic study of 72 cases  apocrine carcinoma  ac  is an uncommon  poorly characterized type of breast tumor  in this review  55 patients with intraductal  id  ac and 17 patients with infiltrating  if  ac were analyzed retrospectively to define the histologic features and clinical course of this neoplasm  recurrences in the breast occurred in 3 of 20 id ac patients treated by biopsy alone  but not in the 2 patients who received local radiation therapy after biopsy  one patient with id ac had axillary metastases at the time of treatment by mastectomy and died of disease five years later  the remaining patients with id ac treated by mastectomy have remained disease free  one of the three patients with if ac treated by biopsy alone died of disease  and one of two patients with if ac treated by biopsy and radiotherapy was alive with carcinoma  twelve patients with if ac were treated by mastectomy  ten of them were recurrence free at the time of last observation  more than one third of the cases of id ac and if ac were detected by mammography alone  survival analysis of if ac cases compared with nonapocrine duct carcinoma cases matched for stage revealed no statistical difference in estimated recurrence free survival or estimated survival probability  ac is a distinct morphologic entity with a natural history similar to that of nonapocrine ductal carcinoma  
class4	characterization of the morphonuclear features and dna ploidy of typical and atypical carcinoids and small cell carcinomas of the lung  the authors analyzed several cytomorphonuclear parameters related to chromatin distribution and dna ploidy in typical and atypical carcinoids and in small cell lung cancers  nuclear measurements and analysis were performed with a samba 200  titn  grenoble  france  cell image processor with software allowing the discrimination of parameters computed on cytospin preparations of feulgen stained nuclei extracted from deparaffinized tumor tissues  the authors  results indicate a significant increase in dna content  assessed by integrated optical density  iod   from typical carcinoids to small cell lung carcinomas  with atypical carcinoids showing an intermediate value  parameters related to hyperchromatism  short and long run length and variance of optical density  also characterize the atypical carcinoids as being intermediate between typical carcinoids and small cell lung cancers  the systematic measurement of these cytomorphonuclear parameters seems to define an objective  reproducible  scale  of differentiation that helps to define the atypical carcinoid and may be of value in establishing cytologic criteria for differential diagnosis  
class4	merkel cell carcinoma metastatic to the testis  tumor metastases to the testes are rare and are usually found incidentally at autopsy or after orchiectomy for prostatic carcinoma  it is even more unusual for testicular metastases to be clinically detected or symptomatic  the authors report two cases of clinically detected testicular metastases from merkel cell carcinoma of the skin  merkel cell carcinoma metastatic to the testes has not been reported previously  the two tumors  to some degree  resembled testicular lymphomas and the interstitial type of seminoma  
class4	bcr abl recombinant dna analysis versus karyotype in the diagnosis and therapeutic monitoring of chronic myeloid leukemia  karyotype and bcr abl recombinant dna analyses are two means of detecting the chromosomal aberration in chronic myeloid leukemia  the authors compared these two methods in a retrospective study of 36 patients with cml in which they found the bcr abl dna recombinant event in 100   29 of 29  of those patients who had the philadelphia chromosome  to achieve this sensitivity  a battery of two bcr probes and three restriction enzymes is necessary  the authors propose a sequential algorithm for efficient use of these probes and enzymes  in 76  of the patients  bcr abl rearrangement can be detected with a bgl ii digest and a 3  commercial probe  an additional 21  of patients can be detected by a second assay in which the same membrane is rehybridized to a 3  and 5  combination bcr probe  one patient  3   required an additional restriction enzyme digest with bamh i to detect the recombinant event by the same 3  probe  karyotype analysis is used to determine cytogenetic remission in patients with cml under therapy  the authors studied the use of dna analysis by the southern blot technique to detect a decrease in the relative number of leukemic cells  by dilution studies and densitometric scanning of autoradiographs  the authors were able to detect a 15  decrease in the relative number of cells having the bcr abl recombinant event  the authors report the preliminary results of three patients in whom they compared the karyotype and recombinant dna analysis at multiple time points in their clinical course  in conclusion  the bcr abl recombinant dna analysis is superior to karyotype for the diagnosis of cml and can be used for monitoring treated patients  
class4	free alpha subunit of the pituitary glycoprotein hormones  measurement in serum and tissue of patients with pituitary tumors  a solid phase radioimmunoassay was developed that measures the free alpha subunits of pituitary glycoprotein hormones  alpha pgphs  and has negligible cross reactivity with the intact hormones  less than 0 014  for thyroid stimulating hormone  tsh   less than 0 1  for human chorionic gonadotropin  hcg   0 8  for luteinizing hormone  lh   and 2 0  for follicle stimulating hormone  fsh    the assay is standardized with the alpha subunit of hcg but also reacts well with the alpha subunits of the other glycoprotein hormones  84  for alpha tsh  77  for alpha fsh  and 64  for alpha lh   concentrations as low as 0 3 micrograms l can be reliably measured  and the 97 5  reference range in 27 healthy adults  including postmenopausal females  is less than or equal to 1 2 micrograms l  elevated preoperative alpha pgph concentrations were found in 45  9 4   of 479 sera from patients with pituitary adenoma and 3  4 5   of 66 patients with nonadenomatous sellar lesions  postoperative alpha pgph levels were lower in 30 of 39 adenoma patients and 2 of 3 nonadenoma patients  in five  1   of the patients with pituitary adenomas  alpha pgph was the only elevated serum hormone marker  serum values of alpha pgph correlate weakly with alpha subunit immunocytochemical staining  95  of those with negative staining have normal alpha pgph values  but only 18  of those with positive staining have elevated alpha pgph values  
class4	the use of molecular probes to distinguish new primary tumors from recurrent tumors in gynecologic malignancies  this is the first report using dna molecular probe technology to distinguish between recurrent tumor and a second primary malignancy in a patient  tumor dna was extracted from squamous cell carcinoma of the cervix at the time of radical hysterectomy  eighteen months later a squamous cell cancer was found in a vaginal apex biopsy from which dna was extracted  tumor dna from both lesions was subjected to restriction enzyme digestion and dna molecular hybridization with human papillomavirus  hpv  probes  although both lesions were positive for hpv 16  their respective restriction enzyme patterns had different hpv genetic arrangements  thereby demonstrating their distinctness  
class4	the frequency of uterine leiomyomas  as a leading cause of hysterectomy in premenopausal women  uterine leiomyomas are a major public health problem  however  very little work has been done on their epidemiology  indeed  their true frequency has never been established using systematic and meticulous methods  in this study  gross serial sectioning at 2 mm intervals was applied as an adjunct to routine pathology processing in 100 consecutive total hysterectomy specimens  this tripled the number of leiomyomas noted in routine pathology reports  there were 649 leiomyomas in 77 of 100 uteri  with multiplicity of leiomyomas in 84   although leiomyomas were more numerous and larger in women with a clinical diagnosis of myomatous uterus  the incidence was no higher than in uteri removed for other reasons  the postmenopausal incidence of leiomyomas was no lower than the premenopausal incidence  although postmenopausal leiomyomas were smaller and fewer  these findings suggest that epidemiologic studies of leiomyomas may not be valid if they are based only on clinical diagnoses or routine pathology reports  
class4	thyroid carcinoma with mixed tall cell and columnar cell features  tall cell and columnar cell carcinomas have been regarded as aggressive variants of papillary thyroid carcinoma  in the present case report the authors describe a composite tumor where these forms of differentiation coexisted  with transitional changes occurring within single follicular structures  this finding indicates that the two variants are closely related  in local recurrences  one or the other feature appeared in separate lesions  lung metastases developed  and the patient died 5 1 2 years after diagnosis and primary treatment  
class4	anaplastic large cell  ki 1  lymphoma with histiocytic phenotype simulating carcinoma  histiocytic and epithelial cell types share many cytomorphologic and functional characteristics  it is predictable  therefore  that corresponding malignancies might be difficult to distinguish  described is the case of a 52 year old woman in whom disseminated anaplastic large cell lymphoma simulated carcinomatosis by conventional morphologic criteria  evidence of histiocytic differentiation was derived from immunocytochemical  fine structural  and genetic probe analyses  the diagnosis of histiocytic neoplasia is discussed in relation to categories previously termed malignant histiocytosis   ki 1  lymphoma  and regressing atypical histiocytosis  and comparisons are made with animal tumor models  
class4	isolation of measles virus in primary rhesus monkey cells from a child with acute interstitial pneumonia who cytologically had giant cell pneumonia without a rash  the isolation of measles virus in primary rhesus monkey kidney cells  prmk  in patients with documented giant cell pneumonia who have presented without a rash is limited  the diagnosis usually is made by cytologic examination of nasal or bronchial secretions in which characteristic multinucleated giant cells with intranuclear and intracytoplasmic inclusion bodies are observed  the diagnosis of giant cell pneumonia has been associated with measles virus but not exclusively  canine distemper  herpes group viruses  and parainfluenza infections have been associated with these cells  in addition  vitamin a deficiency also has been cytologically associated with multinucleated giant cells  the authors describe the isolation of measles virus from bronchial washing and sputum in prmk cells at 4 days from an 11 year old child with acute interstitial pneumonia who was in remission for acute lymphocytic leukemia  classic cytopathologic effect  cpe  consisting of syncytial and hole formation on the prmk monolayer was apparent  in addition  a foamy appearance of the monolayer was noted in an otherwise clean lot of monkey cells  confirmatory testing with measles antibody of the infected areas of the monolayer by indirect immunofluorescence  ifa  was positive for measles antigen and negative for mumps  parainfluenza  types i  ii  and iii  and influenza a and b virus  serologic studies for measles antibody revealed an ifa igg titer of greater than 1 10 240  and an igm titer of 1 128  cytologic examination of the same bronchial fluid revealed the typical giant cells with characteristic inclusions associated with measles virus  because this disease usually is severe  and often fatal  prompt recognition of this virus is essential  not only to the patient  who can be treated with immunoglobulin and or antiviral therapy  but also to prevent the spread of the virus to other patients and medical personnel  these findings also support direct evidence for the etiologic role of measles virus in giant cell pneumonia that has been detected either histologically or cytologically and in tissue culture at autopsy  
class4	a diagnostic expert system for colonic lesions  the diagnostic expert system for colonic lesions  descl  was designed to discriminate colonic adenoma and adenocarcinoma from normal colonic tissue  although it was originally developed for use in conjunction with a machine vision analytic system  the descl has evolved into a teaching tool and a model for conceptual machine learning  the expert system is table driven and consists of a shell and a knowledge base  the latter comprises a series of architectural and cytologic observations and a quantitative estimate of diagnostic importance relating these observations to diagnostic outcome  in a validation study of 100 colonic lesions  the expert system achieved a success rate of 98   it has the flexibility to allow individual pathologists to  customize  the knowledge base to suit their diagnostic criteria  
class4	estimation of pr and er by immunocytochemistry in breast cancer  comparison with radioligand binding methods  immunocytochemical assays for progesterone receptor  pr  using monoclonal antirabbit pr antibodies  pr ica  and for estrogen receptor  er   er ica  were compared with radioligand binding  dextran coated charcoal  dcc   methods for receptor determination in patients with breast cancer  immunocytochemical staining for pr was exclusively nuclear in localization  in this regard  pr staining is similar to previous findings for er  pr ica showed a sensitivity of 89  and specificity of 100   er ica was also 89  sensitive and similarly specific  there was good correlation between the degree and intensity of staining and quantitative binding of radioligand  receptor positive tumors  however  show considerable variation of immunocytochemical staining  suggesting heterogeneity of cellular pr content  the availability of an immunocytochemical assay for pr increases the discriminatory potential for these methods of receptor determination  
class4	brake mechanics  asbestos  and disease risk  health risks posed by inhalable asbestos fibers are known to exist in a variety of industrial and nonindustrial settings  although early studies described an increased risk of asbestosis  lung cancer  and mesothelioma in asbestos industry workers  subsequent research revealed the existence of a potential asbestos related health hazard in nonasbestos industries such as the textile and railroad industries  brake mechanics and garage workers constitute a large work force with potential exposures to levels of asbestos capable of producing disease  unfortunately  the health risk faced by these workers has received little attention  this article briefly discusses currently available information on the asbestos health risks of workers in this setting  and highlights the need for further investigations of this occupational group  
class4	clinical significance of colonic fermentation  recent evidence of the potential benefits of short chain fatty acids has prompted renewed interest in the area of human colonic fermentation  this paper reviews the clinical and metabolic consequences of colonic fermentation  
class4	features distinguishing secondary achalasia from primary achalasia  eighteen patients with cancer induced or secondary achalasia  sa  were compared to 421 patients with idiopathic or primary achalasia  pa   the aim of the study was to detect any differences in clinical presentation between the two groups  mean age of patients with sa was 57 1  range 15 78  and 47 1  range 1 90  in patients with pa  p   0 02   three patients with sa were 15  24  and 36 yr old  respectively  symptom frequency was comparable in sa versus pa  mean duration of symptoms in sa was 4 5 months  with 15 of the 18 patients experiencing symptoms for six months or less  weight loss occurred in 88 2  of patients with sa and 57 3  of patients with pa  p less than 0 05   cancer was at the gastroesophageal junction in 16 patients  duodenum in one  and breast in one  endoscopy showed tumor in 12  67    the esophagram was suspicious for tumor in only 25   we conclude that patients with sa are older  more likely to lose weight  and have a short duration of symptoms  however  sa may occur in younger patients  and endoscopy with biopsy is necessary in any newly diagnosed case of achalasia  
class4	the value of push type jejunal endoscopy in familial adenomatosis coli gardner s syndrome  push type jejunal endoscopy using a long forward viewing duodenofiberscope was performed in 10 patients with familial adenomatosis coli gardner s syndrome  jejunal polypoid lesions were detected in nine of the 10 patients  90    the lesions appeared sessile  whitish  and measured 3 mm or less in diameter  histologic findings of the biopsy specimens from these polypoid lesions revealed tubular adenoma in all nine patients  in addition  this method led to the detection of duodenal adenomas in one patient  in whom duodenofiberscopy with the side viewing instrument revealed no polypoid lesions in the bulb and second portion of the duodenum  in view of these results  we recommend that push type jejunal endoscopy  as well as side viewing duodenofiberscopy  should be added to the usual preoperative examinations done in patients with this disease  
class4	comparison of a new immunoassay for determining serum pancreatic isoamylase with two standard techniques  a method has recently been developed for measuring serum pancreatic  p  isoamylase  using two monoclonal antibodies specific for salivary isoamylase  we performed this test on 67 healthy controls and 133 patients  15 with acute pancreatitis  53 with chronic pancreatitis  20 during painful relapse and 33 in clinical remission   18 with pancreatic cancer  41 with nonpancreatic disease with abdominal pain  five with macroamylasemia  and one with total pancreatectomy  results were compared with those of a wheat germ inhibition method and with electrophoresis on cellulose acetate  a close correlation was found between the results of immunoinhibition assay and those of the other two tests  all patients with acute pancreatitis had abnormally high values in all three tests  in the group with chronic pancreatitis studied during painful relapse  16 had an increase in p isoamylase  as determined with the immunoinhibition assay  13 with the wheat germ inhibition test  and 15 with electrophoresis  in the group with chronic pancreatitis in clinical remission  we found low values in one patient  by immunoinhibition assay  but found low values in 17 and 19 patients by wheat germ inhibition and electrophoresis  respectively  low p isoamylase values corresponded to a severe exocrine pancreatic insufficiency  in the group with pancreatic cancer  the three tests showed similar results  and the majority of the patients had normal values  in the patients with nonpancreatic diseases  abnormally high levels were found in five  by immunoassay  in four by electrophoresis  and in three by the wheat germ inhibition method  in the five cases with macroamylasemia  both inhibition assays erroneously demonstrated an abnormal p isoamylase elevation  the results show that the three tests are equally useful for the diagnosis of acute pancreatitis  or chronic pancreatitis during an acute relapse  in these diseases  the immunoinhibition test would be the preferred assay because it is simple and rapidly performed  
class4	in vivo evaluation of monopolar versus bipolar electrosurgical polypectomy snares  the energy required and tissue damage in bipolar and monopolar polypectomy snares were compared in a canine model  the bipolar snare required an average of 34 joules of energy  whereas the monopolar snare required 228 joules to cut the same diameter of gastric mucosa tended into a polypoid structure  p   0 0005   the reduced energy delivered to the tissue from the bipolar procedure resulted in only 32  average depth of damage to the underlying gastric wall  whereas the monopolar procedure caused an average 69   p   0 001   surgically created polyps required 247 joules and 69 joules for corresponding monopolar and bipolar polypectomy  p   0 001   the decreased energy required and the correspondingly reduced damage caused to the underlying bowel wall by the bipolar snare should reduce the incidence of perforation and post polypectomy syndrome  the bipolar snare completes a local circuit about the snare  eliminating the return electrode and  consequently  the possibility of any return electrode burns  the bipolar snare thus provides an added safety margin during polypectomy  
class4	endoscopic ultrasonography in staging rectal cancer  endoscopic ultrasonography  eus  was used to stage rectal cancer by assessing depth of invasion through bowel wall layers and or involvement of lymph nodes  eus findings were correlated with histopathologic findings to discern the usefulness of this modality in predicting which patients could be candidates for sphinctersaving procedures and the avoidance of abdominoperineal resection  the olympus eu m3 endoscopic ultrasound system was used to assess depth of penetration through rectal wall layers and to identify lymph nodes  comparison of eus findings to histopathologic findings was possible in 13 patients  eus agreed with histopathology in 9 of 13 cases  69 3     p   0 07  kappa statistic   eus agreed with histopathology as the presence or absence of lymph nodes in 9 of 13 cases  69 3    p   0 07   however  the presence of lymph nodes could not necessarily predict metastatic involvement of these nodes  in one patient  invasion of vaginal cuff was correctly predicted  in nine cases  computed tomographic analysis  ct  was available for comparison to eus in detection of penetration beyond the bowel wall  ct agreed with histopathology in 3 of 9  33    whereas eus agreed with histopathology in 7 of 9  78    
class4	hyperplastic gastric polyps associated with persistent helicobacter pylori infection and active gastritis  we report two cases of patients with 3 yr histories of upper gastrointestinal symptoms  hyperplastic gastric polyps  and active chronic gastritis  biopsies retrospectively stained with giemsa revealed the persistent presence of helicobacter pylori  hp  in gastric biopsies of both patients throughout the 3 yr  after treatment with amoxicillin and bismuth subsalicylate  both became asymptomatic  one demonstrating disappearance and recurrence of the gastric polyps in conjunction with the hp  these cases demonstrate 3 yr of hyperplastic gastric polyps associated with hp and active gastritis  
class4	gallbladder carcinoma producing human chorionic gonadotropin  a primary carcinoma of the gallbladder producing human chorionic gonadotropin  hcg  was encountered in an 83 yr old japanese woman  with elevation of hcg beta hcg in urine and serum  remarkable elevation of serum estradiol was an associated finding  with increased hcg  at autopsy  we found that the primary carcinoma of the gallbladder extensively involved the liver  histologically  the tumor revealed adenosquamous cell carcinoma in the primary site  and moderately to poorly differentiated adenocarcinoma in metastatic foci  immunohistochemical staining for beta hcg showed a positive reaction in adenocarcinoma components  this is an extremely rare case of an hcg producing gallbladder carcinoma  which leads us to speculate that hcg positive tumor cells may occur due to dedifferentiation  
class4	hepatic giant cavernous hemangioma with microangiopathic hemolytic anemia and consumption coagulopathy  we describe a case of hepatic giant cavernous hemangioma with both microangiopathic hemolytic anemia  maha  and consumption coagulopathy  but without thrombocytopenia  which was completely cured by surgical resection of the tumor  the patient was a 54 yr old japanese woman whose chief complaint was right upper abdominal discomfort  angiography and dynamic computed tomography revealed typical findings of hepatic cavernous hemangioma  the patient also had hematological disorders  at surgery  we performed an atypical right lobectomy to preserve as much normal liver tissue as possible  the patient has been well  with no related complaints or abnormal laboratory findings  5 yr since her operation  this case indicates that giant cavernous hemangioma of the liver should be considered in the differential diagnosis of maha  and if surgical treatment is adequate  hematological abnormalities may be eliminated  
class4	genitourinary cancer in the elderly  the subject of genitourinary cancer in the elderly becomes increasingly more important as our population of patients older than 50 years expands  carcinoma of the kidney  bladder  and prostate all have an increasing incidence over the age of 50 and have a predilection for afflicting men more commonly than women  etiologic factors  especially with bladder and kidney carcinomas  are well documented and in some cases preventable  screening the urine for hematuria and careful digital rectal examinations may uncover a higher percentage of these malignancies in earlier  more curable stages  recent advances in the treatment of all of these malignancies have improved survival and quality of life for these patients  
class4	prevention of renal disease and conservation of renal function  in summary  we have reviewed some of the most frequently encountered areas of prevention of renal failure in the elderly  they include obstruction  hypertension  drug interaction  and inappropriate use of drugs and the silent killer of the elderly  renal carcinoma  only by a thorough understanding of the altered physiology of the aging kidney can the physician avoid making the same mistakes when new drugs are developed or new types of diseases are encountered  proper early diagnosis and understanding the guidelines to therapy in these conditions  can save huge human costs in terms of mortality  morbidity  and money  
class4	genetics and biology of human ovarian teratomas  i  cytogenetic analysis and mechanism of origin  one hundred and two benign  mature ovarian teratomas and two immature  malignant teratomas were karyotyped and scored for centromeric heteromorphisms as part of an ongoing project to determine the chromosomal karyotype and the genetic origin of ovarian teratomas and to assess their utility for gene centromere mapping  karyotypic analysis of the benign cases revealed 95 46 xx teratomas and 7 chromosomally abnormal teratomas  47 xxx  47 xx  8  two cases   47 xx  15  48 xx  7  12 91 xxxx  13  mosaic   47 xx  15  21  mar   our study reports on the first cases of tetraploidy and structural rearrangement in benign ovarian teratomas  the two immature cases had modal chromosome numbers of 78 and 49  centromeric heteromorphisms that were heterozygous in the host were homozygous in 65 2   n   58  of the benign teratomas and heterozygous in the remaining 34 8   n   31   chromosome 13 heteromorphisms were the most informative  with 72 7  heterozygosity in hosts  the cytogenetic data indicate that 65  of teratomas are derived from a single germ cell after meiosis i and failure of meiosis ii  type ii  or endoreduplication of a mature ovum  type iii   35  arise by failure of meiosis i  type i  or mitotic division of premeiotic germ cells  type iv   
class4	genetics and biology of human ovarian teratomas  ii  molecular analysis of origin of nondisjunction and gene centromere mapping of chromosome i markers  chromosomal heteromorphisms and dna polymorphisms have been utilized to identify the mechanisms that lead to formation of human ovarian teratomas and to construct a gene centromere map of chromosome 1 by using those teratomas that arise by meiotic nondisjunction  of 61 genetically informative ovarian teratomas  21 3  arose by nondisjunction at meiosis i  and 39 3  arose by meiosis ii nondisjunction  eight polymorphic marker loci on chromosome 1p and one marker on 1q were used to estimate a gene centromere map  the results show clear linkage of the most proximal 1p marker  nras  and the most proximal 1q marker  d1s61  to the centromere at a distance of 14 cm and 20 cm  respectively  estimated gene centromere distances suggest that  while recombination occurs normally in ovarian teratomas arising by meiosis ii errors  ovarian teratomas arising by meiosis i nondisjunction have altered patterns of recombination  furthermore  the estimated map demonstrates clear evidence of chiasma interference  our results suggest that ovarian teratomas can provide a rapid method for mapping genes relative to the centromere  
class4	equal parental origin of chromosome 22 losses in human sporadic meningioma  no evidence for genomic imprinting  inactivation of tumor suppressor genes can occur either by mutation at the gene locus or by loss of part or all of the chromosome region containing the gene  the latter is most frequently detected by dna markers as loss of heterozygosity in the tumor tissue  in several reports  the paternal homologue was preferentially retained in embryonal tumors associated with loss of particular chromosomal regions  suggesting genomic imprinting of the corresponding tumor suppressor loci  to explore the generality of these findings and the possible role of genomic imprinting in adult tumors of the nervous system  we have determined the parental origin of chromosome 22 loss in sporadic meningioma  of nine cases studied  five tumors retained the maternally derived chromosome 22 homologue while four retained the paternally derived chromosome 22  thus  in contrast to the embryonal tumors  the meningioma locus on chromosome 22 is inactivated by random mutation in sporadic adult meningiomas  
class4	the effect of large uterine fibroids on urinary bladder function and symptoms  fourteen patients with large uterine fibroids and urinary symptoms were treated with monthly injections of  d trp6  luteinizing hormone releasing hormone microcapsules  the average uterine size before treatment was 728 ml  it dropped to 323 ml  a drop of 55   after treatment  urinary symptoms of diurnal frequency disappeared in 11 of 12 patients  p less than 0 005  after the reduction of uterine size  urgency decreased in 11 of 13  p less than 0 005  and nocturia in eight of 10  p less than 0 02   no differences were found before and after treatment in the symptoms of urge incontinence and stress incontinence in the cystometric and urethral pressure profile measurements  urinary symptoms of frequency  urgency  and nocturia may be caused by the direct pressure exerted on the bladder by the enlarged uterus  symptoms of urge incontinence and stress incontinence deserve a more specific treatment as they are not related to uterine size  
class4	successful conservative management of primary nonmetastatic cervical choriocarcinoma  primary cervical choriocarcinoma is a rare disease  since 1915 only about 60 cases have been published  the case presented here can be defined as primary cervical choriocarcinoma since it fulfills all the criteria delineated previously  
class4	the prognostic significance of ca 125 half life in patients with ovarian cancer who have received primary chemotherapy after surgical cytoreduction  fifty four patients with advanced epithelial ovarian cancer were monitored with serial serum ca 125 levels after surgical cytoreduction and during multi agent chemotherapy with cisplatin containing regimens  ca 125 half life of less than 20 days was associated with prolonged overall survival  p less than 0 015   in those patients who eventually were found to be disease free at surgical surveillance procedures  normalization of serum ca 125 levels to less than 35 u ml within 65 days of primary operation also suggested an improved survival  p less than 0 059   
class4	colon cancer in pregnancy with elevated maternal serum alpha fetoprotein level at presentation  a case of colon cancer in pregnancy is presented in which the maternal serum alpha fetoprotein level was elevated  failure to evaluate colon cancer as a cause of the elevated maternal serum alpha fetoprotein may have accounted for the poor outcome  
class4	spontaneous infarction of placental chorioangioma and associated regression of hydrops fetalis  we report a case of a large chorioangioma diagnosed prenatally with concomitant meconium peritonitis and hydrops fetalis in the second trimester  spontaneous regression of the tumor occurred  associated with some resolution of the fetal hydrops and delivery near term with good neonatal outcome  
class4	suppression of serum insulin level by diazoxide does not alter serum testosterone or sex hormone binding globulin levels in healthy  nonobese women  suppression of serum insulin levels with diazoxide is associated with a decrease in serum testosterone and an increase in serum sex hormone binding globulin in obese women with the polycystic ovary syndrome  to determine whether physiologic insulin levels play a regulatory role in the androgen status of nonobese women with normal menses  the androgen status of five nonobese normal women was assessed on two occasions  during a control study and after 10 days of oral diazoxide  100 mg  three times daily  administration  insulin release in response to 100 gm oral glucose administration decreased from 108 0     28 2 to 49 3     5 2 nmol min l  p   0 05  after diazoxide administration  however  despite suppression of insulin release  diazoxide administration did not affect serum total testosterone  diazoxide  0 73     0 10  control  0 69     0 11 nmol l  p   ns  or sex hormone binding globulin  diazoxide  79 7     16 6  control  70 2     12 6 nmol l  p   ns  concentrations  these observations suggest that physiologic insulin levels in nonobese healthy women do not regulate testosterone metabolism and that diazoxide does not exert a direct or independent effect on serum testosterone or sex hormone binding globulin levels  
class4	collagen metabolism in gynecologic patients  changes in the concentration of the aminoterminal propeptide of type iii procollagen in serum  we have previously found the serum concentration of the aminoterminal propeptide of type iii procollagen  an indicator of collagen metabolism  to be increased in advanced ovarian cancer  in this study we measured the serum aminoterminal propeptide of type iii procollagen concentration in healthy women during the menstrual cycle and in patients with salpingo oophoritis  leiomyomas  endometriosis  and benign ovarian tumors  the concentration was higher in the luteal phase than that in the follicular phase  suggesting an association of collagen metabolism with ovarian steroid hormones  severe salpingo oophoritis increased the serum level of the aminoterminal propeptide of type iii procollagen with a decrease to normal during recovery  elevated values were occasionally seen in endometriosis and leiomyomas  these findings indicate that the aminoterminal propeptide of type iii procollagen is a relatively unspecific indicator of ovarian carcinoma  
class4	autologous antibodies eluted from membrane fragments in human ovarian epithelial neoplastic effusions  iii  cytotoxic potential in vitro and characterization of antigen s   cyst and ascites fluids from patients with ovarian epithelial neoplasms contain immunoglobulins with antitumor activity  autologous antibodies bound to the cellular membrane fragments obtained from human ovarian neoplastic effusions react with cell surface antigens on different human ovarian cell lines  surgical specimens of human ovarian adenocarcinoma  and human ovarian tumors grown in athymic balb c mice  the antibodies do not react with tissue preparations from normal human ovaries  other nonovarian normal or neoplastic tissues  and nonovarian human cell lines  these studies indicate that these antibodies are capable of complement mediated lysis of human ovarian tumor cell lines in vitro  preliminary characterization of the autologous ovarian tumor associated antigen s  indicates that it may be composed of three large molecular weight proteins of 182 000  164 000  and 122 000 d  
class4	the use of in situ hybridization to show human papillomavirus deoxyribonucleic acid in metastatic cancer cells within lymph nodes  southern blot hybridization has been used to identify human papillomavirus types in both primary tumors and lymph node metastases  however  this technique requires fresh frozen tissue and is incapable of localizing deoxyribonucleic acid sequences to specific cell types in the tumor sample  in contrast  in situ hybridization precisely locates viral sequences within tumor cells while preserving cellular architecture  further  in situ hybridization requires only small samples of formalin fixed  paraffin embedded tissues  five lymph nodes  from four patients  containing metastatic cervical squamous tumor cells  identified with hematoxylin and eosinophil staining  were analyzed with in situ hybridization techniques with human papillomavirus type 16 deoxyribonucleic acid probes labeled with sulfur 35  the primary cervical cancer from all four patients had been shown to contain human papillomavirus type 16 sequences by southern blot  three specimens from two patients clearly showed the presence of human papillomavirus type 16 sequences within the nuclei of metastatic tumor cells  whereas two specimens were nondiagnostic most likely as a result of the small volume of cancer relative to the size of the lymph node  this information indicates that it is the tumor cells themselves that contain viral deoxyribonucleic acid and provides additional evidence linking human papillomavirus with cervical carcinogenesis  
class4	oral contraceptives and breast cancer  among women in general the risk of breast cancer through 59 years of age does not appear to be affected appreciably by the use of oral contraceptives  nonetheless  concern continues to be expressed about the effects of early age at first use  long term duration of use  formulation  and a variety of other factors thought to influence breast cancer risk in the presence of oral contraception  a number of recent studies restricted to young women suggest that long term use may increase the risk of disease occurring very early  but the present lack of consistent findings in well conducted epidemiologic studies prevents any certain conclusion with regard to cause and effect  however  if an increased risk were indeed present  the most plausible interpretation is that long term oral contraception promotes earlier clinical manifestation of breast cancer in some women while having no net impact on their lifetime risk of the disease  
class4	vitrectomy retinotomy aspiration biopsy of choroidal tumors we used an investigational technique for the biopsy of intraocular tumors to aid in the diagnosis of three choroidal tumors  a three port trans pars plana vitrectomy was performed in conjunction with retinotomy  tumor biopsy  endophotocoagulation  and air fluid exchange  vitrectomy was used to decrease the amount of traction secondary to retained vitreous after intraocular surgery  retinotomy sites were chosen under microscopic control to avoid large caliber retinal vessels  then a modified tumor aspiration technique  together with endophotocoagulation and aspiration of intraoperative vitreous hemorrhages  provided an opportunity to sample tumor tissue continually at varied depths  we have added standard vitreous surgery concepts  techniques  and instrumentation to produce vitrectomy retinotomy aspiration biopsy of choroidal tumors  
class4	correlations of acoustic tissue typing of malignant melanoma and histopathologic features as a predictor of death  forty six eyes with uveal melanoma were scanned with a computerized diagnostic ultrasound system before enucleation  and light microscope sections were obtained  tumors were characterized by ultrasonically measured dimensions and power spectrum analysis  which provided information not available in conventional a  or b scan ultrasonography  histopathologic features  including cell clustering pattern  cell type  pigmentation  vascularity  and necrosis  were quantified  statistically significant correlations were found between parameters derived from the power spectrum and histologic characteristics  patients were followed up for up to ten years with 14 deaths occurring because of metastases  using a cox relative risk model with histopathologic data  a risk model comprising pigmentation and cell type  p less than  0001  was obtained  using ultrasonic characteristics  a model comprising tumor volume and scatterer concentration  p    0062  was obtained  the results suggest that ultrasonic tissue characterization and three dimensional biometry may provide improved in vivo prognostic indicators for uveal melanoma  
class4	magnetic resonance imaging of radiation optic neuropathy  three patients with delayed radiation optic neuropathy after radiation therapy for parasellar neoplasms underwent magnetic resonance imaging  the affected optic nerves and chiasms showed enlargement and focal gadopentetate dimeglumine enhancement  the magnetic resonance imaging technique effectively detected and defined anterior visual pathway changes of radionecrosis and excluded the clinical possibility of visual loss because of tumor recurrence  
class4	limbal autograft reconstruction after conjunctival squamous cell carcinoma  two patients who had squamous cell carcinoma with extensive limbal and corneal involvement were treated with surgery and cryotherapy  rarely large areas of the cornea are involved by this tumor  visual prognosis in such patients is poor  in these two patients  autologous limbal transplants were effective in restoring an excellent corneal surface and good visual function  this technique may be useful in the reconstruction of eyes with extensive neoplastic involvement of the corneoscleral limbus and cornea  
class4	an immunohistochemical study of pi class glutathione s transferase expression in normal human tissue  glutathione s transferases  gsts   a family of isoenzymes that play an important role in protecting cells from cytotoxic and carcinogenic agents  can be separated by biochemical and immunologic characteristics into three distinct classes named alpha  mu  and pi  previous studies have indicated that there is marked heterogeneity in the expression of different gst isoenzymes in different normal and malignant tissues  to better understand the regulation of the human pi class glutathione s transferase isoenzyme  gst pi   the tissue distribution of this protein wa studied by an immunohistochemical technique using an anti gst pi polyclonal antibody in normal paraffin embedded human tissues  these studies indicate that there is a broad distribution of gst pi in normal human tissues and establish a precise localization within the different organs studied  gst pi was expressed predominantly in normal epithelial cells of the urinary  digestive  and respiratory tracts  suggesting a possible role for gst pi in detoxication and elimination of toxic substances  previous studies have indicated that gst pi and the putative drug efflux pump p glycoprotein are both overexpressed in multidrug resistant human breast cancer cells and in xenobiotic resistant preneoplastic rat hyperplastic liver nodules  results from this study indicate that there are also similarities between the normal tissue distribution gst pi and that previously reported for mammalian p glycoprotein  particularly in secretory epithelia  this finding suggests that these two gene products  which have been implicated in the development of resistance to cytotoxic drugs  may be coregulated in normal and malignant cells  
class4	decreased expression of integrin adhesive protein receptors in adenocarcinoma of the breast  the integrin superfamily represents a major class of receptors mediating cell substrate adhesion  our recent study of the tissue distribution of the alpha 2 beta 1 integrin  a cell surface collagen receptor  revealed that high levels of receptor expression were associated with orderly  regulated epithelial cell proliferation  those observations prompted the present investigation of alpha 2 beta 1 and other integrins in adenocarcinoma of the breast  the alpha 2 beta 1 integrin was highly expressed on the epithelium of the ducts and ductules of normal breast tissue  normal or nearly normal levels of the receptor were expressed in fibroadenomas  in contrast  markedly decreased or undetectable alpha 2 beta 1 expression was typical of poorly differentiated adenocarcinomas  well differentiated lesions exhibited intermediate levels of expression  similar  but less extensive  decreases in expression were observed for the alpha 5 beta 1  fibronectin receptor  and alpha v beta 3  vitronectin receptor   significant expression of the beta 1 subunit on even poorly differentiated tumors suggests that the expression of other undefined members of the beta 1 family is not reduced to the same low level as alpha 2 beta 1 and alpha 5 beta 1  expression of the alpha 2 beta 1 integrin was highly correlated with estrogen receptor expression  decreased expression of alpha 2 beta 1 and other integrin adhesive protein receptors probably contributes to the altered adhesive properties of tumor cells characteristic of the malignant phenotype  
class4	expression of the human nephron differentiation molecules in renal cell carcinomas  the authors tested frozen sections from 28 renal cell carcinomas  rcc   21 clear  1 eosinophilic  4 basophilic  and 2 spindle shaped cell type  with monoclonal antibodies  mab  reacting against cytokeratin  vimentin  cd24  calla cd10  villin  cd26  and hla class i and class ii molecules  these molecules are markers of specific segments of the mature kidney  and their loss or acquisition reflects the different steps of human nephrogenesis  ki67 mab was used to evaluate cell proliferating activity  all rcc cases expressed cytokeratin  coexpression of vimentin was observed in 21 of 28 cases  whether of clear or chromophilic type  all tumoral cells strongly expressed cd24 molecule  present on primitive blastema cells  all clear type rccs expressed calla cd10 and 60  were also villin positive  some were faintly positive for cd26  calla  villin  and cd26 were not detected in basophilic cell type  hla class i molecules were variably expressed in almost all cases  but hla class ii were never detected on tumoral cells  except for the spindle shaped population  cell proliferating activity was low  these results favor the hypothesis that rccs derive from cells that have  recovered  the different options of metanephric differentiation  clear cells show evidence of maturation toward proximal type  while basophilic cells do not  it would be of interest to evaluate the usefulness of serum measurements of villin and or calla as markers in clear cell type rcc  
class4	initial failure of surgical exploration in patients with primary hyperparathyroidism  to determine the causes of failures of cervical exploration for primary hyperparathyroidism  we reviewed 892 patients operated on by one surgeon from 1953 to 1990  twenty seven patients  3   remained hypercalcemic or developed hypercalcemia within 6 months of surgery  of these  five patients had one adenoma removed initially  at reoperation  three patients had a second adenoma that was successfully removed  whereas the other two patients had hyperplasia and required subtotal parathyroidectomies  no enlarged parathyroid glands were identified in 22 patients  eventually  six patients became normocalcemic spontaneously  seven patients underwent re exploration with a successful outcome in all but one case  two patients had ectopic hyperparathyroidism associated with carcinoma elsewhere  and seven patients refused reoperation and remain hypercalcemic  the failure rate of surgical exploration for primary hyperparathyroidism can be reduced by systematically exploring all four parathyroid glands  all abnormal parathyroids should be removed with histologic verification  when no abnormal glands are found  localization studies should be performed before re exploration  
class4	lymph node metastasis from papillary follicular thyroid carcinoma in young patients  a total of 117 patients under 20 years of age with papillary and or follicular thyroid cancer presented to the m  d  anderson cancer center between 1949 and 1987  the most common presenting symptom was a cervical mass  twenty percent of the patients had a history of prior irradiation  sixty percent initially had palpable lymph nodes  while 26  who had clinically negative examinations had pathologically positive lymph nodes  recurrence was highest in regional lymph nodes at 24   with only a 4  recurrence rate at the primary site and a 3  recurrence rate at distant sites  there were no deaths due to the thyroid cancer  to maintain a low rate of recurrence  near total thyroidectomy with neck dissection followed by iodine 131 treatment should be considered in these young patients  
class4	survival discriminants for differentiated thyroid cancer  since 1975  the american cancer society  illinois division  has published end results of major cancer sites drawn from patient data contributed voluntarily by hospital cancer registries throughout the state  the current study was undertaken  in part  to apprehend information regarding contested areas in the management of patients having differentiated  papillary follicular  thyroid cancer  a total of 2 282 patients with either papillary or follicular carcinoma of the thyroid from 76 different illinois hospitals and providing 10 years of follow up information  life table analysis  were retrospectively analyzed for demographic  disease  and treatment related predictors of survival  multivariate analysis using the cox proportional hazards method was made for stage  age  race  sex  morphology  history of radiation exposure  presence of positive lymph nodes  initial surgical treatment  postoperative iodine 131 therapy  and replacement suppressive thyroid hormone treatment  statistically significant  p less than or equal to 0 05  predictors of favorable survival after thyroid cancer were low stage  i and ii   young age  less than 50 years   white race  female sex  and the administration  postoperatively  of either thyroid hormone or radioactive iodine  factors that had no influence on survival were lymph node status  choice of initial surgical treatment  and a history of prior irradiation  we suggest that where a prospective clinical trial is impracticable  a retrospective analysis of a large and detailed database  such as that available from cooperating hospital based tumor registries  may yet provide useful insights to solutions of cancer management problems  
class4	long term effects of radiotherapy in childhood and adolescence  the records of 50 selected pediatric patients who were treated and followed at m  d  anderson cancer center were reviewed to study the late effects of nonsurgical treatment of cancer in children  there were 26 girls and 24 boys ranging in age between 2 months and 16 years  patients with head and neck cancer received chemotherapy and radiotherapy for rhabdomyosarcoma  n   27   retinoblastoma  n   8   or nasopharynx cancer  n   2   median follow up was 13 years  the most severe side effects were noted in the fields of radiation and included hypoplasia of the jaw  orbit  or hemi face with varying degrees of atrophy of the overlying soft tissues  a wide range of endocrine  dental  and psychologic abnormalities was also documented  since 1 in every 1 000 adults older than 20 years today is likely to be a survivor of childhood cancer  recommendations are made for this  new  class of patients whom the head and neck surgeon will be seeing in the future  
class4	complications of the pectoralis major myocutaneous flap in head and neck reconstruction  a retrospective review of the complications in 211 patients undergoing pectoralis major myocutaneous flap reconstruction is presented  the flap was used for mucosal lining of the oral cavity or oropharynx in 109 patients  for pharyngoesophageal reconstruction in 44  for skin coverage in 47  and for other locations in 14 patients  flap related complications developed in 63  of the patients  these included flap necrosis  suture line dehiscence  fistula formation  infection  and hematoma  analysis of risk factors for the development of flap complications showed the following factors to be significant  age over 70  female gender  nomographic overweight  albumin less than 4 g dl  use of the flap in reconstruction of the oral cavity after major glossectomy  and presence of other systemic diseases  the median length of hospitalization for those developing complications was 33 days compared with 16 days for those who did not develop any complications  thirty five  26   of the 135 patients developing complications required reoperation and only 2 among these required a second flap  similarly  only 13 of the 61 patients who developed fistulas required surgical closure  
class4	soft tissue sarcomas of the head and neck in adults  we reviewed the clinical records and pathologic material of 176 adults with primary soft tissue sarcomas treated at memorial sloan kettering cancer center between 1950 and 1985  seventy two patients  41   had low grade sarcomas and 104  59   had high grade sarcomas  all but 18 patients underwent some form of excision as initial therapy  adjuvant radiotherapy and chemotherapy combined with surgical excision showed no significant effect  a significantly increased risk of treatment failure was associated with large tumor size  positive surgical margins  bone involvement  local recurrence  metastatic spread  and high histologic grade  except for recurrence  the p value by univariate analysis in the log rank test for comparison of survival according to these clinical and pathologic characteristics was p less than 0 0001  although the overall survival was 75  at 2 years  55  at 5 years  and 46  at 10 years  only 20  of the patients with high grade sarcomas were alive 10 years after treatment  most patients with rhabdomyosarcoma  high grade peripheral nerve tumor  and high grade fibrous histiocytoma and all patients with high grade angiosarcoma died of disease less than 5 years after diagnosis  new therapeutic strategies are needed to improve the survival of adult patients with high grade soft tissue sarcomas of the head and neck  
class4	multimodality preoperative treatment for advanced stage iv  mo  cancer of the head and neck  sixty three patients with advanced unresectable squamous cell carcinoma of the head and neck were treated with a combination of chemotherapy  radiation  and surgery  we observed a 75  response to neoadjuvant chemotherapy  the 5 year survival rate for all 63 patients was 20   and only 3 patients were alive at 8 years  the 5 year survival rate for patients who completed the treatment plan and received chemotherapy  radiation  and surgery was 43  compared with 20  for those who had chemotherapy and radiation but refused surgery  development of a second primary cancer was the cause of death in 62  of the patients who survived more than 24 months  
class4	definitive mandibular replacement using reconstruction plates  mandibular defects following radical cancer surgery continue to provide challenges to head and neck surgeons  twenty seven patients with advanced oral cancer underwent primary mandibular replacement with metal reconstruction plates without the use of bone  twenty one patients  78   had successful reconstruction with primary soft tissue healing  six patients required removal of the plate in the postoperative period  two of these patients had their reconstruction plates replaced as a secondary procedure following soft tissue healing  thus  23 of 27 patients  85   had final mandibular reconstruction and were followed for an average of 19 months  functional and cosmetic results were satisfactory  for patients with advanced disease  this technique compares favorably with microvascular transfer in terms of operating time and donor defect  despite problems with plate exposure  the initial and overall success rates of 78  and 85   respectively  make the use of these plates a reasonable choice for immediate reconstructive needs in patients with difficult tumors  
class4	mandibular reconstruction with composite microvascular tissue transfer  microvascular free tissue transfer has provided a variety of methods of restoring vascularized bone and soft tissue to difficult defects created by tumor resection and trauma  over 7 years  26 patients have undergone 28 free flaps for mandibular reconstruction  15 for primary squamous cell carcinoma of the floor of the mouth or tongue  7 for recurrent tumor  and 6 for other reasons  lymphangioma  1   infection  1   gunshot wound  1   and osteoradionecrosis  3    primary reconstruction was performed in 19 cases and secondary in 9  all repairs were composite flaps including 12 scapula  5 radial forearm  3 fibula  2 serratus  and 6 deep circumflex iliac artery  mandibular defects included the symphysis alone  7   symphysis and body  5   symphysis body ramus condyle  2   body or ramus  13   and bilateral body  1   fourteen patients had received prior radiotherapy to adjuvant or curative doses  eight received postoperative radiotherapy  all patients had initially successful vascularized reconstruction by clinical examination  28  and positive radionuclide scan  22 of 22   bony stability was achieved in 25 of 26 patients and oral continence in 24 of 26  one complete flap loss occurred at 14 days  complications of some degree developed in 22 patients including partial skin necrosis  3   orocutaneous fistula  3   plate exposure  1   donor site infection  3   fracture of reconstruction  1   and fracture of the radius  1   microvascular transfer of bone and soft tissue allows a reliable reconstruction  despite previous radiotherapy  infection  foreign body  or surgery  in almost every situation in which mandible and soft tissue are absent  bony union  a healed wound  and reasonable function and appearance are likely despite early fistula  skin loss  or metal plate or bone exposure  
class4	reconstruction of mandibular defects in irradiated patients  in this prospective study  mandibular reconstruction using titanium plates was evaluated in 31 patients treated between july 1988 and january 1990  sixteen patients had prior surgery  13 had prior radiotherapy  in 11 patients  prior radiation and surgery had failed  sixteen patients received postoperative radiotherapy either in standard or accelerated fractions  twelve patients had complications of either intraoral  8   extraoral  5   or combined  1  plate exposure or fistula formation  2   factors significantly related to complications were poor nutrition  accelerated radiation  and recurrence  sixty one percent of all patients healed uneventfully  when patients with complications secondary to recurrence who subsequently died were excluded  the success rate was 73   only one patient had an unacceptable result that produced a cosmetic and functional deformity despite secondary repair  
class4	sequential connection of flaps  a logical approach to customized mandibular reconstruction  microsurgery has improved the success rate for reconstruction of composite defects in the head and neck  restoration of mandibular continuity alone is not adequate for reconstruction  replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration  there is currently no ideal osteocutaneous free flap that provides unlimited length of bone  can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible  and provides thin skin for oral lining  combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps  in six patients  a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects  in these selected patients  the fibula provided the blood supply for the second free flap  which was placed sequentially  the distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle  this approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited  such as following head and neck surgery and radiation  
class4	patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract  a consecutive series of 1 081 previously untreated patients undergoing 1 119 radical neck dissections  rnds  for squamous carcinoma of the head and neck was reviewed to study the patterns of nodal metastases  primary tumors were located in the oral cavity in 501 patients  in the oropharynx in 207 patients  in the hypopharynx in 126 patients  and in the larynx in 247 patients  lymph node metastases were confirmed histologically in 82  of 776 therapeutic neck dissections  and micrometastases were discovered in 33  of 343 elective rnds  lymph node groups in the neck were described by levels  i to v   predominance of certain levels was seen for each primary site  levels i  ii  and iii were at highest risk for metastasis from cancer of the oral cavity  and levels ii  iii  and iv were at highest risk for metastasis from carcinomas of the oropharynx  hypopharynx  and larynx  supramohyoid neck dissection  clearing levels i  ii  and iii  for no patients with primary squamous cell carcinomas of the oral cavity and anterolateral neck dissection  clearing levels ii  iii  and iv  for no patients with primary squamous cell carcinomas of the oropharynx  hypopharynx  and larynx are recommended  
class4	significance of positive margins in oral cavity squamous carcinoma  three hundred ninety eight consecutive  previously untreated patients undergoing surgery for epidermoid carcinoma of the oral cavity from 1979 to 1983 were reviewed  one hundred twenty nine patients were classified as having positive surgical margins  of these  83 patients had tumor within 0 5 mm of the surgical margin  9 had premalignant changes at the margin  9 had in situ carcinoma at the margin  and 28 had invasive cancer at the margin  the remaining 269 patients had uninvolved margins  the significance of positive margins relating to survival  subsequent clinical course  local recurrence  and patterns of treatment failure was examined  along with the impact of adjuvant postoperative radiotherapy on positive margins  the percentage of patients having positive margins progressively increased with increasing t stage  21  in t1 versus 55  in t4 primary cancer  the overall 5 year survival for patients with negative margins was 60   for patients with positive margins  5 year survival was 52   this difference was statistically significant  the incidence of local recurrence in patients having positive surgical margins was twice as much as in those with negative margins  36  versus 18    metastasis rates in the neck and at distant sites were not significantly influenced by the status of the surgical margin  of the 129 patients with positive margins  49 received postoperative radiotherapy  in those patients so treated  a trend toward lower recurrence rates was noted  differences were not statistically significant  this retrospective review confirms the importance of adequate resection of the primary tumor as well as the relative ineffectiveness of adjuvant postoperative radiotherapy in the improvement of local control in patients with positive surgical margins  
class4	treatment selection for carcinoma of the base of the tongue  between 1974 and 1984  173 patients were treated for squamous cell carcinoma of the tongue base  fifty four patients had t1 or t2 primaries  while 115 patients had t3 or t4 tumors  4 were not staged   lymph node metastasis was present in 120 patients  early primary tumors treated with surgery or radiotherapy had a control rate of 83   5 of 6 tumors  and 89   40 of 45 tumors   respectively  for advanced primary tumors  definitive radiotherapy produced a local control rate of 55   42 of 76 tumors   compared with 79   23 of 29 tumors  for surgery and postoperative radiotherapy  if primary control was obtained  the regional failure rate was less than 10   tumor growth patterns were predictive of the response to radiotherapy  the primary control rate at 2 years for 21 patients with exophytic tumors was 84  as opposed to 58  for 62 patients with ulcerative infiltrative tumors  p   0 04   radiotherapy is effective for early stage or exophytic tumors  whereas for advanced or deeply invasive tumors combined therapy enhances local control  
class4	squamous carcinoma of the posterior pharyngeal wall  we have reviewed a 12 year experience with 295 patients treated for squamous carcinoma of the pharynx in order to focus on 78 patients whose lesions arose in the posterior wall  surgery was the definitive therapy for the primary tumor in 57  73    including 3 treatment groups  thirty two patients had limited resections that preserved the larynx  involving local excision  7 patients   anterior pharyngotomy  7 patients   lateral pharyngotomy  6 patients   median labiomandibular glossotomy  6 patients   or median mandibulotomy with paralingual extension  6 patients   the second group consisted of 21 patients with more extensive tumors who required a laryngectomy and complex reconstruction  often with postoperative radiotherapy  finally  there were four patients who developed metachronous second primaries in the pharynx subsequent to a laryngectomy  all required flap reconstruction  of the 21 patients whose primary treatment was radiotherapy  5 had lesions that were implanted after access was provided by a mandibulotomy  cumulative 5 year survival was 32  and ranged from 44  in those with favorable lesions to 15  in those with extensive tumors  our experience highlights the variety of treatment approaches available in patients with pharyngeal carcinomas confined to the posterior wall  surgery in this setting carries acceptable morbidity and yields survival rates that compare favorably with those achieved by external radiation therapy alone  results in patients with extensive lesions still leave much to be desired  despite radical surgery and aggressive radiotherapy  innovative brachytherapy techniques using surgery for access deserve further investigation  
class4	flow cytometric evaluation of chemosensitive and chemoresistant head and neck tumors  for patients with head and neck squamous carcinoma  a clinical response to induction chemotherapy has correlated with a survival advantage  similarly  patients with diploid tumors have displayed a survival advantage when compared with patients with aneuploid tumors  this study examined dna content in 33 patients who had undergone induction chemotherapy as part of two clinical protocols to determine if there was a correlation between the patients with diploid tumors and the patients with a clinical response to chemotherapy  although patients with stage iii tumors had a longer disease free survival than stage iv patients  p less than 0 0002   the addition of dna content information did not improve the ability to predict response  specifically  there was no correlation between dna content and the response to chemotherapy  in addition  for this group of patients  a diploid dna content was not correlated with a survival advantage  we conclude that dna content information did not add significantly to the prediction of clinical outcome in these patients who received induction chemotherapy  
class4	lateral temporal bone resections  eighteen consecutive patients underwent a lateral temporal bone resection for the treatment of tumors originating in the auricle  the external auditory canal  the periauricular skin  or the parotid and were retrospectively analyzed  the different lateral temporal bone resections performed have been categorized into four types  the type i resection consists of the removal of the tympanic bone and the external auditory canal lateral to the tympanic membrane  the type ii resection consists of the removal of the entire tympanic bone  the tympanic membrane  the incus  and the malleus  preserving the facial nerve and the inner ear  type iii resections remove  in addition to the those structures removed in type ii resections  the distal facial nerve and fallopian canal  the mastoid tip  the styloid process  and the stylomastoid foramen  the type iv resection consists of the removal of only the mastoid tip and the inferior portion of the tympanic bone  when the techniques of lateral temporal bone resection are used appropriately  adequate surgical treatment of patients with selected advanced and recurrent malignant tumors of the external ear  the periauricular skin  and the parotid is possible with low morbidity and a high probability of local regional control  
class4	serologic determinants of survival in patients with squamous cell carcinoma of the head and neck  specific circulating serum proteins may reflect unique properties governing the growth and progression of head and neck cancers  one hundred three previously untreated patients with squamous cell carcinoma of the head and neck were prospectively evaluated for serum iga  igg  and igm and c1q binding macromolecules  immunoglobulins were assessed by the immunoturbidimetric technique  c1q binding macromolecules  c1qbm  were measured utilizing the iodine 125 assay of zubler et al  j immunol 1976  116  232 5   neither the level of serum immunoglobulins nor c1qbm values were correlated with the primary site  ajc  american joint committee on cancer  stage of disease  or size of primary lesion  likewise  comparison of serum iga with c1qbm values demonstrated that these laboratory parameters were independent variables  r   0 15 by pearson linear regression   univariate statistical analysis  utilizing the cox proportional hazard model  showed serum iga and c1qbm values to each contribute significantly to the ability to predict survival in patients with advanced squamous cell carcinoma of the head and neck  p   0 01 and 0 003  respectively   furthermore  multivariate analysis reveals that both c1qbm and serum iga levels contribute significantly to the hazards model beyond staging in predicting survival  p less than 0 001   predictive results were most apparent in patients with stage iv disease and related to the probability of both regional and distant metastatic recurrences  conversely  serologic analysis provided no information in patients who were staged early  these results support pretreatment multiparametric serologic analysis of patients with squamous cell carcinoma of the head and neck  
class4	efficacy of radical neck dissection for the control of cervical metastasis after radiotherapy for nasopharyngeal carcinoma  fifty one patients who had persistent or recurrent neck disease from nasopharyngeal carcinoma after radiotherapy underwent radical neck dissection  the follow up period ranged from 0 5 to 9 years  median  2 years   multiple cervical lymph node involvement was present in 51  of the patients  26 of 51   malignant cells were detected in 88  of the resected specimens  45 of 51   the clinical sign of fixation of lymph node is the only factor that affects the successful control of neck disease  p   0 04   extracapsular extension of the nodal disease was present  and 35  of the lymph nodes were adherent to surrounding structures at operation  18 of 51   there was one hospital mortality and the overall morbidity was minimal  the actuarial survival at 5 years was 38   and the probability of control of neck disease was 66   radical neck dissection is effective in controlling post irradiation cervical metastasis from nasopharyngeal carcinoma  
class4	cervical lymph nodes from an unknown primary tumor in 190 patients  over 10 years  475 patients with isolated lateral neck masses were evaluated  190 with lymph nodes from an unknown primary tumor  lnup   188 with neck lymphomas  78 with benign tumors  10 with sarcomas  and 9 with chemodectomas  this study focused on the patients with lnup  only 86 patients were treated with surgery  plus radiotherapy   other patients were treated with radiotherapy  84  or chemotherapy  13  or had no treatment  7   for the overall population  failures in the neck occurred in 51  of the patients and distant metastases in 27   while primary tumors appeared in 16   survival rates at 3  5  and 10 years were 27   19   and 7   respectively  for the overall population and 45   35   and 19   respectively  for the surgical group  the diagnosis and therapeutic approach had a direct effect on neck control  failure in the neck occurred in 7 of 47 patients  15   when fine needle aspiration and radical neck dissection with radiotherapy were performed  in 5 of 12 patients  42   when fine needle aspiration and modified neck dissection with radiotherapy were used  in 5 of 12 patients  42   when adenectomy diagnosis and radiotherapy treatment were performed  and in 6 of 11 patients  54   when diagnosis by incisional biopsy was performed prior to admission  despite subsequent radical neck dissection and radiotherapy treatment  in our opinion  panendoscopy and fine needle aspiration should be the first line diagnostic approach  when cytologic diagnosis proves impossible  the second line approach must consist of cervical exploration with frozen section examination and excisional biopsy  followed by immediate appropriate treatment  in cases of lnup  radical neck dissection seems to be preferable  
class4	delayed reconstruction following mohs  chemosurgery for skin cancers of the head and neck  the case records of 52 patients with 55 cutaneous neoplasms treated by mohs  chemosurgery and subsequently reconstructed by plastic surgeons were reviewed to determine if delay between resection and reconstruction adversely affected the outcome of reconstruction  reconstruction was performed from 5 to 61 days after mohs  chemosurgery for 45 basal cell carcinomas and 10 other cutaneous neoplasms  there were no complications during the interval between resection and reconstruction  following reconstruction  minor wound complications occurred in 6  of patients  there were no major complications  microscopic examination of the re excised wound revealed residual disease in 2 of 45 cases of basal cell carcinoma and 0 of 10 other cutaneous malignancies  both patients with residual basal cell carcinomas  i e   false negative margins after mohs  surgery  had presented to the mohs  surgeon with recurrent tumors  during a follow up period of 3 months to 3 years after complete resection  recurrent tumor developed in 2 of 45 cases of basal cell carcinoma and 3 of 8 cases of squamous cell carcinoma  delayed reconstruction  usually 5 to 20 days after mohs  chemosurgery  can be performed without significant morbidity  re excision of the mohs  chemosurgical wound for pathologic examination can detect residual disease and may be especially indicated for large recurrent wounds  
class4	parascapular free flaps for head and neck reconstruction  we report our experience with single stage  primary reconstruction of the head and neck in 29 consecutive patients using parascapular free flaps  the commonest indications were for craniofacial defects  9   oropharyngeal soft tissue defects  10   and combined mandibular and soft tissue losses  4   ablative surgery was performed for squamous carcinoma  22   melanoma  2   and malignant fibrous histiocytoma  2   seven patients died of recurrent disease during a 3 1 2 year follow up  seven patients are alive with recurrence  flap complications included total loss  2  due to unsalvageable microvascular thrombosis  wound breakdown with oropharyngeal fistula  2   mandibular osteomyelitis  1   trismus  2   neck contracture  1   and donor site wound dehiscence  1   the overall success of this reconstruction was 93   primary wound healing was the general rule with lower morbidity than with other reconstructive techniques  the flap is thin  pliable  and conforms well to three dimensional defects  the lateral border of the scapula can be incorporated on the same vascular pedicle for single stage mandibular reconstruction  no muscle is sacrificed  and the posterior donor defect is an added advantage  the parascapular flap is our first choice for reconstruction of major defects in the head and neck  
class4	a hepatocellular carcinoma of massive arterioportal shunts without tumor stain treated with cddp two route chemotherapy  a case report  massive arterioportal shunts without tumor vessels or tumor stain are sometimes encountered in advanced cases of liver cirrhosis  massive arterioportal shunts without tumor stain that responded well to intensive chemotherapy with cis diamminedichloroplatinum ii are reported  
class4	functional character and augmentation of lymphocytes in regional lymph nodes of patients with lung cancer  it appears that lymph node metastases are more frequent in lung cancer than in other cancers because of impaired defensive mechanisms in the regional lymph nodes  however  little is known about the immunologic function of regional lymph node lymphocytes  rlnl  in patients with lung cancer  we have studied the immunologic properties of rlnl in comparison with peripheral blood lymphocytes  pbl   we measured the natural killer  nk  cell activity of rlnl and pbl in patients with lung cancer and found that the nk activity was significantly more depressed in the rlnl than in the pbl  in contrast  interleukin 2  il 2  production was markedly higher in the rlnl than in the pbl  the cytotoxic effect of rlnl in nonmetastatic lymph nodes on target cells  such as k562 cells  or pc 3 and pc 10 cells  nk resistant  human lung cancer of adenocarcinoma and epidermoid carcinoma  respectively  was significantly enhanced by in vitro incubation with recombinant il 2  ril 2   furthermore  we clarified that both ril 2 and ok 432  which is a biologic response modifier and il 2 inducer as well  augmented the cytotoxicity of rlnl and that these effector cells were lymphokine activated killer  lak  cells  the depletion of lymphocyte subsets by pretreatment with specific monoclonal antibody showed that the lak activity in rlnl was mediated by cd3  and cd8  cells  whereas the lymphocyte subsets contributing the lak activity in pbl were cd3  and cd16  cells  it was concluded that a majority of the effector cells in rlnl were lak cells of the cytotoxic t cell population  
class4	lung lobe torsion following lobectomy  three cases of postoperative pulmonary lobe torsion were reported  two of three showed hemorrhagic infarctions  and as a result underwent rethoracotomies and removal of the affected lobes  from these experiences  we consider that computed tomography  ct  and bronchofiberscopic examinations are useful for the diagnosis of advanced torsion  
class4	histopathologic study of otitis media in individuals with head and neck tumors  five temporal bones  each including the eustachian tube  were obtained from five adults with advanced malignant tumors of the head and neck  the specimens were from the side on which the tumor had occurred  otitis media had been detected clinically in two cases  and was detected histopathologically in the other three  we discuss the possibility that otitis media might have been caused by tumor invasion of the paratubal area  by postoperative inflammation in the nasopharynx  or by an inflammatory reaction of tubal structures to radiotherapy  or that these conditions may have coexisted  
class4	histopathologic grading of salivary gland neoplasms  i  mucoepidermoid carcinomas  histopathologic grading of salivary gland neoplasms has been done with various degrees of success and hence various degrees of acceptance among pathologists and otolaryngologists head and neck surgeons  given their histopathologic diversity  three carcinomas  mucoepidermoid  adenoid cystic  and acinic cell  would seem to be suitable candidates for grading  in this  the first of a three part series  the authors present a three level grading scheme for mucoepidermoid carcinomas  it combines histocytologic and growth features of the carcinomas that independently or together  in other grading proposals  have shown prognostic value  
class4	human central nervous system primitive neuroectodermal tumor expressing nerve growth factor receptors  chp707m  a primitive neuroectodermal tumor  pnet  presented as a cerebral hemispheric mass in a 33 year old man  bone marrow metastases were discovered 11 months later  a cell line  chp707m  was derived from these metastases  in culture  the cells showed features of neuronal differentiation  forming short neurites and synthesizing low molecular weight neurofilament protein  northern blotting showed the tumor cells express nerve growth factor  ngf  receptor messenger rna  and fluorescence activated cell sorting demonstrated ngf receptors on the cell surface  western blotting showed chp707m ngf receptors are truncated  the receptors are functional  they bind iodine 125 labeled mouse ngf with an affinity of 1 6 x 10  9  m  and short term treatment with ngf induces expression by the tumor cells of the proto oncogene  c fos  although chp707m is the first central nervous system pnet cell line proven to express ngf receptors  immunohistological survey of tissue sections prepared from human central nervous system pnets showed that 13 of 35 contained ngf receptor positive tumor cells  thus  more than one third of such tumors might be responsive to the effects of ngf  
class4	a clinical triad to diagnose paraneoplastic retinopathy  two elderly men developed photosensitivity and light induced glare  transient visual symptoms  and progressive visual loss several months before small cell carcinoma of the lung was discovered  both patients had impaired visual acuity and color vision  ring scotomas  and attenuated retinal arteriole caliber  electroretinography demonstrated abnormal cone and rod mediated responses  antiretinal antibodies were identified in their serum  their visual sensory function improved following therapy with immunosuppressive agents  the triad of photosensitivity  ring scotomatous visual field loss  and attenuated retinal arteriole caliber should alert one to a paraneoplastic disorder affecting the retina  
class4	soluble interleukin 2 receptors in cerebrospinal fluid from individuals with various neurological disorders  soluble interleukin 2  il 2r  levels in the cerebrospinal fluid  csf  were studied in infectious  inflammatory  degenerative  and neoplastic disorders to evaluate their usefulness as a marker for the presence of activated t cells  thus indicating an inflammatory process  csf from control subjects and patients with stationary  progressive  and treated multiple sclerosis  ms   aseptic meningitis  lymphoid and nonlymphoid central nervous system  cns  tumors  alzheimer s disease  as well as serum from ms patients and control subjects were studied for levels of soluble il 2r  a significant increase in csf il 2r levels was observed in patients with ms  meningitis  and lymphoid cns tumors  the ms group showed the highest values  csf from individuals with alzheimer s disease and from patients with nonlymphoid tumors did not show significantly elevated values  serum il 2r levels were significantly higher in ms patients than in control subjects  but there was no significant correlation between individual serum and csf il 2r levels  this study suggests the presence of activated t lymphocytes in the cns of patients with ms  
class4	bactericidal effect of doxycycline associated with lysosomotropic agents on coxiella burnetii in p388d1 cells  there is no consistently reliable treatment for endocarditis resulting from chronic coxiella burnetii infection  the causative agent of q fever  although certain antibiotics are recommended on the basis of their in vitro bactericidal activities  results of therapy with these antibiotics are often disappointing  to evaluate whether the currently recommended antibiotic susceptibility tests for c  burnetii give misleading results because of continued division of uninfected cells  thereby resulting in the dilution of infected cells and  hence  a false picture of antibiotic efficacy  we blocked cell division during antibiotic susceptibility testing with cycloheximide  using this new method  we found that the currently recommended antibiotics for the treatment of q fever  doxycycline  pefloxacin  and rifampin  did not reduce the ratio of infected to noninfected cells  either l929 or p388d1  by 9 days postinfection  to test the hypothesis that this lack of antibacterial activity is due to antibiotic inactivation by the low ph of the phagolysosomes in which c  burnetii is found  we used alkalinizing lysosomotropic agents  chloroquine or amantadine  concurrently with doxycycline  this resulted in the sterilization of c  burnetii infection in p388d1 cells  this finding seems to confirm our suspicion that the acidic conditions of the phagolysosomes in which c  burnetii is located inhibit antibiotic activity  this inhibition can be reversed in vitro when lysosomotropic alkalinizing agents are used  
class4	histopathologic spectrum of clinically atypical melanocytic nevi  ii  studies of nonfamilial melanoma  published erratum appears in arch dermatol 1990 dec 126 12  1616  we studied the clinically most atypical pigmented lesion removed from each of 142 patients with newly diagnosed sporadic melanoma  the specimens were categorized as to the type of nevus  ie  junctional or compound  presence of congenital features  and degree of nuclear atypicality  presence of nuclear enlargement  nuclear pleomorphism  hyperchromatism  and prominent nucleoli  of intraepidermal nevomelanocytes  the frequency of nuclear abnormality was graded as 1  rare cells   2  10  to 50  of cells   or 3  greater than 50  of cells  for each nuclear parameter  among all lesions  42  29 6   were junctional nevi  74  52 1   were compound nevi  and 14  9 9   were dermal nevi  eighteen percent of the total were either dysplastic nevi  23 cases  or malignant melanoma in situ  three cases   fourteen nevi  9 9   had congenital features  there were 12 junctional and 39 compound nevi and one dermal nevus that exhibited nuclear abnormality  but only four junctional nevi compared with 19 compound nevi had sufficient atypia for a designation of dysplastic nevus  only two nevi with congenital features demonstrated any nuclear abnormality  and these were clearly nondysplastic  thus  among nevi surgically removed as the clinically most atypical lesion in this study  compound nevi were much more likely to demonstrate nuclear atypia  and dysplasia  than were other nevi  ie  junctional or dermal nevi  or nevi with congenital features  
class4	compound blue nevus  a variant of blue nevus with an additional junctional dendritic component  a clinical  histopathologic  and immunohistochemical study of six cases  we studied six cases of heavily pigmented melanocytic lesions with features of blue nevi within the dermis  but with an additional junctional dendritic component  this compound variant of blue nevus is an uncommon lesion that has not been previously identified as a distinct histologic entity  immunoperoxidase staining for s100 protein and counterstaining with azure b distinguished the presence of melanocytes among numerous melanophages within the dermis  the compound variant of blue nevus can be distinguished histologically from combined blue nevus  pigmented spindle cell nevus  malignant melanoma  and melanosis due to a regressed malignant melanoma  the six lesions were from three men and three women whose ages ranged from 11 to 51 years  mean  31 years   three lesions were located on the trunk  two on the extremities  and one on the head  after a mean follow up period of 47 months  range  38 to 58 months   there was no evidence of recurrence  
class4	magnetic resonance imaging in neurological disorders  to investigate the role of magnetic resonance imaging  mri  in neurological disorders  115 children were studied in two groups  group a  78 patients  was studied by paired computed tomography and mri cranial scans  group b  37 patients  was studied by paired computed tomography assisted myelography  ctm  and mri spinal scans  in group a  the scans were generally equivalent for supratentorial tumours and for investigating fits  hydrocephalus  benign intracranial hypertension  and cerebral atrophies  but mri scanning was superior for posterior fossa tumours and cysts  in group b  mri scans were superior for intramedullary spinal tumours  spinal dysraphic problems with tethering or syrinx  and were complementary to ctm in diastematomyelia  
class4	long term course of patients with persistent hypercalcitoninemia after apparent curative primary surgery for medullary thyroid carcinoma  thirty one patients with persistent hypercalcitoninemia after seemingly adequate primary operation for medullary thyroid carcinoma  mtc  were followed for a mean period of 11 9 years after operation  ten patients had sporadic mtc and the remaining patients were members of families with multiple endocrine neoplasia  men   either men 2a  15 patients  or men 2b  six patients   overall 5  and 10 year survival rates were 90  and 86   respectively  only four patients died at the completion of the study  two of mtc and two of unrelated causes  eleven patients  35 5   underwent surgical re exploration after demonstration of recurrent disease clinically or radiologically  in no patient did the calcitonin level return to normal after re exploration  the presence of more than three metastatic nodes at the time of initial operation was a statistically significant  p   0 003  predictor for disease recurrence  factors approaching statistical significance were patients younger than age 35  p   0 06  and the percentage of cells in the s phase of cell division  0 07   this data supports a conservative surgical philosophy in the management of the patient with persistent hypercalcitoninemia after resection of mtc  
class4	cystic tumors of the pancreas  new clinical  radiologic  and pathologic observations in 67 patients  within a 12 year period we treated 67 patients  49 women  18 men  mean age  61 years  with cystic neoplasms of the pancreas  including 18 serous cystic adenomas  15 benign mucinous cystic neoplasms  27 mucinous cystadenocarcinomas  3 papillary cystic tumors  2 cystic islet cell tumors  and 2 cases of mucinous ductal ectasia  mean tumor size was 6 cm  2 to 16 cm   in 39  the patients had no symptoms  and in 37  the lesions had been misdiagnosed as a pseudocyst  computed tomography was useful for detection  for distinguishing the microcystic subgroup of serous cystadenoma  and for showing rim calcification  all 7 cases were malignant  but was not reliable for distinguishing neoplasm from pseudocyst  serous from mucinous tumors  or benign from malignant  arteriography showed hypervascularity in 4 of 10 serous adenomas  3 of 11 mucinous carcinomas  and 1 of 1 papillary cystic tumors  endoscopic pancreatography showed no communication with the cyst cavity in 37 of 37 cases of cystic neoplasms but opacified the ectatic ducts in 2 of 2 cases of mucinous ductal ectasia  stenosis or obstruction of the pancreatic duct indicated cancer  the tumor was resected by distal pancreatectomy in 25 patients  by proximal resection in 29  and by total pancreatectomy in one  with no operative deaths  forty four per cent of the tumors were malignant  in 10 cases the tumor was unresectable because of local extension or distant metastases  and those patients died at a mean of 4 months  seventy five per cent of those resected for cure are alive without evident recurrence  because the epithelial lining of the tumor was partially  5  to 98   absent in 40  to 72  of cases of the major tumor types  and the mucinous component comprised only about 65  of mucinous cystadenoma lining  misdiagnoses on frozen and even permanent sections were made  mitoses and histologic solid growth correlated with malignancy  neuroendocrine elements were seen in 87  of benign and 47  of malignant mucinous tumors  it is recommended that the terms macrocystic and microcystic be abandoned in favor of the histologic designations serous and mucinous  incomplete examination of the cyst wall can be misleading  however  it is suggested that mucinous ductal ectasia be recognized separately from cystic tumors and that all of these lesions be resected  with the possible exception of asymptomatic confirmed serous cystadenomas  
class4	experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi  from june 1984 to september 1989  43 patients with large vena caval tumor thrombi from retroperitoneal malignancies underwent surgical treatment with cardiopulmonary bypass  cpb  and deep hypothermic circulatory arrest  dhca   the primary malignancies were renal cell carcinoma  rcc   n   39   renal pelvic transitional cell carcinoma  n   1   adrenal pheochromocytoma  n   1   and renal  n   1  or retroperitoneal  n   1  sarcoma  the level of the caval thrombus was either suprahepatic  n   27   intrahepatic  n   14   or subhepatic  n   2   in all cases the primary tumor and caval thrombus were completely removed  concomitant procedures included coronary artery bypass grafting  n   5   pulmonary resection  n   2   and hepatic lobectomy  n   1   the time of circulatory arrest ranged from 10 to 44 minutes  mean  23 5 minutes   there were two operative deaths  4 7    neither of them due to to the use of dhca  major postoperative complications occurred in 13 patients  30 2    there were no ischemic or neurologic complications and no cases of perioperative tumor embolization  the median postoperative hospital stay was 9 days  twenty two patients  51   are alive and enjoying a good quality of life  the 3 year patient survival rates in patients with localized  n   24  versus metastatic  n   15  rcc are 63 9  and 10 9   respectively  p   0 02   we conclude that cpb with dhca facilities excision of retroperitoneal malignancies with large caval thrombi and provides the potential for cure with low morbidity and mortality rates  
class4	surgical therapy in barrett s esophagus  seventy six patients with barrett s esophagus were cared for during a 10 year period  fifty six patients  74   presented with complications of the disease  there were 20 strictures  7 giant ulcers  11 cases of dysplasia  and 29 patients with carcinoma  in patients with benign disease  93  had mechanically defective sphincters and 83  had peristaltic failure of the lower esophageal body  esophageal ph monitoring showed excessive esophageal exposure to ph less than 4 in 93  and excessive exposure to ph more than 7 in 34  of the patients tested  ninety three per cent of patients with excessive alkaline exposure had complications  compared to only 44  with normal alkaline exposure  p less than 0 01   gastric ph monitoring  serum gastrin levels  and gastric acid analysis supported a duodenal source for the alkaline exposure  antireflux surgery was performed using nissen fundoplication in 30  belsey partial fundoplication in 3  and collis belsey gastroplasty in 2  six required resection with colon interposition  good symptomatic control was achieved in 77  after antireflux surgery  four patients had symptoms and signs of duodenogastric reflux  three required a bile diversion procedure  fifteen patients had an en bloc curative resection with colon interposition  one patient with high grade dysplasia on biopsy was found to have intramucosal carcinoma after simple esophagectomy  five tumors were intramucosal  seven were intramural  and four were transmural  lymph node involvement occurred only in the latter two  actuarial survival 5 years after curative resection was 53   median survival time for patients after palliative resection or no resection was 12 months  study of en bloc specimens indicated that extent of resection should be adapted to extent of disease  esophagectomy for intramucosal disease  en bloc esophagectomy with splenic preservation for intramural and transmural disease  serum cea was useful in detecting recurrent disease after surgery when the primary tumor stained positively for cea  
class4	analysis of prognostic factors and clinicopathological staging of thymoma the prognostic value of four clinical variables  age and sex of patients  association with myasthenia gravis  and clinical stage  and histological type was analyzed in 83 consecutive patients with thymoma  histologically classified as cortical  medullary  and mixed  age  sex  and association with myasthenia gravis did not prove to represent significant prognostic factors  clinical stage and histological type  on the contrary  had a highly significant prognostic value  p less than 0 001   a model of clinicopathological staging  based on both clinical stage and histological type  in which three major prognostic groups are considered is proposed  the degree of significance of this model is higher  p less than 0 0001  than that of clinical stage and histological type considered individually  its validity is further supported by the results of multivariate analysis according to the cox regression model  p   0 0001   we think it represents a prognostically valuable approach to the problem of management of thymoma  
class4	surgical treatment of cardiac myxomas  long term results  between 1965 and 1988  22 patients underwent 24 operations for cardiac myxomas  two patients had the complex myxoma syndrome  mitral valve replacement was required at initial operation in 2 patients  one patient died perioperatively  and 5 others died subsequently  the 16 surviving patients recently underwent evaluation at a mean duration of 9 years after operation  ten are asymptomatic and 6 have new york heart association class ii symptoms  nine patients continue to be employed  eleven are in sinus rhythm  3 have permanent pacemakers  and 2 have chronic atrial arrhythmias  echocardiography showed atrioventricular valve insufficiency in 3 patients and reduced contractility in 4  but no new tumor recurrences  the long term prognosis of this relatively large group of patients with cardiac myxomas has been good  patients without the complex myxoma syndrome had no recurrence  whereas 2 patients did require reoperation for mitral valve replacement  long term disability and chronic arrhythmias have been infrequent  and functional status and employability of these patients have been very good  
class4	diagnostic imaging and surgical treatment of dumbbell tumors of the mediastinum  we describe the diagnostic procedures and surgical approaches employed in 5 patients with dumbbell tumors of the mediastinum  magnetic resonance imaging accurately described the existence and longitudinal extension of the intraspinal component of the tumor and assisted in choosing the appropriate surgical approach  both the intrathoracic and intraspinal components of the tumor were resected at one time by a thoracic and neurosurgical team  we employed the grillo technique three times and a separate laminectomy and thoracotomy approach  magnetic resonance imaging proved the most useful diagnostic technique for suspected dumbbell mediastinal tumors  in our experience  the extended thoracotomy proposed by grillo and co workers worked well for small tumors involving only one foramen in which the intraspinal extension was limited to 2 to 3 cm  and when no more than two laminectomies were required  on the other hand  thoracotomy and a longitudinal paravertebral incision are preferable for larger tumors  more than 4 cm  involving more than one foramen in which the intraspinal extension exceeds 2 to 3 cm  for tumors requiring multiple laminectomy  and when bony infiltration is present  
class4	coexisting thymic carcinoid tumor and thymoma  thymic carcinoid tumors are unusual neoplasms that are different from thymomas  we report a case of coexisting thymic carcinoid tumor and thymoma associated with myasthenia gravis  the clinicopathological findings are discussed with a review of the literature  
class4	left superior vena cava  a pitfall in computed tomographic diagnosis with surgical implications  we report 2 cases in which computed tomography of the mediastinum demonstrated an abnormality originally misinterpreted as lymphadenopathy but subsequently shown to represent a left superior vena cava  misinterpretation may result in errors in optimum treatment and may complicate surgical exploration of the mediastinum  these 2 cases are presented to remind radiologists and surgeons of the possibility of this unusual anatomy  
class4	resection of the superior vena cava for primary lung cancer  5 years  survival  we describe a patient with squamous cell carcinoma of the right lung that required a resection of the superior vena cava combined with a tracheal sleeve pneumonectomy  the superior vena cava was totally replaced with a polytetrafluoroethylene graft with 115 minutes cross clamping of the superior vena cava  the patient remains healthy and the polytetrafluoroethylene graft remains patent 5 years 4 months after operation  
class4	risk of gastric cancer after gastric surgery for benign disorders  the objective of this review was to evaluate published evidence for the association between gastric resection for benign disorders and subsequent cancer of the gastric remnant  we searched the literature through medline  1970 to 1988  and through the references of relevant articles  fifty eight studies consisting of case series  uncontrolled surveys  and case control or cohort analyses were identified and critically assessed using defined methodological criteria  there were no consistent differences between the expected and observed number of cancers occurring within 15 years after gastric resection  however  all case control studies and seven of the eight cohort analyses  in which the prevalence of cancer was stratified by time since gastric resection  indicated a twofold to fourfold increase in the risk of gastric cancer in patients who survived 15 or more years after gastric surgery  we conclude that most studies of the association of gastric surgery with subsequent gastric cancer have relatively weak designs  still  the repetitive demonstration of this association by different investigators using different research designs supports the hypothesis that gastric resection increases the risk of cancer in the gastric remnant  
class4	morbidity  mortality  and quality of life for patients treated with levothyroxine in a population study of 1462 middle aged women initiated in 1968 and 1969 we identified 29 women treated with levothyroxine from 1 to 28 years  in a 12 year follow up in 1980 and 1981 we investigated the subjects for end point myocardial infarction  diabetes mellitus  stroke  cancer  and death  the status of 99 7  of the initial participants was established   the women treated with levothyroxine showed no increase in morbidity or mortality  of the 24 women still receiving levothyroxine in 1980 and 1981  22 had serum thyrotropin and triiodothyronine concentrations with in reference limits  these individuals were compared with the 968 women from the population study having no history of thyroid disease  and appeared identical as to laboratory and clinical data  with the exception of a slightly higher body mass  taller stature  and lower serum cholesterol concentration  the treated group did not differ in a life quality estimate based on 19 questions regarding life satisfaction and sensory function  we conclude that the levothyroxine treated woman suffers no side effects from her life long therapy  
class4	fast and effective treatment of malignant hypercalcemia  combination of suppositories of calcitonin and a single infusion of 3 amino 1 hydroxypropylidene 1 bisphosphonate  seventeen patients with malignant hypercalcemia were treated with a combination of a single dose of 3 amino 1 hydroxypropylidene 1 bisphosphonate  apd  also known as ahprbp or palmidronate disodium   and salmon calcitonin given as suppositories for 3 days  to assess whether such a combined short treatment has a significant benefit leading to earlier normalization of the plasma calcium level than does apd alone  17 additional patients matched for the type of tumor  initial plasma calcium level  urinary hydroxyproline level  and the dose of apd served as controls  all patients receiving the combination of calcitonin and apd achieved normalization of the plasma calcium level within 9 days  with a decrease from 3 22     0 90 mmol l  mean     sem  to 2 29     0 03 mmol l  in the group receiving apd alone  the plasma calcium level normalized in only 14 of 17 patients by day 9  in the group receiving calcitonin and apd  the drop in the plasma calcium level occurred more rapidly  and the plasma calcium values were lower from days 2 to 4  this advantage was explained by the calciuric effect of calcitonin  as reflected by a significant decrease in the notional setting of renal reabsorption of calcium  reaching 2 16     0 06 mmol l compared with 2 34     0 06 mmol l in the group receiving apd alone  there were no side effects of both treatments  in particular neither flushing nor nausea induced by the suppositories of calcitonin  clinical improvement occurred after 2 days in the group receiving the combined treatment  in conclusion  the combined treatment is rapidly effective and safe in the treatment of patients with hypercalcemia  particularly when the notional setting of renal tubular reabsorption of calcium is increased and a rapid correction of the plasma calcium level is needed  
class4	the technicon h6000 analyzer discriminates chronic lymphocytic leukemia from other b cell leukemias through automatic assessment of large unstained cells  the separation of chronic lymphocytic leukemia of b cell origin from other chronic b cell leukemias is subjective  being largely based on the morphologic features of the lymphoid cells in the peripheral blood  the percentage of large unstained cells determined with a technicon h6000 analyzer  an automated blood cell differential analyzer  technicon instruments corp  tarrytown  ny  was used as a cell volume variable in an investigation of 70 cases of chronic lymphocytic leukemia of b cell origin and of other chronic b cell leukemias  the significant degree of correlation between the percentage of large unstained cells and morphoimmunophenotypic diagnosis  although obtained for a relatively small number of cases  suggests that this method of cell volume analysis can be used to improve diagnostic reproducibility in chronic b cell leukemia  
class4	sensitivity and specificity of various morphological features of cervical condylomas  an in situ hybridization study  fifty seven cervical biopsy specimens or endocervical curettings showing condyloma  changes suggestive of condyloma  or no changes of condyloma were analyzed for presence of nuclear atypia  nuclear enlargement and irregularity in superficial epithelium   presence of multinucleated cells  and presence of perinuclear cytoplasmic clearing in superficial squamous epithelium  the findings were correlated with results of in situ hybridization with biotin labeled human papillomavirus dna probes  moderate nuclear atypia was significantly more specific than perinuclear cytoplasmic clearing and 100  sensitive for predicting cases positive for human papillomavirus  of the various morphological features analyzed  perinuclear cytoplasmic clearing had the lowest specificity for predicting positive results on in situ hybridization  
class4	study of preneoplastic changes of liver cells by immunohistochemical and molecular hybridization techniques  the status of hepatitis b virus dna was investigated by in situ hybridization in multifocal areas of a noncancerous hepatitis b virus associated cirrhosis  this liver exhibited a marked degree of dysplasia and adenomatous hyperplasia  the results of these studies were correlated with the histopathology and immunohistochemical stains for hepatitis b core and surface antigens  there was clear evidence of a marked reduction to absence of hepatitis b viral dna by in situ hybridization and absence of hbc and hbsag in the foci of liver cell dysplasia and adenomatous hyperplasia  these results support the hypothesis that liver cell dysplasia and adenomatous hyperplasia are preneoplastic in nature  
class4	persistence of mucosal gastric carcinomas for 8 and 6 years in two patients  a small gastric carcinoma was detected in a man  but he refused surgery  eight years later  he was readmitted for a check up  and a partial gastrectomy was performed  pathologic examination revealed a well differentiated adenocarcinoma restricted within the mucosa  in another man  an irregularly shaped  grossly depressed lesion indicating a malignancy was present at the gastric angle  and 6 years later he agreed to a partial gastrectomy  the lesion proved to be a well differentiated adenocarcinoma confined to the mucosa  retrospective examination of the original biopsy specimen revealed a small area of adenocarcinoma  presumably overlooked at the initial examination  thus  some gastric carcinomas of the well differentiated type can grow at an extremely slow rate  without extensive spread or invasion  findings in these cases contribute to knowledge of the biological behavior of gastric carcinomas  
class4	solid and cystic ultimobranchial body remnants in the thyroid  in this study we determined the incidence rate  89   and characterized the morphology of ultimobranchial body  ubb  remnants found in 18 serially sectioned neonatal thyroid glands  although ubb remnants are often referred to as solid cell nests  we found cystic features in 55   ciliated columnar cells were seen in 23   one contained a large pseudo papilla  the ubb cells had nuclei with features reminiscent of papillary carcinoma nuclei in that they were enlarged  oval  and contained finely dispersed chromatin when compared with follicular cell nuclei  both papillary carcinomas and ubb remnants are common  occur as tiny  solid  or cystic thyroid entities in patients of all ages  may contain papillary structures  and share some common nuclear features  therefore  it is important to include ubb remnants in the differential diagnosis of minute thyroid entities and to recognize their morphologic features  
class4	mucinous cystadenoma of the lung  a report of two cases with immunohistochemical and ultrastructural analysis  we describe two patients who presented with solitary pulmonary masses that consisted of unilocular cysts lined by columnar mucinous epithelium  the cysts contained copious mucus  the epithelial lining of the cysts showed foci of stratification and papillary infolding  histologically identical lesions have previously been termed unusual mucous cysts or mucinous cystadenomas  we believe that these tumors are true neoplasms differentiating toward the respiratory epithelial mucous cell  they should be distinguished from a variety of pulmonary neoplasms including bronchoalveolar carcinoma  bronchial mucous gland adenoma  mucoepidermoid carcinoma  and metastatic adenocarcinoma  
class4	tumor of the atrioventricular nodal region  a clinical and immunohistochemical study  autopsy specimens of 17 tumors of the atrioventricular nodal region were studied  sudden death occurred in 14 children and adults  seven of these patients had a history of atrioventricular block or syncope  three tumors were incidental findings in infants with other congenital anomalies  diaphragmatic agenesis  pulmonary hypoplasia  and meckel s diverticulum in one patient  mitral atresia in one  and congenital hydrocephalus  ventricular septal defect  patent ductus arteriosus  coarctation of the aorta  and patent omphalovitelline duct in the third  immunohistochemical stains demonstrated strong positivity for carcinoembryonic antigen in 13 of 13 cases  b72 3 antigen in 5 of 7 cases  and cytokeratin in 11 of 11 cases  twenty control cases of mesothelioma and mesothelial hyperplasia were all negative for b72 3  one showed focal carcinoembryonic antigen staining  ultrastructural analysis of one case demonstrated short rudimentary microvilli not characteristic of mesothelial cells  we conclude that so called mesotheliomas of the atrioventricular nodal region are not of mesothelial origin  because of strong carcinoembryonic antigen positivity and occasional positivity with b72 3  as these antibodies react with glycoproteins found in endodermally derived tissue and generally not with mesothelial tissue  conduction system tumors are most likely congenital rests of endodermal origin  can be associated with other congenital anomalies  and often cause symptoms of heart block and sudden death  
class4	a signet ring cell carcinoma of the ampulla of vater  we describe a variant of carcinoma of the ampulla of vater  which  to our knowledge  has not been previously described  classic signet ring cells represented the predominant cell type  and were admixed with more poorly differentiated tumor cells that were chromogranin positive  these findings raise the possibility of an amphicrine tumor of the ampulla  
class4	pulmonary blastoma with malignant melanoma component  pulmonary blastomas are rare primary tumors that consist of tubular or glandular structures embedded in an undifferentiated mesenchymal stroma  focal cartilage  bone  and skeletal muscle as well as squamous differentiation have been described in these tumors  we report a unique case of a pulmonary blastoma showing a malignant melanoma component  immunohistochemical stains for s100 protein and hmb 45 were positive in the areas of melanocytic differentiation  
class4	neonatal intracranial choriocarcinoma  a 1 month old infant died from extensive intracerebral hemorrhage due to a metastatic choriocarcinoma to the brain that presumably originated in the placenta  the clinical course was characterized by hyperbilirubinemia  repeated episodes of seizures  and intracranial hemorrhage  a computed tomographic scan revealed a large vascular mass in the left parieto occipital region and a small lesion in the left frontal lobe  the placenta was expelled during the delivery and was not examined  in view of the high level of maternal human chorionic gonadotropic hormone and the autopsy finding of metastasis  we presumed that the mass was a metastatic choriocarcinoma that had originated in the maternal placenta  to our knowledge  only one previous instance of this phenomenon has been reported  
class4	is liver transplantation justified for the treatment of hepatic malignancies  twenty eight patients received orthotopic liver transplants for malignant disease between february 1  1984  and december 31  1989  preoperative diagnoses included hepatocellular carcinoma  n   16   cholangiocarcinoma  n   3   other primary hepatic tumors  n   6   and metastatic diseases to the liver  n   3   overall actuarial survivals at 6 months  1 year  and 5 years were 67 3   51   and 31   respectively  long term survival longer than 5 years was achieved in 3 patients  the recurrence rate in patients surviving longer than 3 months is 48   median  7 months   hepatocellular carcinoma and cholangiocarcinoma had the poorest survival and highest recurrence rates  specific prognostic factors correlating with survival or recurrence could not be elucidated  these results indicate that orthotopic liver transplants can provide long term cure and palliation for malignant disease  however  patient selection is extremely important in predicting outcome  
class4	the impact of microinvasion on axillary node metastases and survival in patients with intraductal breast cancer  a rational approach to the local treatment of intraductal breast cancer continues to generate considerable debate  however  the finding of an invasive component in intraductal breast cancer is widely regarded as an appropriate indication for axillary node dissection as part of the local treatment and staging of this disease  despite this view  the natural history of patients with intraductal breast cancer with foci of microinvasion is poorly defined  between 1965 and 1988  41 patients with this pathologic finding of intraductal carcinoma with foci of microinvasion were seen at the ucla medical center  twenty three patients presented with mammographic abnormalities  while 17 patients presented with a palpable mass  one patient presented with paget s disease of the nipple  thirty three patients underwent axillary node dissection as part of their local treatment  no lymph node metastases were identified  the median follow up in 37 patients was 47 months  there have been no local recurrences and no deaths from recurrent breast cancer  intraductal breast cancer associated with microinvasion appears to be an extremely favorable lesion with minimal risk of nodal metastases  
class4	immediate breast reconstruction following mastectomy is as safe as mastectomy alone  we evaluated wound complications and potential risk factors after mastectomy with immediate breast reconstruction and compared them with similar data after modified radical mastectomy  the incidences of infection  seroma  hematoma  and epidermolysis were compared among 395 patients  305 with modified radical mastectomies and 90 with mastectomy with immediate breast reconstruction  from virginia mason medical center  seattle  wash  between 1983 and 1989  obesity  age  60 years or older   smoking  antibiotics  and wound drainage were examined as possible risk factors  there were more wound complications in the modified radical mastectomy group  48  vs 31    and specifically  more seromas  30  vs 13    in the modified radical mastectomy group  age of 60 years or older was associated with seroma and infection  drainage greater than 30 ml per day  at time of drain removal  with seroma  and smoking with epidermolysis  in the mastectomy with immediate breast reconstruction group  obesity was associated with seroma and epidermolysis  we conclude that mastectomy with immediate breast reconstruction appears to be as safe as modified radical mastectomy alone with respect to wound complications  
class4	the operative management of coexisting thyroid and parathyroid disease  three hundred eight patients who underwent operation for hyperparathyroidism were studied  fifty two  17   were identified who had a concomitant thyroid nodule  all 52 underwent parathyroidectomy and thyroid resection in a single operation  eleven of these patients  21  of those with a thyroid nodule  had differentiated thyroid cancer  one patient with parathyroid hyperplasia developed permanent hypocalcemia  none had permanent vocal cord paralysis and none required tracheostomy  thorough visual inspection and palpation of the entire thyroid gland should be performed during operations for hyperparathyroidism  incidentally discovered thyroid nodules should prompt formal lobectomy with frozen section diagnosis  unanticipated thyroid malignancies should then be treated as independent entities  treating simultaneous hyperparathyroidism and nodular thyroid disease with a single operation can be done safely  it avoids the expense and risk associated with neck reexploration and can detect unsuspected cancers  
class4	the recalcitrant perineal wound after rectal extirpation  applications of muscle flap closure  perineal wounds developing after abdominoperineal resection result in chronic purulent drainage and intermittent episodes of sepsis and are generally unresponsive to conservative medical and surgical treatment  thirteen consecutive patients  aged 27 to 74 years  mean  48 years  who underwent debridement and immediate muscle flap closure of these wounds were analyzed to identify risk factors for delayed healing and to evaluate the effectiveness of muscle flap coverage  three risk factors were identified  preoperative or postoperative radiation therapy  resection for recurrent carcinoma  and inflammatory bowel disease  a total of 19 muscle flaps  11 gracilis  five gluteal thigh  two gluteus maximus  and one rectus abdominis  were used to close these wounds  during an average 3 5 year follow up  four  31   minor complications and one  8   recurrence were noted to occur  muscle flaps provide safe  effective  single stage procedures for the closure of chronic perineal wounds  
class4	failure to detect human t cell leukemia virus related sequences in multiple sclerosis blood  we tested 11 patients with multiple sclerosis for the presence of human t cell leukemia virus type i  htlv i   or type ii  htlv ii  related sequences  dna from blood mononuclear cells was analyzed by the polymerase chain reaction utilizing three different oligonucleotide primer pairs  two of these primer pairs detect sequences shared between htlv i and htlv ii in either p24  gag protein  or in p21  env transmembrane protein  the third primer pair was synthesized based on regions in the pol gene where amino acid sequences are conserved between htlv i  htlv ii  and the related bovine leukemia virus  the multiple sclerosis samples were consistently negative while appropriate control samples were positive  we conclude that viruses related to htlv i  htlv ii  or bovine leukemia virus are not present in the blood of patients with multiple sclerosis and  therefore  that htlv bovine leukemia virus related viruses are not likely to be involved in the pathogenesis of multiple sclerosis  
class4	metastatic carcinoma to the retina  clinicopathologic findings in two cases  two cases of metastatic carcinoma to the neuroretina are reported  one patient had an oat cell carcinoma of the lung that was metastatic to the brain and retina  this was confirmed postmortem  the other patient had metastatic breast carcinoma with seeding of tumor cells into the vitreous from a focus of retinal embolism  the diagnosis was confirmed from a vitrectomy specimen  
class4	cellular immune response toward human articular chondrocytes  t cell reactivities against chondrocyte and fibroblast membranes in destructive joint diseases  articular cartilage is one of the major targets in destructive joint diseases in humans  we studied cellular immune reactions against cartilage cell surface membranes  because it has recently been suggested that these represent possible antigenic structures  based upon the observation of autoantibodies with this specificity in certain joint diseases  a striking t cell reactivity toward chondrocyte membranes was found both in blood and synovial tissue from patients with rheumatoid arthritis  this reactivity was strongly dependent on the presence of monocytes and had all the characteristics of an antigen driven process  clonal analysis demonstrated high precursor frequencies in peripheral blood t cells that were reactive against chondrocyte membranes  this response to chondrocyte membranes greatly exceeded the t cell stimulation induced by membranes from other sources such as fibroblasts or epithelial cells  in contrast to patients with rheumatoid arthritis  individuals with osteoarthritis showed a strong peripheral blood and synovial fluid t cell response not only to chondrocyte membranes  but also to fibroblast membrane material  however  there was no reactivity to epithelial cell membranes  normal donors generally did not show significant responses to any membrane preparation  these data indicate that there is a strong t cell reactivity toward chondrocyte membranes in destructive joint disorders  and this may significantly contribute to the pathogenetic processes that occur in these diseases  
class4	pseudotumor of the craniocervical junction during long term hemodialysis  a systematic study of the upper cervical spine was performed using magnetic resonance imaging in 25 patients  15 men and 10 women  who had been undergoing hemodialysis for more than 10 years  seven pseudotumors of the periodontoid soft tissue were disclosed  which were similar to the pannus recently described in rheumatoid arthritis  bone cystic radiolucencies were observed in association with these pseudotumors in 5 patients  the radiolucencies were located in the atlas  1 in the lateral mass and 1 in the anterior branch  and in the axis  3 in the odontoid process and 1 in the vertebral body   no horizontal or vertical atlantoaxial subluxation was demonstrated  these features were observed only in patients who had amyloid arthropathy  they could be a frequent  yet thus far little recognized  feature of beta 2 microglobulin amyloidosis  
class4	atrial fibrillation with cardiac tamponade as the initial manifestation of malignant pericarditis this article describes the case of a 72 year old woman with cardiac tamponade and atrial fibrillation as the initial manifestation of a lymphoid malignancy  the pathogenesis of cardiac tamponade  various diagnostic modalities  and therapy of this condition are reviewed  
class4	platelet norepinephrine and epinephrine concentration in patients with pheochromocytoma  platelet and plasma catecholamine concentrations were determined in 17 patients with surgically proven pheochromocytoma  mean age 42 3 years   in 31 patients with borderline hypertension  mean age 35 3 years  and in 9 healthy controls  mean age 39 3 years   both platelet norepinephrine and epinephrine were significantly increased in patients with pheochromocytoma when compared with hypertensive and control groups  p less than  001   no correlation between platelet and plasma catecholamines was detected in all studied groups  the diagnostic accuracy of platelet catecholamine in pheochromocytoma is limited since increased platelet norepinephrine was found in 35 5  and increased platelet epinephrine was found in 19 4  of patients with essential hypertension  
class4	a risk of malignancy index incorporating ca 125  ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer  age  ultrasound score  menopausal status  a clinical impression score and serum ca 125 level were assessed to see how they could best distinguish between patients with benign  n   101  and malignant  n   42  pelvic masses  each criteria used alone provided statistically significant discrimination  the most useful individual criteria were a serum ca 125 level of 30 u ml  sensitivity 81   specificity 75   and an ultrasound score of 2  sensitivity 71   specificity 83    three criteria could be combined in a risk of malignancy index  rmi  which is simply calculated using the product of the serum ca 125 level  u ml   the ultrasound scan result  expressed as a score of 0  1 or 3  and the menopausal status  1 if premenopausal and 3 if postmenopausal   this index was statistically virtually as effective a discriminant between cancer and benign lesions as more formal methods  using an rmi cut off level of 200  the sensitivity was 85  and the specificity was 97   patients with an rmi score of greater than 200 had  on average  42 times the background risk of cancer and those with a lower value 0 15 times the background risk  
class4	serum ca 125 levels during the menstrual cycle  serum concentrations of ca 125 were measured in different phases of the menstrual cycle in 16 women with ovulatory and 12 women with anovulatory cycles  ca 125 levels were significantly elevated during menstruation in both groups  in women with anovulatory cycles  but not in those with ovulatory cycles  ca 125 levels were already increased in the premenstrual phase  a negative correlation was found between serum ca 125 and progesterone concentrations in the premenstrual phase of the cycle  we suggest that premenstrual elevation of serum ca 125 in women with anovulatory cycles is related to premature endometrial vascular changes which are the result of the low serum progesterone concentration leading to insufficient endometrial control  thus the effect of progesterone seems to be indirect rather than a direct effect on ca 125 synthesis  when the ca 125 assay is used for diagnosis of cancer  sampling should not be done immediately before or during menstruation because the physiological elevation of the ca 125 levels may give false positive results  
class4	the effect of abdominal surgery on the serum concentration of the tumour associated antigen ca 125  the ca 125 assay is used to monitor the course of disease in women with adenocarcinoma of the genital tract  we measured serum ca 125 levels longitudinally in three different groups of patients who had normal serum ca 125 levels  less than or equal to 16 u ml  before extensive intraperitoneal abdominal surgery  group 1  second look laparotomy in 28 women with ovarian cancer  group 2  radical hysterectomy in 42 patients with cervical cancer  group 3  13 men and one woman who had aortic surgery for atherosclerotic occlusive disease or aneurysm formation   following surgery  rising serum ca 125 levels were observed in 69 out of the 84 patients  82    irrespective of the primary diagnosis  type of operation or sex  the highest levels were found during the second week after the operation  range 3 336 u ml  and decreased gradually thereafter  to become normal at 8 weeks after surgery  it was concluded that abdominal surgery interferes with the specificity of ca 125 as a tumour marker during the early postoperative period  
class4	choroidal osteoma  osseous choristoma   an atypical case  a case of choroidal osteoma presenting in a 22 year old girl is reported  the tumour  unilateral and in a juxtapapillary site  appeared markedly elevated on the retinal plane  not flat or slightly elevated as in previous reports  visual acuity was not affected  and there was a complete absence of subjective symptoms  echography  fluorangiography  computerised tomography  and visual field tests were performed  echography is the best method for identifying and differentiating this lesion from a malignant tumour  
class4	all trans retinoic acid as a differentiation therapy for acute promyelocytic leukemia  i  clinical results  twenty two patients with acute promyelocytic leukemia were treated with all trans retinoic acid  ra  45 mg m2 per day  for 90 days  of the 22  four patients were previously untreated  two were resistant after conventional chemotherapy  and 16 were in first  n   11   second  n   4   or third  n   1  relapse  we observed 14 complete response  four transient responses  one failure  and three early deaths  length of hospitalization and number of transfusions were notably reduced in complete responders  correction of coagulation disorders and an increase of wbcs were the first signs of all trans ra efficacy  morphologic analysis performed at days 0  15  30  45  60  and 90 showed that complete remissions were obtained without bone marrow  bm  hypoplasia  presence of auer rods in the maturing cells confirmed the differentiation effect of the treatment  at remission  the t 15 17  initially present in 20 patients was not found  the in vitro studies showed a differentiation in the presence of all trans ra in 16 of the 18 tested cases  the single nonresponder to all trans ra in vitro did not respond in vivo  adverse effects of ra therapy  skin and mucosa dryness  hypertriglyceridemia  and increase of hepatic transaminases  were frequently noted  we also observed bone pain in 11 patients and hyperleukocytosis in four patients  whether maintenance treatment consisted of low dose chemotherapy or all trans ra  early relapses were observed  five patients are still in complete remission  cr  at 4 to 13 months  our study confirms the major efficacy of all trans ra in m3  even in relapsing patients  remissions are obtained by a differentiation process  
class4	all trans retinoic acid in acute promyelocytic leukemias  ii  in vitro studies  structure function relationship  all trans retinoic acid induces leukemic cells from patients with acute promyelocytic leukemia  m3  to differentiate in vitro to mature granulocytes which express the cd15 antigen and are capable of respiratory burst function  of 35 m3 samples  only one failed to respond  in eight cases  we compared the efficacy of two naturally occurring isomers of retinoic acid  all trans ra and 13 cis ra  both isomers induce maximal differentiation at 10  6  mol l  the maximal response was maintained at 10  7  mol l for the all trans but not for the 13 cis ra  we also observed that the metabolites 4 oxo all trans and 4 oxo 13 cis were effective at 10  6  mol l  this 1 order of magnitude difference in the in vitro differentiating potencies of all trans ra and 13 cis ra in the blasts of promyelocytic leukemias predicts a difference in the clinical efficacy of the two drugs  
class4	autologous bone marrow transplantation in high risk remission t lineage acute lymphoblastic leukemia using immunotoxins plus 4 hydroperoxycyclophosphamide for marrow purging  fourteen patients with high risk t lineage acute lymphoblastic leukemia  all  in complete remission underwent autologous bone marrow transplantation  bmt  in an attempt to eradicate their residual disease burden  a combined immunochemotherapy protocol using a cocktail of two immunotoxins directed against cd5 tp67 and cd7 tp41 t lineage differentiation antigens in combination with the in vitro active cyclophosphamide congener 4 hydroperoxy cyclophosphamide  4 hc  was used to purge autografts  despite high dose pretransplant radiochemotherapy and effective purging of autografts  9 of 14 patients relapsed at a median of 2 5 months  range  1 2 to 16 8 months  post bmt  two patients remain alive and disease free at 26 and 28 months post bmt  we used a novel quantitative minimal residual disease  mrd  detection assay  which combines fluorescence activated multiparameter flow cytometry and cell sorting with leukemic progenitor cell  lpc  assays  to analyze remission bone marrow  bm  samples from t lineage all patients for the presence of residual lpcs  notably  high numbers of residual lpc detected in remission bm before bmt constituted a poor prognostic indicator  providing the first evidence for the biologic significance and clinical value of in vitro t lineage all lpc assays  the median value for the residual leukemia burden before bmt  was approximately 8 6 x 10 3  lpc 10 8  mononuclear cells  mnc   approximately 0 0086  lpc   patients with a residual leukemia burden less than this median value appeared to have a better outlook for remaining free of relapse after autologous bmt than patients with a greater leukemia burden  53     25  v 14     13   p    006  mantel cox   by comparison  the log kill efficacy of purging  the remaining numbers of lpc in purged autografts  or the estimated numbers of reinfused lpc  did not correlate with the probability of disease free survival  dfs   these results indicate that the primary reason for the recurrence of leukemia was inefficient pretransplant radiochemotherapy rather than inefficient purging of autografts  
class4	human basophils express interleukin 4 receptors  interleukin 4  il 4   a multipotential lymphokine reputed to play an important role in the regulation of immune responses  interacts with a variety of hemopoietic target cells through specific cell surface membrane receptors  the present study was designed to investigate whether human basophils express il 4 binding sites  for this purpose  basophils were enriched to homogeneity  93  and 98  purity  respectively  from the peripheral blood of two chronic granulocytic leukemia  cgl  donors using a cocktail of monoclonal antibodies  moabs  and complement  purified basophils bound 125i radiolabeled recombinant human  rh  il 4 in a specific manner  quantitative binding studies and scatchard plot analysis revealed the presence of a single class of high affinity il 4 binding sites  280     40 sites per cell in donor 1 and 640     45 sites per cell in donor 2  with an apparent dissociation constant  kd  of 7 12 x 10  11      2 29 x 10  11  and 9 55     3 5 x 10  11  mol l  respectively  ku812 f  a human basophil precursor cell line  was found to express a single class of 810 to 1 500 high affinity il 4 binding sites with a kd of 2 63 to 5 54 x 10  10  mol l  no change in the numbers or binding constants of il 4 receptors was found after exposure of ku812 f cells to rhil 3  a potent activator of basophils  for 60 minutes  no effect of rhil 4 on 3h thymidine uptake  release or synthesis of histamine  or expression of basophil differentiation antigens  bsp 1  cd11b  cd25  cd40  cd54  on primary human cgl basophils or ku812 f cells was observed  
class4	developmental regulation of granulocytic cell binding to hemonectin  hemonectin  hn   a component of the bone marrow  bm  extracellular matrix which promotes adhesion of cells in the granulocytic lineage  was purified to near homogeneity and tested for its ability to mediate attachment of normal and leukemic cells of granulocytic lineage  purified hn immobilized on plastic substrates promoted serum free attachment of normal granulocyte macrophage progenitor cells  cfc gm   using an in situ attachment assay in which cell attachment is inhibited by specific polyclonal antisera  when unfractionated bm cells were allowed to attach to purified hn and stained in situ  hn preferentially bound cells at earlier stages of granulocytic differentiation  these observations were confirmed using cells of the hl 60 progranulocytic cell line which mirrored this differentiation stage specific binding to hn  hn promoted attachment of 60  of uninduced hl 60 cells which were arrested at the progranulocyte stage  whereas only 15  of uninduced hl 60 cells attached to uncoated plastic and 4  to attached plastic coated with equal microgram quantities of bovine serum albumin  bsa   when hl 60 cells were induced to differentiate along the granulocytic pathway by incubation with dimethylsulfoxide  dmso   attachment to hemonectin was reduced  thus  both primary bm granulocytic cells and a granulocytic cell line show preferential attachment of those cells at earlier stages of differentiation  this developmentally regulated binding suggests a mechanism for release of maturing bm into the peripheral circulation  
class4	human macrophage colony stimulating factor induces macrophage colonies after l phenylalanine methylester treatment of human marrow  macrophage colony stimulating factor  m csf  has well known effects on murine bone marrow  but its colony stimulating activity for human bone marrow is controversial  after treatment of human bone marrow with l phenylalanine methylester  pme   macrophage colonies  cfu m  were induced by m csf in a dose dependent fashion  the optimal concentration of recombinant human macrophage colony stimulating factor  rhm csf  was 1 000 u ml  purified human urine m csf had colony stimulating activity similar to rhm csf  further studies were performed to determine the factors responsible for the enhanced cfu m formation from pme treated marrow  compared with nylon wool and carbonyl iron monocyte depletion methods  pme eliminated significantly more monocytes and myeloid cells  this observation suggested that these cells may release hematopoietic inhibitory factors for cfu m  low concentrations  1   but not normal  10   concentrations of blood monocytes were inhibitory  mean inhibition  48   to cfu m  high concentrations of monocytes  50   augmented cfu m colonies  hl 60 conditioned media was used to simulate secretory products of early myeloid cells  hl 60 conditioned media  1   inhibited cfu m formation but not granulocyte macrophage or granulocyte colonies  we conclude that m csf has colony stimulating activity for human marrow that can be recognized after removal of inhibitory cells by pme treatment  
class4	immunophenotypic characteristics of cerebrospinal fluid cells in children with acute lymphoblastic leukemia at diagnosis  the presence of meningeal involvement in children with acute lymphoblastic leukemia  all  may have important prognostic and therapeutic implications  conventional methods of diagnosing central nervous system  cns  leukemia rely on the interpretation of cerebrospinal fluid  csf  cell morphology  which may produce ambiguous results in the presence of minimal leukemic involvement  a methodology has been developed for immunophenotyping small numbers of csf cells while preserving cell morphology  csf samples from 33 children with cd10  common all antigen  calla   positive all were examined at initial presentation using both conventional morphology and this combined immunohistopathologic technique  six  18   of the samples contained lymphoblasts or cells considered morphologically suspicious for leukemic involvement  nine additional samples  27  of the total  had normal csf morphology  but contained increased numbers of calla positive cells  twelve of the 33 samples were also examined for the simultaneous presence of nuclear terminal deoxynucleotidyl transferase  tdt  and demonstrated increased numbers of cells positive for both tdt and cd10  these data suggest that a large proportion of children with all may have abnormalities of csf cells at initial diagnosis consistent with the presence of occult leukemic involvement  
class4	ph negative chronic myeloid leukemia  molecular analysis of abl insertion into m bcr on chromosome 22  leukemic cells from a patient with ph negative chronic myeloid leukemia  cml  had a normal karyotype  m bcr was rearranged and chromosome in situ hybridization showed an abl insertion between 5  and 3  m bcr on an apparently normal chromosome 22  the association of 5  bcr and 3  abl at the 5  junction of the chromosome 9 insert was typical of that found for the bcr abl fusion gene in other patients with the standard t 9 22  and cml  with an m bcr 3  probe  we cloned and characterized a 3  junction fragment  field inversion gel electrophoresis and chromosome in situ hybridization studies using a probe isolated from genomic dna 5  of the junction showed that 3  m bcr was joined to a region of chromosome 9q34 rich in repetitive sequences and lying some distance 3  of abl  the chromosome 9 insert was at least 329 kilobases long and included 3  abl and a larger portion of chromosome 9q34  our results allowed us to exclude transposon  or retroviral mediated insertion of abl into chromosome 22  instead  we favored a two translocation model in which a second translocation reconstituted a standard t 9 22  q34 q11  but left the chromosome 9 insert  including 3  abl  in chromosome 22  
class4	new type of bcr abl junction in philadelphia chromosome positive chronic myelogenous leukemia  a new and rare type of bcr abl junction between exon c3 of the 3  portion of the bcr gene and abl exon 2 has been identified in the leukemic cells of two ph1 positive chronic myelogenous leukemia patients in chronic phase  this is the fourth type of bcr abl junction so far identified in ph1 positive hematologic malignancies and is a consequence of an unusual breakpoint position on chromosome 22 that falls approximately 20 kb downstream of the major breakpoint cluster region  bcr  of the bcr gene  the new hybrid mrna is 540 base pairs  bp  longer than that expressed by the k562 cell line and could codify for a bcr abl protein carrying 180 additional aminoacids with respect to the larger p210 protein so far identified  the hematologic phenotype expressed by the two patients carrying this unusual type of bcr abl rearrangement does not significantly differ from that commonly seen in chronic myelogenous leukemia  
class4	shared idiotype expression by chronic lymphocytic leukemia and b cell lymphoma  antiidiotype  id  antibodies identify unique determinants within the surface immunoglobulin  ig  that are present on b cell tumors  anti ids have been used for diagnosis and therapy of b cell lymphoma and leukemia  a panel of 29 anti id monoclonal antibodies  moabs  that recognize shared idiotypes  sids  on b cell lymphomas was tested for reactivity with both b cell leukemias and lymphomas  ten of 40  25   cases of chronic lymphocytic leukemia  cll  reacted with at least one of the 29 anti sid moabs  three cases reacted with more than one anti sid moab  but there was no repetitive pattern of a single anti sid moab reacting with a large proportion of cll cases  in contrast  for b cell lymphoma  in which 11 of 31  36   cases reacted  one anti sid  b4 1  reacted with five of the positive cases  all were diffuse histology  restricted anti sid reactivity may lead to important insights into the etiology of certain b cell lymphomas  in addition  these anti sids may obviate the need to develop  tailor made  antibodies for individual patients  
class4	in vitro rosetting  cytoadherence  and microagglutination properties of plasmodium falciparum infected erythrocytes from gambian and tanzanian patients  to understand the molecular mechanisms that lead to sequestration of red blood cells infected with mature stages of plasmodium falciparum and to examine the relevance of earlier studies on adherence properties of laboratory derived p falciparum parasites to the natural parasite population  we analyzed gambian and tanzanian isolates for in vitro cytoadherence and antibody mediated microagglutination  eighteen cryopreserved isolates of ring stage parasites were cultured for 20 to 30 hours in vitro  in the patients original erythrocytes  to the trophozoite and schizont stage  all parasites were positive in the microagglutination assay with at least one of four african hyperimmune sera  in a rosetting assay  only 2 of the 18 isolates were strongly positive  35  and 41  of parasitized erythrocytes with more than two uninfected cells bound   thirteen isolates showed either intermediate  5  to 18   or low  less than 5   rosetting while three isolates did not form rosettes  infected cell binding of the different isolates to immobilized cd36 or thrombospondin  or c32 melanoma cells correlated with the percentage of mature parasites in the blood samples  r    932 for cd36  r    946 for thrombospondin  and r    881 for c32 melanoma cells   there was a high correlation between binding to cd36 and thrombospondin  r    982   the extent of infected cell rosetting with uninfected cells in these blood samples was not correlated with these other receptor properties  we also observed coexpression of rosetting and cytoadherence receptors on the same parasitized erythrocytes  
class4	autologous bone marrow transplantation in multiple myeloma  identification of prognostic factors  multiple myeloma remains a universally fatal malignancy with a median survival time not exceeding 3 years  a clinical trial was undertaken to determine feasibility and efficacy of marrow ablative chemoradiotherapy supported by unpurged autologous bone marrow  abmt  and to define prognostic variables  total body irradiation and either melphalan or thiotepa were administered to 55 patients  median age 53 years  range 20 to 66 years   the group of 21 patients with resistance to standard melphalan prednisone and to continuous infusions of vincristine and adriamycin with high dose dexamethasone  vad  included 7 with primary unresponsive disease and 14 with resistant relapse  among the 34 patients achieving remission with the vad regimen  14 were in first and 20 in a subsequent remission  marked cytoreduction by greater than or equal to 75  was observed among all 21 patients with refractory myeloma  whereas further cytoreduction of this magnitude was noted in only 56  of the 34 patients already in remission after vad  five of the 6 early deaths among all 55 patients occurred in the 14 patients with resistant relapse  none of whom achieved complete remission and who  as a group  had median durations of relapse free and overall survival of only 8 and 7 months  respectively  among the 41 remaining patients  there was only one early death  and 27  achieved complete remission including a 36  incidence among the 14 patients treated in first remission  their projected 4 year survival rate was 82  regardless of their disease status  first or later remission or primary resistance   when information about sensitivity to prior therapy is unavailable  the presence before abmt of both high beta 2 microglobulin levels  greater than 3 mg l  and non igg isotype helped identify 9 among the 55 patients with a very poor prognosis  all 8 responders relapsed within 9 months  and 8 patients died within 15 months  by contrast  a 4 year projected survival rate of over 70  for the other patients  about 80  of this series  justifies further investigation of this novel treatment approach in comparison with standard dose regimens  our results indicate that marrow ablative therapy cannot be recommended for myeloma patients with resistant relapse or those with a combination of risk factors  advanced tumor burden  absence of igg isotype   the apparent lack of an adverse effect of even marked plasmacytosis in autografts  up to 30   emphasizes the need for better cytoreduction rather than bone marrow purging  
class4	induction of donor type chimerism in murine recipients of bone marrow allografts by different radiation regimens currently used in treatment of leukemia patients  three radiation protocols currently used in treatment of leukemia patients before bone marrow transplantation  bmt  were investigated in a murine model  c57bl 6    c3h hej  for bm allograft rejection  these include  a  a single dose of total body irradiation  8 5 gy tbi delivered at a dose rate of 0 2 gy min    b  fractionated tbi  12 gy administered in six fractions  2 gy twice a day in 3 days  delivered at a dose rate of 0 1 gy min  and  c  hyperfractionated tbi  14 4 gy administered in 12 fractions  1 2 gy three times a day in 3 days  delivered at a dose rate of 0 1 gy min   donor type chimerism 6 to 8 weeks after bmt and hematologic reconstitution on day 12 after bmt found in these groups were compared with results obtained in mice conditioned with 8 gy tbi delivered at a dose rate of 0 67 gy min  routinely used in this murine model  the results in both parameters showed a marked advantage for the single dose 8 5 gy tbi over all the other treatments  this advantage was found to be equivalent to three  to fourfold increment in the bm inoculum when compared with hyperfractionated radiation  which afforded the least favorable conditions for development of donor type chimerism  the fractionated radiation protocol was equivalent in its efficacy to results obtained in mice irradiated by single dose 8 gy tbi  both of which afforded a smaller but not significant advantage over the hyperfractionated protocol  this model was also used to test the effect of radiation dose rate on the development of donor type chimerism  a significant enhancement was found after an increase in dose rate from 0 1 to 0 7 gy min  further enhancement could be achieved when the dose rate was increased to 1 3 gy min  but survival at this high dose rate was reduced  these results demonstrated indirectly that dose rate affects the expression of host type pluripotent stem cells  the progeny of which appear 3 to 6 weeks after treatment with 8 gy tbi delivered at a dose rate of 0 1 gy min  but which are eradicated if radiation is delivered at a dose rate of 1 3 gy min  
class4	contamination of peripheral blood stem cell harvests by circulating neuroblastoma cells  peripheral blood stem cells  pbsc  are being used as one alternative to autologous marrow rescue for patients with neuroblastoma and other solid malignancies  some physicians prefer use of pbsc because less risk of tumor contamination is believed to exist  this hypothesis was evaluated by immunocytologic analysis of blood samples and concurrently drawn bone marrow  bm  samples and of pbsc harvests obtained from 31 patients with disseminated neuroblastoma  we found circulating neoplastic cells in 75  of specimens analyzed at diagnosis  in 36  during therapy  and in 14  of pbsc harvests  tumor cells in blood obtained during therapy did not appear until 3 months after the time of diagnosis  clearance of circulating neuroblastoma cells was documented after two courses of induction chemotherapy  six of 13 patients with minimal or no bm disease had positive blood specimens  we conclude that substantial risk of tumor contamination of pb harvests exists and recommend that induction chemotherapy be administered before hematopoietic progenitor cells are collected from blood  
class4	four and a half year follow up of women with dyskaryotic cervical smears  objective  to determine the proportion of women with mild or moderate dyskaryosis in cervical smears who  a  progress to cervical intraepithelial neoplasia grade iii or worse or  b  regress  design  four and a half year cytological follow up study of women with mild or moderate dyskaryosis in cervical smears  setting  666 women  mean age 28  sd 8  years  range 14 74  found to have borderline  mild  or moderate dyskaryosis on routine screening  results  45 women  6 8   had a cone biopsy recommended on the basis of an abnormal follow up smear  severe dyskaryosis suggestive of cervical intraepithelial neoplasia grade iii or invasive cancer   and in one patient cervical intraepithelial neoplasia grade iii was reported in a biopsy specimen after dilatation and curettage  life table analysis gave a 14  probability of a patient being recommended for a biopsy after four and a half years of follow up  95  confidence interval 12  to 15    there was a significant excess incidence of invasive cancer of the cervix in the series compared with the general population  five cases observed compared with less than 0 1 expected   157 patients  24   showed reversion to a normal cell pattern sustained in several smears over more than 18 months but a single negative smear was an unreliable indicator of apparent regression  having two successive smears showing mild dyskaryosis or a smear at any time showing moderate dyskaryosis was a significant predictor of a subsequent severely dyskaryotic smear  conclusions  women found to have mild or moderate dyskaryosis in cervical smears should be kept under regular surveillance  the optimum management of these patients  by cytology or colposcopy  needs to be determined by randomised controlled trials  
class4	distribution of bony metastases in prostatic carcinoma  fifty five prostate cancer and 55 breast cancer patients with positive bone scintigrams were studied  the pattern of spread in the axial skeleton and pelvis showed differences between the 2 groups  this difference was not related primarily to bone volume at the site of metastasis  the difference in distribution of bony metastases between breast and prostate is explained by our knowledge of batson s vertebral venous plexus  
class4	increased survival of patients with massive lymphadenopathy and prostate cancer  evidence of heterogeneous tumour behaviour  the survival of patients with prostate cancer and radiologically detectable lymph node enlargement has been studied prospectively over an 8 year period  computed tomography in 108 patients presenting with symptoms  signs or biochemical results suggesting lymphatic spread revealed pelvic or abdominal node masses in 60 patients  in 29  48    the masses measured more than 4 cm and the maximum node diameter was 15 cm  two thirds of patients had advanced  t3 t4  tumour stage  following treatment  actuarial survival in all 60 patients with nodal enlargement was 40  at 5 years  within this group  survival in 22 patients with lymphadenopathy but negative bone scans at diagnosis was significantly better than that of 38 patients with both node and bone disease  70  vs 20  at 5 years   this improvement was related both to an apparent inability of certain tumours initially to progress and seed within bone and to a marked sensitivity of the node masses to subsequent hormonal manipulation  primary tumour grade was proportionally similar in both groups  unexpectedly  6 of the 38 patients with combined disease obtained a complete remission after treatment  the reason for this heterogeneous biological behaviour remains unclear  but these observations underscore the importance of vigorous treatment in all patients with advanced lymph node disease  
class4	persistent carcinoma in situ of the testis after chemotherapy for advanced testicular germ cell tumours  the chemosensitivity of testicular carcinoma in situ  cis  was analysed in 25 testes excised 10 weeks to 4 5 years following platinum based chemotherapy  cis was present in 8 of the 23 evaluable cases  35    in 5 of which the lesion coexisted with invasive germ cell tumour  it is concluded that cis may persist or recur after chemotherapy  this has implications for occult presentation of metastatic germ cell tumours and also for the management of the contralateral testis in patients with testicular germ cell tumours  
class4	the importance of prognostic factors in the individual treatment of patients with disseminated germ cell tumours  following chemotherapy for disseminated testicular cancer  55 patients underwent surgery because of residual tumour  the histological findings were viable tumour in 12 patients  mature teratoma in 12 and fibrosis and or necrosis in 31  retroperitoneal abdominal masses were evaluated radiographically before and after chemotherapy  the reduction in size of these masses after chemotherapy appeared to have prognostic significance  a decrease of more than 70  was always associated with fibrosis  a residual mass over 50 mm indicated viable tumour or mature teratoma  seminoma or embryonal carcinoma was more likely to result in fibrosis necrosis in the resected tissue  both the indiana and the eortc classification models can be used for prognosis  radiographic measurements before and after chemotherapy are of considerable prognostic significance  these objective indicators help in planning treatment and so diminish the side effects of therapy and maintain or even increase the high cure rate in disseminated testicular cancer  
class4	bile acids and the increased risk of colorectal tumours after truncal vagotomy  an association between colorectal cancer and previous peptic ulcer surgery is reported  in a prospective screening study  100 asymptomatic patients  80 men and 20 women  who had undergone truncal vagotomy at least 10 years previously were investigated by barium enema  colonoscopy and gallbladder ultrasonography  control data were obtained from forensic autopsy subjects  the incidence of neoplasms greater than or equal to 1 0 cm in the vagotomized group was 14 per cent  11 adenomas  3 carcinomas  and 3 per cent in controls  p   0 01   duodenal bile obtained at endoscopy from 21 vagotomized patients with normal gallbladders and from 21 control patients undergoing endoscopy was analysed by high performance liquid chromatography  the mean percentage of cholic  ca   chenodeoxycholic  cdca   deoxycholic  dca  and lithocholic  lca  acids in the bile of vagotomized patients was 32 3  45 6  20 7 and 1 4 per cent respectively compared with 45 3  36 2  17 9 and 0 7 per cent respectively in controls  the increased proportions of cdca and lca and decreased proportions of ca in the duodenal bile of vagotomized patients were significant  p less than 0 001  p   0 02  p   0 007   abnormalities in bile acid metabolism may help to explain the increased risk of colorectal neoplasia 10 years after truncal vagotomy  
class4	urinary tissue factor activity in colorectal disease  procoagulant activity  pca  in normal urine has been recognized for over 50 years  although tissue factor  tf  is produced by certain tumours  and is increased in both tumour associated macrophages and blood monocytes  the possibility that it might also be increased in urine has not been studied in patients with cancer  we have measured urinary pca in hospital controls without inflammatory or neoplastic disease  n   79   in patients with rheumatoid arthritis  n   8   inflammatory bowel disease  n   19   colorectal cancer  n   70  and in patients undergoing colonoscopy  n   50   urinary pca was higher  p less than 0 001  in patients with colorectal cancer and inflammatory bowel disease than controls or patients with rheumatoid arthritis  fourteen  88 per cent  out of 16 colonoscopy patients subsequently found to have carcinoma or inflammatory bowel disease had levels above the control upper quartile  compared with 8  24 per cent  out of 34 with normal colonoscopy  p less than 0 001   tf inhibitors confirmed the nature of the pca and western blotting studies indicated a urinary tf molecular weight of approximately 38 000  these studies provide further evidence of abnormal haemostasis in malignancy and suggest that determination of urinary tf may provide a useful screening test in patients undergoing colonoscopy  
class4	malignant left sided large bowel obstruction managed by subtotal total colectomy  of 60 patients presenting with acute obstructing carcinoma of the left colon  49 underwent immediate resection either by radical subtotal total colectomy  31 patients  group i  or by radical segmental resection  18 patients  group ii  of whom three had immediate anastomosis after on table bowel irrigation and 15 had a planned staged procedure  the operative mortality rate was 3 per cent in group i and 11 per cent in group ii  not a statistically significant difference   however  substantial differences were found for major morbidity  6 versus 44 per cent in groups i and ii respectively  p less than 0 01  and mean length of hospital stay  17 days in group i versus 35 days in group ii  p less than 0 05   all three patients who had on table lavage developed anastomotic leaks which necessitated a second operation to form a stoma  six patients  19 per cent  in group i required antidiarrhoeal medication in the immediate postoperative period  however  subsequent improvement in stool frequency was noted in all patients  it is concluded that subtotal total colectomy is an acceptable means of managing patients with obstructing carcinoma of the left colon in that it is associated with a low morbidity and mortality rate and good functional results  
class4	blood transfusion and recurrence of colorectal cancer  the role of platelet derived growth factors  efforts to explain the possible effects of blood transfusion on the recurrence of colorectal cancer have been based entirely on the immunosuppressive effects of blood transfusion  however  the relationship between solid tumour development and the immune system is inconclusive  we have investigated an alternative mechanism involving the potential role of growth factors in this phenomenon  using a human fibroblast   125i deoxyuridine uptake mitogenesis assay  the relative amounts of growth factor in the plasma of stored blood were measured  there was a progressive increase in mitogenesis from day 0  n   6  to day 28  n   6  p less than 0 001  mann whitney u test   the effect of growth factors on the development of liver and intraperitoneal metastases was studied in hooded lister rats  following an intraportal injection of 10 5  mc28 tumour cells  the experimental group  n   25  received 2 ml of syngeneic serum intravenously for 4 days  likewise  colonic anastomoses were performed on omentectomized rats and the peritoneal cavity seeded with 10 3  cells  the experimental groups  n   20  received either 2 ml serum intravenously repeatedly or 3 ml serum intraperitoneally  n   19   there was no significant increase in liver metastases or peritoneal disease following intravenous infusion of serum but serum delivered intraperitoneally resulted in a significant increase in tumour from 22 per cent in the controls to 89 per cent in the study group  p less than 0 01   growth factors released from platelets following blood loss into the peritoneal cavity may be important in enhancing local recurrence of colorectal cancer  
class4	laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia  forty patients with widely disseminated or locally advanced malignant obstruction of the middle or lower third of the oesophagus underwent endoscopic treatment by either ndyag laser recanalization or intubation  groups were matched on the basis of tumour location and swallowing was graded clinically before and after treatment  technical success was achieved in 17 of 20 laser treated and 18 of 20 intubated patients  pretreatment swallowing ability  histology  tumour location and overall length were unrelated to functional outcome in both groups  however  circumferential tumour length identified endoscopically strongly influenced the quality of swallowing after laser recanalization  patients with excellent swallowing quality  n   7  had significantly shorter circumferential tumour lengths  3 1 1 0  cm  than those with poorer quality swallowing  n   10   6 3 1 6 cm   p less than 0 001   both methods of treatment had low complication rates and there was one death in the series in the laser treated group  laser recanalization provides a better functional result than intubation for short  less than 4 cm  circumferential tumour  intubation at a single session seems more appropriate than repeated laser therapy when tumour length exceeds 4 cm  
class4	aetiology of pancreatic cancer curative surgery is possible in only a small minority of patients with pancreatic cancer and  to date  responses to chemotherapy and radiotherapy have been disappointing  to make any impact on the incidence of the disease a clearer understanding of its aetiology is required  this review explores present knowledge of the aetiology and epidemiology of pancreatic cancer  
class4	premorphological metabolic changes in human breast carcinogenesis  malignant breast tissue is characterized by morphological and metabolic changes when compared with normal breast tissue  in this study  the cytochemical measurement of glucose 6 phosphate dehydrogenase  g6pd  activity was used to detect abnormal metabolism in breast tissue and to determine whether abnormal metabolic activity precedes morphological change during human breast carcinogenesis  normal and benign breast tissue  morphologically normal tissue from cancer containing breasts  and malignant breast tissue were studied  in malignant tissue  mean s e m   g6pd activity was significantly increased when compared with normal and benign tissue  9 69 2 3  versus 27 02 1 7  mean integrated extinction  mie  x 100  p less than 0 01   g6pd activity was increased in morphologically normal tissue from cancer containing breasts when compared with normal and benign breast tissue from breasts with no known cancer  27 02 1 7  versus 18 42 2 6  mie x 100  p less than 0 05   these findings suggest that metabolic abnormalities precede morphological changes in breast carcinogenesis  abnormal metabolism can be detected widely within a cancer containing breast  the detection of such abnormality may prove helpful in identifying patients at high risk of developing breast cancer  
class4	a phase i study of a new cisplatin derivative for hematologic malignancies  dwa2114r  dwa  is a new derivative of platin compounds that is currently being used in phase ii studies of solid tumors in japan  the dose limiting factor is myelotoxicity with mild extramedullary toxicity  this phase i study consisted of adult patients with relapsed hematologic malignancies  eight patients received a total of 15 treatment courses of dwa  the starting dose was 800 mg m2 over 24 hours by continuous infusion  the dose was first increased to 1200 mg m2 and then to 1600 mg m2  clinical toxicity and urinary excretion studies of dwa suggested that 1200 mg m2 d for successive days would be the best type of administration  when 1200 mg m2 d was given for 5 days  grade 2 to 3 diarrhea and nausea and vomiting were encountered requiring parenteral fluids and nutritional support  this suggested that the dose limiting factor with this schedule was gastrointestinal toxicity  myelotoxicity was severe  as expected  but tolerable  one of the five patients with acute nonlymphocytic leukemia  anll  entered into complete remission and one patient with chronic myelogenous leukemia  cml  in crisis returned to the chronic phase  a phase ii trial of dwa is warranted for hematologic malignancies  especially in myeloid diseases  
class4	toxicity of high dose cytosine arabinoside in the treatment of advanced childhood tumors resistant to conventional therapy  a pediatric oncology group study  experience with high dose cytosine arabinoside  hdac  in pediatric solid tumors is limited  sixteen children with solid tumors resistant to conventional therapies were registered in a pilot pediatric oncology group  pog  study that required the administration of hdac at 3 g m2 every 12 hours for four doses  there were four cases of rhabdomyosarcoma  two cases of fibrosarcoma  four cases of neuroblastoma  and one case each of germ cell tumor  wilm s tumor  retinoblastoma  hepatocellular carcinoma  ewing s sarcoma  and burkitt s lymphoma  all eligible patients had advanced diseases and had previously received extensive chemotherapy  thirteen patients received one course of hdac and three patients received two courses of hdac  due to prior treatments  patients had less than normal marrow reserves  short term toxicity included nausea  vomiting  suppression of hemopoiesis  drug fever  and increased blood urea nitrogen  bun   creatinine  and liver enzymes  all evaluable patients recovered from their toxicities  there were no drug related deaths  none of the patients had neurologic problems  including the only patient with prior irradiation to the skull  with the above schedule  hdac appears to have manageable toxicity  
class4	endoscopic screening of early esophageal cancer with the lugol dye method in patients with head and neck cancers  the poor prognosis for esophageal cancer could be improved if lesions were detected at an early stage  to detect early esophageal cancer  endoscopic screening of the esophagus with the lugol dye method was performed in patients with head and neck cancers who were asymptomatic but regarded as being at high risk for synchronous or metachronous esophageal cancer  of 178 patients screened  9 had esophageal cancer  5 1    eight of these patients  89   were at early stages with no lymph node metastasis  most of the lesions  9 of 13 lesions  were not detectable by barium studies or ordinary endoscopic study  the epidemiologic statistical analysis of the patients confirmed that they had a significantly high observed and expected number  o e  ratio  39 7  p less than 0 001   these results demonstrate the value of endoscopic screening of the esophagus with the lugol dye method in patients with head and neck cancers and imply that endoscopic screening with the lugol dye method may be useful for detecting early esophageal cancer in individuals at risk for other causes  
class4	primary chemotherapy with or without radiation therapy and or surgery for children with localized sarcoma of the bladder  prostate  vagina  uterus  and cervix  a comparison of the results in intergroup rhabdomyosarcoma studies i and ii  a major objective of the second intergroup rhabdomyosarcoma study  irs ii   1978 to 1984  was to preserve the bladder without compromising the survival of children with localized genitourinary sarcomas arising in or near the bladder  after incisional biopsy  109 patients with localized  gross residual sarcoma of the prostate  43 patients   bladder  43 patients   vagina  20 patients   or cervix uterine corpus  3 patients  were treated with vincristine  dactinomycin  and cyclophosphamide  vac   after two to four drug courses  radiation therapy and or surgery were used to treat patients with residual or recurrent tumor  the 3 year survival rate of patients treated on this primary chemotherapy regimen  70   was similar to that of the primary surgery regimens of irs i  78   p   0 46   but the 3 year disease free survival rate was significantly inferior  52  versus 70   p   0 02   since the irs ii encouraged bladder preservation at the onset of therapy  the percentage of patients with bladder and prostate tumors who retained the bladder was initially substantially higher in irs ii  97   than in irs i  58    however  the percentages of 95 patients with bladder prostate  bp  tumors in irs ii who retained the bladder and were alive at 2 and 3 years after starting treatment were only 33  and 22   respectively  compared with 26  and 23   respectively  in the 66 patients with bp tumors in irs i  thus  sequential treatment with primary chemotherapy  followed by radiation therapy and or surgery as given in irs ii  failed to improve the eventual bladder salvage rate  
class4	a phase i study of 4  0 tetrahydropyranyladriamycin  clinical pharmacology and pharmacokinetics  a phase i study of intravenous  iv  bolus 4  0 tetrahydropyranyladriamycin  pirarubicin  was done in 55 patients in good performance status with refractory tumors  twenty six had minimal prior therapy  good risk   23 had extensive prior therapy  poor risk   and six had renal and or hepatic dysfunction  a total of 167 courses at doses of 15 to 70 mg m2 were evaluable  maximum tolerated dose in good risk patients was 70 mg m2  and in poor risk patients  60 mg m2  the dose limiting toxic effect was transient noncumulative granulocytopenia  granulocyte nadir was on day 14  range  4 22   less frequent toxic effects included thrombocytopenia  anemia  nausea  mild alopecia  phlebitis  and mucositis  myelosuppression was more in patients with hepatic dysfunction  pharmacokinetic analyses in 21 patients revealed pirarubicin plasma t 1 2 alpha      se  of 2 5     0 85 minutes  t beta 1 2 of 25 6     6 5 minutes  and t 1 2 gamma of 23 6     7 6 hours  the area under the curve was 537     149 ng ml x hours  volume of distribution  vd  3504     644 l m2  and total clearance  clt  was 204   39 3 l hour m2  adriamycinol  doxorubicin  adriamycinone  and tetrahydropyranyladriamycinol were the metabolites detected in plasma and the amount of doxorubicin was less than or equal to 10  of the total metabolites  urinary excretion of pirarubicin in the first 24 hours was less than or equal to 10   activity was noted in mesothelioma  leiomyosarcoma  and basal cell carcinoma  the recommended starting dose for phase ii trials is 60 mg m2 iv bolus every 3 weeks  
class4	successful treatment of metastatic thymic carcinoma with cisplatin  vinblastine  bleomycin  and etoposide chemotherapy  thymic carcinomas are rare malignant neoplasms of the thymic epithelium that are distinguished from the malignant thymomas by the presence of cytologic atypia  thymic carcinomas may metastasize outside of the thorax and are associated with a very poor prognosis  complete responses of thymic carcinoma to chemotherapy alone have not been reported  a 21 year old man with metastatic undifferentiated carcinoma of probable thymic origin is presented who achieved a pathologic complete response with cisplatin  vinblastine  and bleomycin chemotherapy  additional consolidative chemotherapy with cisplatin and etoposide was administered  the patient remains disease free 5 years after diagnosis  cisplatin  vinblastine  and bleomycin chemotherapy appears to have significant activity against thymic carcinoma  
class4	testicular relapse in children with acute nonlymphoblastic leukemia  the clinical course and other distinctive features of five children who developed a testicular relapse 4 months to 25 months after the diagnosis of acute nonlymphoblastic leukemia  anll  are described  the chief presenting feature at relapse was painless testicular enlargement  as is also seen in children with acute lymphoblastic leukemia who relapse in the testes  by french american british convention  the malignant cells were classified as m4  myelomonoblastic  in four cases and m2  myeloblastic  in one  all children received a course of multiagent reinduction chemotherapy and all but one received local irradiation to the testes  only one of these children  whose relapse was a late event after elective cessation of therapy  is a long term survivor  a comparison with six previously published cases shows similar clinical characteristics and outcome  given the poor responses of such patients to conventional treatment  it seems worthwhile to consider the use of intensive reinduction chemotherapy with concomitant bilateral testicular irradiation followed by remission intensification and an autologous or allogenic marrow transplant  
class4	structural and ultrastructural study of the ovary in childhood leukemia after successful treatment  ovarian biopsy specimens from ten girls  three postmenarcheal  who had undergone antiblastic treatment for acute lymphoblastic leukemia  all  and were in complete remission were examined by light microscope  the biopsy specimens from four of these patients  three postmenarcheal  were also observed by electron microscope  the structural and ultrastructural analysis showed a reduction in the number of follicles which were otherwise normal  no follicles were found in the thin sections from two of the three postmenarcheal girls  whereas normal follicles were observed in the third  the cortical stroma showed moderate to severe signs of fibrosis and changes of capillaries  all of these alterations were more evident in patients where all was diagnosed at an older age and this finding suggests that they are at a higher risk for low fertility or early menopause  
class4	surgical treatment of brain metastases in malignant melanoma  the authors report the results of a retrospective review of 13 patients who underwent 19 craniotomies for resection of metastatic malignant melanoma at the university of colorado  denver  co  between 1983 and 1989  there was preoperative evidence of extracranial disease in 11 patients  eight patients had more than one intracranial metastasis at operation  intraoperative ultrasound was used in 18 of the 19 craniotomies to minimize surgical trauma to the brain  the 30 day mortality was zero  the 30 day morbidity was minimal  no patient acquired a new neurologic deficit as a result of surgery  all patients regained at least their preoperative level of functioning  six of the patients who were living at the time of review have been followed for 4 to 25 months  median  7 5 months   the seven patients who were dead at the time of review survived 4 to 18 months  median  10 months   these results compare favorably with the survival of untreated patients with metastatic melanoma to the brain  median  1 month   patients treated with radiation therapy alone  median  2 4 months   and those treated with chemotherapy alone  median  2 4 months   the excision of metastatic melanoma from the brain  although not curative  may increase survival in patients with this problem with little morbidity and mortality even in the presence of other metastases  
class4	expression of major histocompatibility complex class ii antigens and interleukin 1 by epithelial cells of warthin s tumor  the immunoreactivity for class ii antigens of the major histocompatibility complex and interleukin 1  il 1  in warthin s tumor  wt  cells was studied  in addition to macrophages  dendritic cells  and capillary endothelia  the luminal tumor cells and some keratinocytes in the metaplastic squamous foci exhibited immunoreactivity for both class ii antigens and il 1  the distribution of the class ii antigens in the luminal tumor cells was limited to their basolateral membrane  these data  together with previous findings  strongly suggest that the luminal tumor cells of wt introduce the luminal antigen to the underlying lymphoid tissue and  thus  act as an antigen presenting cell  
class4	loss of expression of blood group antigen h is associated with cellular invasion and spread of oral squamous cell carcinomas  membrane bound carbohydrates may influence the metastatic behavior of cancer cells  forty two squamous cell carcinomas  scc  of the buccal and maxillary alveolar mucosa were studied retrospectively using a monoclonal antibody  be2  that reacts with blood group h  type 2 chain  structure and an immunoperoxidase  avidin biotin peroxidase complex  staining technique  h antigen staining within the entire tumor did not correlate with the stage of the tumor  i e   tumor spread  however  loss of staining within the most invasive sites of the tumors correlated significantly with the stage of tumor development and histologic grade of malignancy  these findings support the view that features regarding the cells of deeper parts of the carcinomas are very important for the clinical behavior of the tumors and that loss of h antigen expression is related to the stage of the tumor and invasion of carcinoma cells  
class4	occurrence of beta hexachlorocyclohexane in breast cancer patients  the residues of polycyclic aromatic hydrocarbon  pah  and neutral organochlorine compounds in breast fat of 44 breast cancer patients and 33 women free of cancer were determined  no statistically significant differences appeared between the two comparison groups with regard to occurrence of pah compounds  of the neutral organochlorine compounds  residues of beta hexachlorocyclohexane  hch  were found more frequently in breast cancer patients  after adjusting for age and parity by stepwise logistic regression  beta hch remained a significant risk factor of breast cancer  using a cutoff point for the residue level of beta hch in breast adipose tissue of more than 0 1 mg kg fat  the odds ratio was 10 51  95  ci  2 00 55 26   
class4	cell lineage markers in human pancreatic cancer  the normal pancreas consists of three major cell types or lineages that share a common embryologic origin from pluripotent endodermal precursors  the type of cell that undergoes neoplastic transformation to form a pancreatic carcinoma is controversial and may influence the phenotype and biologic behavior of the tumor  in this study  immunohistologic techniques were used to determine the cell lineage differentiation expressed in 29 primary exocrine pancreatic adenocarcinomas  five metastatic exocrine pancreatic adenocarcinomas  and five islet cell neoplasma  specimens of normal pancreas and chronic pancreatitis were used for comparison  the cell lineage markers consisted of monoclonal and polyclonal antibodies against trypsin and lipase  acinar cells   secretory component  carbonic anhydrase ii  and pancreatic cancer mucin span 1  ductal cells   and chromogranin a and somatostatin  islet cells   the expression of carcinoembryonic antigen  cea  and lysozyme were also determined  this collection of markers allowed the differentiation between acinar  ductal  and islet cells of normal pancreas and chronic pancreatitis specimens  the expression of cell lineage markers in islet cell tumors was homogeneous and restricted to chromogranin a  in contrast  the expression of these markers in primary and metastatic exocrine pancreatic adenocarcinomas was variable  reactivity with monoclonal anti cea was absent in normal pancreas  and was present in 83  of chronic pancreatitis specimens as well as 90  of exocrine pancreatic adenocarcinomas  in addition  lysozyme reactivity was absent in normal pancreas  however  lysozyme was expressed in one case of chronic pancreatitis  17 cases of primary carcinoma  and three cases of metastatic carcinoma  these findings support the concept that the original transformed cell type in many pancreatic exocrine carcinomas resemble endodermal  stem cells  that retain the capability of differentiation along more than one cell lineage pathway  
class4	expression of pancreatic secretory trypsin inhibitor gene in human colorectal tumor  expression of pancreatic secretory trypsin inhibitor  psti  gene was examined by northern blotting analyses in 31 human colorectal tumors that included two benign adenomas and 26 adenocarcinomas  among the total of 28 cases which proved to be adequate for mrna analyses  all but one showed the expression of psti at various levels  in contrast  psti expression was not detected in two malignant lymphomas of the rectum  the level of psti expression was not correlated with the patient s age  sex  tumor location or size  stage of differentiation  lymph node metastasis  or progression stage  some colorectal adenocarcinomas were also shown to express genes that can hybridize with human trypsinogen cdna probe  it looks as though in these tumors  a protease s  and its inhibitor are produced simultaneously as part of a cellular self defense mechanism  
class4	an analysis of abnormalities of the retinoblastoma gene in human ovarian and endometrial carcinoma  the altered expression of the human retinoblastoma  rb  gene has been demonstrated to play an important role in the pathogenesis of rb and other tumors  to determine whether the rb gene might be involved in the pathogenesis of human ovarian and endometrial cancer  dna from 24 human ovarian tumors  3 normal ovaries  3 endometrial carcinomas  and 1 endometrial hyperplasia was examined with an rb complementary dna probe  evidence for homozygous deletion of the rb gene was observed in only one specimen  interestingly  the specimen was an endometrioid tumor of the ovary of low malignant potential  lmp   this patient experienced rapid progression of the tumor and died 8 months after diagnosis  abnormalities of the rb gene may be involved in the aggressive biologic behavior of certain forms of ovarian carcinoma  particularly those of lmp  
class4	the physical state of human papillomavirus 16 dna in cervical carcinoma and cervical intraepithelial neoplasia  cervical carcinomas and cervical intraepithelial neoplasias  cin  were analyzed for the presence of human papillomavirus  hpv  dna using southern blot hybridization  of the five hpv types examined  hpv types 6  11  16  18  and 33   hpv 16 dna was detected most frequently  in most hpv 16 positive carcinomas examined  hpv 16 dna was present in an integrated state in cellular dna with or without the coexistence of episomal species  in one case  however  only episomal species were detected  among seven cases of hpv 16 positive cin  four contained hpv 16 dna only in the episomal state and the rest contained hpv 16 dna only in the integrated state  but the coexistence of both states was not found  these results suggest that the integration of hpv 16 dna is not necessary for cells to become malignant  although it is frequently associated with malignant cells  
class4	the world health organization s histologic classification of gastrointestinal tumors  a commentary on the second edition  the world health organization s  who  histologic classification of gastrointestinal tumors has been revised  although the general basis of classification and the overall outline remain similar to the first edition  advances in the last decade justified changes in classifying certain entities  among them were malignant lymphomas  endocrine tumors  and dysplasias  several newly recognized entities have also been added  
class4	distribution of immunoglobulins and secretory component in gastric cancer of the aged  the secretory immune system plays an important role in the local humoral immunity of the gastrointestinal tract  in order to evaluate humoral immunity in gastric cancer  distribution of immunoglobulins  ig  and secretory component was immunohistochemically studied in 74 early and 15 advanced primary gastric cancers  in non cancerous gastric mucosa  iga and igm  and secretory component were mainly identified in the cytoplasm of the intestinal metaplasia  in early gastric cancer of well differentiated type  the localization of iga and igm  and secretory component was similar to that of intestinal metaplasia  in advanced gastric cancer  they were faintly observed and showed low positivity  the number of ig containing cells infiltrating cancerous stroma was enumerated  immunoglobulin a containing cells were dominant in the stroma of early gastric cancer  on the other hand  there were few ig containing cells in the stroma of advanced gastric cancer  and the number of iga containing and igm containing cells was also decreased  these results suggest that local humoral immunity is suppressed in gastric cancer  especially in advanced gastric cancer  
class4	growth and spread of hepatocellular carcinoma  a review of 240 consecutive autopsy cases  all 240 consecutive cases of hepatocellular carcinoma  hcc  that underwent autopsy at the national cancer center hospital  tokyo  japan  between september 1962 and august 1986 were reviewed  among these cases  162  for which photographs of cut surfaces of the primary tumors were available  were grossly classified using a combination of both eggel s classification and our own into three major types  i e   nodular  massive  and diffuse as described by eggel  eggel h  beitr pathol anat 1901  30 506 604   and three subgroups of nodular type  i e   single nodular type  type 1   single nodular type with extranodular growth  type 2   and contiguous multinodular type  type 3  by our classification  kanai t et al   cancer 1987  60 810 819   seventy eight cases were classified as nodular type  comprising seven cases of type 1  61 cases of type 2  and ten cases of type 3  sixty seven and 17 cases were classified as massive and diffuse type  respectively  of the 78 nodular type tumors  59 measured less than 10 cm  whereas 64 of 67 massive type tumors were 10 cm or more in size  the incidence of intrahepatic and extrahepatic tumor spread of hcc was significantly higher for tumors measuring more than 5 cm  as to the relationship between macroscopic type and tumor spread  the frequency of spread was lowest for type 1 tumors  and high for the other types  intrahepatic metastasis was detected in 28 6  of type 1  93 4  of type 2  100  of type 3  and 98 5  of massive type tumors  lymph node metastasis was detected in 14 3  of type 1  24 6  of type 2  70  of type 3  38 8  of massive type and 52 9  of diffuse type tumors  hematogenous extrahepatic metastasis was detected in 14 3  of type 1  47 5  of type 2  70  of type 3  74 6  of massive type and 82 4  of diffuse type tumors  it appears that not only primary tumor size but also its macroscopic type has an important influence on the growth and spread of hcc  
class4	dna analysis of multiple synchronous renal cell carcinomas  the authors used retrospective quantitative dna analysis to study interrelationships between multiple synchronous renal cell carcinomas in seven patients  dna content was determined by image analysis on feulgen stained nuclear smears prepared from multiple paraffin blocks from each tumor  tumors were unilateral in four cases and bilateral in three  ten tumors had homogeneous  and four heterogeneous dna stemlines  intertumoral heterogeneity in four cases suggested multifocal origin  identical dna aneuploid indices in bilateral tumors in one case suggested metastasis from a solitary origin  abnormal dna content and heterogeneous populations began to appear in the size range 2 0 to 5 0 cm  all tumors over 5 0 cm contained nondiploid populations  although the interrelationships between these multiple synchronous neoplasms are not entirely clear  the dna analysis suggests that the occurrence of nondiploid stemlines and heterogeneous dna content may parallel both tumor growth and more aggressive behavior  
class4	giant cell tumor of bone  a clinicopathologic and dna flow cytometric analysis  flow cytometric dna analysis was performed on 60 cases of giant cell tumor of bone and the results were correlated with the clinicopathologic features  tumors studied were from 31 men and 29 women whose ages ranged from 18 to 62 years  median  29 years   the most common sites were the distal end of the femur and proximal end of the tibia  accounting for 75  of the lesions  treatment consisted of resection in 29 patients  48    curettage with bone chip packing in 15 patients  25    or curettage with cement packing in 16 patients  27    ten patients  17   had local relapse within 1 to 3 years  and two had lung metastases  forty two patients  70   exhibited tumors with a diploid dna content  16 aneuploid  27    and two tetraploid  3    six  37 5   of the aneuploid patients had relapses  one of those had been treated by resection of the tumor and five by curettage  of the remaining ten  62 5   unrelapsed aneuploid patients  nine had been treated by resection of the tumor and one by curettage  four of the 42 diploid patients  9 5   had relapses  all had been treated by curettage of the tumor  the two tetraploid tumors were treated by resection and none relapsed  histologic parameters did not correlate with relapse rate or dna pattern  although relapse was more common among aneuploid tumors  our study shows that this appears to be influenced by the treatment modality rather than the ploidy status  based on this study the dna analysis of giant cell tumor of bone has a limited utility for predicting the tumor s biologic behavior  
class4	hyperthermia alone in the treatment of recurrences of malignant tumors  experience with 60 lesions  localized hyperthermia alone has been used for the treatment of cancer recurrences in which previous conventional therapies have failed  since 1983 and 1988  57 patients with 60 lesions have been heated by means of a microwave and radiofrequency system  treatment protocol provided 45 minutes of heating at the intratumor temperature of at least 42 degrees c  twice a week  for a total number of six  eight  or ten heating sessions  invasive intratumor thermometry was performed for all lesions  complete response  cr  was obtained in ten cases  16 6   and partial response  pr  in 14  23 4    higher rates of cr were observed in the chest wall  38 5   compared with the head and neck area  11 4    trunk  10    and limbs  none   adenocarcinoma was the most responsive histologic type  40    squamous cells carcinoma had 7 7  cr  the only case of undifferentiated carcinoma showed cr  there were none on five sarcomas  long term local control  24 months  was approximately 7   the multivariate analysis showed the statistical significance of the histologic variety  adenocarcinoma versus others  p less than 0 0001   side effects and complications of the treatment were minimal  
class4	effectiveness of periodic checkup by ultrasonography for the early diagnosis of hepatocellular carcinoma  periodic checkup by ultrasonography was conducted on patients with chronic liver diseases for early detection of hepatocellular carcinoma  in 19 months  a total of 2004 examinations were performed on a total of 660 cases  179 cases with liver cirrhosis in the compensatory stage  younger than 70 years  481 cases with chronic hepatitis  aged 40 to 70 years for men and 50 to 70 years for women   of the 660 cases  22 hcc cases  3 3   were detected and finally diagnosed by angiography and or histologic examination  four of those cases  18   had a single nodule smaller than 1 cm in diameter  and 11 cases  50   had a single nodule smaller than 2 cm  surgical resection was performed on 12 cases  55    in comparison with the control group  83 hcc cases not receiving any periodic checkup   the frequency of small liver cancer and the surgical resection rate in the study group were significantly higher  this examination system by periodic ultrasonography checkup of patients with chronic hepatic diseases was effective for early detection and permitted aggressive therapy of hepatocellular carcinoma  
class4	clear cell adenocarcinoma of the lower genital tract  correlation of mother s recall of diethylstilbestrol history with obstetrical records  the written obstetric records of maternal exposure to diethylstilbestrol  des  were used as a criterion standard and compared with the des exposure history recalled by mothers of women with vaginal  cervical  or indeterminable vaginal exocervical clear cell adenocarcinoma  among cervical cases  the sensitivity of maternal recall was 50   n   2   and its specificity was 100   among vaginal and vaginal exocervical cases  this sensitivity was 72   specificity was 60   and the majority of these mothers who said they did not take des were des positive by written records  thus investigators should avoid using maternal recall alone to measure des exposure  among subjects for whom written maternal obstetric records were available  88  of vaginal cases and 46  of cervical cases were des positive  the authors conclude that few cases of vaginal clear cell adenocarcinoma should occur in young women as the cohort of women exposed in utero to des continues to age  whereas cases of cervical origin may continue to occur  
class4	sarcoid reaction mimicking intrathoracic dissemination of testicular cancer  the close observation of patients treated for testicular cancer led to the suspicion of intrathoracic and or mediastinal metastases on radiologic examination in a number of patients without other evidence of relapse  this report presents two patients with combined seminomatous and nonseminomatous germ cell tumors with isolated sarcoid reactions of hilar and interlobular lymph nodes  detected concomitant with diagnosis and 12 months after diagnosis  respectively  histologic examination appears to be imperative in these cases to avoid unnecessary chemotherapy  
class4	multiple spinal metastases from paraganglioma  isolated vertebral body metastases from paraganglioma are exceedingly rare  they have been reported to occur in the presence of active primary tumor in the neck  local recurrence  or widespread metastases  a unique case of carotid body tumor  paraganglioma  is reported with the following features   1  multiple vertebral body metastases  c6  t9  and l3  presenting with spinal cord compression  and no evidence of local recurrence or other metastatic disease   2  absence of mitoses on the original specimen or the metastatic deposit  and  3  a prolonged interval  9 years  to the development of symptomatic metastases  
class4	malignant fibrous histiocytoma developing in bone 44 years after shrapnel trauma  tumors induced by foreign bodies are uncommon in humans  but they are a relatively common occurrence in some experimental animals  the development of sarcoma in association with metallic foreign bodies has rarely been reported  the development of a malignant fibrous histiocytoma in a 65 year old man 44 years after shrapnel fragments lodged in his left arm is described  the literature regarding metallic foreign body induced cancer in humans is reviewed  
class4	genetic diagnosis of lynch syndrome ii in an extended colorectal cancer prone family  knowledge of colon cancer genetics  with particular attention to precision in hereditary cancer syndrome diagnosis  can often enable highly targeted surveillance and management strategies for patients at high genetic risk  unfortunately  the patient s family history of cancer is often given minimal attention  and knowledge of hereditary cancer syndromes is frequently limited  indeed  many physicians still consider familial adenomatous polyposis  fap  as the only genetic risk factor for colorectal cancer  this concern with fap was noted in a colorectal cancer prone kindred which for decades had been thought to manifest that syndrome  however  after meticulous genetic  medical  and pathologic studies  the cardinal phenotypic characteristics of lynch syndrome ii were observed  the potential for cancer control in current and future generations of families like this one clearly mandates the need for computerized registries which could transmit current information about hereditary colon cancer syndrome diagnosis  surveillance  and management  
class4	cancer in the families of children with soft tissue sarcoma  the cancer experience among 754 first degree relatives  mothers  fathers  and siblings  of a population based series of 177 children with soft tissue sarcoma is reported  the current study represents an extension of our earlier work in which the authors found an excess of breast cancer in the mothers of 143 of these children  there were 40 cancers among all first degree relatives  compared with 24 82 expected  relative risk  rr  1 61  p   0 006   there was no excess in fathers  but an excess of borderline significance was seen in mothers  rr 1 67  p   0 0545   and a significant excess in siblings  rr 4 55  p   0 0002   mainly due to carcinoma of the breast and pediatric tumors  results of a step forward cox multivariate analysis identified three variables in the index child which were independently associated with high cancer risk in relatives  as follows  age younger than 24 months at diagnosis  histologic type  embryonal rhabdomyosarcoma or other and unspecified soft tissue sarcoma  and male sex  it was possible  therefore  to identify a subgroup of children whose relatives are at high risk of early onset cancer  rr in this group 10 14   the pattern of cancers is consistent with the li fraumeni syndrome  the authors conclude that a marked proportion of childhood soft tissue sarcoma has a genetic basis  
class4	cholecystectomy and right colon cancer in puerto rico  a case control study was undertaken to evaluate the possible relationship between cholecystectomy and right colon cancer  two hundred patients with adenocarcinoma of the cecum or ascending colon  diagnosed between 1984 and 1989  were compared with 200 matched neighborhood controls  cholecystectomy history was obtained through interviews using structured questionnaires and subsequently validated from hospital records  a statistically significant association  odds ratio   2 14  was found between right colon cancer and a history of prior cholecystectomy  the altered bile metabolism which occurs after removal of the gallbladder may have a carcinogenic effect on the right colon  dietary habits of the colon cancer patients in our study were consistent with prior reports in the literature  showing that this group has a lower intake of vegetables and cereal fiber than the control population  
class4	concomitant cisplatin chemotherapy and radiotherapy in advanced mucosal squamous cell carcinoma of the head and neck  long term results of the radiation therapy oncology group study 81 17  one hundred twenty four eligible patients with advanced mucosal squamous cell carcinoma of the head and neck were entered into a pilot study of concomitant cisplatin  100 mg m2 given every 3 weeks for three doses  and standard irradiation  the initial complete response  cr  was 71  with an additional two cases salvaged by surgery for an overall 73  cr  when no keratin was identified in the histologic specimen  41 patients  the cr was 90   the nasopharynx showed the best cr  89   among the sites  at 4 years after treatment  the estimated locoregional tumor control rate was 43  and the survival  34   when no keratin was present in the specimen  the estimated locoregional control of tumor was superior  56  versus 38  with keratin identified  p   0 02  and the estimated survival was also superior  48  versus 26   p   0 008   acute treatment related toxicities included one death due to renal damage and two patients with life threatening renal damage  the delivery of radiotherapy was not altered  late toxicity included necrosis  3   fibrosis  4   and one fistula  the results of this study justify a randomized trial for the comparison of this combination of cisplatin and radiotherapy versus radiotherapy alone in advanced mucosal carcinomas of the head and neck  
class4	treatment of the acquired immune deficiency syndrome related kaposi s sarcoma with bleomycin as a single agent  a nonrandomized trial was conducted to assess the efficiency and toxicity of bleomycin as a single agent in treatment of non life threatening aids related kaposi s sarcoma  ks   sixty patients were enrolled in this study  they all had a disseminated and progressive non life threatening aids related ks associated with systemic symptoms and or cd4 lymphocyte count less than 400 mm3  thirty patients were treated with intramuscular bleomycin  5 mg d for 3 days every 2 or 3 weeks  and 30 others with a slow continuous intravenous infusion of bleomycin  6 mg m3 d for 4 days every 4 weeks   the mean duration of therapy was 5 months  range  2 to 24 months   a partial response was observed in 29 patients  48 3   and the disease was stabilized in 18 additional patients  30    bleomycin failed in 21 6  of patients  therapy had to be discontinued in two patients because of side effects  thus bleomycin as a single agent is a good alternative therapy for aids related ks  
class4	final report of the french multicenter phase ii study of the nitrosourea fotemustine in 153 evaluable patients with disseminated malignant melanoma including patients with cerebral metastases  one hundred sixty nine patients with histologic evidence of disseminated malignant melanoma  including patients with cerebral metastases  were entered into a phase ii study of the nitrosourea fotemustine  the treatment regimen consisted of a 100 mg m2 1 hour iv infusion every week for 3 consecutive weeks  followed by a 4  to 5 week rest period  induction therapy   in responding or stabilized patients  maintenance therapy consisted of 100 mg m2 every 3 weeks until the disease progressed  one hundred fifty three patients were evaluable for response  three complete responses and 34 partial responses were observed  according to the world health organization criteria   leading to an objective response rate of 24 2   95  confidence interval  17 4  to 31 0    responses were also documented on cerebral  25 0    visceral  19 2    or nonvisceral  31 8   metastatic sites  the median duration of response was 22 weeks  range  7 to 80 weeks   the objective response rate in previously untreated patients was 30 7   19 of 62 patients   the main toxicity was hematologic with delayed and reversible leukopenia and or thrombopenia  the objective response rate observed  especially in untreated patients   the activity on cerebral metastases  and the small amount of extra hematologic toxicity encountered suggest that fotemustine is an effective drug in disseminated malignant melanoma  
class4	treatment of advanced neuroblastoma with emphasis on intensive induction chemotherapy  a report from the study group of japan  one hundred nine newly treated patients with advanced neuroblastoma were entered in this study between january 1985 and may 1989  the eligible patients included infants younger than 12 months of age with stage iva disease  bone cortex  distant lymph node  and or remote organ metastases  and patients aged 12 months or older with stage iii or iv disease  iva plus ivb with tumor crossing the mid line and with metastases confined to bone marrow  liver  and skin   the patients first received six cyclic course of intensive chemotherapy  regimen a1   consisting of cyclophosphamide  1200 mg m2   vincristine  1 5 mg m2   tetrahydropyranyl adriamycin  pyrarubicin  40 mg m2   and cisplatin  90 mg m2   original tumors and the regional lymph node metastases were removed some time during these first six cycles of chemotherapy  the patients were further divided into three groups  patients in course 1 received alternating treatment by regimen b  cyclophosphamide and acnu  and intensified regimen a1  and those in course 2 were treated with alternating administration of regimen c  cyclophosphamide and dtic  and intensified a1  patients in course 3 were treated with bone marrow transplantation  bmt  preceded by high dose preconditioning chemotherapy  survival rates were 77  in stage iii and 54  in stage iv at 2 years  and 70  in stage iii and 45  in stage iv at 3 years  the major toxicities encountered were bone marrow suppression with leukocyte counts down to 100 mm3  mild cystitis  and hearing impairment  the 2 year survival rate was 78  in 21 patients who underwent bmt when complete remission was achieved  we concluded that our intensive induction chemotherapy is of significant value in increasing the rate of complete response  and in widening the indications for and achieving improved results of treatment with bmt  
class4	toxic dermatitis induced by 10 ethyl 10 deaza aminopterin  10 edam   a novel antifolate  a new methotrexate analog  10 ethyl 10 deaza aminopterin  10 edam   was found to induce a particular form of skin toxicity different than the skin rash reported to result from methotrexate  at histologic examination  it was found to be a toxic dermatitis that clinically most often first appears on the lower legs but can occur anywhere in the body  especially if treatment is continued  nine cases are reported  a specific risk factor could not yet be identified  discontinuation of 10 edam administration leads to complete healing  concomitant corticosteroid treatment also induces healing  
class4	chemotherapy related hemolytic uremic syndrome after the treatment of head and neck cancer  a case report  a 62 year old woman who was being treated for squamous cell carcinoma of the head and neck developed a chemotherapy related hemolytic uremic syndrome during the second cycle of neoadjuvant chemotherapy consisting of cisplatin  bleomycin  and methotrexate  though the syndrome was suspected early  attempts at reversing the hematologic and renal abnormalities were unsuccessful  at postmortem examination  the characteristic microvascular lesions of the hemolytic uremic syndrome were found in the kidneys  
class4	primary carcinoma of the upper urinary tract  effect of primary and secondary therapy on survival  the pathologic material and medical records of 76 patients with primary upper urinary tract carcinomas were reviewed to identify the role of grade and stage in predicting survival  to determine any differences in survival between ureteral and renal pelvic carcinoma  to understand the role of local therapy in low grade  low stage tumors  and to establish the usefulness of adjuvant therapies in metastatic disease  kaplan meier survival curves with cox mantel analysis for statistical significance revealed both grade and stage to be excellent predictors of survival  no differences in survival were noted between renal pelvic and ureteral carcinomas for equivalent stage tumors  for low grade  low stage tumors  although there was an increased risk of local recurrence with local therapy  there were no differences in survival between patients treated with local therapy or radical surgery  finally  cisplatin based chemotherapy seemed to improve survival in patients with metastatic disease  
class4	osteosarcoma of the maxilla in hong kong chinese postirradiation for nasopharyngeal carcinoma  a report of four cases  postirradiation osteosarcoma of the maxilla was seen in four hong kong chinese patients treated for nasopharyngeal carcinoma  these cases represent four of 42  9   cases of osteosarcoma at all sites in this institution during the period 1979 to 1989  when more than 1000 patients were treated with radiotherapy for nasopharyngeal carcinoma  the latent periods varied from 8 to 11 years from completion of radiotherapy treatment to development of osteosarcoma  the radiation dosage varied from 6000 to 6280 cgy in three of the patients  these cases fit the criteria for diagnosis of postirradiation sarcomas  maxillary osteosarcomas after irradiation for nasopharyngeal carcinoma do not appear to have been described  the very high incidence of nasopharyngeal carcinoma  for which radiotherapy is the treatment of choice  in hong kong chinese would make the occurrence of such tumors more likely in hong kong  although the small risk does not contraindicate the use of radiation in the treatment of nasopharyngeal carcinoma in view of its well documented efficacy  
class4	the significance of low grade prostate cancer on needle biopsy  a radical prostatectomy study of tumor grade  volume  and stage of the biopsied and multifocal tumor  twenty one cases showing only low gleason grade prostate carcinoma on needle biopsy were identified  in 15 cases radical prostatectomy was performed with the entire prostate embedded for thorough evaluation of grade  volume  and stage of tumor at the needle biopsy site as well as of multifocal tumor  eight specimens had solitary low grade and low volume tumor  with only one of these cases showing minimal capsular penetration and the others confined to the prostate  four cases had low grade tumor at the biopsy site  yet multifocal higher grade tumor  all of these tumor nodules were low volume and confined to the prostate  in three cases there was both low grade and high grade tumor in the nodule sampled by needle biopsy  in two of these cases the tumor was large and in the third it was small but mostly higher grade  with two of these cases showing capsular penetration  although transrectal ultrasound and repeat needle biopsy would most likely have identified either the tumors  large size or high grade component in these latter three cases  it is unlikely that these techniques would have identified the cases of multifocal higher grade tumor because of their relatively small size  furthermore  preoperative serum prostate specific antigen levels and clinical stage failed to distinguish those cases with higher grade tumor  because of the difficulty in identifying these areas of high grade tumor preoperatively  it is uncertain whether expectant therapy could be recommended even for patients with very low grade cancer on needle biopsy  
class4	perinatal infection of human t lymphotropic virus type i  the etiologic virus of adult t cell leukemia lymphoma  dna amplification of specific human t lymphotropic virus type i sequences  a gene amplification technique  polymerase chain reaction  was used to detect human t lymphotropic virus type i  htlv i   the etiologic agent of adult t cell leukemia lymphoma  in mononuclear cells in peripheral blood and breast milk of ten htlv i carrier gravida  the dna in umbilical cord blood mononuclear cells of the neonates born to the htlv i carrier gravida were also amplified and examined for the possibility of htlv i infection via placenta during pregnancy  the htlv i sequences were detected both in the peripheral blood and milk of all ten carrier gravida by southern blot analysis of amplified dna  however  htlv i proviral dna could not be detected in the cord blood of the carriers  neonates  indicating that transplacental infection of htlv i should be rare and that postpartum infection via breast milk is a likely major perinatal transmission route  
class4	impaired production of tumor necrosis factor in breast cancer  spontaneous and lipopolysaccharide  lps  induced production of tumor necrosis factor  tnf  by peripheral blood macrophages was investigated in breast cancer  whereas spontaneous tnf production by macrophages derived from patients with breast cancer was comparable with the one found in healthy controls  p greater than 0 1   lps stimulated macrophages derived from patients in the disease free interval as well as with metastatic breast cancer were found to produce significantly lower amounts of tnf  as compared with macrophages derived from healthy control individuals  p less than 0 0005   however  the production of tnf did not significantly differ between the two patient populations  p greater than 0 05   the impairment of lps induced tnf production did not depend upon such characteristics of the primary tumor as size  axillary lymph node and estrogen receptor status  or upon the fact of administration of adjuvant chemotherapy and  in patients with metastatic disease  hormone treatment  to further investigate cytokine production by macrophages  spontaneous and lps induced interleukin 1  il 1  production was investigated also  however  no difference was found between patients and controls concerning il 1 generation  the authors thus conclude that lps induced tnf production was impaired in breast cancer independent of the presence of detectable metastatic disease  whereas il 1 production remained unimpaired  
class4	medroxyprogesterone acetate lowers plasma corticotropin and cortisol but does not suppress anterior pituitary responsiveness to human corticotropin releasing factor  the endocrine action of medroxyprogesterone acetate  mpa  has been claimed to be of a glucocorticoid like nature  upon clinical observation  mpa has been shown to improve life quality and overall well being in patients with advanced breast cancer  renal carcinoma  prostatic carcinoma  and uterine adenocarcinoma  the authors have evaluated mpa endocrine action by the administration of human corticotropin releasing factor  hcrf  in a 90 minute assay in 15 patients with advanced breast cancer or renal cell carcinoma both  before the initiation of oral high dose mpa treatment  1000 mg mpa  as well as after at least 10 days of therapy  the curves for corticotropin  beta endorphin  and cortisol responses to hcrf of tumor patients who were tested before the initiation of mpa treatment were parallel to the curves of a healthy control group of probands tested under equal conditions  although at significantly higher respective hormone levels  in patients with malignant disorders assayed after mpa administration  both basal and peak hormone levels were found to be comparable with values obtained in healthy controls  in conclusion  mpa appeared to act at a suprapituitary level since pituitary responsiveness to hcrf was preserved under mpa treatment  moreover  it appeared that mpa brought the hormonal stress state found in patients with malignant tumors back to normal  
class4	possible involvement of the retinoblastoma gene in undifferentiated sinonasal carcinoma  retinoblastoma tumor formation is initiated by the loss of function of both alleles of the rb 1 gene on chromosome 13  patients with the hereditary form of retinoblastoma carry a germ line mutation at one of the two homologous gene loci in all cells and have an increased risk for nonocular tumors  mainly osteosarcoma and other mesenchymal tumors  in later life  the authors studied a 38 year old patient with sinonasal undifferentiated carcinoma  snuc  who had been treated for bilateral retinoblastoma by enucleation  left eye  and irradiation  right eye   respectively  using molecular probes for the rb 1 gene and other loci on chromosome 13  the authors detected a deletion at the rb 1 locus in metastatic snuc cells that was not present in normal tissue  these findings indicate that somatic mutations at rb 1 locus may be involved in the formation or progression of ectodermal tumors  
class4	sialosyl tn  a novel mucin antigen associated with prognosis in colorectal cancer patients  colon cancers typically produce mucin  however  it is not known whether tumor mucin plays a biological role in cancer cell behavior  to address this issue  the expression of a mucin associated antigen  sialosyl tn  was examined by immunohistochemical study in 128 primary colorectal carcinoma specimens from 137 patients who underwent curative surgical resection  antigen expression was correlated with disease free and overall 5 year survival  sialosyl tn antigen expression occurred in 112  87 5   tumors  and was independent of age  gender  tumor location  dukes  stage  depth of invasion  degree of differentiation  and ploidy status  survival at 5 years for patients with sialosyl tn negative versus sialosyl tn positive tumors was 100  versus 73   p less than 0 05  and disease free survival was 94  versus 73   respectively  p   0 12   although more advanced dukes  stage  deeper invasion  and aneuploidy were all associated with poorer overall 5 year survival  antigen negative tumors within each of these groups had much better prognoses than antigen positive tumors  multivariate regression analysis revealed that tumor ploidy  p less than 0 001  and sialosyl tn expression  p less than 0 05  were the two variables of most importance for predicting both disease free and overall survival  the authors conclude that sialosyl tn expression is an independent predictor of poor prognosis in colon cancer  and therefore suggest that qualitative mucin alterations may reflect important differences in the biological behavior of these neoplasms  
class4	characterization of epidermal growth factor receptor in normal and neoplastic human endometrium  growth factors  including epidermal growth factor  egf   have been implicated in the growth of several types of cancer  this study compares egf receptors in normal and neoplastic endometrium  membrane fractions were isolated from surgical specimens  radioreceptor assays demonstrated the presence of receptors with a dissociation constant of 0 64 nmol l in normal endometrium  affinity cross linking revealed receptor molecular weight of 150 to 170 kilodaltons  kd   a survey of samples  n   37  revealed progressive decrease of egf receptors in cancers of increasing grade  grade 1 2 adenocarcinoma decreased 34  from control  n   6  p less than 0 01   whereas grade 3 adenocarcinoma decreased 90   n   7  p less than 0 01  and sarcoma decreased by 72   n   3  p less than 0 01   the dissociation constant and molecular weight of the receptor in neoplastic endometrium did not differ significantly from normal  the inverse relationship with grade suggests receptor alteration or down regulation by hormones and or growth factors  
class4	parathyroid hormone like peptide in normal and neoplastic mesothelial cells  mesothelioma has not been commonly reported as a cause of hypercalcemia of malignancy  we have studied a patient with malignant mesothelioma and hypercalcemia in association with elevated plasma concentrations of parathyroid hormone like peptide  plp   immunohistochemical analysis of the tumor and seven of eight other mesotheliomas that were not associated with hypercalcemia revealed the presence of plp cytoplasmic immunopositivity  plp immunopositivity was also detected in normal and reactive mesothelial cells  the results of these studies suggest that plp immunoreactivity is common in normal and neoplastic mesothelial cells and raises the possibility that plp production may play a role in the pathogenesis of hypercalcemia associated with mesothelioma  
class4	increased expression of the multidrug resistance gene in undifferentiated sarcoma  we analyzed multidrug resistance gene  mdr1 gene  expression in a patient with undifferentiated sarcoma of the liver using the cloned cdna for the mdr1 gene  tissue samples were available at the time of initial diagnosis and of two intracranial relapses after chemotherapy with a regimen including doxorubicin and teniposide  the level of mdr1 gene expression was increased sevenfold in the intracranial tumor at the time of first relapse and 11 fold at the second relapse  this case may be an example of acquired multidrug resistance associated with overexpression of the mdr1 gene  
class4	diffuse intermediate lymphocytic lymphoma  a clinicopathologic study and comparison with small lymphocytic lymphoma and diffuse small cleaved cell lymphoma  controversy has recently arisen as to whether diffuse intermediate lymphocytic lymphoma  ill  should be considered a low grade or an intermediate grade non hodgkin s lymphoma for clinical purposes  therefore  the authors performed a clinicopathologic study to determine the biologic course of diffuse ill  40 cases  and compared it with small lymphocytic lymphoma  sll  51 cases  and diffuse small cleaved cell lymphoma  dsccl  14 cases   they found that patients with diffuse ill having pseudofollicular proliferation centers  pc  had a significantly longer median survival  84 months  than those without pc  46 5 months  p   0 03   the median survival of patients with sll was 72 months  whereas those with dsccl had a median survival of only 18 months  based on these findings  the authors conclude that diffuse ill with pc should be included in the low grade category of sll for clinical purposes  whereas diffuse ill without pc  true diffuse ill  should be considered an intermediate grade non hodgkin s lymphoma  true diffuse ill is similar to centrocytic lymphoma in the kiel classification and should be accorded a similar status in a modified working formulation  
class4	intraoperative pathologic diagnosis of thyroid neoplasms  report on experience with 504 specimens  intraoperative pathologic examination with frozen section  fs  was performed on 504 specimens of thyroid tissue obtained from 457 patients over a period of 9 years  after examination of permanent sections  ps  a malignant neoplasm was diagnosed in 57 specimens  11 3    50  87   of these were primary thyroid carcinoma  four  8   metastatic carcinoma  and three  5   malignant lymphoma  the fs diagnosis was  benign  in 448  88 9     malignant  in  30  5 9   and  deferred  in 26  5 2    the sensitivity of fs diagnosis of malignancy was 53  and the specificity and positive predictive value 100   the negative predictive value was 97 8  and overall accuracy 97 9   the ps disclosed a malignant neoplasm in 62  of specimens in which fs diagnosis was  deferred   sixty eight percent of papillary carcinomas  87  of undifferentiated carcinomas  and a single case of medullary carcinoma were diagnosed with fs examination  a fs diagnosis of malignancy was not made in any of the ten specimens containing follicular carcinoma  in all ten the neoplasms were well differentiated and eight were encapsulated and minimally invasive  the inability to diagnose follicular carcinoma intraoperatively with fs is the most significant factor accounting for the relatively low sensitivity of fs diagnosis of malignant thyroid neoplasms  
class4	cerebral tumor staging in patients with bronchial carcinoma by computed tomography  computerized tomographic  ct  scans of 271 patients with histologically proven bronchial carcinoma accomplished for initial tumor staging were retrospectively evaluated for signs of cerebral metastasis  the results for the histologic subtypes were quite different  in 13 8  of patients with small cell carcinoma and limited disease the authors found signs of brain metastasis  however  routine cerebral staging in these patients did not seem to be useful because of lack of therapeutic consequences  on the other hand  no patient with non small cell carcinoma  n scc  and tumor stage i or ii had brain metastases  all patients with brain metastasis from n scc had been classified as tumor stage iii before cerebral imaging  among these patients  however  the authors found brain metastasis in 17 5  of those without known distant metastatic disease  iii m0   especially in large cell carcinoma and in adenocarcinoma  stage iii m0 patients should undergo routine cerebral imaging if their tumor is surgically resectable and thoracotomy is planned  
class4	infiltration of dendritic cells in relation to tumor invasion and lymph node metastasis in human gastric cancer  the infiltration of dendritic cells determined in 210 patients with gastric carcinoma was investigated from the standpoint of tumor invasion  lymph node metastasis  and prognosis  dendritic cell infiltration was graded as  slight  and  marked   the 39  frequency in the marked infiltration group at the mucosal stage did not change in proportion to invasion into the deeper layers  the 5 year survival rate was 60 4  in patients with marked infiltration and 38 8  in those with slight infiltration  which was statistically different  p less than 0 01   the difference in survival rates was only statistically significant in those with cancer emerging from the serosa  p less than 0 001   there was a similar incidence of lymph node metastasis between the marked and slight infiltration groups in each grade of tumor invasion  however  marked infiltration of dendritic cells prevented widespread nodal involvement beyond the primary node in cases of advanced carcinoma  p less than 0 05   these findings indicate that infiltrating dendritic cells do not prevent the spread of tumor invasion but do prevent nodal involvement  therefore  for patients with a gastric cancer emerging from the serosa  the prognosis will be good  
class4	changes in gastric mucosa that antedate gastric carcinoma  endoscopic biopsy specimens of the gastric mucosa from 13 patients who were found at follow up examination to have gastric carcinoma were compared for abnormal histologic features  type of intestinal metaplasia  and presence of immunoreactive carcinoembryonic antigen  cea   with specimens from 40 tumor free controls  villus like changes and angular infolding  cytologic nuclear pleomorphism  distinct nuclear border  irregular thickness of the nuclear membrane  irregular chromatin clumping  prominent nucleoli  and distinct nucleoli were manifestations of the carcinoma group  angular infolding  distinct nuclear border  irregular thickness of the nuclear membrane  and distinct nucleoli were also observed in the latent stage before detection of carcinoma  the individual features  however  lacked specificity  histochemically  a iib subtype of intestinal metaplasia  and immunoreactive cea in the cytoplasm of foveolar epithelium appeared exclusively in the patients with carcinoma  these findings indicate that the gastric epithelium of patients with gastric carcinoma tends to be morphologically and histochemically abnormal even before the recognition of classical dysplasia  this can be described as abnormal epithelium and is believed to provide the soil on which gastric carcinoma develops  
class4	intraoral adenoid cystic carcinoma  the presence of perineural spread in relation to site  size  local extension  and metastatic spread in 22 cases  twenty two patients with an intraoral adenoid cystic carcinoma  acc   initially treated by surgery with or without postoperative radiotherapy  were examined for the presence of perineural spread in relation to primary site  size  local extension  histologic status of the surgical margins  and metastatic spread of the tumor  there seems to be no correlation between perineural spread and the primary site or size of the tumor  however  perineural spread occurred more often in tumors with local extension and in cases with surgical margins with positive results  there seems to be no statistically significant correlation between perineural invasion and distant metastatic disease  
class4	predicting distant metastases in operable breast cancer patients  risk factors for distant metastases following mastectomy and axillary node dissection for breast cancer were analyzed in a review of 1022 women  from diagnosis until the end of the adjuvant treatment  six stages were identified that corresponded well to patient data acquisition  at each stage  a prognosis study based on the cox model was carried out using all acquired information from the first stage  the results demonstrated that tumor size  nuclear pleomorphism  mitotic index  and nodal status at the top of axilla were stable independent risk factors in predicting metastasis free survival  mfs   these analyses also revealed those factors that were significantly related to mfs at one or several stages and losing their significance at a subsequent stage  this was the case with clinical node status  age  and vascular tumor emboli  other factors such as estrogen  progesterone  histologic grade  and clinical stage were never identified as independent factors at any stage  the four major stable risk factors were used to define a stratification of reference  the results demonstrated that the mere knowledge of clinical information such as tumor size  clinical node status  and age would enable 51  of the patients to be universally well classified according to that stratification  knowledge of additional factors  such as nuclear pleomorphism and mitotic index  would bring the rate up to 61   and then to 64  if supplementary information such as vascular tumor emboli were acquired  these percentages did not appear high enough to claim that the physician may make a reliable prognosis of operable breast cancer patients before acquiring information from the axillary node dissection  however  it was proven that there exist some subsets of patients with stable prognosis  i e   subsets of patients who will belong permanently to the same risk group through the stages  
class4	familial occurrence of gastric cancer in the 2 year experience of a population based registry  the authors studied the familial occurrence of tumors in 154 individuals with gastric cancer by reviewing the clinical data and the genealogical tree of all patients registered in 1986 through 1987 in the local health care district of modena  italy  for cancer of the stomach  crude and age adjusted  world population  incidence rates of gastric cancer were 34 0 and 21 4 new cases 100 000 year  respectively  in men  and 24 5 and 10 9 in women  respectively  among first degree relatives of the registered patients there were 30 cases of gastric carcinoma versus 15 cases in a control group matched for age and sex  mantel haenszel odds ratio  m h or  3 14  p less than 0 01   this excess of gastric neoplasms was observed in siblings  17 versus 7  m h or 4 33  p less than 0 02  but not in parents  13 versus 8  not significant   besides gastric cancer  there was no significant excess of other type of tumors in case families  the familial occurrence of gastric cancer tended to be more frequent in patients with  diffuse  carcinoma  52   than in subjects with  intestinal  cancer  33    although the difference was not statistically significant  in conclusion  the current investigation suggests that a  family history  for gastric neoplasms is usually observed in approximately 10  to 15  of the registered cases  as already described for other common malignancies  therefore  the familial occurrence of gastric carcinoma suggests the existence of a genetic susceptibility to cancer of the stomach  at least in a fraction of these patients  
class4	the prophylactic use of octreotide in a patient with ovarian carcinoid and valvular heart disease  this case report describes the use of octreotide  a long acting somatostatin analogue  in the management of a patient with an ovarian carcinoid tumour and severe cardiac valvular disease  this patient underwent laparotomy and tumour resection without complication  anaesthesia was induced with midazolam  fentanyl  and vecuronium  and maintained with isoflurane as well as additional fentanyl and vecuronium  however  we feel that it was the use of octreotide that prevented a life threatening crisis intraoperatively  and recommend its use in patients with carcinoid syndrome undergoing anaesthesia and surgery  
class4	elevated serum bromide concentrations following repeated halothane anaesthesia in a child  a 20 month old child received 25 brief halothane general anaesthetics over a five week period to allow cranial irradiation treatments for a posterior fossa ependymoma  personality change during the last week of the treatment protocol raised the question of possible bromide intoxication  serum bromide concentrations  using a gold chloride assay technique  were monitored at that time  and at four  and six week intervals thereafter  serum bromide concentrations demonstrated a four fold change during this period ranging from peak levels of 2 2 meq l 1  176 micrograms kg 1  during the fifth week of treatment decreasing to less than 0 5 meq l 1  less than 40 micrograms ml 1  six weeks following the end of treatments  this demonstrates the possibility for repetitive  short halothane exposures to result in elevations of serum bromide and the potential of bromide intoxication in paediatric neuro oncology patients  
class4	the presence of human papillomavirus  hpv  in solitary adult laryngeal papillomas demonstrated by in situ dna hybridization with sulphonated probes  human papilloma virus  hpv  types 6 and 11 have been repeatedly demonstrated in multiple laryngeal papillomas  and there is little doubt that these lesions are caused by hpv  it has been clearly demonstrated in recent reports that the clinical course of solitary adult onset laryngeal papillomas is entirely different from that of multiple papillomas of juvenile as well as of adult onset  we here report the presence of hpv types 6 and 11 in 19 out of 20 solitary papillomas from 16 patients  while hpv types 16 and 18 were totally absent  we conclude that the milder clinical course in such patients is most likely to be due to host factors  rather than to viral factors  
class4	chondrosarcoma complicating total hip arthroplasty in maffucci s syndrome  a 70 year old woman who was followed for 60 years for maffucci s syndrome required a total hip arthroplasty  tha  of the right hip for degenerative arthritis  this did not relieve pain  three years later  chondrosarcoma of the femur developed around the femoral component and was fatal  the roentgenographic changes after the tha were incorrectly interpreted as being caused by infection  
class4	treatment of manifest and impending pathologic fractures of the femoral neck by cemented hemiarthroplasty  thirty four patients with manifest or impending pathologic fractures of the femoral neck were treated between 1971 and 1987  breast carcinoma was the primary tumor in the majority of patients  all patients were treated with cemented hemiarthroplasty  twenty seven patients  79   could walk at an average of nine days postoperatively  all patients experienced relief of pain  two superficial wound dehiscences  one loosening of the prosthesis  and two prosthetic dislocations were encountered  mean survival was 17 6 months overall  12 months for manifest fractures and 40 months for impending fractures   these results indicate that cemented hemiarthroplasty for pathologic fractures is a safe procedure resulting in long lasting palliation without necessitating postoperative irradiation  the importance of tumor excochleation and the advantages of bone cement are emphasized  
class4	complications associated with limb salvage for extremity sarcomas and their management  a retrospective clinical review of 100 consecutive patients with extremity sarcomas managed by limb salvage operations was performed to evaluate local tumor control and morbidity  the mean follow up period was 45 1 months  overall survival was 86   there were local recurrences in 3  of patients  and 26 complications in 22 patients  wound necrosis was the most frequent complication  failure of allogeneic bone graft operations occurred in 25 patients  most of the complications were salvageable without loss of limb  limb salvage is an acceptable surgical treatment of extremity sarcomas based on adequate local control and minimal morbidity  
class4	leiomyoma of a digital artery  benign  soft tissue masses of the hand are common  a vascular leiomyoma is an unusual tumor of smooth muscle origin  in a 62 year old man  the tumor arose from within a digital artery  persistent symptoms prompted an excisional biopsy  requiring resection of a portion of the artery  adequate collateral circulation preempted the need for a vascular graft  vascular repair or grafting may be necessary if collateral circulation is not adequate  
class4	posterior nuchal cystic hygroma  published erratum appears in clin perinatol 1990 dec 17 4  viii  when cystic hygroma is detected antenatally  the prognosis is usually poor  and intrauterine or neonatal death are common  this seems especially true for turner syndrome  the largest etiologic group associated with cystic hygroma  and the lethal multiple pterygium syndromes  however  some fetuses with turner syndrome  and also with certain other diagnoses  had a good outcome  and further study of these conditions is required before more definite prognostic indicators and risk figures will be available  increasing numbers of syndromes are being reported in association with fetal cystic hygroma  and lymphedema may be a common element in their pathogenesis  mild  short lived  or otherwise uncomplicated jugular lymphatic obstruction may be a cause of the neck webbing seen in the noonan  familial pterygium colli  and distichiasis lymphedema syndromes  with earlier and more widespread fetal ultrasonography  and more sensitive techniques  a greater number of resolving fetal cases may be reported  this may clarify the natural history and provide prospective criteria for the conditions that have better prognoses  the associated conditions include autosomal dominant and recessive genetic traits  careful ultrasound study for other malformations  polyhydramnios and fetal growth parameters  a fetal karyotype  and  if appropriate  pathologic examination are required to determine the etiology and recurrence risk  the parents should be asked about exposure to alcohol or other agents and should be examined for signs of pterygium colli or noonan syndrome  if the decision is made to continue the pregnancy  and there is doubt about the natural history and prognosis  multi disciplinary supervision should include social services  neonatology  pediatric surgery  cardiology  and genetics specialties when indicated  
class4	subpleural mononuclear cell infiltration  significance in the differential diagnosis of pleuritis showing nonspecific histologic findings  to determine if patients who had lymphocyte rich pleural effusion and a pleural biopsy without any specific findings could be histopathologically differentiated between those with tuberculous and nontuberculous pleuritis  we histologically re evaluated the pleural biopsies of all patients whose pleural effusion was predominant with lymphocytes and contained no malignant cells  a total of 40 patients with a nonspecific histologic findings of pleural biopsy specimen were categorized based on their ultimate diagnosis as having tuberculous  n   15   carcinomatous  n   10  or nontuberculous  benign pleuritis  n   15   the pleural biopsy specimen of patients with nontuberculous  benign pleuritis frequently showed a band like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate  10 out of 15 patients   while the same finding was infrequent in those with tuberculous pleuritis  0 out of 15  p   0 0001  and pleuritis associated with carcinoma  three out of 10  p   0 082   based on these results  the presence of band like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate in pleural biopsy specimens of patients with lymphocyte rich pleural effusion suggests that the pleuritis is nontuberculous in its nature  
class4	feasibility of intraoperative cytodiagnosis of lung cancer  of 354 thoracotomies  114 cases involved intraoperative cytopathologic evaluation  the study included 86 men and 28 women  and 184 specimens were examined  smears were taken from the lung lesion or lymph node and the chest wall or bronchial stump by imprint or needle aspiration  intraoperative evaluations were compared with histologic findings  in 85 cases not diagnosed as malignant preoperatively  malignancy was confirmed in 97 6 percent of cases and histologic type in 71 8 percent  in the 28 cases diagnosed as malignant preoperatively  there was only one false negative  the most important finding during thoracotomy is whether a lesion is malignant or not  the time required to obtain a pathologic diagnosis also is important  we are able to obtain the results of a cytologic diagnosis within 10 min  cytologic diagnosis of malignancy during thoractomy may be a feasible and convenient method of diagnosis  especially where malignancy is suspected  
class4	concentration of tumor associated trypsin inhibitor  tati  in pleural effusions  we measured the concentration of tumor associated trypsin inhibitor  tati  in plasma and pleural fluid of 84 patients with pleural effusions of various causes  we observed elevated  greater than 30 micrograms l  tati levels in pleural fluid in 45 percent of patients with pleural effusion associated with malignant disease and in 15 percent of patients with benign disease  similar results were obtained for tati in plasma  the concentration of tati in pleural fluid closely parallelled that in plasma  in patients with renal insufficiency and in patients with biliary obstruction  the tati levels were elevated both in plasma and pleural fluid  a positive correlation was seen between the concentration of tati and the activity of alkaline phosphatase in plasma  the results show that simultaneous determination of tati in plasma and pleural fluid improves the diagnosis of cancer only marginally  our results also support the hypothesis that elevated tati levels may reflect an acute phase reaction caused by inflammatory disease or tissue destruction associated with cancer not only in inflammatory conditions  but also in malignant disease where the tumor itself is not producing tati  
class4	determinants of cell type in patients with cancer of the lungs  in order to evaluate the determinants of cell type in patients with primary lung cancer  we compared smoking characteristics in 1 939 patients  1 474 men and 465 women   patients with squamous cell carcinomas  adenocarcinomas  or small cell carcinomas were eligible  this study did not consider smoking as a risk factor for lung cancer  as all subjects had a confirmed diagnosis  we were interested in smoking history and the pattern of smoking among those whose risk was 100 percent  among these patients  we confirmed that a larger subset of nonsmoking individuals developed adenocarcinomas than squamous cell or small cell carcinomas  however  the duration and intensity of cigarette smoking  as measured by pack years  were not determinants of tumor cell type in male patients  small cell carcinomas in women were more strongly associated with cigarette smoking than either squamous cell carcinomas or adenocarcinomas  more than 3 500 different substances have been measured in tobacco smoke  including tumor initiators  promoters  and those involved in tumor progression  these data confirm the hypothesis that factors other than cigarette smoking are more likely to be involved in the initiation of adenocarcinomas than other cell types  endogenous and exogenous factors related to gender may be more important than the duration or intensity of cigarette smoking  
class4	pulmonary malignant angioendotheliomatosis  presentation with fever and syndrome of inappropriate antidiuretic hormone  a 64 year old man presented with protracted fever  hyponatremia  and mononeuritis multiplex  inappropriate antidiuretic hormone secretion was established  the absence of pulmonary infiltrates precluded any lung biopsy  autopsy revealed malignant angioendotheliomatosis involving multiple organs including the alveolar septa and pulmonary vasculature  an early diagnosis of mae in the setting of fever and siadh may be possible via transbronchial biopsy  
class4	a case of massive true thymic hyperplasia with non hodgkin s lymphoma  a case of massive true thymic hyperplasia with non hodgkin s lymphoma of the mediastinum is reported in a 14 year old boy  computed tomographic scan of the chest showed a mass of the anterior mediastinum and conspicuous swelling of the lymph nodes in the upper and lower mediastinum  they were grossly resected  the tumor of the anterior mediastinum was histologically diagnosed as true thymic hyperplasia  all of the mediastinal lymph nodes were diagnosed as non hodgkin s lymphoma  diffuse  mixed small and large cell type  
class4	urogenital dysfunction after abdominoperineal resection for carcinoma of the rectum  the long term urogenital dysfunctions in 46 of 104 surviving patients submitted to abdominoperineal resection for rectal carcinoma between 1972 and 1986 were collected and assessed  urinary retention was present in 41 percent of the men and 35 percent of women  while incontinence was present in 10 percent of men and 29 percent of women  impotence was reported by 59 percent of the males  all sexually active before surgery  dyspareunia was present in 50 percent of the women in the study  the possibility of treating prostatic hypertrophy concurrently with abdominoperineal resection in selected cases to avoid urinary retention is discussed  the limited number of responders to the survey may interfere with the global statistical significance  
class4	a critical review of chemical lymph node clearance and staging of colon and rectal cancer at ferguson hospital  1977 to 1982 a unique opportunity to evaluate the method of chemical lymph node clearance for colorectal cancer exists at ferguson hospital  lymph node clearance has been used at the institution since 1977  and this retrospective analysis was undertaken to ascertain its validity there  furthermore  the node positive group was evaluated to ascertain if the current staging system  turnbull  1967  is prognostically accurate for the dukes  c group  specifically evaluated for possible prognostic variance was the survival of those patients whose tumors demonstrated partial bowel wall penetration and only one to four positive nodes  a  c1 subset   previously reported to have favorable prognosis  eight hundred sixty four cases of colon and rectal cancer treated surgically from 1977 to 1982 were analyzed  there was a mean of 27 lymph nodes retrieved per specimen and a mean of 4 5 positive nodes per dukes  c specimen  there were 43 c1 and 201 c2 cases with five year survival rates of 73 and 38 percent  respectively  the results of chemical clearance at ferguson hospital were found to be comparable with that of other centers using chemical clearance and superior to hand dissection  the c1 subset clearly is noted to have prognostic advantage and should occupy a separate designation in any staging system  
class4	colonoscopic screening of asymptomatic patients with a family history of colon cancer  the records of 201 asymptomatic patients who underwent colonoscopy based solely on a family history of colon cancer were reviewed  eighty five patients  42 percent  had a total of 166 lesions  fifty four  27 percent  patients of the screened population had neoplastic lesions  while 31  15 percent  patients had nonneoplastic polyps  four carcinomas were found  twenty five of the patients with polyps  29 percent  had no polyps distal to the splenic flexure  these proximal polyps  and two carcinomas  would have been missed on screening with fiberoptic sigmoidoscopy  nineteen of these 25 patients had polyps smaller than 0 5 cm  which likely would have been missed with contrast enemas  almost one half  47 percent  of all polyps discovered at screening colonoscopy were proximal to the descending colon  only one patient younger than 40 years old had adenomas  the yield of polyps and cancer in patients with familial risk indicates screening colonoscopy should be considered after age 40  
class4	survival in patients with large bowel cancer  a population based investigation from the melbourne colorectal cancer study  five year survival data were obtained in 97 percent or 1105 of 1140 new patients with histologically confirmed colorectal adenocarcinoma during a 12 month period in 1981 and 1982  as part of a large comprehensive population based study of colorectal cancer incidence  etiology  and survival  the melbourne colorectal cancer study  fifteen percent of patients were dukes  a stage  32 percent were dukes  b  25 percent were dukes  c  and 29 percent were dukes  d  at five years after diagnosis  the observed survival rate was 36 percent and the adjusted rate was 42 percent  dukes  staging was a highly discriminating factor in survival  p less than 0 001   survival rates were better in women than in men and better for patients with colon cancer than for patients with rectal cancer  survival by dukes  staging was not affected by colon subsite or by the tumor being the first and single tumor  metachronous tumor  or synchronous tumor  the survival of younger patients was better for dukes  stages a  b  and c  and worse for dukes  d  survival was worse in the presence of bowel perforation in dukes  c and d stages  within dukes  d  incurable cases   survival was best in the absence of hepatic metastases  slightly worse when only hepatic metastases were present  and poorest in the presence of both hepatic and extrahepatic metastases  statistical modeling of survival determinants other than staging indicated that cell differentiation had the largest effect  survival decreasing with poor cell differentiation   followed by site  survival worse for rectal cancer than colon cancer   then age  survival better for younger patients   while bowel perforation had the smallest effect on survival  
class4	endometrioma  an intra abdominal troublemaker  a ten year review of intestinal and abdominal wall endometriomas is reported  seven cases of intestinal and two cases of abdominal wall endometriomas are presented  symptoms were varied but a majority had some gynecologic complaint  in this select group of patients  preoperative investigations did not assist in establishing the diagnosis  all patients underwent surgery and coexisting inflammatory bowel disease was present in two patients  this review suggests that endometrioma of the intestine requires a high index of suspicion for diagnosis and that danazol does not appear to be effective treatment for these patients  
class4	colonic lipoma as a source of massive hemorrhage  report of a case  colonic lipomas are a rare source of massive lower gastrointestinal bleeding requiring operative intervention  a case of massive hemorrhage from cecal lipomatosis is presented  the methods of preoperative diagnosis and treatment are discussed  
class4	malignant potential of juvenile polyposis coli  report of a case and review of the literature  juvenile polyps of the colon and rectum traditionally have been viewed as being benign inflammatory or harmartomatous lesions without potential for malignant change  the authors report a case of adenocarcinoma developing in a patient with sporadic juvenile polyposis  juvenile polyposis was diagnosed in the patient at age 4 years  he underwent subtotal colectomy at age 6 years  at age 12  he underwent a proctectomy and a swenson pull through because of adenomatous changes in the rectal stump  at age 19 surveillance endoscopy revealed invasive cancer in a juvenile polyp  
class4	early gastric cancer  endoscopic diagnosis of depth of invasion  in order to decide on a treatment strategy against gastric cancers  an accurate preoperative evaluation of the depth of cancer invasion is essential  preoperative endoscopic diagnosis of the depth of invasion was compared with pathological results of the resected specimen in 206 early gastric cancers and 32 early like advanced gastric cancers  the endoscopic distinction between early and early like advanced cancers was correctly made in 83 6  of the cases  among the early gastric cancers  mucosal and submucosal invasion was correctly presumed in 71 9  of the cases  when the tumor was an elevated type  or located in the antrum  the endoscopic diagnosis tended to be deeper than the true depth  the size of tumor contributed little to the depth diagnosis  pathomorphological changes on the tips of converging folds were the important clue for diagnosing depth  
class4	cholecystokinin stimulates growth of human pancreatic adenocarcinoma sw 1990  the effect of a synthetic analogue of cck  thr4 nle7cck 9  on growth of sw 1990 human pancreatic cancer was examined in two experimental models  nude mice bearing sw 1990 pancreatic cancer xenografts were injected with cck  5  15  or 25 micrograms kg  or vehicle twice daily for 20 days  animals were then sacrificed and tumor volume  weight  protein  and deoxyribonucleic acid  dna  content were evaluated  sw 1990 cells were grown in vitro and the effects of cck  secretin  vasoactive intestinal peptide  vip   and proglumide  a cck receptor antagonist  on cell number and dna synthesis were determined  the highest dose of cck  25 micrograms kg  significantly increased tumor weight  protein content  and dna content  p less than 0 005   in vitro  cck caused significant increases in cell counts of up to 47  at six days and 66  at 12 days compared to control  graded concentrations of cck had a biphasic effect on dna synthesis with significant increases of up to 65   p less than 0 005   cck induced cell proliferation was inhibited by proglumide  secretin slightly increased cancer cell growth  although not as potently as cck  vip or secretin in combination with cck did not show potentiation  these results indicate that growth of some human pancreatic cancers may be influenced by gastrointestinal peptides  of which cck is the most potent  
class4	improved scintigraphic assessment of severe cholestasis with the hepatic extraction fraction  in previous studies  we found that biliary scintigraphy with technetium 99m labeled iminodiacetic acid   99mtc ida  provided excellent discrimination between intrahepatic and extrahepatic cholestasis  except in patients with profound cholestasis who had poor visualization of the biliary tree  in this study  we have used deconvolution analysis to determine the hepatic extraction fraction  hef  of a hypothetical single circulatory pass of  99mtc ida  our hypothesis was that extraction of radionuclide from the blood would be normal in patients with extrahepatic obstruction alone  but would be impaired in patients with intrahepatic disease  ihd   the purpose of this study was to compare the hef in patients with profound cholestasis  bilirubin greater than or equal to 3 0 mg dl  due to either ihd or common bile duct obstruction  cbdo   normal subjects  n   13  had an hef of 100   patients with cbdo  n   13  had slightly reduced hef values  92 8     3 2   despite profound hyperbilirubinemia  6 1     1 0 mg dl   patients with ihd  n   23  had a markedly reduced hef  43 1     4 1   which was significantly lower than patients with cbdo and normal subjects  p less than 0 001   we conclude that the determination of the hef during biliary scintigraphy is helpful in distinguishing between intrahepatic and extrahepatic disease in patients with hyperbilirubinemia  bilirubin greater than or equal to 3 0 mg dl   
class4	prospective study of alcohol intake and large bowel cancer  the alcohol intake of a cohort of japanese men in hawaii is directly and significantly related to the risk of developing rectal cancer  whether assessed on the basis of amount consumed or as a percent of total calories  wine and whiskey are directly related to rectal cancer  but beer is the only alcoholic beverage that displays a statistically significant dose response  p   0 008   colon cancer risk also is related directly to alcohol intake  but the association is statistically significant only when measured as a percent of energy intake  this suggests that alcohol might displace cancer inhibitors from the diet  calcium  vitamin c  and dietary fiber are inversely related to colon cancer risk in this cohort  and each of these micronutrients displays statistically significant negative correlation with alcohol intake  a possible positive association between alcohol and lung cancer was ruled out after adjusting for cigarette smoking  cancers of the prostate and stomach were unrelated to alcohol intake  but the risk of acquiring cancer at all other sites combined was strongly related to alcohol intake  
class4	diagnosis of metastatic lesions to the stomach by salvage cytology  a report of three cases  secondary neoplasms of the stomach are rare and are often clinical and diagnostic problems  three patients with bleeding  volcano like  ulcers were diagnosed by combined endoscopic  salvage  cytology and surgical biopsy as having metastatic submucosal lesions from hematologic spread  the combination of endoscopic appearance  clinical findings  and tissue and cytologic examination can lead to the correct diagnosis  the results from these cases support the utility of this cytologic technique in combination with biopsy in this clinical setting  
class4	primary non hodgkin s t cell lymphoma of the esophagus  a case with peculiar endoscopic ultrasonographic pattern  we report a case of primary esophageal non hodgkin s t cell lymphoma in a young white female  at admission  endoscopy revealed large  irregularly shaped  esophageal ulcerations with super imposed candidiasis  endoscopic ultrasonography to assess submucosal alterations and periesophageal involvement revealed a diffuse hypoechogenic thickening  up to 5 mm  of the esophageal wall  a pattern consistent with lymphomatous infiltration  definitive diagnosis was made with the aid of histology and immunohistochemistry  
class4	anionic complex carbohydrate units of human thyroglobulin  human thyroglobulin  htg  contains sulfate in chondroitin 6 sulfate chains and in complex carbohydrates  in this study the sulfate containing complex carbohydrates were characterized by the number of sulfate and sialic acid residues that they contain  samples of normal and nodular thyroid tissue were incubated for 16 h in  35s sulfate containing medium  and htg was purified from the tissues and the media  complex carbohydrates were enzymatically removed from htg  subsequent analysis on an hplc anion exchange column at ph 2 2 separated the carbohydrate units according to their number of negative charges  sulfate containing peaks were monitored by radioactivity  and sialic acid containing peaks were identified by their shift to lower charge after treatment with neuraminidase  peaks corresponding to sialic acid free carbohydrate units with one to four sulfates were identified  also  carbohydrate units with two and three negative charges containing both sulfate and sialic acid were present  in the nodular tissue of one patient there were more sulfated units with higher charge  especially units containing sialic acid  in this patient the proportion of sulfated polyvalent units with sialic acid was 22 4  for normal and 64 6  for nodular tissue  no difference in the composition of the charged units between the tissues and their corresponding media was seen  making it unlikely that the sulfate containing carbohydrates play a role in htg release  it is concluded that htg contains complex carbohydrate units with up to four sulfate groups and units with both sulfate and sialic acid  in some patients  the sulfate containing anionic carbohydrate units of htg from normal and nodular thyroid tissue are different  
class4	hormonal treatment of functional ovarian cysts  a randomized  prospective study  estrogen  e  progestin therapy for functional ovarian cysts is widely used in clinical practice  but the efficacy of this treatment has not been determined in controlled trials  in this study  we examined the effect of e progestin administration in a group of infertility patients enrolled in a program of ovulation induction who had cysts identified by transvaginal sonography  patients were randomized to receive either norethindrone 1 mg mestranol 0 05 mg d  group a  n   24  or no treatment  group b  n   24  for up to 6 weeks  patients were re evaluated by sonography at 3  6  and 9 weeks after entry into the protocol  the ages  mean cyst diameters  and proportions of patients having received gonadotropins in the previous menstrual cycle were not significantly different among the two groups  all patients who had a sonographic abnormality persisting for 9 weeks were surgically explored and found to have pathological cysts  the rate of disappearance of functional ovarian cysts was not affected by e progestin treatment  
class4	multiple hormone elevations in zollinger ellison syndrome  prospective study of clinical significance and of the development of a second symptomatic pancreatic endocrine tumor syndrome  in the present study of 45 patients with zollinger ellison syndrome  the frequency and clinical importance of the release of multiple gastrointestinal peptides were assessed prospectively  during an initial evaluation  extent of gastrinoma  clinical symptoms  disease duration  and presence or absence of multiple endocrine neoplasia  type i  men i  were assessed  all patients had determinations of fasting plasma gastrin  human pancreatic polypeptide  motilin  neurotensin  and somatostatin  35 had determinations of insulin and gastrin releasing peptide and 21 had determinations of glucagon  a plasma elevation of additional peptides besides gastrin was detected in 62   with 44  having one  18  having two  and 0  having three additional peptides elevated  motilin was elevated in 29   human pancreatic polypeptide in 27   neurotensin in 20   and gastrin releasing peptide in 10   whereas insulin  glucagon  and somatostatin were not elevated in any patient  the presence or absence of elevation of any peptide did not differ in patients with or without men i  with gastrinoma size  with the presence or absence of metastatic disease  or with various clinical symptoms  patients were assessed yearly for clinical evidence of a secondary symptomatic pancreatic endocrine tumor syndrome with a median follow up of 146 and 84 months from onset or diagnosis  respectively  only one patient  2  of patients  developed a second syndrome  rate  2 patients per 100 patients observed for 10 years   these results demonstrate that the plasma elevation of multiple gastrointestinal peptides is common in patients with zollinger ellison syndrome  however  the rate of developing a second symptomatic pancreatic endocrine tumor syndrome is much lower than generally believed  furthermore  no evidence is found to support the conclusions that the detection of the plasma elevation of these peptides is clinically important in assessing men i status  disease extent  or presence of metastatic disease or that elevated levels of motilin  neurotensin  gastrin releasing peptide  or human pancreatic peptide are associated with any distinct clinical symptoms  therefore  we recommend that plasma concentrations of these additional gastrointestinal peptides should not be assessed routinely but rather only if new symptoms develop  
class4	detection of duodenal gastrinomas by operative endoscopic transillumination  a prospective study  the ability of operative endoscopic transillumination of the bowel wall to detect duodenal gastrinoma was evaluated prospectively in 26 patients with the zollinger ellison syndrome  the results were assessed by exploratory laparotomy and compared with the results of other localization techniques  twelve duodenal gastrinomas were resected from 10 patients  operative endoscopic transillumination detected 10 of the 12 gastrinomas  a sensitivity of 83   which was significantly greater  p less than 0 05  than that for either preoperative imaging  25   or intraoperative ultrasonography and palpation  42    the sensitivity of operative endoscopic transillumination was a result of the ability to detect focal areas that did not transilluminate on the serosal side of the duodenum  and not the mucosal appearances seen through the endoscope  which were not helpful  operative endoscopic transillumination detected gastrinomas less than 1 cm in diameter throughout the duodenum  of the patients in this study  39  had duodenal gastrinomas  a greater frequency than previously reported  these results indicate that operative endoscopic transillumination is the most sensitive technique yet described for detecting duodenal gastrinomas and should be performed routinely in all patients with the zollinger ellison syndrome who undergo exploratory laparotomy for cure  
class4	liver fatty acid binding protein  a marker for studying cellular differentiation in gut epithelial neoplasms  human liver fatty acid binding protein is a 127 residue cytoplasmic protein synthesized in liver and in the intestinal epithelium  previous studies of normal and transgenic mice indicated that the liver fatty acid binding protein gene is a sensitive marker of enterocytic differentiation  this study shows the use of immunohistochemical methods to examine liver fatty acid binding protein gene expression in normal human colonic epithelium  colonic villoglandular adenomas  nonmucinous and mucinous adenocarcinomas  and several types of noncolonic epithelial neoplasms  cells containing liver fatty acid binding protein were found in normal colonic epithelium  in two thirds of colorectal villoglandular adenomas and nonmucinous adenocarcinomas  and in one third of mucinous adenocarcinomas but not in noncolonic  nonhepatic carcinomas  all liver fatty acid binding protein positive colonic adenomas and adenocarcinomas contained patches of immunoreactive cells distributed among histologically identical patches of cells without liver fatty acid binding protein immunoreactivity  this  mosaicism  was also found in metastases from liver fatty acid binding protein positive colonic adenocarcinomas  immunostaining of these liver fatty acid binding protein positive tissues for carcinoembryonic antigen did not show a mosaic cellular pattern in its expression  these data suggest that within a given neoplasm  differences exist in the differentiation programs of monoclonally derived  malignant colonic epithelial cells and that liver fatty acid binding protein is a useful marker for operationally defining these subpopulations  liver fatty acid binding protein is also a potentially useful diagnostic marker for colorectal and hepatic carcinomas  
class4	caseating hepatic granulomas in hodgkin s lymphoma  a 68 year old man presented with recurrent hodgkin s lymphoma after a 9 year disease free interval induced by chemotherapy  in addition to histological evidence of recurrent hodgkin s disease  the liver biopsy specimen showed extensive caseating granulomas  cultures of bone marrow and liver tissue tested negative for mycobacterium tuberculosis  no antituberculous treatment was administered  and the patient had an excellent clinical response to additional chemotherapy for lymphoma  hodgkin s lymphoma should be added to the list of disease entities associated with caseating granulomas in the liver  
class4	colonic lipomas  outcome of endoscopic removal  colonic lipomas are benign adipose tumors which are usually submucosal  with the increase in the number of endoscopic procedures being performed  these tumors are often detected incidentally at colonoscopy  although the risks of removing these tumors have been recognized  numerous reports have documented safe removal by snare electrocautery  we have reviewed the clinical outcome and the endoscopic and histopathologic features of seven lipomas that were endoscopically removed over a 5 year period  four patients recovered uneventfully  while three patients  42 8   developed colonic perforation after the polypectomy  in the latter group  the lipomas were significantly larger than they were in the patients who did not develop colonic perforation  1 9     0 4 and 4 2     0 7 cm  respectively  p   0 048   furthermore  the polypectomy specimens from those patients who developed perforation all contained significant muscularis propria  lipomatous polyps that are identified at endoscopy to be greater than or equal to 2 cm in diameter and to have a limited pedicle are at the greatest risk for endoscopic perforation  
class4	expandable biliary metal stents for malignancies  endoscopic insertion and diathermic cleaning for tumor ingrowth  seventeen patients with malignant biliary strictures have been treated by endoscopic insertion of self expandable metallic prostheses  two patients received two prostheses inserted simultaneously in both the left and right hepatic ducts for klatskin tumor type iii  immediate results were satisfactory despite an operative mortality of 18   and neither early nor late clogging was observed even in patients who presented previously with sludge above plastic stents that were removed  however  among five patients followed for more than 4 months  two presented with obstruction due to tumor ingrowth into the stent through the metallic mesh  accordingly  initial enthusiasm concerning long term patency of these stents has decreased  however  we describe a technique of  diathermic cleaning  of tumor ingrowth which can easily restore the stent patency  the advantages of these wire mesh 30 f stents are their easier insertion  better immediate drainage  and absence of dislocation or perforation  
class4	performing screening flexible sigmoidoscopy using colonoscopes  experience in 500 subjects  there is still controversy regarding the optimal length of flexible sigmoidoscopes  we performed screening distal colon examinations using 168 cm colonoscopes in 500 asymptomatic subjects who were unsedated and had sigmoidoscopy cleansing preparation  the mean depth of penetration was 66 cm and was similar in persons in whom the examination was discontinued because of poor preparation versus those with discomfort  polyps were detected in 87 patients  but only 5 subjects had polyps detected above 60 cm  we conclude that in a group of unsedated subjects scheduled for flexible sigmoidoscopy after a sigmoidoscopy prep  the use of instruments longer than 60 cm gives very little additional yield  
class4	hormonal and enzymatic parameters of hepatic regeneration in patients undergoing major liver resections  thirteen patients who underwent 40  to 80  removal of their livers had blood samples drawn initially and daily on postoperative days 1 to 7  the enzyme marker of heightened polyamine metabolism  ornithine decarboxylase  and the indicator of dna synthesis  thymidine kinase  were measured  in addition  the hormones  insulin  glucagon  estradiol and androgen   which in animals are known to reflect and possibly modulate regeneration  were measured  changes in all these indices followed the same pattern as in rats  dogs and swine but at a slower rate  ornithine decarboxylase and estradiol increased within 24 hr  but thymidine kinase and insulin rises did not become statistically significant until 3 to 5 days  using these plasma or serum indices as surrogate measures of biochemical events in the liver itself  regeneration reached a maximum after 4 or 5 days  by computed tomography scan analysis  restoration of hepatic cell mass was not complete until 3 wk  
class4	pathological observations of intrahepatic peribiliary glands in 1 000 consecutive autopsy livers  iii  survey of necroinflammation and cystic dilatation  pathological changes and significance of intrahepatic peribiliary glands  hitherto poorly recognized intrahepatic elements  have been evaluated in our laboratory  in this report  we surveyed necroinflammatory and cystic changes of the peribiliary glands in 1 000 consecutive autopsy livers because these two changes coexisted frequently in the same liver  the necroinflammatory change was found in 228 livers  22 8   and the cystic change in 202 livers  20 2    and 103 cases showed both changes in the same liver  the necroinflammatory change was frequently found in intrahepatic cholangitis and extrahepatic biliary obstruction with bacterial infection  suggesting that biliary bacterial inflammation extends into these peribilary glands  this change was also frequent in systemic infection or septicemia without biliary bacterial infection  implying that the peribiliary glands were also damaged in such conditions without direct infection  the cystic change was frequent in livers with portal hypertension or obstruction  adult polycystic disease and necroinflammation of the glands  suggesting that the cystic change of the glands could occur as the result of the disturbance of intrahepatic circulation or as the result of inflammatory destruction of the glandular conduits  some of peribiliary cysts may be of congenital origin  dysfunction related to these pathological changes in the glands may diminish seromucous secretion and cause alterations in hepatic bile composition  the cystic change of the glands may retard bile flow by compressing bile duct lumina  
class4	efficacy of transesophageal echocardiography as a perioperative monitor in patients undergoing cardiovascular surgery  analysis of 149 consecutive studies  to evaluate the usefulness of transesophageal echocardiography as a perioperative monitor in patients undergoing cardiovascular surgery  149 consecutive patients were studied since 1985  left ventricular function was assessed by measurement of left ventricular dimension and ejection fraction in patients with valvular disease  this monitoring was useful in detecting the changes in left ventricular performance in patients with volume overload and in managing patients in the early postoperative period  cardiac tamponade was clearly demonstrated before changes in electrocardiogram and hemodynamic data  in 27 patients  transesophageal color doppler echocardiography was used to confirm that there was no residual regurgitation immediately after valvular reconstructive surgery  transesophageal color doppler echocardiography was also useful in detecting the entry of false lumen before surgery in 7 patients with dissecting aortic aneurysm  there were no unsuccessful introductions  no traumatic or thermal injuries  18 patients  12 1   with hoarseness and 5 patients  3 4   with transient arrhythmia  in conclusion  transesophageal echocardiography provides a good imaging window to the heart and great vessels perioperatively  this expedient  safe informative imaging method can be used more routinely in patients during surgery  
class4	three staged approach to the surgical management of renal cell carcinoma extending into the right atrium  case report  left renal cell carcinoma extending into the right atrium was treated by angioinfarction  removal of right atrial tumour using cardiopulmonary bypass and ten days later abdominal radical nephrectomy and inferior vena cava thrombectomy  twenty four months later the patient remains well with no evidence of tumour recurrence  
class4	substance p is present in a subset of thyrotrophs in the human pituitary  substance p immunoreactivity and tachykinin like peptides are present in the pituitary gland of several mammalian species  in humans  however  the biochemical nature and cellular localization of pituitary substance p has not been defined  we report here that substance p immunoreactive material is present in low concentrations in both the anterior and posterior lobes of the human pituitary gland  gel chromatography and reverse phase high performance liquid chromatography indicate that the majority of the substance p immunoreactivity in human pituitaries elutes as authentic substance p and its oxidized derivative  immunohistochemical studies showed substance p immunoreactive fibers and terminals in the posterior pituitary gland and occasional substance p immunoreactive cell bodies in the anterior lobe  the substance p immunoreactive cells were found to colocalize with a small subpopulation of tsh beta immunoreactive cells  thyrotrophs   substance p immunoreactivity was also found in a pituitary microadenoma that contained numerous tsh beta immunoreactive cells  these studies indicate that substance p is present in the human pituitary gland  and they suggest a relationship between substance p and thyroid function  
class4	parathyroid hormone like peptide in normal and neoplastic human endocrine tissues  pth like peptide  plp  is produced by tumors commonly associated with hypercalcemia as well as nonneoplastic tissues and several endocrine glands and tumors  to characterize the distribution of plp in human endocrine tissues and tumors  we localized plp in formalin fixed paraffin embedded material using the avidin biotin peroxidase technique with polyclonal antisera  among peptide hormone producing tissues  plp was identified in nontumorous adenohypophysis and pituitary adenomas  medullary thyroid carcinomas  normal  hyperplastic  and adenomatous parathyroids  adrenal medulla and pheochromocytomas  normal pancreatic islets  and endocrine tumors of pancreas  gut  and lung  including small cell carcinomas  in other endocrine tissues plp was identified in nontumorous thyroid follicular epithelium  colloid nodules  and follicular neoplasms  normal adrenal cortex  adrenocortical adenomas  and carcinomas  nontumorous testicular leydig cells  normal ovarian granulosa and thecal cells  an ovarian thecoma and a granulosa cell tumor  placental trophoblast  and decidua  these results demonstrate that plp is localized in many normal and neoplastic endocrine cells  including those not known to influence extracellular calcium homeostasis  the presence of plp in a variety of endocrine tissues suggests that it may play a local physiological role in the growth or function of endocrine cells  
class4	insulin like growth factor ii  possible local growth factor in pheochromocytoma  pheochromocytomas  neural crest tumors  express an abundance of insulin like growth factor ii  igf ii   to assess further the potential for igf ii to play an autocrine role for these tumors  we measured 1  igf ii content by rra in 7 pheochromocytomas and peripheral blood in these patients  2  igf ii receptors by western analysis  and 3  characterized the tumor binding proteins by ligand blot studies  igf ii levels in the tumors varied from 2 8 41 micrograms g  chromatography revealed that 60  of the peptide eluted as a large mol wt form of igf ii  8 7 10 kda   the remainder coeluted with mature peptide  7 5 kda   this was in contrast to igf ii levels in normal adrenal tissue  0 225     0 005 micrograms g  or another neural crest derived tumor  medullary carcinoma of the thyroid  0 63     0 02 micrograms g   serum igf ii levels in the 7 patients with pheochromocytoma  720     71 ng ml  were similar to those in 35 normal controls  762     69 ng ml   radiolabeled igf ii  9     1   and igf i  20     2   bound specifically to pheochromocytoma membranes  western analysis of these membranes using a specific antiserum directed against the type ii receptor demonstrated a band at 210 kda  affinity cross linking studies with  125i igf i demonstrated a specific band at 140 kda  ligand blot analysis was performed on the void volume pools from the sephadex g 75 column and demonstrated bands at about 30 and 25 kda  in conclusion  these data 1  confirm that pheochromocytomas have increased levels of igf ii  2  demonstrate that despite high igf ii concentrations in the tumors  peripheral levels are not elevated  suggesting that very little tumoral igf ii is released into the circulation  unlike catecholamines  3  demonstrate the presence of igf ii and igf i receptors  4  describe binding protein species similar to those present in other tissues  thus  the presence of high levels of igf ii and both type i and type ii receptors suggests that igf ii may act through both receptors to alter tumor growth  
class4	insulin like growth factor i receptors in nonfunctioning thyroid nodules  we have recently demonstrated the production of insulin like growth factor i  igf i  as well as the presence of type i igf receptors in human thyroid cells in primary culture  the role of igf i in the control of thyroid cell growth has been well established  in order to investigate the involvement of igf i in abnormal thyroid growth  the density of igf i receptors in solitary  cold  micro  and macro follicular thyroid adenomas  and in extranodular histological normal tissue was studied  forty three euthyroid patients with isolated cold nodules were selected for the study  in 30 patients the presence of igf i receptors was evaluated by using quantitative immunohistochemistry  in 10 patients by using radioligand binding studies  and in 3 patients by using affinity labeling  cross linking and binding studies clearly demonstrated the presence of a homogeneous class of binding sites for type i igf receptors  furthermore  radioligand studies did not show any significant differences in receptor density between the 2 types of thyroidal tissues  conversely  the computerized analysis of 900 fields of nodular and normal thyroid tissues immunostained with the monoclonal antibody alpha ir3  strongly indicated that higher concentrations of igf i receptors were present in the epithelial cells of non functioning thyroid nodules than in the adjacent extranodular thyroid tissues  these studies strongly suggest that the same type i igf receptor is present in thyroid follicular adenomas as in histological normal thyroid tissue removed from the same patient  the higher concentration of igf i receptors as documented by immunostaining in the adenomas suggests that igf i may contribute to the abnormal growth of the neoplasms  
class4	transthyretin receptors on human astrocytoma cells  transthyretin  ttr   a transport protein for t4 and retinol binding protein  is the principal t4 binding protein of cerebrospinal fluid  its function in regard to the delivery of its ligands and in other respects is unclear  the binding of  125i  ttr to cultured human astrocytoma cells was studied to determine whether these cells carry receptors for ttr  scatchard analysis was consistent with a single class of binding sites with a kd of 3 nm  no significant cross reactivity with transferrin or serum albumin was observed  internalization of ttr was temperature dependent and proportional to receptor occupancy  dilutions of cerebrospinal fluid displaced  125i ttr in proportion to their content of radioimmunoassayable ttr and in parallel with purified ttr  the uptake and internalization of ttr increased in the presence of high t4 or t3 concentrations  these results demonstrate that ttr binds to specific high affinity receptors on human astrocytoma cells  receptor binding of ttr provides a potential mechanism for the delivery of its ligands within the central nervous system  
class4	clinical review 16  parathyroid hormone related proteins  coming of age in the 1990s  the last 3 yr have yielded a fertile harvest of new information on the hhm clinical syndrome and on the novel peptide hormone family responsible for the syndrome  whereas the clinical riddle enshrouding the hhm syndrome first posed in the early 1940s appears to have been largely solved  a whole new field  concerning the physiological role s  of pthrp has opened  the field has evolved rapidly and provides an example of fruitful clinical investigation  the original problem was a clinical one  the hhm syndrome   understanding the clinical disorder led to pursuit of the problem in the laboratory  adenylate cyclase assays  protein purification  molecular cloning  pthrp synthesis   and observations made in the laboratory have rapidly yielded clinical fruits  pthrp immunoassays  and opened a new window on normal physiology  
class4	clonal origin of pituitary adenomas  as the pathogenesis of pituitary adenomas remains unclear  the tumor clonal composition of these common neoplasms was studied  clonality was determined in female patients by analysis of restriction fragment length polymorphisms of the x chromosome genes hypoxanthine phosphoribosyl transferase and phosphoglycerate kinase in conjunction with their respective methylation patterns  peripheral lymphocyte dna was screened from 62 female patients undergoing transsphenoidal surgery for pituitary adenoma  eleven patients were heterozygous for the bgli site on pgk  4 for the bamhi site on hprt  and 1 patient for both sites  of these 16 patients  3 had acromegaly  4 had cushing s disease  7 had hyperprolactinemia  and 2 were clinically nonfunctional  after surgery  morphological study  including immunohistochemistry and electron microscopy of the pathological specimens  allowed a direct comparison between clonality and tumor cell type  control fresh normal pituitary tissue was found to be polyclonal  the following tumors were monoclonal  all 3 somatotroph adenomas  4 of 4 lactotroph tumors  3 of 4 corticotroph cell adenomas  a gonadotroph adenoma  and a nonsecretory adenoma  a mixed plurihormonal adenoma was polyclonal  as were 2 tumors consisting of adenomatous lactotrophs interspersed with nontumorous adenohypophyseal pituitary tissue and one corticotroph adenoma mixed with normal pituitary tissue  functional pituitary adenomas derived from somatotrophs  corticotrophs  or lactotrophs and nonsecretory tumors are monoclonal in nature  suggesting that somatic cell mutations precede clonal expansion of these cells and play a major role in pituitary tumorigenesis  
class4	androgen response to endogenous insulin secretion during the frequently sampled intravenous glucose tolerance test in normal and hyperandrogenic women  women with ovarian hyperandrogenism frequently have insulin resistance  whose underlying mechanism remains to be determined  in the present study we have investigated the relationship between insulin sensitivity and the acute effect of endogenous insulin secretion on circulating androgen levels  insulin sensitivity  glucose mediated insulin release  and glucose insulin stimulated androgen responses were determined during a frequently sampled iv glucose tolerance test in a group of 19 women with clinical evidence of polycystic ovary syndrome  pcos  and 9 age  and weight matched controls  insulin  i   glucose  androstenedione  testosterone  t   free t  and dehydroepiandrosterone  dhea  levels were measured before and during the 3 h following iv administration of glucose  300 mg kg   intravenous tolbutamide  300 500 mg  was injected 20 min after the glucose injection  insulin sensitivity  si  was calculated by application of the minimal model of glucose kinetics  fasting androstenedione  t  free t  and i concentrations were significantly higher in the women with pcos than in controls  p less than 0 02   in pcos subjects  fasting i was correlated with both t  r   0 51  p less than 0 05  and dhea  r   0 706  p less than 0 01   si was significantly lower in pcos subjects  si  68 35     8 34 min 1  nmol ml  than in control subjects  si  133 36     21 7 min 1  nmol ml    a significant decline in dhea levels was observed in control subjects 3 h after glucose administration  from 28 4     3 0  final  16 2     2 4  p less than 0 02   pcos women with normal insulin sensitivity  si  greater than 75 0 min 1  nmol ml   showed a similar fall in dhea  from 20 3     2 5 to 12 8     1 8 nmol l  p less than 0 02   no significant change occurred in insulin resistant pcos subjects  si  less than 75 0 min 1  nmol ml    other androgen levels showed a modest nonsignificant decline during the study in pcos and control groups  these findings confirm the weight independent insulin resistance of some hyperandrogenic women  the failure of glucose stimulated endogenous insulin secretion to significantly depress dhea levels in insulin resistant women with pcos may account in part for their androgen excess  
class4	growth of cultured human cerebral meningiomas is inhibited by dopaminergic agents  presence of high affinity dopamine d1 receptors  we have found that microm concentrations of the dopamine agonist bromocriptine significantly decrease the proliferation rate of human meningioma cells in culture  25 56  inhibition   this effect was also seen with direct application of dopamine  as well as the dopamine d1 agonist     skf 38393  both applied in microm concentrations  to meningioma cell cultures  receptor studies with the dopamine d1 ligand  125i sch 23982  dopamine d1 antagonist  indicated that dopamine d1 binding sites were present in the membranes of meningioma tissue  the mean dissociation constant  kd  was 325       74 5 sem  pm and the receptor density  bmax  was 25 4       1 5 sem  fmol mg pellet protein in 5 human meningiomas  the pharmacological specificity was proven by     skf 38393       skf 83566 or     butaclamol and their inactive isomers     skf 38393 and     butaclamol in a 1000 fold excess  these results provide evidence that human meningiomas possess high affinity dopamine d1 receptors and that dopamine agonists have an antiproliferative effect on these tumors in culture  we conclude that the proliferation of cerebral meningiomas may be under dopaminergic control and that dopamine agonists may have a role in the medical treatment of patients with meningiomas  
class4	endothelin like immunoreactivity in human breast cyst fluid  immunoreactive endothelin has been detected in 21 of 43 samples of breast cyst fluid  21 cases  3 5     0 6 pmol l  mean     sem  other 22 cases  not detectable  less than 0 5 pmol l   fast protein liquid chromatographic analysis of the immunoreactive endothelin of pooled breast cyst fluid showed two immunoreactive peaks  one in the void volume and the other in the position of endothelin 1  it is probable that endothelin 1 is produced by the epithelial cells lining breast cysts  but significance of the presence of endothelin 1 in breast cyst fluid remains to be elucidated  
class4	sensitivity of digoxigenin and biotin labelled probes for detection of human papillomavirus by in situ hybridisation  the sensitivity of digoxigenin and biotin labelled dna probes for the detection of human papillomavirus  hpv  by dot blotting and in situ hybridisation was compared in tissues from cervical  laryngeal  and anogenital neoplasia  probes were either labelled with digoxigenin by the random primer technique and detected with anti digoxigenin antibody  or labelled with biotin by nick translation and detected with streptavidin  both methods having a common final visualisation procedure using alkaline phosphatase  digoxigenin labelled probes proved two to 10 fold more sensitive by quantitative dot blotting and four fold more sensitive in detecting hpv 16 dna in a series of 31 anal carcinomas  compared with biotinylated probes  the digoxigenin method also produced less non specific background staining of tissue sections than biotin labelled probes  it is concluded that digoxigenin dna labelling and detection provides a simple  reliable  and efficient alternative to the use of biotin or radioactive isotopes for the detection of hpv dna by in situ hybridisation  digoxigenin labelled probes also offer the possibility of double labelling in situ hybridisation procedures when used with biotin labelled probes to provide simultaneous identification of different dna sequences  
class4	application of 1 nm gold probes on paraffin wax sections for in situ hybridisation histochemistry  an in situ hybridisation technique that uses 1 nm immunogold reagents and silver enhancement was devised to detect biotinylated dna viral probes in formalin fixed  paraffin wax sections of human cervix  dna probes labelled with biotin 11 deoxyuridine triphosphate were detected after hybridisation to nucleic acid sequences by an antibiotin antibody  followed by a gold labelled secondary antibody  silver enhancement then permitted visualisation of the signal at the light microscopic level  the method was reliable and produced less background staining than previously described methods  the signal could be enhanced by epi polarisation microscopy  furthermore  biotinylated dna probes may be detected directly by a 1 nm gold labelled goat antibiotin antibody without loss of labelling intensity  and this may be preferable to the longer two layer technique  previously described  
class4	importance of sampling method in dna analysis of lung cancer  lung carcinomas are characterised by considerable histological variation within the tumour  the possible effects of this morphological heterogeneity on the estimation of tumour ploidy were investigated  multiple tissue blocks were systematically taken from 20 lung tumours and analysed by flow cytometry  the routine  archival paraffin wax embedded diagnostic blocks from these cases were also analysed  nineteen  95   of the tumours were shown to contain aneuploid stemlines by systematic sampling  but if only one of these systematic tissue blocks had been taken from each case the incidence of dna aneuploidy could have been as low as 45   only 15  75   tumours were aneuploid when all the routine archival blocks were analysed  but by specifically selecting tumour areas from the archival material the accuracy of this method was increased to 90   it is concluded that tumour sampling methods are of primary importance in assessing the dna content of lung tumours  routine paraffin wax embedded archival tissue provides a suitable source of material for this purpose  provided that  turnover  selection is carried out  
class4	cells immunoreactive for neuropeptide in human thymomas  the presence of opioid peptides  bombesin  and substance p was investigated by immunohistochemistry in tissue sections from six human thymomas  the number of immunoreactive cells seemed to vary from one case to another  ultrastructural investigation  showing the presence of desmosomes in labelled cells  allowed these cells to be classified as epithelial lineage cells  the occurrence of cells containing neuropeptide in thymomas suggest that peptide molecules could have modulated the behaviour of this tumour  given the reported influence of these molecules on immune functions and their growth promoting activity on several cell types  including mesenchymal and epithelial cells  
class4	tissue preparation for simultaneous flow cytometric quantitation of tumour associated antigens and dna in solid tumours  a multiparameter flow cytometric assay for the simultaneous study of tumour associated antigens  taa  and dna in fresh solid tumours was devised  cell suspensions were prepared by disaggregating unfixed solid tumour samples mechanically over a stainless steel mesh  indirect immunofluorescence was used to identify the taa  and dna was stained with propidium iodide  cell morphology was well preserved  cell clumping was negligible  and high quality indirect immunofluorescence quality indirect immunofluorescence and dna staining were obtained  the technique is simple  rapid  and reproducible  multiparameter assays can be developed to study prognostic indicators such as membrane oncoproteins  receptors  and multidrug resistance in solid tumours  with a suitable panel of antibodies the technique might become an aid in the differential diagnosis and biochemical diagnosis of some solid tumours  
class4	value of monoclonal anti myeloperoxidase  mpo7  for diagnosing acute leukaemia  the expression of myeloperoxidase  mpo  was studied in 100 cases of acute leukaemia  83 with acute myeloid leukaemia  aml  and 17 acute lymphoblastic leukaemia  all  by both a conventional cytochemical method and the immunocytochemical antiperoxidase  apaap  technique using the monoclonal antibody mpo7  in each case the staining was evaluated by light microscopical examination  percentage of positive cells   of the 83 cases of aml  78  93 9   were positive for mpo7 compared with 70  84 3   by cytochemistry  antibodies against the myeloid markers cd13 and cd33 were positive in 71  85 5   and 70  84 3   cases  respectively  importantly  all cases of all were negative for both mpo7 and cytochemical mpo staining even when they were positive for cd13 and cd33  these results indicate that the anti myeloperoxidase antibody mpo7 is the most sensitive and specific reagent for the diagnosis of aml and should therefore be included in routine immunophenotyping panels  
class4	cutaneous manifestations of postthymic t cell malignancies  description of five clinicopathologic subtypes  this study was undertaken to identify the cutaneous manifestations among different prognostic subgroups of postthymic t cell malignancies  cutaneous involvement was demonstrated in 43 of 88 cases  we recognized five clinicopathologic subtypes  type i  classical cutaneous t cell lymphoma  ctcl  or mycosis fungoides  six cases  type ii  primary large cell type ctcl  ki 1 antigen  ki 1  or ki 1    seven cases  type iii  primary angioinvasive t cell lymphoma  three cases  type iv  human t lymphotropic virus type i  htlv i   adult t cell leukemia lymphoma  atl   eight cases  type v  secondary cutaneous involvement by peripheral t cell lymphoma  ptl   19 cases  primary ctcl and atl tend to involve papillary dermis with or without epidermotropism  whereas ptl and angioinvasive t cell lymphoma predominantly affect skin adnexae  vessels  and subcutis  cutaneous lesions in type v ptl are heterogeneous and may be confused with panniculitis  vasculitis  or an eczematous eruption  classic ctcl  ki 1  lymphoma  and angioinvasive t cell lymphoma have a chronic course  whereas atl  ki 1  large cell lymphoma  and ptl are clinically aggressive  
class4	giant eccrine acrospiroma  four cases of large eccrine acrospiroma  three benign  one malignant  are reported  the benign tumors involved the lower extremities of two women and one man  73 to 89 years of age   the duration of the lesions ranged from 10 to 20 years  the malignant tumor involved the left side of the chest of a 60 year old man  its occurrence in a lesion that had been present for 40 years suggested malignant transformation of a pre existing benign eccrine acrospiroma  each tumor showed little to no cellular atypia  mitotic rates  mitotic figures per 10 high power fields  varied both between and within lesions  average mitotic rates did not differentiate the benign from the malignant tumors  the most important distinguishing features of large benign eccrine acrospiromas are the relative circumscription  the lack of cellular atypia  and the absence of stromal  perineurial  and angiolymphatic invasion  
class4	intralesional interferon therapy for basal cell carcinoma  in a clinical trial of 172 patients at four medical centers  interferon alfa 2b  1 5 x 10 6  iu  or a placebo was injected directly into biopsy proved noduloulcerative or superficial basal cell carcinomas three times weekly for 3 weeks  for a cumulative dose of 13 5 million iu  efficacy of treatment was determined at 16 to 20 weeks by examination of biopsy specimens that demonstrated cure of lesions in 86  of interferon treated patients and in only 29  of placebo treated patients  during the treatment course and follow up  an initial inflammatory response was observed at the treatment sites  followed by diminished erythema  improvement in overall appearance  and a decrease in size of lesions  side effects of treatment  mainly flu like symptoms  were usually mild and transient and occurred more commonly in the interferon treated group  only three patients  all in the interferon treated group  discontinued therapy because of side effects  one year after initiation of therapy  81  of interferon recipients and 20  of those given the placebo remained tumor free  noduloulcerative and superficial lesions were equally responsive to treatment with interferon  for some patients with noduloulcerative or superficial basal cell carcinomas  intralesional interferon alfa 2b may be an alternative  effective treatment  
class4	autoimmunity and malignancy  in patients with autoimmune diseases malignancy is observed more frequently than in an age matched control group  in strains of mice susceptible to autoimmune diseases  the incidence of lymphoreticular malignancies is increased  although viruses have not been directly implicated in their pathogenesis or etiology  there are suggestions that slow viruses may be involved  viruses have been found to be important in the development of lymphomas  hence in genetically susceptible animals  viruses can initiate the autoimmune process  prolonged stimulation of the autoimmune process or a prolonged state of immunodeficiency could trigger or activate genes or their products  which could result in the development of malignancy  
class4	buschke loewenstein tumor  verrucous carcinoma of the penis  the buschke loewenstein tumor is an anogenital tumor of characteristic clinical and histologic pattern best considered as a low grade  well differentiated squamous cell carcinoma  this remarkable neoplasm and its features are reviewed in detail  stressing salient advances in our understanding of it  
class4	cutaneous melanoma and bilateral retinoblastoma  we report the case of an otherwise healthy 37 year old man who had had bilateral enucleation during early childhood for bilateral retinoblastomas  in addition to two cutaneous melanomas  the first appearing at age 27 years   he also had dysplastic melanocytic nevi and a history of cutaneous melanoma in his mother  retinoblastoma may aggregate in families and is associated with dna abnormalities of chromosome 13  recent reports have emphasized the appearance of second malignancies in retinoblastoma survivors  the second malignancies include osteosarcoma  soft tissue sarcoma  and cutaneous melanoma  cutaneous melanoma also may aggregate in families  usually in the setting of dysplastic melanocytic nevi  the features of this case and of similar reported cases suggest that there may be a greater than expected association between retinoblastoma and cutaneous melanoma  
class4	multicentric cloacogenic carcinoma  report of a case with anogenital pruritus at presentation  a case of multicentric cloacogenic carcinoma of the perianal skin and vulva in a 79 year old woman is presented  and the embryologic basis for the multicentricity is discussed  histologically  cloacogenic carcinoma can be differentiated from other small cell neoplasms that affect the area  cloacogenic carcinoma should be considered a rare cause of anogenital pruritus  it is important to perform an early biopsy of anogenital lesions that do not respond to conventional therapy  
class4	severe lidocaine intoxication by cutaneous absorption  a severe lidocaine intoxication by cutaneous absorption is described  data are presented to show a significant absorption of lidocaine through diseased skin when lidocaine cream is used as a local anesthetic  awareness of this route of intoxication might be important in patients in whom neurologic or psychiatric symptoms develop while large amounts of lidocaine cream are being used  
class4	disseminated kaposi s sarcoma not associated with hiv infection in a bisexual man  we report a 42 year old white bisexual man with disseminated kaposi s sarcoma limited to the skin and gastrointestinal tract  results of several serum tests for human immunodeficiency virus  hiv  antibodies have been negative  the cd4 cd8 ratio has remained normal  and his kaposi s sarcoma has had a benign clinical course during 30 months of follow up  similar reports of disseminated kaposi s sarcoma with a benign clinical course in homosexual or bisexual men without demonstrable hiv infection are reviewed  some cellular immune impairment that might be more prevalent in the homosexual population may be implicated in the pathogenesis of this type of kaposi s sarcoma  
class4	cutaneous horn of the penis  its association with squamous cell carcinoma and hpv 16 infection  cutaneous horns of the penis are rare  including this case  only 19 cases have been reported in the english language literature  in 37  of the reported cases a malignant tumor was found beneath the cutaneous horn  our case is remarkable because a stage i squamous cell carcinoma developed on the shaft of the penis of a neonatally circumcised man  human genital carcinoma resulting from a multifactorial process in which  promoting  papillomavirus is an integral element is being increasingly reported  we review the relationship of circumcision to genital human papillomavirus infection and their synergism in the development of squamous cell carcinoma  
class4	lip paresthesia associated with a jaw mass  a case is reported in which mandibular swelling and lower lip numbness were the first signs of a metastatic adenocarcinoma of the lung  the development of paresthesia  with or without other oral symptoms  requires that a diagnosis of malignancy be considered until confirmed or ruled out by tissue biopsy  a thorough head and neck examination in all patients  especially in those whose history or habits may indicate increased risk of malignancy is necessary  
class4	oncogenes and suppressor genes  their involvement in colon cancer  editorial  abnormalities in oncogenes  which are broadly classified into viral and cellular oncogenes  and suppressor genes appear critical for the development of colon cancer  cellular oncogenes contribute to malignant transformation when they become activated by point mutation  translocation  amplification  or loss of regulator sequences  the properties of the oncoproteins  the proteins encoded by oncogenes which are essential for carcinogenesis  are unclear  suppressor genes normally suppress the tumorigenic phenotype by keeping the growth of cells in check  it is their inactivation that contributes to malignant transformation  development of colon cancer appears to take place by stepwise accumulation of multiple genetic alterations during the progression from normal colon to adenoma and carcinoma  activation of ras  an early event in this sequence  is found in 50  of colon cancers  overexpression of c myc is found in approximately 80   inactivation of suppressor genes  which occurs during later stages  is noted in greater than 70  of tumors  a current model of colonic tumorigenesis is presented  
class4	liver transplant for metastatic neuroendocrine tumor  generally  the results of liver transplantation for metastatic liver disease have not been favorable  one exception has been the unique group of neuroendocrine tumors  the slow growth of which allows liver transplantation to effectively palliate and control symptoms  we report two cases   a  a 51 year old man who underwent orthotopic liver transplantation and resection of the pancreatic primary tumor for a nonfunctioning malignant neuroendocrine tumor with features of both carcinoid and islet cell glucagonoma remains symptom free and without evidence of tumor recurrence at 13 months follow up   b  a 47 year old man who underwent orthotopic liver transplantation and whipple resection for a metastatic islet cell tumor in the head of the pancreas is fully recovered at 5 months follow up  
class4	a nongastrin malignant ampullary tumor causing gastric acid and pepsin hypersecretion  a case report  we report a case of multiple duodenal ulcers with gastric hypersecretion due to a nongastrin secretagogue produced by a malignant tumor of the pancreas in a 78 year old man  the case resembled a zollinger ellison syndrome  zes  with high acid output  basal acid output 27  sham meal stimulated 37  maximum acid output 47 meq h   but with fasting gastrin 43 pg ml  nonresponsive to secretin  as in zes  pepsin output was comparatively low  and secretion was inhibitable by atropine  50  inhibited by 1 microm   the tumor removed at surgery contained less than 1 ng gastrin per gram  but was many times more potent than pentagastrin in stimulating acid from a lumen perfused rat stomach  the tumor also contained cholecystokinin  cck 8 and cck 33   motilin  insulin  and somatostatin  which were also present in adjacent normal pancreas  in addition  the tumor contained pancreatic polypeptide and pancreatic cancer associated antigen  this case represents a rare syndrome due to an as yet undefined peptide secreted by a  frequently malignant  pancreatic endocrine tumor and masquerading as zes  this is the first report of studies of pepsin secretion and of the effect of atropine  suggesting that the physiologic effects of the secretagogue resemble that of gastrin  
class4	insulinoma after streptozotocin therapy for metastatic gastrinoma  natural history or iatrogenic complication  islet cell carcinoma frequently produces more than one chemical product  although its clinical expression is usually restricted to a single hormone  we describe an unusual patient who presented with full blown metastasizing gastrinoma  he was treated with cimetidine for five years and then streptozotocin therapy  which resulted in a regression in hepatomegaly and a fall in serum gastrin levels  following one year s therapy with streptozotocin  he was admitted in hyperinsulinemic hypoglycemic stupor  this appears to be the first reported case of a  shift  from clinical gastrinoma to insulinoma possibly related to prolonged streptozotocin therapy  
class4	insulin like growth factor i supports proliferation of autocrine thymic lymphoma cells with a pre t cell phenotype  we have studied the phenotypic characteristics and growth properties of murine t lymphoma cell lines derived from primary x ray induced thymic lymphomas at the earliest stage at which they can be detected  and well before spreading to other organs has occurred  these cell lines serve as model systems for the earliest events in t cell lymphoma induction  before tumor cell progression and spreading to other organs  we find that primary x ray induced t cell lymphoma lines have phenotypic characteristics of thymic pre t cells and show no proliferative response to any of the il tested nor to other hematopoietic growth factors  however  they do proliferate in response to insulin like growth factor i  igf i  and to a small autocrine peptide distinct from igf i  which we term lymphoma growth factor  one of the earliest lesions in t cell lymphoma induction may therefore be an inhibition of differentiation at one of several specific points  in its early stages  t lymphoma cell growth may be restricted to an environment where local concentrations of specific growth factors such as igf i or lymphoma growth factor are sufficiently high  
class4	regional and systemic distribution of anti tumor x anti cd3 heteroaggregate antibodies and cultured human peripheral blood lymphocytes in a human colon cancer xenograft  anti tumor antibody  317g5  covalently coupled to an anti cd3 antibody  okt3  produces a heteroaggregate  ha  antibody that can target pbl to lyse tumor cells expressing the appropriate tumor ag  the i v  and i p  distribution of radiolabeled ha antibody 317g5 x okt3 and of radiolabeled cultured human pbl were studied in athymic nude mice bearing solid intraperitoneal tumor established from the human colon tumor line  ls174t  mice were injected with 125i labeled ha antibody  125i labeled anti tumor mab  or 111in labeled pbl  and at designated timepoints tissues were harvested and measured for radioactivity  125i 317g5 x okt3 localized specifically to tumor sites  tumor radioactivity levels  percent injected dose gram  were lower with 125i 317g5 x okt3 ha antibody than with 125i 317g5 anti tumor mab  but were similar to levels reported for other anti tumor mab  the major difference in radioactivity levels observed between i v  and i p  administration of 125i 317g5 x okt3 was an increase in hepatic radioactivity after i v  ha antibody administration  ha antibodies produced from f ab  2 fragments  which exhibit decreased m  w  and decreased fc receptor mediated binding  demonstrated improved tumor tissue ratios as compared to intact antibody ha  125i 317g5 f ab  2 x okt3 f ab  2 antibody levels were equivalent to intact ha antibody levels in tumor  but were lower than intact ha antibody levels in the blood  bowel  and liver  tumor bowel ratios  20 1 at 48 h  were highest when 317g5 f ab  2 x okt3 f ab  2 was injected i p  autoradiography confirmed that anti tumor x anti cd3 ha antibodies localized specifically to intraperitoneal tumor  that i p  administered ha antibodies penetrated tumor directly  and that i v  administered ha antibodies distributed along tumor vasculature  cultured human pbl distributed in moderate concentrations to intraperitoneal tumor when administered i p   but not when administered i v  the poor localization of i v  injected pbl to tumor may reflect species disparity in homing receptors and or endothelial ligands  a problem which may be overcome with a syngeneic model  these results suggest that regional therapy with ha antibodies and pbl may offer advantages over systemic therapy for initial clinical trials  
class4	lymphokine activated killer  lak  cells  v  8 mercaptoguanosine as an il 2 sparing agent in lak generation  guanine ribonucleosides  substituted at the c8 position with either a bromine or a thiol group  have recently been shown to regulate several immunologic responses  we have previously shown that 8 mercaptoguanosine  8mg  can replace the requirement for cytokines in the generation of mhc restricted ctl  in this paper  we examined the ability of 8mg to induce mhc nonrestricted killer cells  we found that 8mg did not induce significant lytic activity from normal resting lymphocytes  however  8mg was able to synergize with minimal amounts of il 2 in inducing lytic activity similar to lymphokine activated killers  lak  in that both nk sensitive and nk resistant tumor cells were killed  both the precursors and effectors of 8mg lak activity were similar to nk cells and were cd4  cd8  asialo gm1  nk1 1   similar to il 2 induced lak  8mg lak were b220   8mg appeared to  stage  these precursor lymphocytes to become more responsive to il 2 because optimal induction of 8mg lak required preincubation with 8mg before the addition of il 2  this  staging  appeared to be due to the release of a  second signal  since it was readily inhibited by cyclosporine a  anti ifn alpha beta was as efficient as cyclosporine a in inhibiting 8mg lak generation  whereas anti ifn gamma and anti il 1 did not exhibit significant inhibition  these findings suggest that 8mg can be of possible utility as an il 2 sparing agent in lak generation from nk cells  
class4	excision repair of pyrimidine dimers induced by simulated solar radiation in the skin of patients with basal cell carcinoma  one prominent lesion induced in dna by ultraviolet  uv  radiation is the cyclobutyl pyrimidine dimer formed between adjacent pyrimidines on the same dna strand  we investigated whether people who have developed basal cell carcinoma on sun exposed skin have an altered ability to repair uv induced pyrimidine dimers in dna  twenty two patients with at least one basal cell carcinoma  aged 31 84 years  and 19 healthy volunteers  aged 25 61 years  took part in the study  both groups were given one minimal erythema dose  med  of simulated solar radiation on the lower back  dna was extracted from the irradiated skin 0 to 6 h later  and the number of uv induced pyrimidine dimers was determined using a dimer specific endonuclease  at time 0  the average number of dimers per unit of dna was similar in the two groups  after 6 h  an average of 22     4  of the dimers were removed in the group with basal cell carcinoma compared to 33     4  in the cancer free group  in the basal cell carcinoma group  only 23  of the patients repaired more than 30  of the dimers after 6 h  compared with 53  of the cancer free subjects  p less than 0 05   we conclude that patients who develop basal cell carcinoma on sun exposed skin may have a decreased ability to repair pyrimidine dimers induced in skin exposed to simulated solar radiation  
class4	susceptibility to effects of uvb radiation on induction of contact hypersensitivity as a risk factor for skin cancer in humans  normal  healthy human volunteers and patients with proved history of non melanoma skin cancer have been tested for their capacity to develop contact hypersensitivity to dinitrochlorobenzene  dncb  following exposure of buttock skin to acute  low dose ultraviolet b  uvb  radiation  using a radiation protocol that achieves virtually complete depletion of normal appearing langerhans cells from irradiated skin  it was learned that approximately 60  of healthy volunteers developed vigorous contact hypersensitivity  ch  when 2000 micrograms dncb was painted on the irradiated site  these individuals were designated uvb resistant  and were distinguished from other individuals  designated uvb susceptible  who failed to develop contact hypersensitivity following an identical treatment protocol  it was then discovered that virtually all  92   skin cancer patients exposed to uvb and dncb failed to develop ch  i e   were uvb susceptible  in subsequent experiments  epicutaneous application of 2000 micrograms dncb to unirradiated skin of uvb susceptible individuals revealed a further distinction between normal persons and skin cancer patients  approximately 45  of the latter  and none of the former  remained unresponsive  failed to develop contact hypersensitivity following this second attempt at sensitization   implying that they had been rendered immunologically tolerant  these tolerant individuals responded normally to the unrelated hapten  diphencyprone  we conclude that human beings resemble inbred strains of laboratory mice in that some individuals are uvb susceptible  whereas others are uvb resistant  because the incidence of uvb susceptibility was significantly higher in skin cancer patients  and as specific unresponsiveness could be demonstrated only in these patients  we propose that uvb susceptibility  as we define it in this hapten system  may be a risk factor for the development of skin cancer  
class4	premalignant lesions and cancers of the skin in the general population  evaluation of the role of human papillomaviruses  to evaluate the role of human papillomaviruses  hpv  in the development of premalignant lesions and cancers of the skin in the general population  314 biopsies obtained from 227 patients with benign neoplasms  premalignant lesions  and cancers of the skin and from 25 patients with squamous cell carcinoma of the lip were analyzed by southern blot hybridization  dna probes specific for various cutaneous and genital hpv types were used in hybridizations conducted under nonstringent or stringent conditions  hpv dna sequences were only detected in eight specimens obtained from six patients  hpv 34 in one case of periungual bowen s disease  hpv 36 and an as yet uncharacterized hpv in two cases of actinic keratosis  hpv 20 in one case of basal cell carcinoma  an as yet unrecognized hpv in one case of squamous cell carcinoma  and hpv 16 in one case of squamous cell carcinoma of the lip  none of the specimens of cutaneous horn and keratoacanthoma contained detectable hpv dna  in contrast  hpv dna sequences  mostly hpv 16  were detected in 13 of 23 cases of anogenital bowen s disease and invasive bowen s carcinoma  hpv dna sequences were not detected in 90 cutaneous samples further analyzed by the polymerase chain reaction technique  using amplification primers that contain conserved sequences among the genomes of hpv  these results strongly suggest that the known hpv types play only a minor role  if any  in skin carcinogenesis in the general population  
class4	cytomegalovirus in the brain  in vitro infection of human brain derived cells  models for human cytomegalovirus  hcmv  brain infection have been developed in a variety of brain derived cells in which the factors governing virus infectivity might be studied in vitro  studies were initiated with brain endothelial cells  the likely portal of entry for virus into the central nervous system  primary explant cultures of brain endothelial cells  derived from homogenates of healthy human brain  supported complete viral gene expression and cytopathic effect  cpe   endothelial cells do not appear to be a barrier for hcmv passage into the central nervous system  astroglial lines  primary explant or tumor derived  varied in their ability to support hcmv replication  some  t98g  supported incomplete  immediate early  gene expression while others  a 172  did not support any detectable gene expression  some astroglial lines  hs 683  supported extensive virus replication with minimal viral cpe  neuronal cell lines  sk n mc  were fully permissive  the more differentiated glial lines  astrocytoma  were fully permissive to hcmv infection  however  the less differentiated glial lines  glioblastoma  were partly or nonpermissive  
class4	distribution and specific identification of papillomavirus major capsid protein epitopes by immunocytochemistry and epitope scanning of synthetic peptides  monoclonal  mabs  and polyclonal antibodies were produced against the major capsid protein of detergent disrupted  purified bovine papillomavirus type 1  bpv 1   the precise locations of the corresponding epitopes were identified by the reactivity of mabs and selected polyclonal antibodies with synthetic  overlapping  hexameric peptides corresponding with 95  of the bpv 1 major capsid protein  the topography of these epitopes was determined by reactivity of antibodies with intact  conformational and nonconformational surface epitopes  and disrupted  external or internal nonconformational epitopes  bpv 1 virions  the distribution of epitopes in various papillomaviruses of 13 different species was determined by reactivity of the mabs and polyclonal sera with productively infected  formalin fixed papillomas  fibropapillomas  and fibromas  epitope scanning  using mabs and polyclonal antisera  resulted in the precise location of bpv 1 hexameric epitopes that could be correlated with their topography on the capsid and distribution in papillomatous lesions of various species  
class4	second primary tumours of the larynx following bronchial carcinoma  the occurrence of multiple primary malignancies in patients with laryngeal cancer is well known  the possibility that lung cancer patients may be at risk of subsequent laryngeal cancer is less well recognized  the possibility of laryngeal cancer developing later has implications for the follow up of lung cancer patients  three cases of subsequent laryngeal primary cancer occurring in survivors of bronchial cancer are presented and the implications are discussed  
class4	alternating cisplatinum and vac ineffective in end stage squamous cell carcinoma of the head and neck  sixteen patients with end stage squamous cell carcinoma of the head and neck were admitted to a phase ii study of alternating courses of cisplatinum  100 mg m2  and vac  vincristine 1 4 mg m2  adriamycin 50 mg m2  cyclophosphamide 750 mg m2  given at three weekly intervals  only two patients achieved a response  12 per cent   the median survival time was 62 days which is much the same as that of a similar group of patients who received no chemotherapy in a previous trial  70 days   
class4	head and neck cancer and ageing  a retrospective study in 438 patients  to evaluate whether age over 70 years represents a prognostic factor in head and neck cancer  we reviewed all cases observed between 1981 and 1984  four hundred and thirty eight  438  patients were considered in relation to three age groups  less than or equal to 59  60 69  and greater than or equal to 70 years  defined as non elderly  mid elderly and elderly respectively   the main parameters analyzed included histological diagnosis  no difference emerged among the three age groups   anatomical site  hypopharyngeal carcinoma was most frequent in non elderly patients   tnm stage  an higher incidence of early stages was seen in the elderly   performance status  better in the non elderly   previous illnesses  life style related diseases were more frequent in the non elderly   contraindications to surgery  more frequent in the elderly   surgical treatment   en bloc  resections were more often employed in the non elderly   post operative complications and local control  no difference between the three groups   multiple primary malignancies  head and neck  oesophagus and lung were more frequent in non elderly patients  and survival  no difference   although age affects several features of head and neck cancer patients  it does not appear from the present study to be an independent prognostic factor for local control and survival  with regard to survival  stage appeared to be the most important prognostic factor  
class4	rhinosporidiosis associated with squamous cell carcinoma in the tongue  the peritumoural region of a squamous cell carcinoma of the tongue when examined with light and electron microscope showed nodular bodies in the submucosa with all the distinctive features of  sporangium and  spores  of rhinosporidiosis  the occurrence of rhinosporidiosis in the tongue along with malignancy has not been reported hitherto  some interesting observations and causal relationships are discussed  
class4	malignant adenolymphoma of the parotid gland  report of carcinomatous transformation  malignant transformation of an adenolymphoma  warthin s tumour  is a rare event  this paper presents a case of carcinoma arising in an adenolymphoma of the parotid gland  
class4	multiple primary malignancies in patients with malignant tumours of the nasal cavities and paranasal sinuses  the incidence of multiple primary malignancies  mpm  was analysed in 1297 patients with malignant tumours of the nasal cavities and paranasal sinuses  the patients were followed for a minimum of six years or until death  the incidence of mpm was 3 4 per cent  44 1297  which is lower in patients with malignant tumours of other regions in the upper aerodigestive tract  five of the 44 patients had second malignancies within previously irradiated areas  there was a difference between the proportion of histologies occurring in irradiated tissues compared with the overall 1297 patients  this finding suggests that radiotherapy may induce a second cancer  
class4	radiation therapy of laryngeal cancer  a twenty year experience  this paper reviews a 20 year experience of radiation treatment of 286 laryngeal cancers and presents results with a minimum five year follow up  all cases presented had glottic or supraglottic squamous cell carcinomas with no clinical evidence of nodal metastasis  a policy of primary radiotherapy with surgery for salvage of treatment failures  produced control of primary disease and prevention of metastases superior to most other regimes documented in the literature  
class4	effect of microwave and ionizing radiation in patients with recurrent laryngeal carcinoma  this study describes the treatment and survival of 54 patients with gross recurrent laryngeal carcinoma after radiotherapy  twenty six patients were treated with local ultra high frequency hyperthermia in combination with radiotherapy and chemotherapy  hrch   twenty eight control patients were treated with radiotherapy and chemotherapy  rch   eight patients  33 per cent  in hrch showed a three year survival but no patient in the rch group  at two years 18 patients  75 per cent  in hrch and two  7 per cent  in rch survived  
class4	benign parotid tumour enucleation  a reliable operation in selected cases  the method of surgical treatment for benign tumours of the parotid gland had not yet been rationalized  but many authors recommend parotidectomy as the most appropriate procedure  a series of 289 operations for parotid swelling is reported  the majority of mixed and warthin s tumours underwent enucleation without either complications or recurrence  the rationale of parotidectomy versus enucleation is discussed but in fast growing  deeply infiltrating and recurrent tumours  parotidectomy appears to be the best choice  in the other group of more commonly occurring tumours  enucleation represents a reliable time saving option  
class4	hoarseness as the sole presenting symptom of foramen magnum meningioma  foramen magnum tumours are rare  they may present with bizarre symptoms and mimic many conditions  we report a presentation with the sole complaint of hoarseness  never previously described in the literature  voice returned to normal after surgical removal of the foramen magnum meningioma  
class4	laryngeal metastasis from colonic adenocarcinoma  metastases to the larynx from distant primaries are very rare  usually the secondary lesion comes from an hypernephroma or malignant melanoma  a case of metastatic laryngeal tumour from a colonic adenocarcinoma  occurring in a 59 year old woman  is presented and the routes for laryngeal spread are discussed  the poor survival rate of these patients justified only conservative surgery  
class4	intralaryngotracheal thyroid  a case of intralaryngotracheal thyroid in a 57 year old man is presented  the treatment modalities are considered and the previous literature is reviewed  
class4	mid line presentation of cervical lymphomata  three cases of lymphoma are reported  all of which presented as a mid line cervical swelling and appeared to be localised disease  the importance of early removal of such lesions is emphasized  
class4	causes of death in hospitalized intravenous drug abusers  the authors reviewed at autopsy the causes of death of 274 patients with evidence of intravenous drug abuse who had been admitted to a large public hospital  there were 127 who died from diseases unrelated to intravenous drug abuse  and in 41  of these  chronic alcoholism was implicated  deaths from overdose syndromes and drug related organ pathology comprised only 11  of all cases  the mean age at death was 39 years  there was a male female ratio of 3 6 1  half of all patients died from infection  72 from acquired immunodeficiency syndrome  aids  alone  these findings indicate that persons hospitalized with a history of intravenous drug abuse usually die from causes other than overdose and that aids and chronic alcoholism are significant problems  emphasis should be placed upon detecting  hidden  intravenous drug deaths to provide more accurate statistical information  
class4	lambert eaton syndrome  autonomic neuropathy and inappropriate antidiuretic hormone secretion in a patient with small cell carcinoma of the lung  a patient with small cell carcinoma of the lung developed asymptomatic autonomic neuropathy  inappropriate antidiuretic hormone  adh  secretion and lambert eaton myasthenic syndrome  the autonomic neuropathy and inappropriate adh secretion were present at the time of diagnosis of the tumour  following chemotherapy these resolved  but 5 months later the patient developed lambert eaton syndrome which responded to 3 4 diaminopyridine  this sequence of changes appears to be unique  
class4	prognostic value of c myc proto oncogene overexpression in early invasive carcinoma of the cervix  the prognostic effect of c myc oncogene overexpression was assessed in a multivariate analysis of 93 patients with invasive carcinoma of the cervix  stage ib  iia  and iib proximal  the treatment was based on the association of brachytherapy colpohysterectomy and lymphadenectomy  analysis of c myc gene expression was done using northern and slot blot hybridization techniques  overexpression of c myc  ie  levels at least three times the mean observed in normal tissues  was present in 33  of the tumors  the proportion of carcinomas with c myc overexpression significantly increased with the size of the primary tumor  p    04   no relationship was found between c myc overexpression and the other clinical and histologic parameters  including the nodal status  the relative risk of relapse  overall  pelvic failure  distant metastases  was analyzed in a cox s proportional hazards model  three factors were significantly related to the risk of overall relapse when the multivariate analysis was performed  namely  the tumor size  the nodal status  and c myc expression  a combination of c myc expression and the nodal status provided a very accurate indication of the risk of relapse  indeed  patients with negative nodes had a 3 year disease free survival rate of 93   95  confidence interval  cl   79  to 98   when c myc was expressed at a normal level  whereas this rate was only 51   95  cl  26  to 63   when c myc was overexpressed  log rank test  p    02   in addition  in the subgroup of patients with positive nodes  this rate was 44   95  cl  25  to 77   and 15   95  cl  4  to 49   when c myc gene was expressed at normal level  or overexpressed  respectively  finally  c myc gene overexpression was  in the multivariate analysis  the first factor selected by the model regarding the risk of distant metastases  
class4	high  versus standard dose megestrol acetate in women with advanced breast cancer  a phase iii trial of the piedmont oncology association  one hundred seventy two patients with advanced breast cancer were randomized to receive oral standard dose megestrol acetate  ma   160 mg d or high dose ma  800 mg d  all but two patients had one prior trial of tamoxifen therapy for either metastatic disease  74   or as adjuvant treatment  26    pretreatment characteristics were similar for both arms  high dose ma resulted in a superior complete plus partial response rate  27  v 10   p    005   time to treatment failure  median  8 0 v 3 2 months  p    019   and survival  median  22 4 v 16 5 months  p    04  when compared with standard dose therapy  these differences remained significant after adjustment for other covariates  thirty four patients were given high dose ma after failure of standard dose ma treatment  and none responded  weight gain was the most distressing side effect  with 13  of standard dose and 43  of high dose patients gaining more than 20 lbs  four major cardiovascular events occurred in patients receiving high dose treatment and one in patients given standard doses  other toxicity was modest  high dose ma may represent a significant improvement in secondary endocrine therapy for advanced breast cancer patients refractory to initial endocrine treatment  but its use on a regular basis should be reserved until these results are confirmed by other clinical trials  
class4	epirubicin cardiotoxicity  a study of 135 patients with advanced breast cancer  the cardiotoxicity of epirubicin  epi  was evaluated clinically  radiologically  with ecg  and with multiple ecg gated radionuclide determination of the left ventricular ejection fraction  lvef  during rest in 135 patients with advanced breast cancer  the epi doses were 60 mg m2 on days 1 and 8 every 4 weeks or 45 mg m2 plus vindesine 3 mg m2 on the same schedule  the median cumulative dose of epi was 500 mg m2  range  47 to 1 563   eight of the 135 patients developed congestive heart failure  chf   of 67 patients treated with epi less than 500 mg m2  none developed chf  among 48 patients treated with doses between 500 and 1 000 mg m2  one had chf  2   95  confidence limits  0 1 to 11 1   among 20 patients who received epi from 1 000 to 1 563 mg m2  seven developed chf  35   95  confidence limits  15 4 to 59 2   four patients died due to cardiotoxicity  the risk of epi cardiotoxicity at the present schedule is considerable at doses above 1 000 mg m2  at doses between 500 and 1 000 mg m2 the risk of chf decreases  and at doses below 500 mg m2  it is negligible  for all patients  the prevalence of chf was 6  and the sensitivity of lvef high  95    mainly due to the low incidence of chf  among the 20 patients who received epi at more than 1 000 mg m2  the prevalence of chf was 35  and the sensitivity only 64   the specificity was maximally 62   our results suggest that lvef is of no value as a predictor for chf  
class4	acute renal dysfunction during interleukin 2 treatment  suggestion of an intrinsic renal lesion  adoptive immunotherapy with interleukin 2  il 2  and lymphokine activated killer  lak  cells has been effective in treating some advanced malignancies in animals and humans  one complication of this treatment is a reversible  oliguric  acute renal failure  which has been ascribed to renal hypoperfusion and resultant prerenal azotemia  we serially studied renal function in 10 patients receiving high dose regimens of recombinant interleukin 2  ril 2  to attempt to delineate further the nature of the renal dysfunction caused by il 2 treatment  renal plasma flow was computed from iodine 131  i 131 hippuran  mediphysics  paramus  nj  orthoiodohippurate  excretion curves  and glomerular filtration rate  gfr  was determined by creatinine clearance  studies done prior to and on day 4 of treatment showed that gfr fell in nine of 10 patients  with a mean decrease of 43      8   and renal plasma flow fell in five of the 10 patients with a mean decrease of 5      10   the average pretherapy filtration fraction was calculated to be 23      1  and after 4 days of treatment  decreased to a mean value of 15     2   the bun to creatinine ratio also declined in all patients  these findings collectively suggest that il 2 nephrotoxicity may result from an intrarenal defect in addition to the previously described prerenal azotemia  additionally  radionuclide studies of renal function are a reliable and reproducible noninvasive method of assessing these changes in renal function  
class4	long term sequelae of conservative treatment by surgery  brachytherapy  and chemotherapy for vulval and vaginal rhabdomyosarcoma in children  between 1970 and 1978  17 girls with rhabdomyosarcoma  rms  of the vulva or vagina were treated at the institut gustave roussy  igr  by conservative treatment including surgery  brachytherapy  and chemotherapy  twelve pubescent or postpubescent girls were studied for long term sequelae  eleven of 12 patients have had a normal puberty  two have a total of three healthy children  11 have normal menses  and 10 normal menarche  one after hormonal replacement   only one patient underwent hysterectomy following low dose brachytherapy  five girls have no vaginal complications  and three are sexually active  three have had minimal vaginal sequelae  which required surgical correction to permit sexual intercourse  four girls sustained serious sequelae  colorectal  vaginal  urethral  and ureteral stenosis   these sequelae  secondary to irradiation  are potentially avoidable in the future given the current advances in brachytherapy and improvements in dosimetry  this conservative treatment is useful and appropriate for girls with rms of vulvar or vaginal origin when complete remission cannot be obtained with chemotherapy and partial colpectomy  
class4	questionable role of cns radioprophylaxis in the therapeutic management of childhood rhabdomyosarcoma with meningeal extension  a series of 15 consecutive children with head and neck nonorbital rhabdomyosarcoma  rmsa  with meningeal extension were prospectively treated with chemotherapy consisting of adriamycin  doxorubicin  adria laboratory  columbus  oh   adm   vincristine  vcr   cyclophosphamide  cpm   and dactinomycin  dact  followed by radiotherapy  60 gy  to the primary tumor volume  along with intrathecal methotrexate  it mtx   thirteen of 15 responded to preradiation chemotherapy  four of 13 relapsed  relapse occurred at the level of the primary tumor in three of four  the 3 year progression free survival  pfs  was 59   similar to that achieved in a previous series treated with a comparable therapeutic approach that also included whole brain radiotherapy as a prophylaxis of possible occult meningeal seeding  it is concluded that cns prophylaxis with radiotherapy is questionable in the management of childhood rmsa with meningeal extension  
class4	treatment of metastatic melanoma with an autologous tumor cell vaccine  clinical and immunologic results in 64 patients  we treated 64 patients with metastatic melanoma using a melanoma vaccine preceded by low dose cyclophosphamide  cy   and monitored immunologic effects and antitumor activity  on day 0  the patients were given cy 300 mg m2 intravenously  three days later  they were injected intradermally with vaccine consisting of 10 to 25 x 10 6  autologous  enzymatically dissociated  cryopreserved  irradiated  25 gy  tumor cells mixed with bacillus calmette guerin  bcg   this treatment sequence was repeated every 28 days  of 40 assessable patients with measurable metastases  five had responses  four complete and one partial  with a median duration of 10 months  7 to 84  months   in six additional patients  we observed an antitumor response that seems to be peculiar to this vaccine therapy  the regression of metastatic lesions that appeared after the immunotherapy was begun  delayed type hypersensitivity  dth  to autologous  mechanically dissociated melanoma cells that had not been exposed to extraneous antigens  such as enzymes or fetal calf serum  increased significantly following immunotherapy  day 0 v day 49  p less than  001  day 0 v day 161  p less than  001  day 0 v day 217  p    021   antitumor responses to the vaccine were strongly associated with dth  as indicated by three observations   1  eight of 10 patients who exhibited tumor regression had positive dth   2  in postsurgical adjuvant patients  there was a highly significant linear relationship  p less than  001  between the intensity of dth to autologous melanoma cells and the time to recurrence of tumor  and  3  nine patients who developed dth to the autologous melanoma cells in their original vaccine developed new metastases that failed to elicit dth or elicited a much smaller response  in three cases  we were able to excise regressing tumors for histologic examination  such tumors were characterized by an intense infiltration of lymphocytes  this demonstration that an immune response to melanoma associated antigens can be elicited in cancer bearing patients provides some basis for optimism about the prospects for developing active immunotherapy that has practical therapeutic value  
class4	human tumor fluorouracil trapping  clinical correlations of in vivo 19f nuclear magnetic resonance spectroscopy pharmacokinetics  we previously reported that fluorouracil  5fu  accumulation and metabolism in human livers and tumors can be studied by in vivo nuclear magnetic resonance spectroscopy  nmrs   we have extended these observations by evaluating the pharmacokinetics of 5fu in the tumors of 11 patients with carcinoma of the breast  colon  endometrium  cervix  and kidney  using 19f nmrs in a 1 5 magnetom  siemens medical systems  cerrito  ca  magnetic resonance imaging unit  mri   these nmrs measurements detected a long lived tumor pool of 5fu in six of 11 tumors in our patients including carcinomas in the pelvis  breast  lung  and liver  the half life  t1 2  of this tumor pool of  trapped  5fu was 0 33 to 1 3 hours  20 to 78 minutes   much longer than the t1 2 of 5fu in blood  5 to 15 minutes   neither the anabolites of 5fu  fluorinated nucleosides  nucleotides  5fu rna  or 5fu thymidylate synthase  nor the catabolites  eg  fluorobetaalanine  fbal   were detectable by 19f nmrs  patient response to chemotherapy appeared to correlate with the extent of trapping of free 5fu in the human tumors  in the seven patients receiving 5fu  or 5fu or fudr plus leucovorin  four of four patients whose tumors trapped 5fu responded to fluorinated pyrimidine chemotherapy  whereas three patients in whom there was a failure to detect tumor trapping were resistant to 5fu  we conclude that nmrs is clinically feasible  and enables investigators to study 5fu pharmacokinetics and metabolism in tumors in vivo  19f nmrs of 5fu allows for in vivo evaluation of 5fu metabolic modulation and might be able to guide therapeutic decisions  
class4	changes in the clearance of total and unbound etoposide in patients with liver dysfunction  the disposition of total and non protein bound etoposide was investigated in 21 cancer patients receiving etoposide and cisplatin combination chemotherapy  etoposide plasma concentrations were determined using a specific high performance liquid chromatography  hplc  method  and etoposide plasma protein binding was determined by equilibrium dialysis  the patients had a wide range of renal function  creatinine clearance  32 to 159 ml min m2  and hepatic function  total bilirubin range  0 3 to 21 5 mg dl  aspartate aminotransferase  ast  range  14 to 415 iu l  serum albumin range  2 7 to 4 1 g dl   the mean etoposide total systemic clearance was not different in 15 patients with total bilirubin less than 1 0 mg dl versus six patients with total bilirubin 1 1 to 21 5 mg dl  18 7     5 9 ml min m2 v 26 4     10 7 ml min m2  t test p    06   with a trend toward higher total clearance in the patients with abnormal bilirubin values  however  the mean clearance of unbound etoposide was significantly lower in patients with increased total bilirubin  220     90 ml min m2 v 135     61 ml min m2  t test p    027   the fraction of etoposide unbound  fu  in plasma was significantly higher in patients with increased bilirubin  9      3  v 27      15   t test p    002   explaining the trend toward higher total clearance in these patients  etoposide clearance  total or unbound  in the 14 patients with measurable hepatic metastases was not different from the clearance in the seven patients without hepatic metastases  this study provides an explanation for why patients with increased bilirubin do not have lower total systemic clearance of etoposide  and indicates that such patients have a higher exposure to unbound etoposide  the results of ongoing pharmacodynamic studies of total and unbound etoposide in patients with increased bilirubin will determine the clinical relevance of altered etoposide protein binding  
class4	clinical evaluation of a side entry access port  a novel dual lumen venous access device  the initial clinical experience with a low profile side entry access  sea  dual lumen implantable venous access port for cancer chemotherapy administration is summarized in this report  the catheter material is polyurethane  the overall experience in 35 patients in this study was a total of 6 224 patient days  with a mean of 178 days per patient  a variety of chemotherapeutic agents  biologic response modifiers  and antibiotics were administered  in 26  of the patients  the device chambers were in simultaneous use during the treatment period  a 6  incidence of clinical subclavian vein thrombosis was noted  there was no infectious complications  inconsistencies in blood withdrawal and temporary catheter dysfunction were comparable to other access ports in clinical use  the novel design of this side entry port and the catheter material of low thrombogenicity make this device a good option in patients requiring a low profile system and dual access  nursing staff should be made aware of the side entry design and that in service training for accessing the septum is required in centers where such devices are not routinely used  
class4	a prospective  randomized evaluation of the treatment of colorectal cancer metastatic to the liver  over a 4 year period  1982 to 1986   91 patients with solitary or multiple metastases from colorectal cancer were stratified  based on findings at laparotomy  to one of three groups and then prospectively randomized to one of two treatment arms within each group  group a patients had solitary resectable metastases  group b patients had multiple  resectable metastases  and group c patients had multiple  unresectable metastases  patients were randomized to one of two treatment arms within a group  group a arm a1  resection only  arm a2  resection and continuous hepatic artery infusion  chai  of fluorodeoxyuridine  fudr   group b arm b1  resection and chai  arm b2  chai only  group c arm c1  chai  arm c2  systemic fluorouracil followed by chai  median time to failure  ttf  was 31 8  11 1  and 8 8 months for groups a  b  and c  respectively  arm a2 had an improved ttf when compared with arm a1  p    03   median survival correlated with extent of disease and was 37 3  22 4  and 13 8 months for groups a  b  and c  respectively  survival was not changed by treatment variation  arms  within each group  two  and 5 year cumulative survivals for groups a  b  and c were 72 7  and 45 4   45 8  and 16 7   and 31 7  and 3 2   respectively  in patients with multiple metastases  groups b and c   those patients whose original tumor was a dukes  b had a significantly improved ttf and survival over those patients whose tumor was a dukes  c  p less than or equal to  02   
class4	quantitative analysis of antibody localization in human metastatic colon cancer  a phase i study of monoclonal antibody a33  a33 is a mouse immunoglobulin g2a  igg2a  monoclonal antibody  mab  that detects a heat stable  protease  and neuraminidase resistant epitope  the antigen is homogeneously expressed by virtually all colon cancers and in the colon mucosa but not other epithelial tissues  the biodistribution and imaging characteristics of iodine 131  131i  maba33 were studied in colorectal carcinoma patients with hepatic metastases  antibody labeled with 2 to 5 mci of 131i was administered intravenously  iv  7 to 8 days before surgery at five dose levels  ranging from 0 2 mg to 50 mg  with three or more patients entered at each dose level  in addition  three patients received 2 mg 131i mabta99  an isotype matched control mab  together with 125i maba33  evaluation included whole body imaging with a gamma camera  technetium 99  99mtc  human serum albumin blood pool scans  liver spleen scans  abdominal computed tomographic  ct  scans  hepatic arteriograms  antibody pharmacokinetics  and assessment of antibody distribution in biopsied malignant and normal tissues  selective maba33 localization to tumor tissue was demonstrated in 19 of 20 patients  and external imaging correlated with surgical inspection  pathologic examination  and tissue radioactivity  one week after antibody administration  tumor liver ratios ranged from 6 9 1 to 100 1 and tumor serum ratios from 4 1 1 to 25 2 1  99mtc albumin blood pool studies showed that liver metastases were hypovascular  emphasizing the selective localization of maba33 despite poor tumor blood flow  control mabta99 studies showed maba33 localization was antigen specific  tumor liver ratios were 2 3  to 45 fold higher for specific antibody  in metastatic lesions  radioisotope was localized primarily in the viable periphery  however  even the necrotic tumor core concentrated specific antibody  external imaging showed isotope visualization in some patients  large bowel  whether this represents specific antibody uptake or gastric iodine secretion is unclear  
class4	an early phase ii study of cpt 11  a new derivative of camptothecin  for the treatment of leukemia and lymphoma  an early phase ii study of a new camptothecin analog and an inhibitor of topoisomerase i  cpt 11  was conducted in 62 patients with refractory leukemia and lymphoma by four different treatment schedules in a multiinstitutional cooperative study  cpt 11 therapy resulted in four complete remissions  crs  and three partial remissions  prs  in 29 assessable non hodgkin s lymphoma  nhl  patients  one pr in three hodgkin s disease  hd   one cr and one pr in 11 acute lymphoblastic leukemia  all   and one pr in 15 acute myelogenous leukemia  aml  patients  single infusion of 200 mg m2 every 3 to 4 weeks produced no response in both leukemia and lymphoma patients  sixty minute infusions of 40 mg m2 d for 5 days every 3 to 4 weeks or for 3 days weekly produced four crs  17   and four prs  17   in 24 patients with malignant lymphoma  sixty minute infusions of 20 mg m2 twice a day for 7 days every 3 to 4 weeks resulted in one cr and two prs in 12 patients with acute leukemia  no response was seen in an acute leukemia patient by another treatment schedule  cpt 11 was effective in two  15   of 13 primarily refractory leukemia and lymphoma cases  in two of four relapsed cases  and in seven  17   of 41 relapsed and refractory cases  major side effects were leukopenia  91   and gastrointestinal  gi   76    cpt 11 was shown to be effective against refractory leukemia and lymphoma  and thus deserves further clinical study  the novel antitumor activity mode of this drug predicts no cross resistance to presently available antitumor drugs  
class4	the unique aspects of acute promyelocytic leukemia  acute promyelocytic leukemia  apl  accounts for approximately 10  of cases of acute myeloid leukemia  aml   distinctive features of this disorder at the time of diagnosis include leukopenia coexisting with a marrow replaced with granulated dysplastic promyelocytes  disseminated intravascular coagulopathy  lack of ia  hla dr  antigen expression  and translocation between the long arms of chromosomes 15 and 17  t 15 17    heparin is widely but not universally used to interfere with the coagulopathy during the initial phases of treatment  serial bone marrow examinations during the induction period demonstrate the achievement of remission despite the persistence of malignant appearing promyelocytes  patients with apl are generally younger than those with other subtypes of aml  have a 70  to 80  likelihood of entering remission  and are thought to have a more favorable prognosis than other individuals with aml  remission may be achieved with a conventional anthracycline cytarabine combination  anthracycline alone  or  apparently  all trans retinoic acid  genes potentially important in myeloid differentiation such as granulocyte colony stimulating factor  g csf  and myeloperoxidase are located close to the breakpoint in the t 15 17  but have not been conclusively shown to be rearranged in the translocation  a better understanding of the unique aspects of apl may well shed light on the pathogenetic processes of aml  
class4	intraperitoneal yttrium 90 labeled monoclonal antibody in ovarian cancer from march 1987 to march 1988  a phase i to ii study was carried out in 25 patients with ovarian cancer  they received escalating doses of intraperitoneally  ip  administered yttrium 90  y 90  labeled monoclonal antibody  hmfg1  against a tumor cell surface antigen  myelosuppression prevented an escalation of the administered y 90 activity above 25 mci  y 90 labeled antibody was absorbed from the peritoneal cavity into the circulation  maximum blood y 90 activity was observed 40 hours after the ip injection with a mean of 21  of the injected activity  range  14 2  to 26 4   in the circulation  the radiation dose the bone marrow received from circulating y 90 labeled antibody  the blood radiation dose  was calculated by applying the medical internal radiation dose  mird  formulation to the measured y 90 activity in patients blood  myelosuppression occurred following calculated blood radiation doses to bone marrow of only 10 to 30 cgy  the excessive myelosuppression following such modest radiation doses from circulating y 90 labeled antibody could be explained by the uptake of y 90 by bone  in an attempt to reduce bone absorption of y 90  seven patients received an intravenous  iv  infusion of edta  sinclair pharmaceuticals ltd  godalming  united kingdom   this increased the urinary excretion of y 90 from a mean of 11 1  to 32 3  of the injected activity  p    0001   fourteen patients had assessable tumor at laparoscopy  tumor regression was observed in one patient  and palliation of ascites in a further patient  
class4	pediatric osteosarcoma  therapeutic strategies  results  and prognostic factors derived from a 10 year experience  ninety eight pediatric patients were treated with three separate protocols  treatment and investigation of osteosarcoma  tios  i  ii  and iii  and 47 developed recurrent disease  metastases and or local recurrence   actuarial overall disease free survival  hereafter designated survival  was 43   over 90  of the patients were treated initially with preoperative intraarterial cisplatin  cdp   postoperative chemotherapeutic regimens comprised high dose methotrexate with leucovorin rescue  mtx cf   adriamycin    adr  doxorubicin  adria laboratories  columbus  oh   and cyclophosphamide  primary definitive treatment comprised amputation or limb salvage  tios i and tios iii   patients treated with preoperative cdp and surgery  tios i and iii  had a 62  survival  patients in tios ii refused surgical extirpation  they were treated exclusively with chemotherapy and had a 23  survival  survival in patients treated with amputation was 55  and limb salvage 58   prognostic factors considered significant in relation to development of pulmonary metastases comprised tumor burden  p    04  and the percentage of tumor necrosis induced by preoperative chemotherapy  p    01   histopathologic subtype was marginally significant  chondroblastic was more favorable as opposed to osteoblastic  p    05   these findings are compared with results and prognostic factors published in the literature  
class4	current urinary mass screening for catecholamine metabolites at 6 months of age may be detecting only a small portion of high risk neuroblastomas  a chromosome and n myc amplification study  we studied 96 infants and children with untreated neuroblastomas  chromosomes of tumor cells were analyzed in 68  and n myc copy numbers were determined in 67 patients  patients found by a mass screening program for 6 month old infants  group a1  39 patients  or those less than 12 months of age found clinically  group a2  13 patients  were rarely in the disseminated stage  a1  three of 39  a2 one of 13   their tumors usually had near triploid  3n  or hypertetraploid  greater than 4n  karyotypes  a1  28 of 37  a2  nine of 11   and never had n myc amplification  a1  zero of 34  a2  zero of 11   in contrast  children 12 months or over  group b  27 patients  were usually in the disseminated stage  19 of 27   p less than  0001   their tumors usually had near diploid  2n  or near tetraploid  4n  karyotypes  16 of 20   p    0027   and often had n myc amplification  nine of 22   p less than  0001   of the 40 clinically found patients  a2 and b   six had undergone the screening with a negative result at the age of 6 months  two of the six patients had n myc amplification in the tumors  most tumors found by the screening showed known characteristics predicting a good prognosis  and the majority of tumors showing characteristics predicting a poor prognosis were found in patients aged between 12 and 36 months  our chromosome and n myc amplification studies suggest that a low risk tumor does not usually evolve to a high risk tumor  thus  the current mass screening program may be detecting only a small portion of highly malignant neuroblastomas at the earliest stage  infants should be screened twice  at 6 months as well as at 12 months of age  for the early detection of high risk neuroblastomas  
class4	mechlorethamine  vincristine  and procarbazine chemotherapy for recurrent high grade glioma in adults  a phase ii study  we undertook a phase ii study of combination chemotherapy with mechlorethamine  nitrogen mustard  6 mg m2 intravenously day 1 and day 8  vincristine 2 mg intravenously day 1 and day 8  and procarbazine 100 mg m2 orally days 1 through 14  mop  in adults with recurrent high grade glioma  there were 31 patients entered and 27 patients assessable for response  the median age was 49 years old  all patients had prior maximal radiotherapy  and eight had previous chemotherapy  responses were determined based on clinical and computed tomographic  ct  scan magnetic resonance imaging  mri  criteria  the response rate  partial response  pr  plus objective qualitative response  oqr  plus complete response  cr   was 52  with one cr  the response rate was higher in patients with anaplastic astrocytoma as compared with glioblastoma multiforme  p less than  05   the median duration of response was 42 weeks  median survival for all assessable patients was 30 weeks  and for responders  it was 60 weeks  response was correlated with ability to decrease dexamethasone doses and improved performance status  toxicity was mainly hematologic with leukopenia being common  there was one treatment related death from listeria meningitis  and two patients developed pneumocystis carinii pneumonia  there were three episodes of neutropenic fever  we conclude that mop is active and merits further investigation in adult high grade glioma  
class4	phase ii study of fluorouracil and recombinant interferon alfa 2a in previously untreated advanced colorectal carcinoma  we conducted a phase ii clinical trial of fluorouracil  5fu  and recombinant interferon alfa 2a  rifn alpha 2a  in 52 previously untreated patients with bidimensionally measurable metastatic colorectal cancer  during week 1  5fu was administered as a continuous intravenous infusion  750 mg m2 d for 5 consecutive days  intravenous bolus administration of 5fu 750 mg m2 was given weekly for 7 weeks starting on day 12  rifn alpha 2a  roferon  hoffman laroche  nutley  nj   9 x 10 6  u  was administered subcutaneously three times weekly during weeks 1 to 8  patients were evaluated for response on week 9  of 52 patients enrolled in the study  51 were assessable for toxicity  and 45 were assessable for response  fifteen patients experienced partial response  and one patient achieved a clinical complete response for an overall response rate of 35   95  confidence interval  ci   22   50    median duration of response is 7 5 months  range  4 to 11 months   seventy percent of patients entered on the study are alive with a median follow up duration of 7 months  twenty five percent of patients developed grade 4 toxicity  and 82  developed grade 3 toxicity  one drug related death in the presence of sepsis was reported  and two treatment related seizures occurred  our experience with this schedule produced a lower response rate with greater toxicity than previously reported  current randomized trials comparing this schedule of 5fu with rifn alpha 2a to 5fu plus folinic acid  leucovorin  or single agent 5fu may determine its role in the treatment of advanced colorectal carcinomas  
class4	adjuvant cyclophosphamide  methotrexate  and fluorouracil in patients with axillary node positive breast cancer  an update of the guy s manchester trial  between 1976 and 1985  391 patients  202 premenopausal  189 postmenopausal  with operable breast cancer and positive axillary lymph nodes were randomized after total mastectomy and axillary clearance to receive cyclophosphamide  methotrexate  and fluorouracil  cmf   n   193  or no adjuvant therapy  n   198   after a median follow up of 8 years  both relapse free survival  rfs  and survival  s  were significantly prolonged in premenopausal patients receiving cmf  rfs  p less than  001  s  p    003   treatment with cmf resulted in a significant improvement in rfs in premenopausal patients both with steroid receptor positive and steroid receptor negative tumors and also in subgroups of premenopausal patients defined by the number of axillary nodes involved  premenopausal patients who developed permanent amenorrhea following cmf had a significantly better rfs than those who continued to menstruate  induction of amenorrhea following cmf was related to age  with almost all patients over 40 years becoming amenorrheic  for patients less than or equal to 40 years  development of amenorrhea following cmf did not influence outcome  no difference was detected between control and cmf groups  rfs  p    9  s  p    9  in postmenopausal patients nor in any subgroup of these patients  the results of this trial of the efficacy of cmf for improving rfs and s have strengthened with longer follow up  
class4	node negative breast cancer  prognostic subgroups defined by tumor size and flow cytometry adjuvant systemic therapy for women with node negative breast cancer is most easily justified for those patients at highest risk of relapse  we have examined the impact of tumor size  histologic grade  estrogen receptor  er  status  tumor ploidy  and s phase fraction  spf  on relapse free survival  rfs  for 169 patients with node negative breast cancer in order to identify groups of patients at high and low risk of relapse  patients with small tumors  less than or equal to 1 0 cm  had a significantly better rfs than those with larger tumors  p    005   with 96  remaining relapse free at 5 years  patients with tumors less than or equal to 1 0 cm were thus excluded from analysis when attempting to define a group with a poor prognosis  within the group of patients with tumors greater than 1 0 cm  tumor ploidy  p    63   er status  p    3   or progesterone receptor  pgr  status  p    24  did not predict for rfs  patients with grade 1 or 2 infiltrating ductal tumors had a significantly better prognosis than those with grade 3 tumors  p    04   the prognostic factor that gave the widest separation between subgroups  however  was spf  patients whose tumors were greater than 1 0 cm with an spf less than or equal to 10  had a 5 year rfs of 78  compared with a 5 year rfs of 52  for those with an spf greater than 10   p    006   we have combined tumor size and spf to identify three prognostic groups   1  tumor less than or equal to 1 0 cm  5 year rfs 96    2  tumor greater than 1 0 cm plus spf less than or equal to 10   5 year rfs 78   3  tumor greater than 1 0 cm plus spf greater than 10   5 year rfs 52   these prognostic groupings may help identify patients most suitable for adjuvant therapy  
class4	drug induced dna damage and tumor chemosensitivity  cytotoxic drugs act principally by damaging tumor cell dna  quantitative analysis of this interaction provides a basis for understanding the biology of therapeutic cell kill as well as a rational strategy for optimizing and predicting tumor response  recent advances have made it possible to correlate assayed dna lesions with cytotoxicity in tumor cell lines  in animal models  and in patients with malignant disease  in addition  many of the complex interrelationships between dna damage  dna repair  and alterations of gene expression in response to dna damage have been defined  techniques for modulating dna damage and cytotoxicity using schedule specific cytotoxic combinations  dna repair inhibitors  cell cycle manipulations  and adjunctive noncytotoxic drug therapy are being developed  and critical therapeutic targets have been identified within tumor cell subpopulations and genomic dna alike  most importantly  methods for predicting clinical response to cytotoxic therapy using both in vitro markers of tumor cell sensitivity and in vivo measurements of drug induced dna damage are now becoming a reality  these advances can be expected to provide a strong foundation for the development of innovative cytotoxic drug strategies over the next decade  
class4	magnetic resonance imaging contrast agents  theory and application to the central nervous system  the theoretical aspects of magnetic resonance  mr  imaging contrast agents are reviewed  and their current applications to the central nervous system  cns  and their future applications are discussed  profound differences exist between contrast agents used for mr imaging and computerized tomography  ct   in mr imaging  the contrast agents are not imaged directly but rather act on adjacent protons to shorten t1 and t2 relaxation times  this in turn results in signal intensity changes  the lanthanide metal  gadolinium  in the form of gadopentetate dimeglumine  has been found to be both safe and efficacious as the only currently approved contrast agent for mr imaging  magnetic resonance imaging revolutionized the detection and treatment of disease affecting the brain and spine  initially  it was thought that signal characteristics on mr imaging would allow differentiation of specific pathology  it was soon found that mr studies were able to detect more abnormalities but were less able to characterize them  the recent development of contrast agents for mr imaging has allowed this modality to surpass ct for the evaluation of most cns lesions  at present  contrast enhanced mr imaging is generally accepted as the study of choice for evaluating acoustic neurinomas  pituitary lesions  meningeal disease  primary and secondary brain tumors  active multiple sclerosis  intradural spinal neoplasms  intramedullary spinal disease  and postoperative states in both the spine and brain  even when contrast enhanced ct can detect the same abnormalities  evaluation of the lesions in multiple planes on mr imaging can sometimes yield invaluable information  especially prior to surgery  future developments of contrast material for mr imaging include non gadolinium compounds  intrathecal contrast media  cerebral blood flow and volume evaluation  and  possibly  antibody labeled contrast agents  
class4	clinoidal meningiomas  anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas  masking their notorious association with a high mortality and morbidity rate  failure of total removal  and recurrence  to avoid injury to encased cerebral vessels  most surgeons are content with subtotal removal  without total removal  however  recurrence is expected  recent advances in cranial base exposure and cavernous sinus surgery have facilitated radical total removal  the author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved dura and bone  this experience has distinguished three groups  i  ii  and iii  which influence surgical difficulties  the success of total removal  and outcome  these subgroups relate to the presence of interfacing arachnoid membranes between the tumor and cerebral vessels  the presence or absence of arachnoid membranes depends on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid cistern  total removal was impossible in the three patients in group i  with postoperative death occurring in one patient and hemiplegia in another  total removal was achieved in 18 of the 19 patients in group ii  with one death from pulmonary embolism  in the two patients in group iii  total removal without complications was easily achieved  
class4	motility factor produced by malignant glioma cells  role in tumor invasion  to better understand the cellular mechanism of tumor invasion  the production of a cell motility stimulating factor by malignant glioma cells was studied in vitro  serum free conditioned media from cultures of rat c6 and human t98g cell lines contained a factor that stimulated the locomotion of the producer cells  this factor was termed the  glioma derived motility factor   the glioma derived motility factor is a heat labile protein with a molecular weight greater than 10 kd and has relative stability to acid  the factor showed not only chemotactic activity but also chemokinetic  stimulated random locomotion  activity in the two types of glioma cells studied  although glioma derived motility factors in conditioned media obtained from two different cell origins are likely to be the same  chemokinetic migration of t98g cells to their conditioned medium was much stronger than that of c6 cells to theirs  coincubation of cells with cytochalasin b  which disrupts the assembly of cellular actin microfilaments  almost completely inhibited the cell migration stimulated by glioma derived motility factor  cytochalasin b also induced marked alterations in cell morphology  including cell retraction and arborization  while the drug did not affect cell attachment to culture dishes  these results indicate that glioma cells produce a motility factor which may play a role particularly when tumor cells are detached and migrate away from the original tumor mass  thus promoting tumor invasion  also  glioma cell migration stimulated by the motility factor requires the normal organization of cytoskeletons such as actin microfilaments  
class4	antigen related to cell proliferation in malignant gliomas recognized by a human monoclonal antibody  a human monoclonal antibody  cln igg  was produced from a human human hybridoma derived from lymphocytes of a patient with cervical carcinoma  the reactivities of this antibody with various human glioma tissues and cultured glioma cells and the characterization of the antigen recognized by cln igg on malignant glioma cells were analyzed and reported  cln igg reacted with various human glioma cells and glioma tissues  especially glioblastoma  but did not react with normal brain tissues or fetal brain tissues  a large amount of antigen recognized by cln igg was expressed on cell membranes of undifferentiated glioma cells and of glioma cells at the g2 m tumor growth phase in cycling cells  antigen recognized by cln igg was detected in only one of seven samples of cyst fluid  and was not detected in 27 serum samples or 18 samples of cerebrospinal fluid from glioma patients  cln igg exhibited antibody dependent cell cytotoxicity against u 25 1 mg glioma cells and primary cultured cells of glioblastomas and anaplastic astrocytomas  these data suggest that the antigen recognized by cln igg might be related to cell proliferation in malignant gliomas  thus  cln igg might be useful for immunotherapy or immunoimaging of malignant gliomas  
class4	evidence of a local immune activation in cystic brain tumors  the fluid of cystic brain tumors was characterized with regard to the protein content  in most malignant tumors  the concentrations of immunoglobulins g and m  igg and igm  were higher relative to other proteins in the cyst fluid than in the serum of the same patient  a markedly elevated ratio of monomeric to pentameric igm was detected in the cyst fluid of two patients with glioblastomas  the results indicate a local immunoglobulin synthesis in malignant cystic brain tumors  it is hypothesized that higher than expected concentrations of igg and igm in cyst fluid as compared to plasma are a sign of an ongoing immune response triggered by the tumor  
class4	epithelial cyst of the fourth ventricle  case report  a case of epithelial cyst in the fourth ventricle of a 4 year old child is described  a single epithelial layer with a clear basement membrane lining the cyst wall was observed  there were no prominent histological findings to suggest a pathogenesis for this cyst based on immunohistochemical or ultrastructural studies  however  the cyst fluid contained significant amounts of carcinoembryonic antigen  it is considered that the epithelial layer lining the cyst wall was possibly of endodermal origin  
class4	recurrence of acoustic neurilemoma as a malignant spindle cell neoplasm  case report  a 75 year old man presented with a right cerebellopontine angle tumor 11 months after complete macroscopic resection of a right acoustic neurilemoma  histological examination of the recurrent tumor showed a malignant spindle cell neoplasm with positive staining for s 100 protein  the patient had no stigmata of von recklinghausen s disease  it is proposed that this recurrence represents progression from a benign to a malignant acoustic nerve sheath tumor  an event that is extremely rare outside the clinicopathological context of neurofibromatosis  
class4	administered dose and tumor dose of bleomycin labeled with cobalt 57 in mice and men  tumor concentrations of the chemotherapeutic drug  bleomycin  labeled with cobalt 57  co bleo  were compared in mouse tumor models and in human lung tumors using quantitative single photon emission computed tomography  drug concentrations in histologically similar human tumors showed marked variability for the same injected dose  id   small cell carcinomas showed concentrations between 1 09 and 8 85  id cc x 10  3  while non small cell lung tumors showed a concentration variation between 0 36 and 6 75  id cc x 10  3   in contrast to the situation in human tumors  uptake in mouse tumors showed only slight variability in animals with the same tumor model  emt 6 tumors in mice showed at 6 hr significantly higher uptake of co bleo  p less than 0 001  and significantly higher tumor to lung ratio  p less than 0 001  when compared to murine fibrosarcomas  the emt 6 tumors in contrast to the fibrosarcomas responded to bleomycin treatment in a dose dependent manner  the results indicate that while in mice the tumor dose closely follows the administered dose  in humans  the tumor dose and the tumor to lung ratio in the individual patient cannot be predicted from the administered dose  
class4	imaging of tumor in patients with indium 111 labeled biotin and streptavidin conjugated antibodies  preliminary communication tumor localization in patients has been achieved through the in vivo use of streptavidin and biotin  in these preliminary studies  the monoclonal antibody hmfg1 was conjugated with streptavidin and 1 mg was administered intravenously to each of 10 patients with documented squamous cell carcinoma of the lung  two to 3 days later  111in labeled biotin was also administered intravenously  no evidence of toxicity was observed  background radioactivity levels were reduced in liver  1  id at 24 hr  and kidneys  2   and in all other normal tissues and blood  images of lung tumor were obtained in as little as 2 hr following administration of labeled biotin  in eight patients  tumor was detected with labeled biotin alone without the previous administration of streptavidin conjugated antibody but in three of these patients  the images were improved with the prior administration of conjugated antibody  these results suggest that this approach may improve the tumor to normal tissue radioactivity ratios in radioimmunotargeting  
class4	immunoscintigraphy of ovarian cancer with indium 111 labeled ov tl 3 f ab  2 monoclonal antibody  the safety and diagnostic accuracy of immunoscintigraphy with the indium 111 labeled monoclonal antibody ov tl 3 f ab  2 111in ov tl 3 f ab  2  for diagnosis and follow up of ovarian cancer was prospectively studied in 31 patients  planar and spect scintigraphy were performed up to 4 days after i v  injection of 140 mbq 111in ov tl 3 f ab  2  surgical evaluation was possible in 22 out of 31 patients  imaging results were compared with x ray computed tomography  ultrasound  and ca 125 serum level using the histologically confirmed surgical findings as a  gold standard   apart from a transient rash observed in two patients  no other immediate or delayed adverse reactions were observed  within the surgically evaluated group  ovarian cancer lesions were detected in 16 out of 17 patients  94    of 45 distinct tumor deposits found at operation  67  were detected and localized with immunoscintigraphy while x ray computed tomography and ultrasound visualized 53  and 23   respectively  
class4	the potential of 2 deoxy 2 18f fluoro d glucose  fdg  for the detection of tumor involvement in lymph nodes  to assess the potential of fdg for pet imaging of nodal tumor metastases  we evaluated its uptake into normal lymph nodes  tumor involved lymph nodes  and subcutaneous tumor xenografts in rodents  normal lymph nodes in mice and rats accumulate fdg moderately  developing node blood ratios of 1 3 11 9 1 at 2 hr following i v  injection  by contrast  fdg given subcutaneously to healthy sprague dawley rats developed very high normal draining lymph node blood ratios  272 1  versus 7 7 1 by i v  injection  in nude mice  subcutaneous human ovarian cancer xenografts had 1 27 fold more uptake relative to blood than did normal popliteal lymph nodes  subcutaneous tumor xenografts of rat breast cancer developed tumor normal node uptake ratios of 4 91     0 43 1 and tumor blood ratios of 6 6     0 9 at 2 hr postinjection  mouse nodes involved with 38c13 murine b cell lymphoma had mean node blood ratios of 42 9     6 7 1 and tumored node normal lymph node uptake of 6 3 1  thus  fdg given intravenously but not subcutaneusly  due to high normal nodal uptake  has potential as an agent for the detection of metastatic tumors in regional lymph nodes using pet scanning  
class4	radioimmunoscintigraphy using iodine 131 anti cea monoclonal antibodies and thallium 201 scintigraphy in medullary thyroid carcinoma  a case report  this case report demonstrates the use of thallium 201  201tl  scans versus iodine 131   131l  anti cea f ab  2 scans in a patient with high serum cea levels due to metastases of medullary thyroid carcinoma in the suprarenal region and sacroiliacal region  scintigraphy using monoclonal antibodies directed against cea showed a higher tumor uptake  0 26  dose and 0 64  dose  respectively  than a thallium scan and is believed to be promising for future radiotherapeutic applications  
class4	treatment planning for internal radionuclide therapy  three dimensional dosimetry for nonuniformly distributed radionuclides  a calculational approach is described that provides the spatially varying radiation absorbed dose  presented as isodose contours superimposed on ct images  from nonuniform and or irregular cumulated activity distributions  ct images are read from magnetic tape and are displayed on a high resolution color graphics display monitor  source tissue geometries are defined on a series of contiguous ct images automatically  by an edge detection algorithm  or manually  using a trackball   thereby obtaining a three dimensional representation of the various source volumes of activity  dose calculations are performed using a radionuclide specific absorbed dose point kernel in the form of a lookup table  the method described yields the spatially varying dose delivered to tumor and normal tissue volumes from a patient specific cumulated activity distribution in a clinically implementable manner  this level of accuracy in determining normal tissue and tumor doses may prove valuable in the evaluation and implementation of radionuclides and radiolabeled compounds for therapeutic purposes  
class4	effects of energy restriction on mouse mammary tumor virus mrna levels in mammary glands and uterus and on uterine endometrial hyperplasia and pituitary histology in c3h shn f1 mice  we investigated the effects of energy restriction on the pituitary ovarian axis and on a hormone responsive gene  the mouse mammary tumor virus  mmtv   female c3h shn f1 hybrid mice  known to display a high incidence of mammary tumors  ate an energy restricted diet  48 kcal wk  or a control diet  95 kcal wk  beginning at the time of weaning  by 67 wk of age  12 of 32 mice in the control group  but none of the 33 mice in the energy restricted group  had developed mammary tumors  six tumor free mice from each group were studied in detail at 67 wk of age  all six tumor free control mice  but none of the six energy restricted mice  showed uterine endometrial hyperplasia at autopsy  mice subjected to energy restriction did not display an estrous cycle  the average levels of mmtv mrna in mammary glands and uteri were strongly reduced by energy restriction  mmtv mrna levels in mammary glands from control mice were two orders of magnitude lower than those in mammary tumors  energy restriction lowered the percentage of pituitary mammatropes and suppressed proliferation of mammatropes with advancing age  energy restriction thus appeared to inhibit endometrial hyperplasia and to decrease mmtv production at the mrna level in the mammary glands and in the uterus  these effects may be a consequence of hormonal changes originating at the pituitary ovarian axis  
class4	implementation of cancer prevention guidelines in clinical practice  data from several sources  including consumer surveys  physician surveys  and medical record audits  indicate that consumers do not receive cancer screening tests as recommended by the national cancer institute  the american cancer society  and the u s  preventive services task force  performance rates are consistently below published standards for all tests except pap tests  major reasons physicians do not perform the recommended tests include physician forgetfulness  disagreement with recommendations  lack of time  and patient refusal  physicians also tend to overestimate their own performance rates  barriers to screening test performance can be categorized into patient factors  physician factors  test factors  and health care delivery system factors  interventions  such as computerized reminder systems  physician audits with feedback  and patient education and reminders  can be effective in promoting performance of such screening  interventions that target both physician and patient may be particularly effective  
class4	implementation of preventive services in an hmo practice  practice does not conform to guidelines unless the guidelines are specifically implemented and performance is monitored  several examples of implementation in one health maintenance organization  hmo  are given  these include immunization for influenza and follow up of positive screening tests for colorectal and cervical cancer  each implementation effort has required the development of systems  which in this hmo are automated  several issues influencing implementation are discussed  including resource constraints and priorities for the allocation of new resources  developers cannot expect that their guidelines will be incorporated into clinical practice  they must foster specific implementation plans  
class4	breast cancer screening  who should be included  the recommendations of the u s  preventive services task force are reviewed in regard to screening for breast cancer  in contradistinction to those issued by some other national organizations  screening for breast cancer using mammography at ages 40 49 is not recommended  it is concluded that the scientific evidence is insufficient at present to recommend mammography screening for women aged 40 49  the recommendations of the task force are  all women over age 40 should receive an annual breast examination  all women should have mammography every one or two years beginning at age 50 and concluding at approximately age 75 unless disease has been detected  and it may be prudent to begin mammography at an earlier age for women at high risk of breast cancer  these recommendations are appropriate in light of the available evidence  though at present there is no evidence that clinical examination of the breasts at any age reduces breast cancer mortality  the upper age beyond which breast cancer screening no longer has a significant effect in reducing breast cancer mortality is unknown  and there is no evidence that women at high risk for breast cancer benefit to a different degree from screening than women not at high risk  
class4	colorectal cancer  have we identified an effective screening strategy  three currently used screening methods are aimed at detecting colorectal cancer when it is asymptomatic and curable  and at detecting polyps so that they can be removed before they can progress to cancer  digital rectal examinations are relatively cheap and easy but can detect only a small fraction of large bowel cancers  sigmoidoscopy is more sensitive  but its low acceptability to patients has been only partially mitigated by the introduction of the 35 cm flexible instrument  fecal occult blood testing has limited sensitivity because blood from cancers and polyps is neither continuously shed nor uniformly distributed in feces  specificity and positive predictive value are also low because of other sources of blood in the stool  prudent judgment suggests that all of these screening tests may prevent death from colorectal cancer in some patients  however  none has been proven effective in general use by well controlled studies  case control studies can provide timely and valuable new evidence in this regard  the authors  investigations in progress are described  the current lack of strong evidence in support of these screening tests should not be interpreted as evidence against their use  
class4	the impact of the u s  preventive services task force guidelines on cancer screening  perspective from the national cancer institute  the u s  preventive services task force evaluated the medical literature  utilizing strict criteria to judge the merits of experimental trials designed to show benefit in screening for cancer  for individuals at normal risk  the task force was not able to make recommendations for or against screening for colorectal  prostate  skin  oral  or testicular cancers  only one physical examination cancer screening procedure has ever been tested in a randomized trial  during the past 27 years  the national cancer institute  nci  has funded six randomized screening trials  thus far  only one has shown a decrease in mortality  recognizing the limitations of such trials  the nci published  working guidelines for early cancer detection   designed for the practicing physician  these guidelines were based upon the best available evidence and on the judgment of representatives of medical professional organizations  
class4	squamous cell carcinoma antigen for detection of squamous cell and mucoepidermoid carcinoma after primary treatment  a preliminary report  this study evaluated the efficacy of using the periodic measurement of the serum level of squamous cell carcinoma antigen  scc antigen  for determining the local recurrence and or metastasis of squamous cell and mucoepidermoid carcinomas after primary treatment  it was found that at the time of clinical recognition of recurrence  the scc antigen level was normal  but metastasis to regional lymph nodes or to remote organs generally was accompanied by an increase of scc antigen  changes in the scc antigen level with mucoepidermoid carcinoma seemed to be less sensitive than with squamous cell carcinoma  
class4	pedunculated soft tissue mass on the alveolar gingiva  clinical conference  a case of peripheral ameloblastoma  a rare intraoral neoplasm  has been presented  the lesion appears most commonly as a mass on the mandibular lingual gingiva of patients in their fifth and sixth decades of life  the peripheral ameloblastoma does not share the aggressive nature of the intraosseous variant  the lesion has been overtreated in the past and warrants only a local supraperiosteal excision  
class4	mucous cell hyperplasia in an odontogenic cyst from a patient with muir torre syndrome  mucous cell proliferation in a periapical radicular cyst from a patient with a family history of colonic malignancies and multiple sebaceous neoplasms of the skin  so called muir torre syndrome  is reported  such goblet cell hyperplasia has not been previously reported to be associated with any known syndrome  we believe the finding of mucous cell hyperplasia in an odontogenic cyst may not simply be coincidental  but should raise suspicion of paraneoplastic potential and warrant further evaluation for possible occult neoplastic disease  
class4	serial magnetic resonance imaging in neonatal hypoxic ischemic encephalopathy  we prospectively performed magnetic resonance imaging  mri  studies during the neonatal period  and at 4 and 8 months of age  on 15 term infants with hypoxic ischemic encephalopathy  and compared the results with their neurodevelopmental outcome at 18 months of age  cerebral palsy developed in nine infants  two infants were classified as having abnormalities of tone and delayed motor milestones that were suggestive of cerebral palsy  and four infants were normal  structural abnormalities  delayed myelination  or a combination of the two were detected with mri at 8 months of age in all nine infants with later development of cerebral palsy  three of the four normal infants and one infant with suggestive abnormalities had normal serial mri findings  each of the remaining two infants  one normal  one with suggestive abnormalities  had isolated persistent ventricular dilation on all three mri studies  our results suggest that 8 months appears to be the earliest time at which mri findings correlate well with later adverse neurodevelopmental outcome in this population  
class4	interaction between trimethoprim sulfamethoxazole and methotrexate in children with leukemia  because trimethoprim sulfamethoxazole  tmp smx  causes neutropenia in children with leukemia  we investigated the possibility that pharmacokinetic interaction between methotrexate  mtx  and tmp smx causes accumulation of the antileukemia agent  we studied the pharmacokinetics of mtx given intravenously or orally to nine children with acute lymphoblastic leukemia  once with and once without tmp smx  there was an increase in free mtx fraction during tmp smx therapy in all patients  from  mean     sd  37 4     11  without tmp smx to 52 2     6 4  with tmp smx  p less than 0 01   plasma clearance of total mtx did not change significantly  whereas clearance of free mtx decreased significantly  from 12 5     4 to 7 6     1 5 ml kg min  p less than 0 05   there was a consistent decrease in the renal clearance of free mtx  from 12 1     6 8 to 5 6     2 4 ml kg min  p less than 0 05   elimination half life of mtx was not affected significantly by tmp smx  there was a significant correlation between serum concentrations of tmp smx and the percentage of decrease in the renal clearance of free mtx  r   0 91  p less than 0 05   these changes in protein binding and tubular clearance of mtx  caused by competition with tmp smx  result in a mean 66  increase in systemic exposure to mtx and may explain the myelotoxicity often observed with the coadministration of the two drugs  
class4	laparoscopic management of ovarian cysts  one hundred two women with ovarian cysts were managed laparoscopically over a 13 year period  thirteen were treated with laparoscopic inspection followed by laparotomy  6 with laparoscopic fine needle aspiration followed by laparotomy and 83 with laparoscopic fenestration and biopsy  with or without coagulation or removal of the cyst lining  satisfactory results were noted in patients treated completely with laparoscopy  only 1 of 56 functional  simple or paraovarian cysts recurred during the study period  two of the 18 ovarian endometriomas treated with fenestration and coagulation or removal of the lining recurred  whereas 8 of 9 such lesions recurred when treated with fenestration alone  there were no surgical complications  
class4	expression of the mdr1 gene in human gastric and colorectal carcinomas  we measured expression of the mdr1 gene  also known as the pgy1 gene  in the human gastrointestinal tract  mdr1 messenger rna  mrna  levels were elevated in 13 of 15 colorectal carcinoma specimens and in six of 13 gastric carcinoma specimens  well differentiated colorectal carcinomas contained significantly higher concentrations of mdr1 mrna than moderately differentiated colorectal carcinomas  similarly  moderately differentiated gastric carcinomas contained higher concentrations of mdr1 mrna than poorly differentiated gastric carcinomas  mdr1 gene expression in normal colorectal and gastric tissues adjacent to carcinomas was similar to that in the carcinomas  mdr1 gene expression in xenografts of colorectal and gastric carcinomas in nude mice was also investigated  elevated expression of the mdr1 gene was seen in only four of 18 xenografts of colorectal carcinoma and was not seen in any xenografts of gastric carcinoma  p glycoprotein was distributed over the luminal surface of the colorectal carcinoma  these results imply that the higher levels of mdr1 mrna found in well differentiated carcinomas derived from colorectal tissues are the results of increased expression of the mdr1 gene in the luminal surface cells  the level of expression of the mdr1 gene in colorectal and gastric carcinomas appears to correlate with the degree of differentiation and also appears to be affected by transplantation into nude mice  
class4	race  nutritional status  and survival from breast cancer  the effects of nutritional status on differences in the survival of black and white women with breast cancer were studied in a cohort of 1 960 georgia women diagnosed during 1975 1979  after data were adjusted for stage of disease  socioeconomic status  and other prognostic factors  poorer survival rates were shown in black women  within each stage classification  lower levels of serum albumin and hemoglobin and higher relative body weight were more common among blacks and were independently associated with poorer survival  among women with stage 3 disease  adjustment for these variables substantially reduced the excess mortality rate among blacks  suggesting that racial differences in survival may be partly explained by differences in nutritional status or extent of disease within stage  
class4	effect of tamoxifen on serum insulinlike growth factor i levels in stage i breast cancer patients  insulinlike growth factor i  igf i  has been shown to be a potent mitogen for breast cancer cells in vitro  and igf i receptors have been demonstrated on human primary breast neoplasms  in a randomized  placebo controlled study  we document that administration of the antiestrogen tamoxifen to patients with breast cancer was associated with a statistically significant  p    002  reduction in the serum level of igf i  the mean igf i level was 1 4 u ml in the placebo treated group and 0 9 u ml in the tamoxifen treated group  because serum igf i level is growth hormone  gh  dependent and because data suggest that the pubertal surge in gh and igf i levels is sex steroid dependent  we speculate that the mechanism underlying our observation may involve blockade by tamoxifen of estrogen action in the hypothalamic pituitary axis  we conclude that tamoxifen treatment reduces igf i levels and that this reduction may contribute to the therapeutic effect of the drug  
class4	reduction of the membrane fluidity of human breast cancer cells by tamoxifen and 17 beta estradiol  the intracellular steady state levels of methotrexate were previously shown to be reduced in estrogen receptor  er  negative human breast cancer mda mb 436 cells and er positive human breast cancer mcf7 cells following treatment with pharmacologically relevant concentrations of 17 beta estradiol  e2   we now report that both e2 and tamoxifen  tmx  significantly decreased the fluidity of mcf7 and mda mb 436 cellular membranes  with e2 or tmx at concentrations greater than 1 microm  perturbations in membrane fluidity were accompanied by apparently non er mediated cytotoxicity  alterations in membrane structure may have contributed to the cytotoxicity of high dose endocrine therapy and to the ability of e2 to inhibit methotrexate transport and cytotoxicity in some human breast cancer cells  
class4	antitumor activity of liposome encapsulated doxorubicin in advanced breast cancer  phase ii study  previous studies in animals have demonstrated liposome encapsulated doxorubicin  led  has substantially less cardiac toxicity than free doxorubicin but retains antitumor activity  in a phase i clinical study of led  the maximum tolerated dose was 90 mg m2 and dose limiting toxicity was considered to have been reached when granulocytopenia was produced  we used led to treat 20 patients with advanced  measurable breast cancer  led was given at doses of 60 75 mg m2 every 3 weeks as an intravenous infusion  regression of disease was objectively measured in nine patients  in five of these patients  complete regression of the index lesion occurred  the mean duration of the responses was 7 months  hematologic toxicity consisted of grade 1 2 leukopenia in some patients  gastrointestinal toxicity and mucositis were generally mild and tolerable  alopecia occurred in all patients and usually was complete  twelve patients received cumulative doses of led of greater than 400 mg m2 and were evaluated with radionuclide ventriculograms  in eight patients  the cumulative dose was greater than 500 mg m2  and five had endomyocardial biopsies  four of these biopsy results were billingham grade 0  while one  cumulative led dose  750 mg m2  showed grade 1 changes with mild myofibrillar loss and dilatation of the sarcoplasmic reticulum involving less than 5  of cardiac myocytes  two patients had decreases in left ventricular ejection fraction  one of these patients had received a total dose of led of 630 mg m2 and had a decline of 13  in left ventricular ejection fraction  but had no clinical evidence of congestive heart failure and had a billingham grade 0 endomyocardial biopsy  
class4	oral zidovudine  continuous infusion fluorouracil  and oral leucovorin calcium  a phase i study  a phase i clinical  pharmacologic  and biochemical evaluation of escalating oral zidovudine  azt  given over 2 days with a fixed dose of continuous infusion fluorouracil  800 mg m2 per day x 3 days  and oral leucovorin calcium was performed  eighteen patients were treated with doses of azt ranging from 1 0 to 9 0 g m2 per day  nausea and vomiting were dose limiting  with a maximally tolerated dose of 7 5 g m2 per day  rash and mucositis occurred but were not dose limiting  a dose related increase in peak plasma levels of azt was observed  and the alpha half life of azt in plasma  75 min  was unaffected by these high doses  at doses above 4 0 g m2 per day  trough levels significantly increased  perhaps reflecting prolonged absorption from the gut  no responses were observed  however  a significant increase in dna single strand breaks was observed in peripheral blood cells after a threshold dose of 4 0 g m2 per day  confirming a biological effect of azt in this regimen  further trials with an intravenous formulation capable of maintaining plasma levels and circumventing dose limiting toxicity are warranted  
class4	validation of intermediate end points in cancer research  investigations using intermediate end points as cancer surrogates are quicker  smaller  and less expensive than studies that use malignancy as the end point  we present a strategy for determining whether a given biomarker is a valid intermediate end point between an exposure and incidence of cancer  candidate intermediate end points may be selected from case series  ecologic studies  and animal experiments  prospective cohort and sometimes case control studies may be used to quantify the intermediate end point cancer association  the most appropriate measure of this association is the attributable proportion  the intermediate end point is a valid cancer surrogate if the attributable proportion is close to 1 0  but not if it is close to 0  usually  the attributable proportion is close to neither 1 0 nor 0  in this case  valid surrogacy requires that the intermediate end point mediate an established exposure cancer relation  this would in turn imply that the exposure effect would vanish if adjusted for the intermediate end point  we discuss the relative advantages of intervention and observational studies for the validation of intermediate end points  this validation strategy also may be applied to intermediate end points for adverse reproductive outcomes and chronic diseases other than cancer  
class4	inhibition of invasion of invasive human bladder carcinoma cells by protein kinase c inhibitor staurosporine  to study the effect of the protein kinase c  pkc  inhibitor staurosporine on invasion  we selected the invasive human bladder carcinoma cell line ej  total pkc activity was more than twofold higher in the ej cells than in rt4 cells  superficial human bladder carcinoma cells   which do not pass through an artificial basement membrane  there was more pkc activity in the cytosol than in the membrane of ej cells  staurosporine  at nontoxic concentrations  inhibited the invasion of ej cells through an artificial basement membrane in a dose dependent manner  staurosporine caused a dose dependent inhibition of cell motility but did not inhibit cell attachment  staurosporine represents a new agent for the inhibition of tumor cell invasion and may prove useful in studying the mechanisms responsible for this phenomenon  
class4	anti idiotype monoclonal antibody carrying the internal image of ganglioside gm3  murine anti idiotype monoclonal antibodies were generated against a human igm monoclonal antibody  l612  that recognizes ganglioside gm3 on human melanoma  hybridomas secreting antibodies that bound specifically to l612 were selected by enzyme linked immunosorbent assay using l612 and three negative control human igms  including monoclonal anti gm2 and anti gd2 antibodies  as well as purified serum igm  as antigen sources  gm3 binding inhibition and cell binding inhibition assays were used to identify seven anti idiotype monoclonal antibodies that recognized determinants located within the antigen combining sites of l612  to determine whether these anti idiotype monoclonal antibodies possessed the internal image of the original antigen  we immunized syngeneic balb c mice with one of the anti idiotype monoclonal antibodies  4c10  coupled with keyhole limpet hemocyanin  sera from the immunized mice reacted strongly with an antigen positive m12 melanoma cell line and with purified gm3  because l612 detects and kills melanoma tumor cells in vitro and in vivo in the presence of complement without affecting normal tissues  anti idiotype monoclonal antibodies carrying the internal image of gm3 may be an effective tool for active specific immunotherapy in patients with melanoma  
class4	nonrandom chromosomal abnormalities in primary uveal melanoma  we report on 14 cases of clonal chromosomal anomalies in patients with primary uveal melanoma  an increased dosage of chromosome 8 or of parts of the long arm of chromosome 8  8q  were detected in eight patients  57    the smallest multiplied area of 8q appeared to be the region 8q2 1    qter  monosomy of chromosome 3 was seen in six patients  43    five of which were associated with anomalies of chromosome 8  increased dosage of parts of chromosome 8q and loss of heterozygosity of chromosome 3  or the combination of both  seemed to be nonrandom for uveal melanoma and may distinguish it genetically from cutaneous malignant melanoma  anomalies of chromosome 6  mostly resulting in additional material of 6p or a deletion of 6q  were found in six patients  43    these anomalies  which seem to be common features of cutaneous malignant melanoma  were considered secondary rather than primary changes in uveal melanoma  since they were present only in subclones in most cases  loss of the y chromosome  restricted to tumor cells  was detected in four male patients  and loss of one x chromosome was detected in a female patient  
class4	prospective study of the frequency and size distribution of polyps missed by colonoscopy  an important determinant in interpreting the results of colorectal polyp chemoprevention trials is the rate of polyps missed during colonscopic examination  we prospectively examined 90 patients by tandem colonoscopy performed by two alternating examiners  in 69  76 7   patients  221 neoplastic lesions were documented histologically  of a total of 58 lesions detected in 31 patients  no neoplastic lesion greater than or equal to 10 mm in size was missed  16  of diminutive  less than or equal to 5 mm  neoplastic polyps and 12 3  of medium sized  6 9 mm  neoplastic polyps were missed by the first examiner  we conclude that an experienced colonoscopist will miss about 15  of colorectal neoplastic polyps less than 10 mm in size in the setting of adequate bowel preparation  large  greater than or equal to 10 mm  polyps were rarely missed  however  with the  miss  rate in our study equal to 0  with a 95  confidence limit of 4 64   
class4	mutagen sensitivity in patients with head and neck cancers  a biologic marker for risk of multiple primary malignancies  eighty four patients with head and neck cancers were evaluated for in vitro sensitivity to mutagens and then followed longitudinally for development of multiple primary malignancies  we assessed mutagen sensitivity by exposing lymphocytes to bleomycin in vitro and quantitating the bleomycin induced chromosomal breaks per cell  the mutagen hypersensitive patients  ie  those who expressed greater than 1 0 break per cell  were significantly more likely to develop multiple primary cancers than were patients who were less sensitive  less than or equal to 1 0 break per cell   relative risk   4 4  95  confidence limits   1 2  15 8   this relationship was independent of age  sex  site  and treatment of first primary cancer and tobacco or alcohol exposures  sensitivity to bleomycin induced chromosomal damage serves as an indicator of genetic susceptibility to multiple primary malignancies in patients with head and neck cancers  
class4	parotid gland and facial nerve trauma  a retrospective review  included in this study are all patients with trauma to the parotid region seen at our center from 1979 to 1989  there was a total of five patients with injury to the parotid area  two patients with isolated facial nerve injury  one with isolated parotid duct injury  two with combined duct and nerve injury  there were four males and one female  with a mean age of 34 years  range  16 to 62 years   the three patients with parotid duct injury required other procedures for associated trauma  a total of eight nerve branches were severed in four patients  seven of the eight nerve branches  82 5   were primarily repaired  with excellent functional results  two of the three ductal injuries were repaired primarily over a stent  and one was ligated  no complications resulted from either treatment  based on our clinical experience and review of the literature  we suggest that the treatment of parotid region injuries should include  1  a complete initial assessment  2  primary repair of parotid duct transection within 24 hours when possible  3  primary repair of all facial nerve injuries  although delayed nerve repair remains a viable alternative  and 4  nonsurgical treatment of sialoceles and fistulae  
class4	neoadjuvant chemotherapy in invasive bladder cancer  the evolving role of surgery  the role of an operation in patients receiving neoadjuvant chemotherapy for clinically localized but invasive transitional cell carcinoma of the bladder currently is evolving  an operation is essential for case selection and evaluation of local response but it also contributes to bladder preservation and survival  the procedure that is necessary to select for and assess response to chemotherapy may itself alter the actual or proceed to evolution of invasive bladder cancer  neoadjuvant chemotherapy is a reasonable therapeutic strategy in selected patients but it remains to be seen whether the results will prove to be superior to those achieved with standard endoscopic and open operations  
class4	incidence and properties of renal masses and asymptomatic renal cell carcinoma detected by abdominal ultrasonography  renal ultrasonography was performed in 45 905 adults  including 41 364 without any signs suggesting urinary tract malignancies  1 667 with microscopic hematuria only and 2 874 with some signs of malignancy  renal lesions were found in 355 adults  0 858   in the asymptomatic  39  2 3   in the microscopic hematuria and 75  2 6   in the symptomatic groups  respectively  renal cell carcinoma was found in 35  7 5   lesions  19  5 4   in the asymptomatic  none in the microscopic hematuria and 16  21 3   in the symptomatic groups  a total of 47 patients  including 12 other renal cell carcinoma patients transferred from related hospitals  was grouped into 28 without and 19 with symptoms  primary tumor size and clinical stages were significantly smaller and lower  respectively  in the asymptomatic group than in the symptomatic group  radical nephrectomy was performed in all but 2 asymptomatic patients  the 5 year survival rates after nephrectomy were 94 7 and 60 9  for the asymptomatic and symptomatic groups  respectively  p less than 0 01   the results indicate that ultrasonography is a useful tool to detect low stage asymptomatic renal cell carcinoma at low cost  
class4	magnetic resonance imaging for assessment of vena caval tumor thrombi  a comparative study with venacavography and computerized tomography scanning  we assessed the accuracy of magnetic resonance imaging in demonstrating the presence and extent of vena caval tumor thrombi  the study group included 20 patients with vena caval thrombi from renal cell carcinoma  18   renal pelvic transitional cell carcinoma  1  and adrenal pheochromocytoma  1   preoperative diagnostic studies included magnetic resonance imaging in all patients  inferior venacavography in 16 and computerized tomography scanning in 15  all patients underwent an operation in which the presence and extent of the vena caval thrombus were confirmed  magnetic resonance imaging accurately delineated the presence and extent of the thrombus in all 20 patients  100    venacavography was accurate in 15 patients  94   but 8  50   required a retrograde and antegrade study  computerized tomography scanning demonstrated the presence of a tumor thrombus in all 15 patients but accurately delineated the cephalad extent of the thrombus in only 5  33    in patients with vena caval tumor thrombi magnetic resonance imaging can provide accurate information regarding the extent of vena caval involvement while avoiding the need for an invasive contrast imaging study  
class4	ureterosigmoidostomy  long term results  risk of carcinoma and etiological factors for carcinogenesis  we followed postoperatively 75 patients who underwent ureterosigmoidostomy between 1942 and 1987  of the patients 30 were asked to undergo routine examination  including fiberoptic sigmoidoscopy with biopsy and analysis of a urine feces slurry for nitrate  nitrite and nitrosamines in comparison to 20 control volunteers  after a mean observation of 14 years 7 months  1 to 46 years  64 5  of the patients had bilaterally normal kidneys without any previous complications  77 5  of the renal units being normal  sigmoidoscopic biopsy revealed 3 carcinomas at the ureterocolonic junction resulting in an 8 5 to 10 5 fold increased risk of colon carcinoma compared to the general population  the excretion of nitrite and n nitrosamines was increased  and nitrate excretion was decreased compared to healthy control volunteers  suggesting endogenous formation of nitrosamines by bacterially reduced nitrate and endogenous amines  the urological long term results of ureterosigmoidostomy are similar to those of conduits  however  the increased incidence of colon carcinoma is not yet proved to be higher than in conduits  
class4	primary adenocarcinoma of the bladder  favorable prognostic significance of deoxyribonucleic acid diploidy measured by flow cytometry  flow cytometric nuclear deoxyribonucleic acid ploidy analysis was done successfully on 38 specimens of primary bladder adenocarcinoma treated between 1954 and 1985  of the specimens 10  26   were deoxyribonucleic acid diploid  8  21   were tetraploid and 20  53   were aneuploid  distribution of ploidy patterns between the 14 histological low grade and 24 high grade tumors was similar  of 38 tumors 35  92   showed muscle invasion  one tumor arose in a previously exstrophied bladder  10 were of urachal origin and 27 arose in an anatomically normal bladder  of the urachal origin tumors 80  were deoxyribonucleic acid aneuploid  at 5 and 10 years after diagnosis 80 and 70   respectively  of the patients with diploid tumors were free of disease  by contrast  at 5 and 10 years after treatment only 20 and 12   respectively  of the patients with nondiploid tumors have not had disease progression  p less than 0 001 log rank test   none of the 6 patients with diploid  high grade  high stage  muscle invasive tumors had subsequent progression  in contrast  16 of 17 patients  94   with high grade  high stage  nondiploid tumors had either local or distant tumor recurrence  p less than 0 0005   nuclear deoxyribonucleic acid ploidy pattern appears to be the most significant prognostic information currently available to stratify expected prognosis for patients with muscle invasive adenocarcinoma of the bladder  this test probably should be a standard tool in the clinical management of patients with this rare bladder malignancy  
class4	randomized phase ii evaluation of carboplatin and chip in advanced transitional cell carcinoma of the urothelium  the eastern cooperative oncology group  a total of 83 patients with metastatic transitional cell carcinoma who had previously received no systemic therapy entered a randomized phase ii evaluation of carboplatin and cis dichloro transdihydroxy bis isopropylamine platinum iv  chip   administered respectively at 400 and 270 mg  m 2 every 28 days  among evaluable patients with measurable disease response rates were 3 of 22  14   95  confidence interval 5 to 35   for carboplatin and 4 of 25  16   95  confidence interval 5 to 36   for chip  among 17 patients with evaluable but not measurable metastases  10 carboplatin and 7 chip recipients  there were no responses  median survival for 64 evaluable patients was 4 8 months  5 0 months for carboplatin and 4 3 months for chip recipients   independent factors prognostic for survival  p less than 0 01  were performance status  0 or 1 versus 2 or 3   liver metastases  prior radiation therapy and recent weight loss  p   0 02   multivariate analysis confirmed that a performance status of 2 or 3 and liver metastases were predictive of shorter survival  a total of 31  of the patients treated with carboplatin and 34  of those who received chip experienced severe or life threatening myelosuppression  while the response rates with carboplatin and chip are modest  we believe that the characteristics of these agents indicate that they should be evaluated further  
class4	perioperative methotrexate  vinblastine  doxorubicin and cisplatin  m vac  for poor risk transitional cell carcinoma of the bladder  an eastern cooperative oncology group pilot study  a total of 18 patients with locally advanced transitional cell carcinoma of the bladder underwent 2 preoperative cycles of chemotherapy with methotrexate  vinblastine  doxorubicin and cisplatin followed by radical cystectomy and 2 postoperative cycles of chemotherapy  radical cystectomy was performed in 17 of 18 patients  94   with a pathological partial response in 3  17   and a pathological complete response in 2  11    for an over all response rate of 28   95  confidence limits 10 to 53    at 23 month median followup 9 patients  50   remained without evidence of recurrent disease  while 9  50   died of metastatic bladder cancer  average relative dose intensity of all therapy given was 78   hematological toxicity was moderate  with no septic deaths or bleeding complications  however  4 thromboembolic events occurred  while downstaging of the primary bladder tumor can occur with this perioperative schedule our results were not as impressive as some previously reported findings  the incidence of thromboembolic events is worrisome  
class4	local recurrence and survival following nerve sparing radical cystoprostatectomy  from march 1982 through july 1988  76 men underwent nerve sparing radical cystoprostatectomy for carcinoma of the bladder at our hospital  of the 76 patients 2  2 6   had positive surgical margins  dome of the bladder and left ureter  and neither had positive margins at the site of nerve sparing modifications  of 3 patients  3 9   who had local recurrence none had positive surgical margins  the 5 year actuarial local recurrence rate is 7 5   thirteen of 76 patients  17   died of transitional cell carcinoma and 7  9   died of other causes  while 53  70   are alive without evidence of disease with a mean followup of 38 4 months  the 5 year actuarial survival rates are 64  over all  68  without disease and 78  disease specific  of the 42 evaluable men who underwent cystoprostatectomy alone 27  64   are potent  compared to 2 of the 12 men  17   who also underwent urethrectomy  we conclude that the nerve sparing modifications do not compromise cancer control  that local recurrence and survival rates are at least comparable to those achieved with standard radical cystoprostatectomy  and that it is possible to preserve potency in most men undergoing this procedure  
class4	testicular carcinoma in patients positive and at risk for human immunodeficiency virus  patients with the acquired immunodeficiency syndrome are at increased risk for certain malignancies  because acquired immunodeficiency syndrome and testicular cancer affect primarily young men  the potential complications that acquired immunodeficiency syndrome might impose raise significant concern  to address this question we performed a retrospective review of all cases of testicular cancer during an 11 year period  of 140 patients 6 had human immunodeficiency virus infection and 7 were from human immunodeficiency virus risk groups  all cases were either stage i or ii disease with seminoma in 8  teratocarcinoma in 3  embryonal cell carcinoma in 1 and teratoma in 1  the clinical presentations of these patients were comparable to those of patients without human immunodeficiency virus risk factors  the majority of the patients received standard therapy  including orchiectomy followed by lymphadenectomy  radiation therapy or chemotherapy depending on stage and pathological subtype  patients tolerated therapy well with only 1 course of radiation therapy complicated by pneumocystis carinii pneumonia  all patients achieved complete remission and none died of testicular cancer  since treatment of these patients may worsen the immunosuppression  surveillance is recommended after orchiectomy for acquired immunodeficiency syndrome patients with stage i disease  however  the majority of patients with human immunodeficiency virus infection should receive standard therapy  
class4	clinical stage 1 testicular cancer  the role of modified retroperitoneal lymphadenectomy  a total of 85 patients underwent modified retroperitoneal lymphadenectomy for clinical stage i nonseminomatous germ cell tumor of the testis from 1982 to 1989  the technique was a modified bilateral dissection via a thoracoabdominal approach  a full bilateral dissection was done above the level of the inferior mesenteric artery but unilateral dissection was performed below the inferior mesenteric artery using a template method  of the 85 patients 64 had pathological stage a and 21 had stage b1 disease  relapses have occurred in 4 of 64 stage a cancer patients  6   and 3 of 21 stage b1 cancer patients  15    antegrade ejaculation was preserved without pharmacological therapy in 75 of 85 patients  88   and 5 others were converted to antegrade ejaculation with imipramine  therefore  80 of 85 patients  94   have recovered antegrade ejaculation  with a median followup of 38 months 7 relapses have been noted  we conclude that modified retroperitoneal lymph node dissection allows for preservation of ejaculation  decreases concern about retroperitoneal understaging and represents the preferred alternative to surveillance protocols for patients with low stage testicular cancer  
class4	erythrocyte polyamine levels in human prostatic carcinoma  abnormally high red blood cell polyamine levels were found in benign prostatic hyperplasia and in prostatic adenocarcinoma patients  in prostatic adenocarcinoma patients a relationship was noted between the importance of red blood cell spermidine and spermine concentrations  and the clinical stage of the disease  whitmore classification   considering prostatic adenocarcinoma patient populations  patients with metastases  groups 3 and 4  statistically differed from those without metastases  group 2   furthermore  red blood cell polyamine level determination discriminated patients in the hormonal escape group  group 4  from those usually considered as hormone responsive  groups 2 and 3   no statistically significant correlation was observed between red blood cell polyamine levels and usual tumor markers  prostatic acid phosphatase and prostate specific antigen   these results confirmed that red blood cell polyamine levels must be considered as a circulating index of cell proliferation that might be of clinical importance during the long term followup and treatment of prostatic adenocarcinoma patients  
class4	the relationship of prostate specific antigen levels and residual tumor volume in stage a prostate cancer  preoperative serum prostate specific antigen correlates well with morphometrically determined prostate tumor volume in prostatectomy specimens  however  since prostate specific antigen is produced by hyperplastic as well as malignant prostatic epithelium  the contribution of hyperplastic epithelium  benign prostatic hyperplasia  to serum prostate specific antigen interferes with the ability of serum prostate specific antigen to predict tumor volume in individual patients  we wondered if the removal of benign prostatic hyperplasia tissue would increase the correlation between prostate specific antigen and tumor volume  and  thus  make prostate specific antigen a more accurate predictor of residual cancer volume after transurethral resection of the prostate  a total of 67 patients with clinical stage a cancer underwent radical retropubic prostatectomy  22  or 33   with stage a1 and 45  or 67   with stage a2 disease   and had pre radical prostatectomy measurement of serum prostate specific antigen and morphometric determination of residual cancer volume in the radical prostatectomy specimen  the correlation between serum prostate specific antigen and residual cancer volume for all 67 patients was 0 66  and for stages a1 and a2 disease it was 0 64 and 0 70  respectively  all stage a1 cancer patients with a serum prostate specific antigen value of 1 ng  ml  or less had residual tumor volumes of less than 0 5 cc and all stage a cancer patients with a serum prostate specific antigen value of more than 10 ng  ml  had residual tumor volumes of greater than 0 5 cc  of the patients 51  had levels of 1 to 10 ng  ml  and serum prostate specific antigen was not useful to predict residual tumor volume in this group  serum prostate specific antigen measurements may be helpful in stage a1 cancer patients with levels of 1 ng  ml  or less  or greater than 10 ng  ml  in choosing the most appropriate therapy  
class4	prostate specific antigen for assessing response to ketoconazole and prednisone in patients with hormone refractory metastatic prostate cancer  serial prostate specific antigen levels were assessed in 15 patients with hormone refractory metastatic prostate cancer treated with ketoconazole and prednisone  of the men 12  80   with continually increasing prostate specific antigen levels before treatment had a decrease in prostate specific antigen with a median duration of response of 3 months  three patients  20   had a prolonged response  greater than or equal to 8 months  as seen by a persistently decreasing prostate specific antigen and improvement in bone pain  there appears to be a small subgroup of patients with progressive prostate cancer despite androgen ablation who will benefit from ketoconazole and glucocorticoid treatment  the use of serial prostate specific antigen levels appears to help define this subgroup and avoid the need for multiple radiological procedures to assess response  
class4	radical prostatectomy for clinical stage t1 2n0m0 prostatic adenocarcinoma  long term results  a total of 441 stage t1 2n0m0 and 11 stage t1 2n0m0 cancer patients with an elevated acid phosphatase level only  and 18 stage t1 2n m0 cancer patients underwent radical prostatectomy  analysis of the 441 stage t1 2n0m0 cancer patients demonstrated that failure and survival were a function of the disease being organ confined  specimen confined or margin positive  with 10 year failure rates of 12  30 and 60   respectively  of the patients with positive margins 44 were and 79 were not irradiated postoperatively  postoperative radiation produced no survival advantage  no difference in interval to failure or of survival could be identified between 105 patients whose disease was diagnosed by transurethral resection and 328 who had a palpable abnormality  eleven patients had negative bone and node findings but they had an elevated acid phosphatase level  all 8 patients not treated with immediate androgen deprivation failed within 36 months  
class4	pheochromocytoma in the pediatric age group  the prostate  an unusual location  pheochromocytomas of the prostate are rare  with only 3 cases in adults reported in the literature  we present the case of an 8 year old boy with a pheochromocytoma of the prostate and a second tumor in the region of the left internal iliac artery  
class4	nuclear morphometry as a prognostic indicator for genitourinary rhabdomyosarcoma  a preliminary investigation  rhabdomyosarcoma of the urogenital tract is a malignant mesenchymal tumor seen primarily in childhood  multimodal therapy  encompassing surgery  radiotherapy and chemotherapy  has dramatically improved the survival of patients with this disease  however  the quest for markers of tumor aggression is important to decrease the morbidity of treatment given to patients with good prognosis tumors  while at the same time intensifying treatment of tumors with poor prognosis  using archival tumor specimens from 13 patients with genitourinary rhabdomyosarcoma  a multivariate analysis of multiple nuclear shape descriptors was done with the hopkins morphometry system  three nuclear shape descriptors clearly separated patients with no evidence of disease recurrence or progression from those with recurrent disease  progressive disease or death of disease  these nuclear shape descriptors were standard error of the chain code standard deviation analysis  p   0 010   range of the feret ellipticity distribution  p   0 016  and standard error of the chain code range analysis  p   0 037   with multivariate analysis these shape descriptors taken together separated patients with good and poor prognoses to a level of significance of p   0 007  thus  nuclear morphometric analysis may prove to be useful as an individual prognostic indicator in childhood genitourinary rhabdomyosarcoma and warrants further analysis in a much larger  blinded  controlled study  
class4	de novo carcinoma of the lower urinary tract in renal allograft recipients  immunocompetence has been postulated as an important defense against the progression of urothelial carcinoma  three cases of de novo lower urinary tract carcinoma in renal transplant recipients demonstrated the potential for unusually rapid urothelial extension and invasion in chronically immunosuppressed patients  two patients had a history of perineal condyloma acuminata  tumors from 1 of these harbored the genetic sequences of human papillomavirus type 6  one patient had multiple manifestations of cyclophosphamide related urothelial injury  including bladder carcinoma  treatment of 2 patients culminated in a radical operation during which the remaining native urinary system was resected completely  with sacrifice of the allograft kidney in 1 and diversion into an ileal conduit in 1  the remaining patient underwent urethrectomy and partial cystectomy with a sigmoid conduit  
class4	retroperitoneal lymph node dissection in malignant mesothelioma of tunica vaginalis testis  a case of metastatic mesothelioma of the tunica vaginalis testis in a 57 year old man is reported  clinicopathological findings and treatment options are reviewed  
class4	long term effects of gastrocystoplasty in rats  twenty prepubescent rats underwent microsurgical gastrocystoplasty by a technique which is described  an equal number of control rats had their bladders opened and closed  rats were sacrificed at 16 to 18 months postoperatively  there were no differences in final weight  serum electrolytes  or renal function between the two groups  prominent histopathologic changes of the bladder occurred in the gastrocystoplasty group  these changes included papillomas present in five of the 15 rats surviving long term  no significant changes occurred in the bladders of the control group of rats  possible etiologies and the significance of the rats  possible etiologies and the significance of the gastrocystoplasty related lesions are discussed  
class4	fatal sepsis following intravesical bacillus calmette guerin administration for bladder cancer  intravesical administration of bacillus calmette guerin has been shown to be highly effective treatment of superficial bladder cancer  complications from bacillus calmette guerin therapy are usually minor but serious and even fatal reactions can occur  five recent cases illustrate the gravity of bacillus calmette guerin sepsis  one man with severe debility and the organic brain syndrome died acutely with a fever of 40 c  two men had frank sepsis that progressed to multiorgan failure and death  sepsis progressed despite the use of isoniazid  rifampin and streptomycin  two men who had equally progressive sepsis with intravesical bacillus calmette guerin survived with the use of cycloserine for the first 72 hours of treatment  triple antituberculous antibiotics  including cycloserine  may be lifesaving  sepsis resulted from intravenous absorption through inflamed or disrupted urothelium  bacillus calmette guerin treatment should not be administered in the presence of severe cystitis or after grossly traumatic catheterization  
class4	fatal disseminated mycobacterial infection following intravesical bacillus calmette guerin  we describe a fatal case of disseminated mycobacteriosis after intravesical bacillus calmette guerin immunotherapy  we summarize the prior safety record of this therapeutic modality  discuss local and systemic pathophysiological mechanisms by which dissemination might have occurred  and review the reported clinical experience with antituberculous chemotherapy for significant bacillus calmette guerin infection  finally  we offer suggestions for prophylaxis of certain patients with a history of exposure to intravesical bacillus calmette guerin  
class4	nephron sparing surgery for renal cell carcinoma with venous involvement  a nephron sparing operation recently has been shown to provide extended survival free of disease in selected patients with localized renal cell carcinoma  particularly for tumors of lower stage  to define better the role of conservative surgical treatment in more locally advanced renal cell carcinoma we reviewed 9 patients with venous tumor involvement in solitary functioning kidneys who underwent a nephron sparing operation  complete tumor resection with adequate preservation of renal function was accomplished in all cases  of the 9 patients 5 had no evidence of disease 7 to 93 months  mean 33 2 months  postoperatively  the remaining 4 patients died of metastatic renal cell carcinoma 17 to 47 months  mean 35 5 months  postoperatively  2 of whom had concomitant local recurrences in the renal remnant  based on previously reported results of total nephrectomy for renal cell carcinoma with venous involvement and the morbidity associated with renal replacement therapy  we believe that a nephron sparing operation is a viable option in the management of these patients  
class4	adverse impact of fibrin clot inhibitors on intravesical bacillus calmette guerin therapy for superficial bladder tumors  although intravesical bacillus calmette guerin therapy has proved to be efficacious in the treatment and prophylaxis against tumor recurrence of superficial bladder tumors  its mechanism of action has not been fully elucidated  previous work has suggested that bacillus calmette guerin organisms attach to the matrix protein  fibronectin  during fibrin clot formation at sites of urothelial disruption and that this attachment was required for the antitumor effect of bacillus calmette guerin to be expressed  furthermore  drugs inhibiting clot formation were found to abrogate the antitumor effect of intravesical bacillus calmette guerin therapy in a murine bladder tumor model  to examine the effect of inhibitors of fibrin clot formation on the results of intravesical bacillus calmette guerin therapy  a retrospective analysis of 149 evaluable patients receiving intravesical bacillus calmette guerin for superficial bladder tumors was performed  the over all response rate free of tumor for 29 patients who concomitantly received inhibitors of fibrin clot formation with bacillus calmette guerin therapy was 48   as compared with 67  for 120 patients who were not receiving these medications  p   0 0655  chi square   the most striking difference was noted for patients who failed with recurrent superficial disease  of the patients who received fibrin clot inhibitors during intravesical bacillus calmette guerin therapy 35  had recurrent superficial tumors compared to only 8  of those who did not receive these drugs during a mean followup of 29 8 plus or minus 11 months  p   0 005  chi square   our study suggests that inhibitors of fibrin clot formation may have an adverse influence on the results of intravesical bacillus calmette guerin therapy for superficial bladder tumors  
class4	outpatient flexible cystoscopy and fulguration of recurrent superficial bladder tumors  flexible cystoendoscopy and fulguration were used in the outpatient management of 185 patients with superficial bladder tumors followed for 24 months  this method provided optimal surveillance for recurrence and successful tumor control in selected cases  
class4	primary malignant lymphoma of the bladder  we treated 11 patients with primary malignant lymphoma of the bladder  the typical patient is a woman more than 50 years old who presents with urgency and frequency of micturition  and occasionally gross hematuria  hydronephrosis is present in half of the patients and cystoscopy usually reveals a solid tumor  partial cystectomy  when feasible  with or without radiotherapy and chemotherapy is the usual treatment modality  when localized to the bladder  malignant lymphoma has an over all favorable prognosis  
class4	clinical and pathological findings in prostates following intravesical bacillus calmette guerin instillations  the prostates of 36 patients who were treated with intravesical bacillus calmette guerin were evaluated by digital rectal examination and transrectal ultrasonography  when abnormal palpatory and or ultrasonographic findings were detected  core needle biopsies from the suspicious areas were performed  of the 36 patients 20 underwent biopsies of the prostate  pathological findings revealed typical granulomas in 8 patients  3 caseating and 5 noncaseating multifocal granulomas   nonspecific chronic prostatitis was noted in 4 patients and benign prostatic hyperplasia was noted in 8  the number of bacillus calmette guerin instillations ranged from 6 to 19  the interval from initiation of therapy to biopsy ranged from 1 5 to 14 5 months  caseating granulomas were found during the early course of bacillus calmette guerin instillations  1 5 to 3 0 months   whereas noncaseating granulomas were detected at later stages  4 to 14 5 months   these findings present a high incidence of granuloma formation in patients treated with intravesical bacillus calmette guerin  the duration of therapy is a determinant factor in the induction of granuloma type  
class4	the prognostic value of modal deoxyribonucleic acid in low grade  low stage untreated prostate cancer  we selected for a prospective surveillance study 167 patients with untreated grades 1 and 2 prostate cancer  the tumors were classified regarding modal deoxyribonucleic acid value  ploidy  by flow cytometry  cytological grade by transrectal fine needle aspiration biopsy and local tumor stage  of the patients 146 could be evaluated  mean followup was 50 months  the initial ploidy was statistically correlated to cytological grade but not to initial local tumor stage  prostatic acid phosphatase activity or patient age  initial ploidy and cytological grade had a prognostic value regarding local tumor progression when considered as single predictors and in combination  two patients with diploid and 8 with nondiploid tumors initially had metastases during the surveillance  five patients  1 with diploid and 4 with nondiploid disease  died of prostatic cancer  modal deoxyribonucleic acid value and cytological grade were of prognostic value in untreated prostate cancer  
class4	evaluation of tumor progression by repeated fine needle biopsies in prostate adenocarcinoma  modal deoxyribonucleic acid value and cytological differentiation  repeated fine needle aspiration biopsies of the prostate were taken during a period of 24 months or more from 84 patients with untreated prostate cancer  serial followup regarding modal deoxyribonucleic acid values and cytological differentiation of the tumor cells was possible in 72 and 78 patients  respectively  during followup the modal deoxyribonucleic acid values in the tumor cells changed towards an increased aneuploidy in 17 patients and the cytological differentiation decreased in 18  these findings of a change in modal deoxyribonucleic acid values and cytological differentiation of prostate cancer cells during the course of untreated patients support the concept of a gradual dedifferentiation of prostate cancer  
class4	management of stage d1 adenocarcinoma of the prostate  the johns hopkins experience 1974 to 1987  there is no consensus on the proper management of men with stage d1 adenocarcinoma of the prostate  although cure is unlikely  many men survive for long intervals apparently free of metastatic disease  thus  effective palliation of the local lesion with low morbidity is desirable  from 1974 to 1987  120 consecutive men with stage d1 prostate cancer were treated with 3 primary modes of therapy  mean followup 48 months   1  expectant therapy  35   2  external beam radiotherapy  21  and 3  radical prostatectomy  64   these patients were statistically homogeneous as determined by gleason grade but not by extent of metastatic disease  the over all 5 and 10 year projected actuarial survival rates for the radical prostatectomy patients were 97 and 62   respectively  and the apparent clinical survival free of disease at 5 years and 80 months  respectively  was 83 and 68   the direct disease specific 10 year survival free of disease was 46   however  only 3 of 27 patients followed for 3 years or longer had undetectable levels of prostate specific antigen  using a cox univariate proportional hazards model several factors appeared to have significant prognostic value including volume of lymph node metastases  macroscopic greater than 2 mm    percentage of positive lymph nodes sampled and frozen section diagnosis  gleason grade  clinical stage and the number of positive nodes did not have significant prognostic value  local recurrence requiring an operation was noted in 8 of 35 patients  23   treated expectantly  5 of 21  24   treated with radiotherapy and 2 of 64  3   treated with radical prostatectomy  significant gastrointestinal or genitourinary complications occurred in 33  of the men treated with radiotherapy and 1 5  of those undergoing radical prostatectomy  since the introduction of nerve sparing radical prostatectomy in 1982  potency resumed in 55  of the 33 patients who were potent preoperatively and have been followed 1 year or longer  these data suggest that in properly selected patients radical prostatectomy  although not curative  can provide excellent palliation of the local lesion with acceptable morbidity and that symptomatic local recurrence of prostatic cancer achieved with radiation therapy is identical to the results in men who were managed expectantly  
class4	total pelvic exenteration with simultaneous bowel and urinary reconstruction  the technique of total pelvic exenteration with simultaneous bowel and urinary reconstruction is described as a surgical option for the management of pelvic sarcoma in adults and for highly selected patients with other types of advanced pelvic malignancy  the surgical technique is presented in detail as performed in a 43 year old man who presented with extensive primitive pelvic sarcoma  we believe that this approach may provide the benefits of an exenterative operation without the undesirable psychosocial sequelae of a permanent colostomy and external urinary diversion  
class4	isolated primary aldosteronism in a patient with adrenal carcinoma and xy xxy mosaic klinefelter s syndrome  although breast cancer  germ cell tumors and other neoplasms are known to occur in patients with klinefelter s syndrome  adrenal carcinoma has not yet been reported in such patients  we describe a rare case of severe primary aldosteronism as the unique manifestation of a large adrenocortical carcinoma in a patient with klinefelter s syndrome  complete biological and hormonal evaluation was performed  surgical treatment was successful and the patient remained asymptomatic with normal biological and hormonal values after 1 year of followup  
class4	transrectal ultrasonography in the evaluation of the infertile man  a report of 3 cases  the traditional evaluation of the infertile man with azoospermia or low ejaculate volume includes determination of serum testosterone and follicle stimulating hormone levels  a seminal fructose test  post ejaculate urinalysis and  sometimes  vasography  transrectal ultrasonography  a technique currently familiar to most urologists  recently has been added to our diagnostic armamentarium  this office based imaging procedure provides an accurate assessment of the prostate  ejaculatory ducts and seminal vesicles  which can be helpful in the evaluation of certain infertile patients  we describe 3 patients who presented with either azoospermia or decreased ejaculate volume in whom transrectal ultrasonography had a critical role in the fertility evaluation  the clinical indications for and interpretation of transrectal ultrasonography in the infertile population are described  transrectal ultrasonography currently is the most accurate  inexpensive and readily available noninvasive imaging technique used to diagnose obstruction of the ejaculatory ducts in the infertile patient with either azoospermia or low ejaculate volume  
class4	gonadoblastoma in an anatomically normal man  a case report and literature review  gonadoblastoma  a rare gonadal neoplasm  presents most frequently in phenotypic female or phenotypically male patients with dysgenetic gonads or undescended testes  to date  only 2 cases of gonadoblastoma have been reported in anatomically normal male patients with scrotal testes  both of these patients presented with testicular masses and germ cell tumors  we report a case of a genotypically and phenotypically normal  fertile man with descended testes who on evaluation for chronic orchialgia had a gonadoblastoma unaccompanied by a germ cell neoplasm  the tumor was nonpalpable and was initially discovered on scrotal ultrasound  
class4	in situ hybridization of prostate specific antigen mrna in human prostate  prostate specific antigen  psa  mrna was detected by in situ hybridization utilizing a 428 base pair  35s  labelled cdna probe from the 3  noncoding region of the psa gene  thirty six fresh surgical specimens were collected from patients undergoing radical retropubic prostatectomy for carcinoma of the prostate  quantitative analysis of the levels of psa mrna in both the benign and malignant tissues was performed using an ibas 2000 image analysis system  the results of this study demonstrated that there is a significant decrease in the expression of psa mrna in the carcinoma tissue when compared to the benign epithelium  the average binding  number of silver grains 1 x 10 4  microns  2  for 20 specimens of malignant epithelium was 475     161 and 586     140 for 16 specimens of benign epithelium  p less than 0 05   eleven patients had both benign and malignant tissue from the same surgical specimen available for study  from these paired specimens  the psa mrna expression was also significantly reduced in the malignant epithelium when compared to the benign epithelium  445     162 and 588     135 respectively  p less than 0 005   the psa protein was detected using a monoclonal antibody to psa with an immunohistochemical staining technique  the psa protein expression paralleled the expression of the psa mrna in the majority of the tissue sections  many of the tumor specimens showed a heterogeneous expression of psa  whereas all of the benign epithelium had a uniform high level of psa expression  in conclusion  psa mrna and protein are located only within the glandular epithelial tissue  the expression of psa protein parallels that of the psa mrna  and both the psa protein and psa mrna are significantly decreased in the malignant epithelium when compared to benign prostatic epithelium  
class4	popliteal artery occlusion caused by cystic adventitial disease  successful treatment by urokinase followed by nonresectional cystotomy  preoperative diagnosis of an occluded popliteal artery caused by cystic adventitial disease allowed use of urokinase to successfully dissolve secondary thrombosis  subsequent non resectional adventitial cystotomy and evacuation of cyst contents allowed lasting restoration of a patent arterial lumen and return of normal distal pulses  this nongrafting technique may serve as a model for future patients with occluded arteries caused by this condition  
class4	prospective study of estrogen replacement therapy and risk of breast cancer in postmenopausal women  published erratum appears in jama 1991 apr 10 265 14  1828  we prospectively examined the use of estrogen replacement therapy in relation to breast cancer incidence in a cohort of women 30 to 55 years of age in 1976  during 367 187 person years of follow up among postmenopausal women  722 incident cases of breast cancer were documented  overall  past users of replacement estrogen were not at increased risk  relative risk  0 98  95  confidence interval  0 81 to 1 18   including even those with more than 10 years since last  corrected  use  relative risk after adjustment for established risk factors  0 70  95  confidence interval  0 45 to 1 10   however  the risk of breast cancer was significantly elevated among current users  relative risk  1 36  95  confidence interval  1 11 to 1 67   among current users  a stronger relationship was observed with increasing age but not with increasing duration of use  these data suggest that long term past use of estrogen replacement therapy is not related to risk of breast cancer but that current use may modestly increase risk  
class4	preoperative cell mediated immune function and the prognosis of patients with gastric carcinoma  the cell mediated immune function of 83 patients with gastric carcinoma was assessed preoperatively and the results were compared to that of 52 patients with benign lesions  the data were subjected to an analysis in order to evaluate their prognostic significance  the abilities to induce allogeneic cytotoxicity and to produce interleukin 2  il2  in patients with stage iv carcinoma were significantly depressed  as compared to those in patients with benign lesions  whereas natural killer  nk  cell activity was not significantly impaired  there was no significant correlation among these immune functions  when the patients were stratified into two groups  those who had high  greater than the mean value in patients with benign lesions  and low  less than the same value  values of these immune reactivities  the survival of patients with high nk activity  greater than or equal to 43   was significantly better  as compared to that of patients with low cytotoxicity  less than 43    however  there was no correlation between the survival and allogeneic cytotoxicity in these patients  the high ability to produce il2  greater than or equal to 1 3 u ml  correlated with the better survival in the patients  but not in the group of patients who underwent curative resection  
class4	adenocarcinoma arising in barrett s esophagus  a review of nine adenocarcinomas of the esophagus arising in barrett s epithelium was undertaken  we found the disease among white males disproportionately  risk factors and incidence rate remain to be clarified  only one patient was in a surveillance program and only he had carcinoma discovered  early   he still survives while only one of the eight whose diagnosis followed investigation of symptoms remains alive  
class4	small cell carcinoma of the pancreas and biliary tract  four cases of anaplastic carcinoma of the pancreas or biliary tract were studied clinicopathologically and immunohistochemically  all four cases were intermediate cell type and contained a minimum amount of microscopic foci of differentiated glandular adenocarcinoma  argyrophilic tumor cells were not seen in any of the four tumors  immunohistochemically  no tumor was positive for hormonal products  but all tumors were positive for epithelial markers  these findings suggest that the anaplastic carcinoma are not derived from argyrophilic cells  but rather from adenocarcinomas which have the potential for anaplastic metaplasia  the long term survival of one patient emphasized the importance of chemotherapy in the treatment of small cell carcinoma of the pancreas and biliary tract  
class4	neoadjuvant cis ddp in esophageal cancers  an experience at a regional cancer centre  india  we are analysing the results of 80 patients who underwent surgery during 1983 84 for esophageal cancer  forty patients who received pre operative single agent cis ddp were grouped under  a  and 40 patients who went for surgery directly were grouped under  b   twenty two patients  55   of group a showed tumor necrosis  both groups underwent resection and hand sewn anastamosis of the esophagus  there were 10 post operative deaths among 80 resected cases  9 of them being from anastomatic leak  cis ddp has induced negligible side effects  a comparatively high survival rate during early years in patients who responded to cis ddp suggests that neoadjuvant chemotherapy might be of value  
class4	obstructing carcinoma of the cecum  carcinoma of the cecum  the third most common location for malignancy of the large bowel  was examined with attention centered upon cecal cancers producing obstruction  reviewing 136 patients revealed 11 obstructing lesions  8 1   presenting as distal small bowel obstructions  the mean age of the patients was 74 years  all but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy  there was no operative mortality or significant morbidity  bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment  
class4	complications of stapled anastomoses in anterior resection for rectal carcinoma  colorectal anastomosis versus coloanal anastomosis  postoperative results of 48 patients who underwent anterior resection using the eea stapler were evaluated  in all but 2 cases the indication for surgery was colorectal carcinoma  in 24 patients an anastomosis was created above the 5 cm level  above the anal verge  colorectal anastomosis  and in 24 at the 0 5 cm level  coloanal anastomosis   there was no perioperative mortality  the only complication observed in the colorectal anastomosis group was one case of late anastomotic stenosis  in the coloanal anastomosis group there were 4 cases with early anastomosis leaks  3 cases with late stenosis and 5 cases with various degrees of late fecal incontinence  ultimately resulting in a permanent diverting stoma in 5  10 4   patients  we conclude that for rectal tumors the eea stapled anterior resection provides excellent functional results in most cases  stapled coloanal anastomoses more often demonstrate various  early and late  complications  nevertheless in spite of chronic discomfort  many patients still prefer their complaints to a permanent stoma  
class4	carcinoma of the pancreas  a retrospective review  eighty five patients with adenocarcinoma of the pancreas were reviewed in order to evaluate the efficacy of our methods of diagnosis and treatment  the most useful diagnostic test was percutaneous transhepatic cholangiography  ptc  with a diagnostic rate of 96   pancreaticoduodenectomy  whipple procedure  and total pancreatic resection were performed in 13 and 2 patients  respectively  the remaining 50 patients underwent various palliative drainage procedures  twenty patients did not undergo operation for various reasons  the primary tumor was found in the head of the pancreas in 50 patients  59    the body in 6 patients  7    and in the tail in 8 patients  9    postoperative complications  including sepsis  bleeding  intra abdominal abscesses  and anastomotic leaks  occurred in 37  of the patients  there were one operative and 9 postoperative deaths  the average survival for those patients undergoing surgical intervention was 6 months  there were no 5 year survivors  
class4	in vivo selection and characterization of a murine mammary tumor subline with high potential for spontaneous lymph node metastasis  a transplantable mammary adenocarcinoma  grown in balb c mice  with a marked enhancement in its draining lymph node metastatic ability  mm3ln   was obtained through an in vivo procedure from a variant tumor moderately metastatic to lymph nodes  mm3   both mm3 and mm3ln presented a similar latency and tumor growth rate and reached the same tumor mean diameter at death  mm3ln tumor bearing mice exhibited a larger mean survival time  the new variant showed a 2 5 fold higher incidence of tumor draining lymph node metastases than mm3 line  with no differences in the incidence of lung metastases  morphology as well as cytogenetic and in vitro adhesion properties were studied in order to characterize the new subline  this murine tumor model has potential application in the study of the metastatic process in lymphoid tissue  
class4	ampullary carcinoma in patients under 50 years of age with a poor prognosis  clinicopathologic features of 145 japanese patients with ampullary carcinoma were compared among three age groups  the 145 patients were divided into three groups by the patient s age at the time of operation  there were 24 patients in group i  younger  aged less than or equal to 50 years  99 in group ii  ordinary  aged 51 69  and 22 in group iii  elderly  aged greater than or equal to 70  the three groups showed no significant difference in sex  icterus  duration of icterus  size of the tumor  year of operation  macroscopic type  histopathologic type  tumor margin  lymphatic permeation  venous invasion  or pancreatic invasion  the survival curve of group i was worse than those of groups ii and iii  multivariate regression analysis using 11 prognostic variables failed to reveal that the age of the patient at the time of operation was an independent factor  the younger patients aged less than or equal to 50 fared worse than the elderly patients aged greater than or equal to 70  because the group i tumors included a significantly greater number of advanced ampullary carcinoma with more frequent perineural invasion than did the group iii tumors  
class4	colon carcinoma associated with ureterosigmoidostomy  a patient developing a colonic adenoma 38 years following ureterosigmoidostomy is presented  the mechanisms of neoplastic transformation associated with ureterosigmoidostomy is now better understood  this knowledge is being applied to develop modifications both of the surgical technique and the management of patients with this form of urinary diversion  and is a subject of discussion  
class4	metastatic tumors of the umbilicus  a review 1830 1989  umbilical metastases from known and unknown primary cancers are rare  the eponym  sister mary joseph s nodule  has been used by generations of physicians  the first reports of this clinical sign were from walshe in 1846  a review of the literature revealed 265 cases from then until 1989  only 85 cases of umbilical metastasis from unknown primary tumors were found  this review should help us to focus on the common and uncommon primary sites in the diagnosis of patients with this finding  a single case report and the work up for the hidden primary tumor are described  
class4	parathyroid hormone related peptide in plasma of patients with hypercalcemia and malignant lesions we developed and validated a radioimmunoassay for circulating human parathyroid hormone related peptide  pthrp   based on a commercial antiserum to the synthetic 1 34 fragment of pthrp  125i tyr degrees pthrp 1 34  as radioligand  and prior extraction of the native peptide from plasma with c 2 cartridges  we determined immunoreactive pthrp concentrations in plasma samples from 48 healthy persons  mean     sd  3 1     1 0 pmol liter  range  less than 2 to 5 pmol liter   8 patients with primary hyperparathyroidism  36 patients with hypercalcemia and a concurrent malignant lesion  and 9 normocalcemic patients with cancer and increased serum levels of carcinoembryonic antigen or prostate specific antigen  pthrp was normal in samples from patients with primary hyperparathyroidism  3 2     1 1 pmol liter   secondary hyperparathyroidism  2 5     1 3 pmol liter   and cancer without hypercalcemia  2 4     1 0 pmol liter   in contrast  plasma immunoreactive pthrp levels were increased  6 0 to 85 0 pmol liter  in 47  of patients with hypercalcemia and cancer of various types  with or without bone metastatic lesions  large amounts of pthrp were also found in conditioned medium from cultured human prostatic carcinoma cells  thus  pthrp may be a causative factor for hypercalcemia associated with a malignant lesion in at least half of the cases  measurement of circulating pthrp may be of differential diagnostic help in hypercalcemic states  
class4	diagnosis of malignant cardiac disease by endomyocardial biopsy among oncology patients  endomyocardial biopsy has been used primarily for the evaluation of anthracycline cardiotoxicity  in addition  however  endomyocardial biopsy may be useful for the detection of malignant cardiac neoplasms  between 1982 and 1989  metastatic involvement of the heart was diagnosed by endomyocardial biopsy in seven patients at our institution  all except one of these patients were older than 50 years of age and had dyspnea as an initial symptom  and all had a known malignant lesion  results of endomyocardial biopsy confirmed cardiac involvement by a hematologic malignant lesion in four patients and metastatic melanoma in two patients  in one patient  who had a history of breast cancer and lymphoma  a metastatic neoplasm of uncertain differentiation was observed  myocyte damage was evident in endomyocardial biopsy specimens from two of the four patients with hematologic malignant disease  endomyocardial biopsy was performed to confirm the possibility of metastatic involvement in five patients  in the other two  endomyocardial biopsy was performed to determine whether anthracycline cardiotoxicity was present  and metastatic involvement was unanticipated  
class4	paraneoplastic cerebellar degeneration  a clinical comparison of patients with and without purkinje cell cytoplasmic antibodies  in a review of 32 patients with paraneoplastic cerebellar degeneration  pcd   16  all of whom were women  had purkinje cell cytoplasmic antibodies  pcab  and 16  8 women  did not  most patients  15 of 16 seropositive and 12 of 16 seronegative patients  had active cancer at the time of neurologic diagnosis  gynecologic or breast cancers were found in 14 of 16 seropositive and in 2 of 8 seronegative female patients  lung cancer was diagnosed in 7 of 16 seronegative patients but in no seropositive patient  in seropositive patients  the onset of the syndrome was more often abrupt and abnormalities of affect  mentation  ocular motility  and cerebrospinal fluid igg index were more common than in seronegative patients  additional paraneoplastic neurologic syndromes were present in five seronegative patients but in no seropositive patient  clinical impairment was equivalent in both groups  approximately 75  of patients were confined to a wheelchair or bed at last follow up  four of 16 seropositive patients died  4 to 18 months after onset of pcd   and 7 of 16 seronegative patients died  7 to 120 months after onset of pcd   thus  pcab seem to be a marker for a clinical subset of female patients with gynecologic or breast cancer  the high frequency of other autoimmune paraneoplastic syndromes in patients with seronegative pcd suggests that pcd in both seropositive and seronegative patients may have a common pathogenic basis that involves an as yet unidentified antineuronal autoimmune mechanism  
class4	renal cell carcinoma associated with sarcoidlike tissue reaction  a 60 year old man was referred to our institution with the diagnosis of sarcoidosis  because of several months  complaint of right flank pain and weight loss  the patient had consulted his local physician  after an extensive workup revealed only cholelithiasis  he underwent a cholecystectomy for presumed chronic cholecystitis  at the time of operation  biopsy of several liver nodules and peripancreatic nodes revealed noncaseating granulomas  consistent with sarcoidosis  on initial examination at our institution  the patient had microhematuria  a chest roentgenogram demonstrated multiple pulmonary nodules  an abdominal computed tomographic scan showed an indeterminate left renal mass  and magnetic resonance imaging of the spine revealed abnormal signals in the body of t 12  open lung biopsy showed an adenocarcinoma with clear cell features  likely of renal origin  the patient was diagnosed as having a metastatic renal carcinoma associated with a sarcoidlike tissue reaction  although noncaseating granulomas have been reported in association with other malignant lesions  to our knowledge this is the first report of such an association with renal carcinoma  in addition  this case illustrates several points  first  sarcoidosis is a multisystem disorder with protean extrapulmonary manifestations  in fact  all our patient s findings could have been attributed to sarcoidosis  second  noncaseating granulomas occur with many types of processes  including infections  chemical exposures  and  as in this case  neoplasms  thus  noncaseating granulomas are not pathognomonic for sarcoidosis  third  sarcoidosis is a clinical diagnosis that cannot be based on histologic findings alone  
class4	malignant transformation of adenomatous hyperplasia to hepatocellular carcinoma  to clarify the course of adenomatous hyperplasia  ah  of the liver  17 patients with 20 biopsy proven ah nodules were followed clinically for 1 5 years  at the initial biopsy the mean nodular diameter was 10  sd 4  mm and the relative cellularity    mean cellularity of ah divided by mean parenchymal cellularity  x 100  141  27   the criteria for diagnosis of malignant transformation of ah were both a doubling of nodular volume and changes on imaging  between 6 and 50 months after biopsy  9 of the 18 nodules which could still be accurately identified met the criteria for transformation  histological proof of hepatocellular carcinoma  hcc  was obtained later for 7 of these 9 nodules  the product of diameter and cellularity  transformation index  was the strongest predictor of the time to transformation  9 ah nodules did not undergo transformation  7 did not meet one or both criteria and 2 became undetectable by imaging  because of the high risk of malignant transformation  it can be concluded that ah is an absolute precursor of hcc  it should therefore be treated as a potential malignant disorder  
class4	efficacy and morbidity of partial laryngectomy and postoperative radiation therapy  in recent years  we have seen increasing use of partial laryngectomies for larger lesions that were previously treated by total laryngectomy  the resultant closer margins have made postoperative radiation therapy an important adjuvant treatment to conservation laryngeal surgery  we review the university of california  los angeles  experience with combination partial laryngectomy and postoperative radiation therapy between 1973 and 1987 for treatment of carcinoma of the larynx  twenty four such patients who underwent partial laryngectomies and postoperative radiation therapy are examined  techniques of treatment  complications  and the functional ability of the remaining larynx are discussed  the locoregional control rate at 5 years was 80   risk factors associated with an increased risk of recurrence were positive margins  vascular invasion  and extranodal spread  there were no major problems with postoperative wound healing or airway management during the radiation treatment  vocal and swallowing function were well preserved in most cases  we conclude that combination partial laryngectomy and radiation therapy permits preservation of laryngeal function without serious complications  and therefore is an effective treatment for selected patients with carcinoma of the larynx  
class4	1990 ogura memorial lecture  moral dilemmas in head and neck cancer  neither morality nor dilemma can be defined meaningfully in the concept of the practical management of head and neck cancer  although both have important implications  particularly with regard to ethnic and social factors  they play a relatively minor role in determining management policy  with little knowledge of the intrinsic causes of cancer and with a treatment strategy limited to radiotherapy and surgery  our desire for cure must be tempered by concern to avoid any increase in patient privations  my philosophy  based upon the care of more than 3500 patients over almost 30 years  reflects some of the difficulties of applying the concept  do nothing that may cause harm   while offering each patient the opportunity for long term cure  
class4	the efficacy of comprehensive neck dissection with or without postoperative radiotherapy in nodal metastases of squamous cell carcinoma of the upper respiratory and digestive tracts  neck recurrence free curves corrected for local recurrence were compared for 494 patients who underwent 565 comprehensive neck dissections  in 42 dissections  no radicality could be obtained  of the 523 histologically radical dissections  examination revealed tumor in 352 cases  patients in whom three or more positive nodes or extranodal spread in one or more nodes were found received postoperative radiotherapy  in the histologically n0 group  the incidence of neck recurrence after 5 years was 3   in the n  group as a whole  it was 10   analysis of the influence of extranodal spread and the number of positive nodes showed that the group with one or two positive nodes without extranodal spread  that did not receive postoperative radiotherapy  did not statistically differ from the other groups  this suggests that the results of the group with one or two positive nodes without extranodal spread can be improved by postoperative radiotherapy  
class4	flexible nd yag laser palliation of obstructive tracheal metastatic malignancies  flexible nd yag endoscopic laser surgery may become an effective new modality for palliation in patients with obstructive endotracheal metastatic malignancies  we report the results of the treatment of two patients with severely obstructing intraluminal tracheal metastatic melanoma and medullary thyroid carcinoma  using the neodymium yag laser via the flexible fiberoptic bronchoscope  both patients complained of significant dyspnea  orthopnea  cough  and hemoptysis and were not candidates for rigid bronchoscopy because of underlying medical contraindications and anatomical problems  multiple treatment sessions were used with treatment intervals of 1 to 2 weeks  all treatments were performed in the operating room under sedation  without intubation  with topical lidocaine and standard superior laryngeal nerve block  successful relief of airway obstruction with complete regression of the endotracheal masses was achieved and no recurrences were seen after 9 months  follow up  flexible nd yag laser bronchoscopy offered an alternative for the relief of obstructing endotracheal or bronchial malignancies in patients in whom the rigid bronchoscope could not be passed  it seemed to prolong survival in selected cases  and provided definite improvement in quality of life  
class4	carcinoma of the external auditory canal  an update  this review is a continuation of the series of 35 cases of carcinoma of the external auditory canal originally reported by the senior author and colleagues  eighteen additional cases have been evaluated and treated since 1976  preoperative high resolution computed tomographic scanning has replaced polytomography  and improved surgical skull base approaches have allowed for extended resections of advanced lesions  a revised classification for local and extensive lesions is presented  the prognosis for localized tumors treated by en bloc resection remains excellent  whereas prognosis for extensive lesions might be more dependent on histologic type and grade of tumor  
class4	variations on the temporoparietal fascial flap  an improved understanding of the vascular supply of the layers of the temporal fossa has increased the potential of this region for new and ingenious reconstructive techniques  separate and independently vascularized layers of this region include hair bearing scalp  glabrous skin  tempororoparietal fascia  and galea aponeurotica   temporalis muscle and fascia  and pericranium  island flaps of glabrous skin and scalp provided esthetically appropriate tissue to cover a variety of defects  the malleable bulk of the subcutaneous fascial layers were combined with skin grafts to restore thin lining  and used as a vascularized bed for cartilage grafts in otherwise unsatisfactory recipient sites  illustrative cases from our 5 year clinical experience are presented to demonstrate various combinations of the temporoparietal fascial pedicle with tissues from the temporal region to reconstruct the eyebrows  eyelids  orbits  cheeks  and lips  
class4	primary central nervous system lymphoma in patients with and without the acquired immune deficiency syndrome  a retrospective analysis and review of the literature  twenty two cases of pcl were reviewed  in which 9 patients had aids and 13 did not  a review of the literature identified 247 cases of aids related pcl  differences between patients with aids and immunocompetent pcl were noted in our series  aids related pcl when compared to non aids pcl in our series has the following notable clinical features  1  significantly younger age at presentation  median age 34 versus 59 years  2  significantly higher incidence of b symptoms  44  versus 8   3  worse median performance status at presentation  3 versus 1  and  4  shorter median survival  3 versus 10 months  differences in performance status and survival  however  were not significant  aids related pcl is further characterized by frequent  44   ring enhancing mass lesions on head ct scan  a finding that makes it clinically difficult to distinguish from toxoplasmosis  median survival appears to be improved in the absence of opportunistic infection at time of diagnosis of pcl  6 versus 2 months  the therapeutic approach to patients with pcl  with and without aids  is variable  combined modality therapy may improve the survival in patients with non aids pcl  therapy for patients with aids related pcl is tailored to the status of the individual and it is  therefore  difficult to make comparisons to non aids pcl patients  aids patients are often too ill to tolerate aggressive surgery or systemic treatment and in this instance  radiotherapy alone may be an acceptable alternative  nonetheless  overall survival for patients with aids related and non aids pcl remains poor  
class4	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  
class4	relation of meat  fat  and fiber intake to the risk of colon cancer in a prospective study among women  background  the rates of colon cancer in various countries are strongly correlated with the per capita consumption of red meat and animal fat and  to a lesser degree  inversely associated with the consumption of fiber  methods  we conducted a prospective study among 88 751 women 34 to 59 years old and without a history of cancer  inflammatory bowel disease  or familial polyposis who completed a dietary questionnaire in 1980  by 1986  during 512 488 person years of follow up  150 incident cases of colon cancer had been documented  results  after adjustment for total energy intake  animal fat was positively associated with the risk of colon cancer  p for trend   0 01   the relative risk for the highest as compared with the lowest quintile was 1 89  95 percent confidence interval  1 13 to 3 15   no association was found for vegetable fat  the relative risk of colon cancer in women who ate beef  pork  or lamb as a main dish every day was 2 49  95 percent confidence interval  1 24 to 5 03   as compared with those reporting consumption less than once a month  processed meats and liver were also significantly associated with increased risk  whereas fish and chicken without skin were related to decreased risk  the ratio of the intake of red meat to the intake of chicken and fish was particularly strongly associated with an increased incidence of colon cancer  p for trend   0 0005   the relative risk for women in the highest quintile of this ratio as compared with those in the lowest quintile was 2 49  95 percent confidence interval  1 50 to 4 13   a low intake of fiber from fruits appeared to contribute to the risk of colon cancer  but this relation was not statistically independent of meat intake  conclusions  these prospective data provide evidence for the hypothesis that a high intake of animal fat increases the risk of colon cancer  and they support existing recommendations to substitute fish and chicken for meats high in fat  
class4	overall mortality and cancer mortality around french nuclear sites higher than expected mortality from leukaemia has been observed in the population under age 25 living around sellafield and dounreay  nuclear reprocessing plants in the united kingdom  we report the results of a similar study for the population residing around nuclear sites in france  the number of leukaemia deaths was 58  comparable to the 62 in control areas  and slightly less than the 67 expected from national mortality statistics  twelve deaths due to hodgkin s disease were observed around nuclear sites  this is about twice the number of hodgkin s deaths observed in control areas and twice the number expected from national mortality statistics  this observation must  however  be interpreted in light of the fact that several causes of deaths were studied  increasing the play of chance  
class4	a downstream initiation element required for efficient tata box binding and in vitro function of tfiid  the gfa gene encodes glial fibrillary acidic protein  an intermediate filament protein expressed in glial cells  in vitro transcription analysis has shown that the human gfa promoter contains two initiation elements that can independently specify the transcription startpoint  one of the elements is a tata box 25 base pairs  bp  upstream from the transcription startpoint  the other is located between 10 and 50 bp downstream from the transcription initiation site  we have now shown by transfection that both elements are required for efficient transcription in cultured cells  a partially purified natural human tata box binding factor  tfiid  from hela cells gave footprints that extended from upstream of the tata box through the downstream initiator  deletion of the downstream initiator inhibited both tfiid binding to the tata box and transcription in vitro  in contrast to natural human tfiid  clone human and yeast tfiids expressed in bacteria gave footprints covering only the tata box region  although hypersensitive sites were observed in the downstream region  the cloned tfiids also showed less dependence than natural human tfiid on the downstream initiator for both tata box binding and in vitro transcription  these results suggest that natural human tfiid contains an additional component s  that contribute s  to stable tfiid binding and effective transcription by interacting with the downstream initiator  
class4	circulating cd8  cytotoxic t lymphocytes specific for htlv i px in patients with htlv i associated neurological disease  the human t lymphotropic virus type i  htlv i   the first human retrovirus to be characterized  is associated with adult t cell leukaemia and a chronic progressive disease of the central nervous system termed tropical spastic paraparesis  or htlv i associated myelopathy  only 1  of individuals infected with htlv i develop clinical disease however  the various manifestations of an htlv i infection may be related to differences in the genetic backgrounds of individuals  infection with variant strains of htlv i  differences in viral tropism or host immune response to the virus  whereas the humoral response to htlv i is well characterized  little is known about the human cellular immune response  such as the production of cytotoxic t lymphocytes  here we report the presence of high levels of circulating htlv i specific cytotoxic t lymphocytes in patients with htlv i associated neurological disease but not in htlv i seropositive individuals without neurological involvement  these cytotoxic t lymphocytes are cd8   hla class i  restricted and predominantly recognize the htlv i gene products encoded in the regulatory region px  these findings suggest that htlv i specific cytotoxic t lymphocytes may contribute to the pathogenesis of associated neurological disorders associated with htlv i  
class4	inhibition of tumor growth in a glioma model treated with boron neutron capture therapy  this investigation attempts to determine whether increased survival time seen when the f98 glioma model is treated with boron neutron capture therapy  bnct  is a result of inhibition of tumor growth caused by radiation induced alterations in endothelial cells and normal tissue components  this indirect effect of radiation has been called the tumor bed effect  a series of tumor bearing rats was studied  using a standardized investigational bnct protocol consisting of 50 mg kg of na2b12h11sh injected intravenously 14 to 17 hours before neutron irradiation at 4 x 10 12  n cm2  ten rats  serving as controls  received no treatment either before or after tumor implantation  a second group of 10 rats was treated with bnct 4 days before tumor implantation  these animals received no further treatment  the remaining group of 10 rats received no pretreatment but was treated with bnct 10 days after implantation  histological and ultrastructural analyses were performed in 2 animals from each group 17 days after implantation  survival times of the untreated control animals  mean  25 8 days  did not differ statistically from the survival times of the rats in the pretreated group  mean  25 5 days   the rats treated with bnct after implantation survived significantly longer  p less than 0 02  mean  33 2 days  than the controls and the preirradiated animals  tumor size indices calculated from measurements taken at the time of death were similar in all groups  these results indicate that  with this tumor model  bnct does not cause a tumor bed effect in cerebral tissue  the therapeutic gains observed with bnct result from direct effects on tumor cells or on the peritumoral neovascularity  
class4	characterization of a newly established malignant meningioma cell line of the human brain  iomm lee  a permanent malignant meningioma  mm  cell line of the human brain designated  iomm lee  is reported  this cell line was successfully established from the tumor of a 61 year old chinese man with repeated recurrent primary intraosseous malignant meningioma of the skull  it has been subcultured for more than 60 passages during the past 30 months  the doubling time of cultured cells is approximately 62 hours  tumorigenicity in athymic nude mice  balb c nu nu  who develop multiple pulmonary metastases was observed  the doubling time of tumor volume in vivo is approximately 5 days  karyotypic analysis revealed this cell line to be of human origin and near diploid  with a modal chromosome number of 49  the mesenchymal tumor marker vimentin and intracytoplasmic microfilaments were identified in the cytoplasm of tumor cells by indirect immunohistochemical peroxidase anti peroxidase assays and immunogold ultrastructural localization by transmission electron microscopy  respectively  scanning electron microscopy of cultured cells and xenografted tumors revealed ellipsoidal or carrot shaped tumor cells presenting a wrinkled surface with short sparse microvilli  potential proliferating activity was determined by ki 67 monoclonal antibody  the ki 67 labeling index of cultured cells and xenografted tumors was approximately 36  and 30   respectively  this newly established malignant meningioma cell line of the human brain may prove useful as a research model  
class4	functional results of facial nerve suture after removal of acoustic neurinoma  analysis of 25 cases  the facial nerve is sometimes severed during the removal of acoustic neurinomas  either intentionally to ensure complete removal  or unintentionally because of difficulties in identification  in such cases we have  if possible  sutured the nerve stumps microsurgically  either end to end or by use of an intervening nerve graft  we analyzed the outcome of 25 instances of facial nerve suturing in a series of 219 patients operated on for acoustic neurinoma from 1979 to 1987  the first signs of recovery appeared at an average of 12 months  and there was continued improvement for several years  recovery was graded from 1 to 6  the anastomosis was successful in 24 of the 25 sutured nerves  in that at least some facial movement and tone were restored  grade 5 or higher   in 11 of the 25 cases  facial appearance at rest and with movement was moderately good  grade 2 or 3   a grade 1 result  with no perceivable facial dysfunction  was never achieved  typically  oral muscles showed the most improvement and frontal muscles the least  facial appearance was better at rest than with movement  which was always complicated by some degree of synkinesis  closure of the eye was so good in 13 of the 25 cases that neither tarsorrhaphy nor an eyelid spring was necessary  when the facial nerve is severed  intraoperative suture is recommended  because it provides a chance for moderately good restoration of facial appearance  
class4	extracranial repair of cerebrospinal fluid fistulas  technique and results in 37 patients  although neurosurgeons have traditionally preferred intracranial repair for the management of cerebrospinal fluid  csf  fistulas  this approach is associated with the complications of a craniotomy  anosmia  and a high incidence of recurrent fistulas  extracranial repair  on the other hand  produces no central nervous system morbidity  preserves olfaction  and is associated with a low incidence of recurrence  although there have been several reports of extracranial repair of csf fistulas by otorhinolaryngologists  this approach has received scant mention in the neurosurgical literature  we report here our experience with 37 patients with csf rhinorrhea or otorrhea who underwent extracranial repair  the etiology of the fistula was postoperative in 22  traumatic in 6  and spontaneous in 9  the fistulas were repaired using one of four techniques  external ethmoid sphenoid in 18 patients  transmastoid in 9  transseptosphenoid in 7  and osteoplastic frontal sinusotomy in 3  in 32 of the 37 patients  86   the fistulas were successfully repaired with the initial procedure  of the 5 patients requiring a second operation  the fistula was successfully closed in 4 for an overall success rate of 97   complications were few and consisted of a transient facial paresis in a patient undergoing transmastoid repair and one death from meningitis  the authors conclude that because of low morbidity and mortality and a high success rate in closing fistulas  extracranial repair is the preferred technique for the operative management of csf rhinorrhea and otorrhea  
class4	symptomatic pineal cyst  case report  pineal cysts are being described with increasing frequency since the advent of magnetic resonance imaging  although pineal cysts are incidental findings in as many as 4  of magnetic resonance imaging studies  symptomatic pineal cysts are quite rare  we present a case of pineal cyst causing aqueductal obstruction with symptomatic hydrocephalus and resultant headache and syncope  which was treated by surgical resection  a review of the relevant literature and discussion follow  
class4	clinical study of intracranial nongerminomatous germ cell tumors producing alpha fetoprotein  we present six patients with intracranial nongerminomatous germ cell tumors that produced alpha fetoprotein  afp   their ages ranged from 8 to 20 years  average  11 5 years old   two were male and four were female  four of the tumors originated in the pineal region and two in the suprachiasmatic region  one patient treated with only radiation therapy died within 3 months of admission as a result of intraperitoneal metastasis via a ventriculoperitoneal shunt  another patient  treated with radiation therapy and intrathecal administration of neocarzinostatin  died after 12 months because of tumor progression and subarachnoid dissemination  two patients who received radiation and combination therapy with cisplatin  vinblastine  and bleomycin died after 13 and 25 months  the remaining two patients treated with radiation therapy and adjuvant chemotherapy  cisplatin and etoposide  are now alive without recurrence after 16 and 19 months from admission  adjuvant chemotherapy with cisplatin and etoposide appears to be efficacious in the treatment of intracranial nongerminomatous germ cell tumor  
class4	vagal schwannoma associated with syncopal attacks and postural hypotension  a case report  a case of vagal schwannoma in the cerebellomedullary angle is reported  preoperatively  the patient had paroxysmal episodes of postural hypotension with syncope  after total removal of the vagal tumor  her systemic blood pressure returned to normal  
class4	multiple intracranial tumors of different cell types  multiple intracranial tumors of different cell types are rare  we report nine patients with multiple intracranial tumors  who did not have a history of trauma  irradiation  or phacomatosis  the clinical  radiological  and histopathological findings as well as indications for operations in patients with asymptomatic second tumors are discussed  
class4	occult vascular malformations of the optic chiasm  magnetic resonance imaging diagnosis and surgical laser resection  angiographically occult vascular malformations of the optic nerve and chiasm are extremely rare  before the advent of magnetic resonance imaging  mri   it was difficult to diagnose these lesions preoperatively  we report mri scan findings of optic chiasm cavernous angiomas in two patients with chiasmal syndrome  mri was useful in localizing the vascular malformation and delineating its characteristics  especially chronic hemorrhage  one patient underwent biopsy of the lesion  the other patient underwent complete microsurgical resection of the malformation with the carbon dioxide laser with preservation of vision  occult vascular malformations of the optic nerve and chiasm may be a more common cause of visual deterioration than previously recognized  the mri scan is the imaging modality of choice for diagnosing and following these lesions  in certain patients  these vascular malformations may be amenable to complete surgical removal with stabilization or improvement of visual function  
class4	a case of dyschondroplasia associated with brain stem glioma  diagnosis by stereotactic biopsy  we present a 24 year old patient with multiple chondromas of both hands  the pelvis  the left leg  and an associated brain stem glioma  there was no evidence of hemangioma or dyschromia  and the condition was diagnosed as ollier s disease  a special type of dyschondroplasia like maffucci s syndrome and kast s disease  an increased overall risk for development of malignant skeletal and nonskeletal tumors is associated with maffucci s syndrome  the risk of malignant degeneration is lower in ollier s disease  a glioma in the pons and the right lobe of the cerebellum was found in this patient  the literature describes an association with gliomas in only 12 cases of dyschondroplasia and an infratentorial localization in just one case  signs of malignancy were histologically confirmed in 7 cases without significant preponderance of any one type  our patient had a low grade brain stem astrocytoma with fibrillar and gemistocytic components  a stereotactic serial biopsy made it possible to rule out malignant degeneration  stereotactic brain tumor biopsy as a routine neurosurgical procedure is particularly valuable for deep space occupying processes and forms the basis for therapy  in the present case  irradiation was not recommended  
class4	an unusual complication of silastic dural substitute  case report  a case is presented in which a patient developed an unusual complication after the use of silastic dural substitute  in 1983  the patient underwent removal of a meningioma with the involved dura  five years later  he developed around the graft material a very thick connective tissue capsule  which simulated a recurrent meningioma clinically and radiologically  
class4	brain stem and spinal metastases of supratentorial glioblastoma multiforme  a clinical series  although the spread of supratentorial glioblastoma multiforme to the brain stem and spine has been extensively described in published autopsy series  information on the diagnosis  treatment  and subsequent clinical course of patients manifesting symptoms of glioblastomatous dissemination ante mortem remains scant  we report a series of 11 patients having the signs and symptoms of neuraxis dissemination of supratentorial glioblastoma multiforme  all patients had radiographic documentation of metastases by either contrast enhanced myelograms or enhanced magnetic resonance imaging scans  ten presented with spinal involvement  whereas one presented with lower cranial neuropathies secondary to diffuse involvement of the basal cisterns  the mean age of the patients was 38 5 years  and the mean time interval between diagnosis of intracranial disease and diagnosis of metastases was 14 1 months  after diagnosis of tumor spread  subsequent mean survival time was 2 8 months  all patients received additional radiotherapy to the areas of metastasis  but the clinical response to radiotherapy was quite poor  this study confirms previous reports in the literature suggesting that metastases occur in younger patients and in patients with extended survival  the findings suggest that the relatively infrequent clinical incidence of the symptomatic spread of glioblastoma multiforme  as compared with the frequent incidental discovery of such spread at autopsy  may be the result of the limited survival of the affected patients  and not due to the biology of the tumor  
class4	ultrastructural evidence for differentiation in a human glioblastoma cell line treated with inhibitors of eicosanoid metabolism  human glioblastoma cells incubated in the presence of inhibitors of eicosanoid biosynthesis show decreased cellular proliferation without cytotoxicity  we studied the ultrastructural morphology of a human glioblastoma cell line cultured with nordihydroguaiaretic acid  ndga   a lipoxygenase inhibitor  or 5 8 11 14 eicosatetraynoic acid  a cyclooxygenase and lipoxygenase inhibitor  when glioblastoma cells were treated for 3 days with antiproliferative concentrations of either agent  they shared many morphological characteristics  including evidence for increased astrocytic differentiation with only limited signs of toxicity  the inhibited glioma cells demonstrated an increase in the number and length of astrocytic processes containing greater numbers of glial filaments  and the ndga treated cells also demonstrated extensive lateral pseudopod formation along the processes  the glioblastoma cell shape also became more elongated  losing the usual nuclear lobularity and nuclear inclusions  especially in ndga treated cells  many cytoplasmic organelles packed the cytosol of the inhibited glioma cells  including prominent golgi apparatus  dilated smooth endoplasmic reticulum evolving into dilated vesicles  cytoplasmic vacuoles  and numerous concentric laminations  there was limited evidence for toxicity  however  as the mitochondria were more pleomorphic with some mitochondrial distention and disruption of the cristae along with an increase in cytoplasmic vacuolization  we conclude that the inhibitors of eicosanoid biosynthesis  ndga and 5 8 11 14 eicosatetraynoic acid  not only suppress glioblastoma cell proliferation  but also induce increased astrocytic differentiation  
class4	epidermoid tumors of the 4th ventricle  report of seven cases  epidermoid tumors occur very rarely in the 4th ventricle  we discuss the history  clinical course  and the surgical results for seven patients  one patient had a remittal of symptoms  probably due to the emergence of the tumor from the 4th ventricle into the cisterna magna  total removal of the capsule was possible only in the youngest patient  at present  four patients  mean follow up  6 years  enjoy good general and neurological health  
class4	changes in intracochlear and intracanalicular nerves after acoustic neurinoma excision confirmed by magnetic resonance imaging  postoperative magnetic resonance imaging findings related to the vestibulocochlear and facial nerves within the internal auditory canal were analyzed in acoustic neurinomas  t1  and proton weighted magnetic resonance images showed that the vestibulocochlear nerves distal to the internal auditory meatus increased in signal intensity after surgical intervention  these nerves were conspicuously enhanced after intravenous administration of gadolinium diethylene triamine pentaacetic acid  the preserved facial nerves were also markedly enhanced postoperatively  as a possible cause of these findings  we suggest operative disruption of the blood nerve barrier with ensuing nerve edema  although the operative procedures were carefully carried out using a surgical microscope  the clinical significance of traumatic disruption of the blood nerve barrier and subsequent nerve edema are discussed from the standpoint of preservation of cochlear nerve function  
class4	clinicopathological experience with pineocytomas  report of five surgically treated cases  the clinicopathological experience associated with five cases of pineocytoma is presented  all patients were treated by surgical removal without postoperative radiotherapy  in three individuals  2000 cgy was administered to the tumor as a presurgical diagnostic test  with no evidence of response  all cases demonstrated histological features of pineocytoma  according to the criteria of borit et al   and of the so called  pineocytoma with neuronal differentiation   according to the criteria of rubinstein  the experience obtained from the present series reveals that these tumors can occur in the initial decades of life  that a cystic appearance and the presence of calcifications are distinctive features of their radiological evaluation  and that they have a good prognosis after surgical removal  even when the histological data indicate local invasion  the convenience of reserving the term  pineocytoma  for these tumors  and of including the so called  pineocytomas without further differentiation  within the group of pineoblastomas  is suggested in order to achieve a practical clinicopathological assessment of parenchymatous pineal tumors  
class4	subdural hematoma associated with metastatic neoplasms  two cases of subdural hematoma  one acute and the other chronic  associated with cancer metastatic to the dura are reported  various mechanisms of the association of hematomas with cancer are reviewed  
class4	maffucci s syndrome with bilateral cartilaginous tumors of the cerebellopontine angle  maffucci s syndrome is characterized by the combination of multiple enchondromas  ollier s disease  and hemangiomatosis  these hemangiomas develop in the subcutaneous tissue and form red blue tumors dispersed over the whole body  intracranial involvement is rare  making a preoperative radiological diagnosis and differentiation from other tumors rather difficult  the radiological characteristics and successful removal of the intracranial part of a chondrosarcoma of the cerebellopontine angle in a case of maffucci s syndrome are reported in this paper  
class4	concurrent intradural and extradural meningiomas of the cervical spine  a case of an extradural spinal meningioma presenting with a separate intradural meningioma at the same cord level is reported  review of the english literature on spinal epidural meningiomas reveals a high incidence of concurrent intradural tumors in patients with epidural meningiomas  this leads to the conclusion that the intradural space should be evaluated carefully when an epidural meningioma is encountered  
class4	intradural spinal cord tumor presenting as a subarachnoid hemorrhage  magnetic resonance imaging diagnosis  negative findings on four vessel angiography after a subarachnoid hemorrhage are seen in 5 to 30  of patients  a previously silent lesion in the spinal canal may be responsible for the ictus in a small percentage of this group  the etiological factors include tumors and arteriovenous malformations  however  investigations of such lesions have been limited to patients with signs and symptoms of spinal cord or nerve root pathological processes  this report describes the management of a 56 year old woman with clinical findings typical of an aneurysmal subarachnoid hemorrhage and negative findings on cerebral angiography  in whom magnetic resonance imaging with gadolinium enhancement revealed an intradural extramedullary cervical schwannoma  for this reason  cervicothoracic magnetic resonance imaging with gadolinium enhancement should be considered as an adjunctive scanning examination in all patients with a subarachnoid hemorrhage and negative findings on angiography  
class4	radiation necrosis of the optic chiasm  optic tract  hypothalamus  and upper pons after radiotherapy for pituitary adenoma  detected by gadolinium enhanced  t1 weighted magnetic resonance imaging  case report  a 26 year old woman was treated for a prolactin secreting pituitary adenoma by surgery and radiotherapy  5860 rads   fourteen months later  she developed right hemiparesis and dysarthria  a t1 weighted magnetic resonance imaging scan using gadolinium contrast showed a small  enhanced lesion in the upper pons  seven months later  she had a sudden onset of loss of vision  and radiation optic neuropathy was diagnosed  a t1 weighted magnetic resonance imaging scan showed widespread gadolinium enhanced lesions in the optic chiasm  optic tract  and hypothalamus  magnetic resonance imaging is indispensable for the early diagnosis of radiation necrosis  which is not visualized by radiography or computed tomography  
class4	pituitary hemorrhage into a rathke s cleft cyst this report describes a case of symptomatic pituitary hemorrhage into a rathke s cleft cyst in a 25 year old woman  the literature on pituitary hemorrhage in nonadenomatous sellar tumors is reviewed  
class4	suprasellar pituitary adenoma arising from the pars tuberalis  case report  a rare case of suprasellar pituitary adenoma arising from the pars tuberalis in a 53 year old woman is presented  the tumor was located exclusively above the diaphragma sellae  and no invasion into the sella turcica was noted  
class4	central neurogenic hyperventilation  pharmacologic intervention with morphine sulfate and correlative analysis of respiratory  sleep  and ocular motor dysfunction  central neurogenic hyperventilation  cnh   for which there is no effective therapy  can eventually result in respiratory fatigue and death  this report describes a patient with cnh due to a brainstem anaplastic astrocytoma who also exhibited disturbances of sleep and ocular motor function  the cnh responded clinically to morphine sulfate and methadone  analysis of ventilatory response to co2 before and after morphine demonstrated a depression of ventilatory response  49 to 53  of baseline  and occlusion pressure response  35 to 50  of baseline  to co2  with a requirement for high doses of naloxone  10 mg iv  to reverse the effect  polysomnography revealed sustained hyperventilation  elevated o2 saturation  and low end tidal co2 throughout all stages of non rapid eye movement  nrem  sleep  and absence of rapid eye movement  rem  sleep  ocular motor evaluation disclosed absence of horizontal and reflexive saccades with compensatory head thrusts  correlation of the clinical and physiologic data with the mri abnormalities suggested that the lesion responsible for cnh in this patient might reside in the medial tegmental parapontine reticular formation  since recurrent episodes of hyperventilation responded in a sustained fashion to iv and oral opiates  this treatment may warrant consideration in other patients with cnh  
class4	procarbazine chemotherapy in the treatment of recurrent malignant astrocytomas after radiation and nitrosourea failure  the brain tumor study group has shown procarbazine  pcb  to be as effective an adjuvant treatment as 1 3 bis 2 chloroethyl  1 nitrosourea  bcnu   we treated 35 patients with recurrent malignant astrocytomas after radiation and nitrosourea failure with successive courses of pcb 150 mg m2 d for 28 days every 8 weeks  after 2 courses  2 patients had complete responses  7 had partial responses  11 had stable disease  and 15 had progression  significantly more patients receiving pcb had complete or partial responses or stable disease than a similar group of patients in a previous trial who received intra arterial  ia  cisplatin  ddp   there is a significant advantage in time to disease progression for those receiving pcb compared with those receiving ia diaziquone  azq   our results suggest that pcb is a more effective 2nd agent than ia ddp or azq following radiation and nitrosourea failure  
class4	antibodies to synthetic peptide  125 148  of the alpha subunit of human nicotinic acetylcholine receptor in sera from patients with myasthenia gravis  we measured the amount of antibodies to a synthetic peptide that corresponds to the alpha subunit residues lys125 thr148 of human acetylcholine receptor  achr  in myasthenic sera  we detected anti peptide antibodies in 52   89 171  of the patients with myasthenia gravis  mg   but none in any of the healthy controls  anti peptide antibodies should provide a valuable immunologic parameter for the clinical evaluation of mg  but no apparent correlation was observed between the titers of anti peptide and anti achr antibodies  
class4	cavernous hemangioma of the spinal cord  report of 2 unusual cases  we present 2 cases of spinal cord intramedullary cavernous hemangioma  1 patient is the 1st reported case of multiple spinal cord lesions  diagnosis is greatly enhanced by the use of mri  
class4	classification of endometrial cells on cervical cytology  one hundred eighty eight women who had endometrial cells on cervical cytologic specimens during the secretory phase or in the postmenopausal period were studied retrospectively  each had undergone hysterectomy or endometrial biopsy within 12 months of the original smear  the endometrial cells were classified as typical  atypical  or suspicious for carcinoma  among premenopausal subjects  three of 57 with typical cells had endometrial hyperplasia  one of two with atypical cells had endometrial polyps  and both with cells suspicious for carcinoma had endometrial carcinoma  in the postmenopausal group  ten  13 5   of 74 with typical endometrial cells had either hyperplasia or carcinoma  and five  22 7   of 22 with atypical cells and 24 77 4   of 31 patients with suspicious cells had either hyperplasia or carcinoma  the present findings and a review of the pertinent literature demonstrate that the classification system used is helpful in predicting the risk for endometrial disease in patients with endometrial cells seen on cervical cytologic smears during the secretory phase or in the postmenopausal period  
class4	a randomized trial comparing two methods of cold knife conization with laser conization  in a randomized study  62 women were submitted to cold knife conization with application of sturmdorf sutures  60 to cold knife conization without sutures  and 61 to laser conization  early hemorrhage occurred in 1 6  13 3  and 6 6  of women  respectively  p less than  05   and late hemorrhage in 15 3  3 6  and 11 7   respectively  considering early and late hemorrhage together  there was no significant difference among the three treatment groups  dysmenorrhea tended to be more common after application of sturmdorf sutures  as it was reported by 27 8  13 2  and 14 3  of patients  respectively  but the difference was not statistically significant  dysmenorrhea occurred in 13  of the cases with a cone height of 20 mm or less and in 26  of the cases with a cone height greater than 20 mm  p less than  05   endocervical cells were present significantly more often after sampling with a cytobrush than with a cotton swab  p less than  0001   whereas the method of conization had no influence  in smears obtained with a cytobrush  endocervical cells were present in 88 0  84 9  and 82 5  of the cases  in smears obtained with a cotton swab  endocervical cells were present in 46 6  57 7  and 54 5   respectively  we conclude that cold knife conization without sturmdorf sutures is about equal to laser conization in overall complications  but the laser is preferable for outpatient treatment because of a lower frequency of early hemorrhage  sturmdorf sutures should be avoided  smears at follow up should be taken with a cytobrush and a wooden spatula  
class4	basement membrane of cervical adenocarcinoma  an immunoperoxidase study of laminin and type iv collagen  the basement membrane components type iv collagen and laminin were examined immunohistochemically in 14 cases of adenocarcinoma of the cervix  the patterns of staining in adenocarcinoma in situ  invasive adenocarcinoma  and early invasive adenocarcinoma were compared to see whether characteristic patterns could be delineated  adenocarcinoma in situ had a uniform intact basement membrane  whereas the basement membrane of invasive adenocarcinoma was fragmented and irregular  cases of early stromal invasion showed early gland buds and outpouchings with defective basement membrane staining  the degree of histologic differentiation of the tumor was not clearly related to the amount of basement membrane component staining  the concept of early stromal invasion in cervical adenocarcinoma  as supported by our immunohistochemical studies  is discussed as it relates to a possible pathogenic mechanism in early invasion and infiltration of adenocarcinoma of the cervix  
class4	treatment of fallopian tube carcinoma with cisplatin  doxorubicin  and cyclophosphamide  primary carcinoma of the fallopian tube is uncommon and is often treated using regimens active in ovarian carcinoma  evidence is scant that such therapies benefit patients with fallopian tube carcinoma  between december 1979 and july 1988  we treated 18 patients who had adenocarcinoma of the fallopian tube with the combination of cisplatin  50 mg m2   doxorubicin  50 mg m2   and cyclophosphamide  500 mg m2  administered intravenously on 1 day every 28 days  histologic confirmation of fallopian tube carcinoma was obtained before entry in the study  three patients had stage i disease  five had stage ii  nine had stage iii  and one had stage iv  sixteen patients received the combination therapy as first line treatment after cytoreductive surgery  and two patients received it for recurrent carcinoma  seven patients had clinically measurable disease at the start of therapy  two of these patients had a complete clinical response  two had stable disease  and three had progressive disease  eight of the 15 patients with stages ii iv disease underwent second look laparotomy  four had a complete response to therapy and four had a partial response  making the overall response rate 53   the toxicity of the regimen was moderate  the median survival was 81 months  patients with stages ii iv disease had a median survival of 43 9 months and a progression free survival of 22 5 months  this regimen appears to be active in fallopian tube carcinoma and can result in response rates comparable to those reported for epithelial ovarian cancer  
class4	debulking of pelvic and para aortic lymph node metastases in ovarian cancer with the cavitron ultrasonic surgical aspirator  six patients with metastatic ovarian cancer with extensive involvement of the pelvic and or para aortic lymph nodes underwent surgical debulking with the cavitron ultrasonic surgical aspirator  intraoperative and postoperative morbidity was minimal  it is suggested that this technique may be used for cytoreductive surgery in combination with standard surgical techniques  
class4	the significance of moderate and severe inflammation on class i papanicolaou smear the significance of a cytologic diagnosis of moderate and severe inflammation with a normal  class i  papanicolaou smear has not been addressed  a retrospective review of 596 consecutive cervical smears performed over 13 months revealed 85 women who had a class i cytologic smear with moderate to severe inflammation  seventy eight patients had colposcopic examinations and were considered for this study  fifty nine  75 6   had cervical punch biopsies and or endocervical biopsies  of the 78  19  24 4   had cervical condylomata and nine  11 5   had cervical intraepithelial neoplasia  we conclude that class i cytologic smears with moderate to severe inflammation may be associated with findings of condylomata and cervical dysplasia  
class4	vitreous changes and macular edema in central retinal vein occlusion  the condition of the posterior vitreous was determined in 56 eyes with central retinal vein occlusion  crvo   using a life table analysis  it was studied in 56 eyes  the incidence of posterior vitreous detachment  pvd  in the crvo eyes at the first vitreous examination did not differ significantly from that in 64 age matched control eyes  however  the incidence of pvd in crvo eyes increased from 39 3  at the first vitreous examination to 58 5  after 6 months  and to 69 6  1 year from the examination  the incidence of pvd in crvo eyes during follow up was statistically higher than that of the controls  p    009   the incidence of pvd after the first vitreous examination was significantly higher in eyes with hemorrhagic retinopathy than in eyes with venous stasis retinopathy  p    04   in the 34 eyes with macular edema  the edema lasted significantly longer in those with vitreomacular attachment  vma  at the first examination than in those without vma at this time  p    02   vma may play an important role in the pathogenesis and chronicity of macular edema in crvo  
class4	management of macular puckers associated with retinal angiomas  monocular visual loss in four patients was caused by epiretinal macular membranes associated with peripheral retinal capillary angiomas or angioma like lesions  three patients had solitary vascular lesions and one had two discrete vascular lesions  all patients were in good health  with no evidence of the von hippel lindau syndrome  in three patients  spontaneous peeling of the macular membranes and visual improvement occurred 2 to 6 months after obliteration of the angioma like lesions with cryotherapy  two patients   or cryotherapy combined with argon laser  one patient   the fourth patient underwent a vitrectomy 8 months after the macular pucker had failed to respond to treatment of the vascular lesion  
class4	experience with photocoagulation in behcet s disease  between 1973 and 1987 we examined both eyes of 300 patients with the uveoretinitis type lesions characteristic of behcet s disease  of the 556 eyes whose fundus could be examined  38 eyes  6 8   in 33 patients  11   had developed retinal capillary nonperfusion  branch retinal vein occlusion  or retinal or disc neovascularization  these eyes were treated by photocoagulation  primarily to forestall vitreous hemorrhage and the development of neovascular glaucoma  as well as to decrease the macular edema resulting from vein occlusion  the treatment  which was well tolerated  was successful in closing retinal capillary nonperfusion areas and eliminating retinal neovascularization  disc neovascularization was resolved completely in some cases  and partially in others  
class4	fluorescein angiography in ciliary body melanomas  we retrospectively studied the value of iris fluorescein angiography in predicitng benignity or malignancy in 10 cases of ciliary body melanoma with iris extension  no correlation between fluorescein angiographic appearance and histopathologic features was observed  fluorescein angiography adds little to the management of ciliary body melanomas with iris extension  
class4	visual disturbance in patients with melanocytoma of the optic disk  visual disturbance in 11 patients with melanocytoma of the optic disk was analyzed  goldmann visual field examination showed enlargement of mariotte s blind spot in 7 of 10 patients  70   and visual field defect or depression in 7 patients  70    in 6 of the 7 patients with visual field defect of depression  86    the portion of visual field damage corresponded with the location of the tumor and retinal nerve fiber bundle defect  in 1 patient  sudden loss of visual acuity occurred  presumably due to anterior ischemic optic neuropathy induced by melanocytoma  
class4	argon green  514 nm  versus krypton red  647 nm  modified grid laser photocoagulation for diffuse diabetic macular edema  between 1984 and 1988  225 eyes of 132 patients were entered in a prospective  randomized clinical trial to determine if any significant differences exist between treatment with argon green  514 nm  and krypton red  647 nm  modified grid laser photocoagulation for patients with diffuse diabetic maculopathy with or without cystoid macular edema  at the 12  and 24 month follow up visits  no statistically significant difference was found between the two groups with respect to all of the following  reduction or elimination of macular edema  improvement in visual acuity  worsening of visual acuity  number of treatments per eye  and effect on the visual field  at the 12 month follow up visit  none of the following factors statistically affected the visual outcome in either of the two groups  a history of systemic hypertension  systemic vascular disease  cystoid macular edema  or initial poor visual acuity  
class4	the epidemiology of ophthalmic malignancies in new york state  the epidemiologic characteristics of more than 1400 primary eye cancers  icd 9  site 190  diagnosed among new york state  nys  residents between 1975 and 1986 are described  among nys male residents  the average annual age adjusted incidence rate was 7 5 per 1 000 000  and among nys female residents  the rate was 5 4 per 1 000 000  male female rate ratio  1 39   the majority of ophthalmic malignancies were included within three histologic groupings  melanomas  70 4    retinoblastomas  9 8    and squamous cell carcinomas  9 2    the average annual incidence of retinoblastoma among persons in nys who were less than 5 years of age was 9 5 per 1 000 000 for boys and 8 7 per 1 000 000 for girls  male female rate ratio  1 09   the average annual incidence  age adjusted  of ocular melanomas was 4 9 per 1 000 000 among men and 3 7 per 1 000 000 among women in nys  male female rate ratio  1 32   expanded knowledge of the epidemiology of ophthalmic cancers can help to develop a foundation on which to monitor disease patterns and can serve to stimulate further etiologic research involving these rare malignancies  
class4	introducing the  walk up  flap  reconstructive oral and maxillofacial surgeons often find the need for additional soft tissue even when a myocutaneous flap has been previously placed  this article introduces the principles  technique  and results of 32  walk up  muscle flaps derived from existing myocutaneous flaps  the anastomotic vascular ingrowth at the original myocutaneous flap s distal end permits its proximal detachment and axial vessel ligation to rotate the proximal two thirds to a tissue deficient site  in our experience at the university of miami  these flaps have been predictable  97  viable transfer rate   have provided vascular soft tissue in deficient areas  and have been skin grafted at their surface to increase oral lining or skin cover  among several other uses  
class4	multiple myeloma and bullous lichenoid lesions  an unusual association  many associations of lichenoid reactions have been described but this case appears to be a previously unreported association  with multiple myeloma  this case also demonstrates the necessity of a mucosal biopsy with adequate hematologic and serologic investigations to obtain a definitive diagnosis  
class4	thermally induced  nicotine  stomatitis  a case report  a palatal lesion resembling  nicotine  stomatitis was found in a woman who did not smoke  however  the patient frequently drank extremely hot beverages  after she was instructed to reduce the temperature of the beverages  the lesion almost completely resolved  this suggests that heat was the primary cause of this lesion and also implicates heat as the major cause of nicotine stomatitis  
class4	diagnosis of oral hairy leukoplakia by ultrastructural examination of exfoliative cytologic specimens  lingual exfoliative cytologic specimens  scrapings  were obtained from 18 patients positive for human immunodeficiency virus with clinical oral hairy leukoplakia  buccal mucosal scrapings were obtained from 12 of these patients  the specimens were processed for examination by transmission electron microscopy  tem   sixteen  89   of the lingual specimens revealed infection of keratinocytes by herpes type virus  there was no evidence of virus infection in the 12 buccal mucosal scrapings  fungal hyphae were seen by tem in 14  78   of the lingual scrapings and two  17   of the buccal scrapings  one exfoliative specimen and two biopsy specimens were stained for epstein barr virus dna with a dna probe  the demonstration of herpes type virions by tem in keratinocytes from a lesion clinically suspected to be hairy leukoplakia provides direct  objective diagnosis  furthermore  use of exfoliative cytologic specimens provides a clinically simple  noninvasive technique  
class4	the cellular composition of basal cell adenoma of the parotid gland  an immunohistochemical analysis  four cases of basal cell adenoma of the parotid gland were examined immunohistochemically to characterize their cellular composition  in all cases epithelial membrane antigen and keratin were detected in the inner luminal cells  some cells also showed positive staining for secretory functional markers  indicating their differentiation toward secretory epithelium  in tubular and trabecular types the outer cells consistently displayed an intense staining for vimentin and some were also positive for actin  indicating their myoepithelial nature  in the solid type  most tumor cells resembled the ductal cells or basal cells of larger ducts in normal gland with regard to their immunoreactivity  our results may suggest that the proportion and arrangement of heterogeneous tumor cells are responsible for different histologic patterns of the salivary basal cell adenoma  
class4	primary malignant melanoma in the parotid gland  reports of primary malignant melanoma arising from the parotid salivary gland are extremely rare and  to date  have been sporadic  we report a pertinent case  and tabulate and correlate the clinical findings of the 13 cases reported thus far in the literature  the most common symptom is a progressively enlarging  asymptomatic  firm  and fixed mass  total excision has been the established treatment of choice  the contribution of radiotherapy  chemotherapy  and immunotherapy remains unclear  and it is not possible at present to predict the outcome of treatment in individual patients  although rare  primary malignant melanoma should be considered in the differential diagnosis of parotid tumors  the clinical significance of establishing the diagnosis of primary malignant melanoma of the parotid gland is emphasized  
class4	clinical and instrumental evaluation of sensory function before and after percutaneous anterolateral cordotomy at cervical level in man  sensory perception thresholds were assessed by clinical testing and by quantitative instrumental testing before and after operation in 16 subjects for whom unilateral percutaneous cervical cordotomy was performed for the relief of pain due to malignant disease  and compared with clinical assessments of sensory function  we were able to confirm the association between deficit in pin prick sensation and pain relief in the majority of instances  though the completeness or otherwise of pain relief does not correspond to absence of pin prick sensation  there is no objective interference with low threshold mechanical sensation as measured instrumentally  although cordotomised subjects do not experience startle  tickle  or cutaneous erotic sensation when subjected to appropriate low intensity tactile sensation  quantitative instrumental testing shows that the greatest deficits produced by cordotomy are in the sensations of skinfold pinch      tissue damage pain  and skin cooling  the latter is transduced in the periphery by a delta fibres  sensations of warmth and hot pain  transduced by primary afferent c fibres  are much less significantly affected  our findings thus fail to resolve the question as to whether chronic clinical pain is mainly an a delta  or a c fibre mediated phenomenon  
class4	screening for neuroblastoma at 3 weeks of age  methods and preliminary results from the quebec neuroblastoma screening project  a large neuroblastoma screening study was recently started in the province of quebec  canada  this project  a collaboration between the quebec network for genetic medicine and the university of minnesota  is studying the impact of screening infants for the preclinical detection of neuroblastoma on the population based mortality caused by this tumor  all infants born in quebec during a 5 year period will be screened twice  at 3 weeks and at 6 months  urinary homovanillic acid and vanillylmandelic acid determination from dried filter paper samples is used for screening  initial qualitative screening is done by means of thin layer chromatography with confirmatory quantitative screening by gas chromatography mass spectrometry  gc ms   during the initial 6 months of 3 week screening  41 673 neonates  92  compliance rate  were screened and 10 6  of them were tested also by gc ms  nine of these neonates had positive results on two gc ms tests and were referred for evaluation to rule out the presence of neuroblastoma  four had the tumor  1 had a calcified adrenal gland  and 4 had no tumor detected  three additional neonates had clinical diagnosis of neuroblastoma before they reached the screening age of 3 weeks  a neuroblastoma that did not secrete homovanillic acid or vanillylmandelic acid was diagnosed clinically in 1 additional patient who tested negative by screening  
class4	when epilepsy masquerades as heart disease  awareness is key to avoiding misdiagnosis  autonomic neural impulses that accompany discharges during a seizure can cause a variety of cardiac manifestations  including cardiac arrhythmias  sudden death  anginal chest pain  neurogenic pulmonary edema  and symptoms of pheochromocytoma  either generalized or focal seizures may generate such signs and symptoms  a better appreciation of cardiac problems caused by epilepsy is helpful in preventing misdiagnosis  because the clinical picture in such a patient may be confusing  
class4	expression of murine renin genes in subcutaneous connective tissue  a renin promoter large tumor antigen  t antigen  fusion gene was constructed to provide a reporter function for renin expression in transgenic mice  these transgenic mice gave rise to tumors in subcutaneous soft tissue  which was attributed to transgene expression at this site  an immunohistochemical analysis of transgenic fetuses from several independent lines revealed scattered t antigen containing mesenchymal cells and fibroblasts in the subcutaneous layer of the skin between the panniculus carnosus muscle of the skin and the skeletal muscle of the body wall  this localization is consistent with the location of overt tumorigenesis in adult mice  this pattern was specific for the renin t antigen fusion gene as no immunohistochemical staining was observed in transgenic fetuses containing a heterologous promoter t antigen fusion gene  northern blot analysis of tumor rna indicated that most of the tumors expressed both t antigen and the endogenous renin gene ren 1c  in addition  when multiple renin genes were introduced by crossing transgenic mice with nontransgenic dba 2j mice  which contain another allele of the ren 1 locus as well as the duplicated locus ren 2  the resultant tumors expressed the ren 2 gene  northern blots were then used to analyze renin expression in the subcutaneous tissue of normal mice  fully processed renin mrna was detected in eviscerated 15 5 day postcoitus fetal and newborn carcasses and in newborn skin  our data indicate that there is a renin expressing cell population in fetal and newborn subcutaneous tissue  
class4	e1a dependent expression of adenovirus genes in otf963 embryonal carcinoma cells  role of e1a induced differentiation  some undifferentiated f9 embryonal carcinoma cells allow adenovirus genes to be expressed independently of the e1a oncogene normally required for their activation  this has been attributed to a cellular equivalent of e1a in f9 cells  however  transcription of all early genes was low in undifferentiated otf963 embryonic carcinoma cells during the first 48 hr after infection with adenovirus type 5  ad5   transcription then increased to about the level seen 16 hr after infection of cells induced to differentiate by retinoic acid  ra   referred to as ra df9 cells   but this increase did not occur in cells infected by the e1a deletion mutant dl312  addition of e1a in trans  or of ra  had no immediate effect on viral transcription in otf963 cells  but viral transcription increased about 48 hr after these additions  ad5 induced transcription of several differentiation specific genes in otf963 cells with about the same kinetics as their induction by ra  these genes were superinduced in ra df9 cells by camp or infection by adenovirus  we suggest the small amount of e1a produced early in infection of otf963 cells activates cellular genes  some of which are differentiation specific and required for efficient transcription of viral genes  so that e1a both induces and is induced by differentiation  the simple hypothesis of a cellular equivalent to e1a does not adequately explain the complex interactions between viral and cellular genes in otf963 embryonic carcinoma cells  
class4	the human immunodeficiency virus type 2 vpr gene is essential for productive infection of human macrophages  the human immunodeficiency virus  hiv  genetic determinant s  responsible for tropism in human t cells or macrophages are not well defined  we studied the role of the hiv type 2  hiv 2  nef and vpr genes in viral tropism  hiv 2 mutants  lacking either vpr or nef genes  or both vpr and nef  were obtained by site specific mutagenesis of a biologically active hiv 2 proviral clone  hiv 2sbl isy   which is infectious in both human t cells and macrophages  viral progeny carrying mutations of nef  vpr  or of both nef and vpr genes replicated more efficiently than the parental virus in primary human peripheral blood cells and in the human hut 78 t cell line  in contrast  the hiv 2 nef  mutant infected human macrophages as efficiently as the parental virus  whereas viruses lacking the vpr gene either alone or in conjunction with the lack of the nef gene did not replicate in macrophages  thus  some lack of nef in hiv 2 enhances viral replication in t cells and does not interfere with viral replication in primary macrophages  whereas vpr is essential for replication of hiv 2 in human macrophages  because the parental hiv 2sbl isy cloned virus also infects rhesus macaques  the use in animal studies of these hiv 2 mutants with differences in cell tropism and rates of replication will be highly useful in understanding the mechanism of viral infectivity and possibly pathogenicity in vivo  
class4	human colorectal cancers display abnormal fourier transform infrared spectra  fourier transform infrared spectroscopy  ft ir  was applied to the study of tissue sections of human colorectal cancer  pairs of tissue samples from colorectal cancer and histologically normal mucosa 5 10 cm away from the tumor were obtained from 11 patients who underwent partial colectomy  all cancer specimens displayed abnormal spectra compared with the corresponding normal tissues  these changes involved the phosphate and c o stretching bands  the ch stretch region  and the pressure dependence of the ch2 bending and c   o stretching modes  our findings indicate that in colonic malignant tissue  there are changes in the degree of hydrogen bonding of  i  oxygen atoms of the backbone of nucleic acids  increased    ii  oh groups of serine  tyrosine  and threonine residues  any or all of them  of cell proteins  decreased   and  iii  the c   o groups of the acyl chains of membrane lipids  increased   in addition  they indicate changes in the structure of proteins and membrane lipids  as judged by the changes in their ratio of methyl to methylene groups  and in the packing and the conformational structure of the methylene chains of membrane lipids  the cell s  of the malignant colon tissues responsible for these spectral abnormalities is unknown  cultured colon adenocarcinoma cell lines displayed similarly abnormal ft ir spectra  the diagnostic potential of the observed changes is discussed  
class4	a rhesus monkey model for sexual transmission of a papillomavirus isolated from a squamous cell carcinoma  recently we molecularly cloned and characterized a papillomavirus from a lymph node metastasis of a primary penile carcinoma found in a rhesus monkey  this virus species  rhesus papillomavirus type 1  rhpv 1   is similar to oncogenic human papillomaviruses  hpvs   such as hpv 16 or hpv 18  in that the rhpv 1 dna was found to be integrated in the tumor cell dna  to compare the sexual transmission and oncogenic nature of rhpv 1 with these hpvs  we undertook an extensive retrospective study of a group of rhesus monkeys whose sexual mating and offspring histories were known  these animals had mated directly with the index male mentioned above or were secondarily exposed to this virus through intermediate sexual partners  this study combines cytological  histopathological  and several complementary hybridization and dna amplification techniques on multiple tissue samples to demonstrate the sexually transmitted nature of rhpv 1  the oncogenic potential of rhpv 1 is suggested in several of the infected animals by the presence of various degrees of neoplasia including squamous cell cancer of the cervix  
class4	transfer of secretory proteins from the endoplasmic reticulum to the golgi apparatus  discrimination between homologous and heterologous transfer in intact heterokaryons  to examine aspects of the transfer of secretory proteins from the endoplasmic reticulum to the golgi apparatus in situ  heterokaryons were formed between hep g2 human hepatoma cells and wi 38 human fibroblasts  the cells were appropriately treated with cycloheximide before fusion  which emptied them of their respective secretory proteins  serum albumin for the hep g2 cells and procollagen i for the wi 38 cells  after fusion was complete  the cycloheximide was washed out  protein synthesis was resumed  and the rates of reappearance of serum albumin and procollagen i in the two separated golgi apparatuses within each heterokaryon were followed by immunofluorescence microscopy  serum albumin was found to always reappear first in the golgi apparatus contributed by the hep g2 half of the heterokaryon  and procollagen i in the golgi apparatus of the wi 38 half  these results suggest that the endoplasmic reticulum to golgi apparatus transfer in situ is not simply a stochastic process but is either spatially restricted or exhibits cell type specificity or both  
class4	adult t cell leukemia derived factor thioredoxin  produced by both human t lymphotropic virus type i  and epstein barr virus transformed lymphocytes  acts as an autocrine growth factor and synergizes with interleukin 1 and interleukin 2  interleukin 1  il 1  has been obtained from the epstein barr virus infected b lymphoblastoid cell line 3b6 and shown to be involved in autocrine growth of 3b6 b cells  independently  adult t cell leukemia derived factor  adf  was purified from human t lymphotropic virus i infected leukemic t cell line  atl 2  and reported as an interleukin 2  il 2  receptor inducing factor  we have previously reported the same molecular mass  pi  and nh2 terminal amino acid sequence for both 3b6 derived il 1 and adf  cdna cloning of adf demonstrated high homology with the prokaryotic disulfide reducing enzyme thioredoxin  we show here that adf and 3b6 derived il 1 are identical  by rna blot  3b6 and atl 2 cells were shown to contain high levels of 0 6 kilobase mrna corresponding to adf  such message was not detected in resting peripheral blood lymphocytes but could be weakly induced by lymphocyte activation  antibodies have been raised against synthetic peptides corresponding to the nh2 terminus and the cooh terminus of adf  immunoblotting and sequential immunoprecipitation with these antibodies revealed the same 13 kda protein in 3b6 and atl 2 cells  recombinant adf could sustain growth of 3b6 and atl 2 cells at low cellular concentration without fetal calf serum  adf  thus  appears involved in their autocrine growth  similarly  recombinant adf could enhance growth of other b cell lines  including the epstein barr virus negative burkitt lymphoma line bl41 and the lymphoblastoid cell lines crag8  crb95  and 1g8  finally  recombinant adf exhibits marked synergism with other cytokines  such as il 1 and il 2  allowing virally infected lymphocytes to respond to suboptimal amounts of a variety of growth factors  
class4	the recombinant immunotoxin anti tac fv  pseudomonas exotoxin 40 is cytotoxic toward peripheral blood malignant cells from patients with adult t cell leukemia  anti tac fv  pe40 is a recombinant single chain immunotoxin containing the heavy and light variable regions of the anti tac monoclonal antibody fused to a mutant form of pseudomonas exotoxin  pe   anti tac binds to the p55 subunit of the human interleukin 2  il 2  receptor  and anti tac fv  pe40 kills human or monkey cell lines that contain either the intact il 2 receptor or its p55 subunit alone  to assess the usefulness of anti tac fv  pe40 in treatment of il 2 receptor positive leukemia  we tested peripheral blood mononuclear cells from six patients with adult t cell leukemia  in each of the six patients  anti tac fv  pe40 was extremely cytotoxic to the malignant cells  metabolic activity and sensitivity of the fresh cells improved when a small amount of il 2  10 units per ml  was present during incubation  the toxin concentration necessary to inhibit protein synthesis by 50  after 16 hr incubation of cells with immunotoxin varied from 1 6 to 16 ng ml  2 5 25 x 10  11  m   in every case  binding was by means of the tac antigen because anti tac fv  pe40 cytotoxicity was prevented by adding excess anti tac antibody  moreover  anti tac alone or an inactive mutant of anti tac fv  pe40 without adp ribosylation activity had very little cytotoxic activity  peripheral blood mononuclear cells from normal controls  from a patient with tac negative leukemia  and from adult t cell leukemia patients without significant peripheral blood involvement were not sensitive to anti tac fv  pe40  these results indicate that anti tac fv  pe40 is a potent cytotoxin against adult t cell leukemia cells in vitro and warrants clinical testing  
class4	a 170 kda membrane bound protease is associated with the expression of invasiveness by human malignant melanoma cells  malignant spreading of cancer cells requires cell surface proteases that cleave the crosslinked collagenous matrix of connective tissues  from correlating the morphologically defined invasiveness of tumor cells with the presence of specific membrane associated proteases  we have identified a malignant human melanoma cell line  lox  that invades crosslinked gelatin films in vitro and contains uniquely a neutral 170 kda gelatinase in the cell membrane  a similar gelatinase was found in membranes recovered from culture media conditioned with lox  the 170 kda gelatinase is a wheat germ agglutinin binding protein  the proteolytic activity is maximal at neutral ph  enhanced by edta and dithiothreitol  inhibited by the cysteine protease inhibitors n ethylmaleimide  hgcl2  and phenylmethylsulfonyl fluoride  and can bind to an organomercurial adsorbent  suggesting that it is a neutral sulfhydryl sensitive protease  this 170 kda gelatinase of lox cells was not found in a control melanoma cell line  sk mel28  or in 32 other tumor cell lines that did not show extracellular gelatin degradation  thus  we have identified a large membrane bound protease that may be a specific marker molecule for melanoma cell invasiveness  
class4	homeobox gene expression plus autocrine growth factor production elicits myeloid leukemia  in the murine myelomonocytic leukemia wehi 3b  proviral insertions have induced expression of the hox 2 4 homeobox gene and the gene for the myeloid growth factor interleukin 3  il 3   to assess their potential oncogenic role  normal bone marrow cells were infected with retroviruses bearing the genes for il 3 or il 3 plus hox 2 4  unlike the il 3 virus  the il 3 hox 2 4 virus was highly leukemogenic  infected cells expressing both genes exhibited retarded differentiation in vitro  generated myelomonocytic cell lines  and provoked a rapid  transplantable myeloid leukemia in vivo  the oncogenic action of hox 2 4 appears to derive from its ability to impede the il 3 driven terminal differentiation of myeloid cells  the results suggest that homeobox genes can regulate key differentiation processes such as self renewal capacity and that their inappropriate expression can be oncogenic  
class4	introduction of nerve growth factor  ngf  receptors into a medulloblastoma cell line results in expression of high  and low affinity ngf receptors but not ngf mediated differentiation  expression of the cloned human nerve growth factor receptor  ngfr  cdna in cell lines can generate both high  and low affinity binding sites  since the inability to respond appropriately to differentiation factors such as ngf may contribute to determining the malignant phenotype of neuroblastomas  we sought to determine whether the same is true of medulloblastomas  to generate a human central nervous system neuronal cell line that would respond to ngf  we infected the medulloblastoma cell line d283 med with a defective retrovirus carrying the cdna coding for the human ngfr  the resultant cells  med ngfr  expressed abundant low  and high affinity ngfrs  and ngf treatment induced a rapid transient increase of c fos mrna in the ngfr expressing cells but not in the parent line or in cells infected with virus lacking the cdna insert  however  the med ngfr cells did not internalize the ngfr at high efficiency  nor did they differentiate in response to ngf  three important conclusions emerge from this study   i  internalization of ngfrs is not necessary for some early rapid transcriptional effects of ngf   ii  an unknown factor s  that cooperates with the cloned ngfr in allowing high affinity ngf binding is found in a primitive central nervous system cell line  and  iii  ngfrs introduced into and expressed by d283 med  i e   med ngfr  cells are partially functional but are unable to induce differentiation in these primitive neuron like tumor cells  implying that high efficiency receptor mediated endocytosis of ngf and its receptor may be a necessary step in the cascade of events leading to ngf mediated differentiation  
class4	rapid  nonradioactive detection of clonal t cell receptor gene rearrangements in lymphoid neoplasms  southern blot hybridization analysis of clonal antigen receptor gene rearrangements has proved to be a valuable adjunct to conventional methods for diagnosing lymphoid neoplasia  however  southern blot analysis suffers from a number of technical disadvantages  including the time necessary to obtain results  the use of radioactivity  and the susceptibility of the method to various artifacts  we have investigated an alternative approach for assessing the clonality of antigen receptor gene rearrangements in lymphoid tissue biopsy specimens  this approach involves the amplification of rearranged gamma t cell receptor genes by the polymerase chain reaction and analysis of the polymerase chain reaction products by denaturing gradient gel electrophoresis  by use of this approach  clonal rearrangements from neoplastic lymphocytes constituting as little as 0 1 1  of the total cells in the tissue are detected as discrete bands in the denaturing gel after the gel is stained with ethidium bromide and viewed under ultraviolet light  in contrast  polyclonal rearrangements from reactive lymphocytes appear as a diffuse smear along the length of the gel  our findings suggest that polymerase chain reaction combined with denaturing gradient gel electrophoresis may offer a rapid  nonradioactive  and sensitive alternative to southern blot analysis for the diagnostic evaluation of lymphoid tissue biopsy specimens  
class4	dioxin inducible  ah receptor dependent transcription in vitro  we have developed a homologous in vitro transcription system that requires  i  2 3 7 8 tetrachlorodibenzo p dioxin  called tcdd or dioxin    ii  the ah receptor  and  iii  a dioxin responsive enhancer for activity  unfractionated nuclear extracts from mouse hepatoma cells contain an inhibitor and fail to direct transcription in vitro  however  following phosphocellulose chromatography and reconstitution  the fractionated nuclear extract directs accurate transcription in vitro  using as a template the promoter enhancer region from the mouse cytochrome p1 450 gene  cyp1a1  linked to a  g free cassette   which generates a transcript with no guanosine residues   extracts from tcdd treated cells exhibit higher activity than extracts from untreated cells when transcribing a template containing both the promoter and enhancer but not when transcribing a template containing the promoter alone  extracts from ah receptor defective cells fail to direct in vitro transcription in a tcdd inducible fashion  a regulatory element that contains two binding sites for the liganded ah receptor plus a truncated cyp1a1 promoter suffices to direct tcdd inducible  ah receptor dependent transcription in vitro  the inducible  receptor dependent  enhancer dependent properties of this system make it appropriate for analyzing in vitro the mechanism of dioxin action and the function of the ah receptor  
class4	molecular structure of a major insulin mitogen activated 70 kda s6 protein kinase  the molecular structure of a rat hepatoma 70 kda insulin mitogen stimulated s6 protein kinase  obtained by molecular cloning  is compared to that of a rat homolog of the 85 kda xenopus s6 protein kinase alpha  both kinases were cloned from h4 hepatoma cdna libraries  the 70 kda s6 kinase  calculated molecular mass of 59 186 da  exhibits a single catalytic domain that is most closely related in amino acid sequence  56  identity  to the amino terminal  kinase c like domain of the rat p85 s6 kinase  calculated molecular mass of 82 695 da   strong similarity extends through a further 67 residues carboxyl terminal to the catalytic domain  40  identity   corresponding to a region also conserved among the kinase c family  outside of this segment of approximately 330 amino acids  the structures of the p70 and p85 s6 kinases diverge substantially  the p70 s6 kinase is known to be activated through serine threonine phosphorylation by unidentified insulin mitogen activated protein kinases  a model for the regulation of p70 s6 protein kinase activity is proposed wherein the low activity of the unphosphorylated enzyme results from the binding of a basic  inhibitory pseudosubstrate site  located carboxyl terminal to the extended catalytic domain  to an acidic substrate binding region  located amino terminal to the catalytic domain   substrate binding is thereby prevented  s6 kinase activation requires displacement of this inhibitory segment  which is proposed to occur consequent to its multiple phosphorylation  the putative autoinhibitory segment contains several serine and threonine residues  each followed directly by a proline residue  this motif may prevent autophosphorylation but permit transphosphorylation  two of these serine residues reside in a maturation promoting factor  mpf  cdc 2 consensus motif  thus  hormonal regulation of s6 kinase may involve the action of mpf cdc 2 or protein kinases with related substrate specificity  
class4	identical splicing of aberrant epidermal growth factor receptor transcripts from amplified rearranged genes in human glioblastomas  the epidermal growth factor receptor gene has been found to be amplified and rearranged in human glioblastomas in vivo  here we present the sequence across a splice junction of aberrant epidermal growth factor receptor transcripts derived from corresponding and uniquely rearranged genes that are coamplified and coexpressed with non rearranged epidermal growth factor receptor genes in six primary human glioblastomas  each of these six tumors contains aberrant transcripts derived from identical splicing of exon 1 to exon 8 as a consequence of a deletion rearrangement of the amplified gene  the extent of which is variable among these tumors  in spite of this intertumoral variability  each intragenic rearrangement results in loss of the same 801 coding bases  exons 2 7  and creation of a new codon at the novel splice site in their corresponding transcripts  these rearrangements do not  however  affect the mrna sequence for the signal peptide  the first five codons  or the reading frame downstream of the rearrangement  
class4	correlation of the structure of the transmembrane domain of the neu oncogene encoded p185 protein with its function  the human homologue of the neu oncogene is frequently found in human tumors  certain amino acid substitutions at position 664 in the transmembrane domain of the neu oncogene encoded p185 protein product are known to cause malignant transformation of cells  using conformational energy analysis based on ecepp  empirical conformational energies for polypeptides program   we have previously determined the preferred three dimensional structures for the transmembrane domain of the p185 protein with a transforming  glutamic acid  and a nontransforming  valine  substitution at the critical position 664 and found that the global minimum energy conformation of this region in the nontransforming protein contains a sharp bend  whereas the global minimum energy conformation for this region from the transforming protein is entirely alpha helical  we now demonstrate that this result holds for other known nontransforming  glycine  histidine  tyrosine  and lysine  and transforming  glutamine  substitutions at position 664  furthermore  a simple statistical thermodynamic analysis of the results indicates that approximately 85  of each of the nontransforming sequences exist with the bend at positions 664 and 665  while approximately 90  of each of the transforming sequences exist as an alpha helix  about 9  of the nontransforming sequences exist as the alpha helix  these results suggest that if the intracellular concentration of the normal protein is increased at least 10 fold  thereby increasing the alpha helical form by this factor  cell transformation should result  this conclusion is directly supported by genetic experiments in which this level of overexpression of the normal protein was achieved with attendant cell transformation  
class4	sixty consecutive breast reconstructions with the inflatable expander  a critical appraisal  breast reconstruction using inflatable expanders has become an established and preferred technique  although our knowledge of the biomechanical changes occurring in expanded skin has increased greatly  little information is available regarding average aesthetic results achieved with this technique  in order to eliminate the bias of best case selection reports  this study of 60 consecutive patients undergoing skin expansion breast reconstruction was undertaken  results of the study demonstrated a significant frequency and diversity of complications  in particular  immediate breast reconstruction with skin expanders was identified as a high risk procedure because of its association with skin necrosis and delayed wound healing  although two procedures  insertion and replacement  had been anticipated  patients from both the boston and new york groups required approximately three operations to complete the expansion process  average aesthetic results  often characterized by problems of symmetry  ptosis  and contour  need to be recognized and improved  
class4	a prospective clinical evaluation of autogenous vein grafts used as a nerve conduit for distal sensory nerve defects of 3 cm or less  the purpose of this study was to determine the efficacy of autogenous vein grafts as nerve grafts  avnc  for bridging of small peripheral sensory nerve gaps as compared with direct repair and with conventional nerve grafting techniques  ang   patients with painful neuroma or segmental nerve injury of 3 cm were chosen as the test group  those amenable to direct repair were classified as controls  between 1982 to 1988  a total of 22 patients were enrolled in this study  a total of 34 nerves were repaired  15 with a venous nerve conduit  4 with a sural nerve graft  and 15 with direct repair  significant symptom relief and satisfactory sensory function return were uniformly observed  the two point discrimination measurements indicated superiority of direct repair and probably of conventional nerve grafting  however  the universally favorable patient acceptance and the return of measurable two point discrimination indicates the effectiveness of autogenous vein grafts as nerve conduits when selectively applied to bridge a small nerve gap  less than or equal to 3 cm  on nonessential peripheral sensory nerves  
class4	dacron fabric enveloped hydroxyapatite prosthesis for sternal tumor defect  an autopsy report  a 38 year old housewife with solitary plasmacytoma of the manubrium who underwent a subtotal sternectomy treated by resection of the lesion is reported  this was followed by replacement with a dacron fabric enveloped hydroxyapatite prosthesis  the dacron fabric was sutured to the surrounding tissues  and then the clavicle was passed through the cylindrical shaped dacron fabric to form a sternoclavicular joint capsule  the patient returned to her daily life 3 months after the operation  she had no trouble in her daily living  without any dislocation of the sternoclavicular joints or any displacement of the artificial sternum  the autopsy examination about 1 year after the operation showed that the dacron fabric enveloping the artificial sternum became stronger with time  the sternoclavicular joint also was stably fixed  and the dacron fabric fulfilled its function as an artificial articular capsule and biologic fixation of the surrounding supporting tissues  
class4	interventional radiology of the biliary tract  intraductal radiation  one palliative method of treating patients with a high duct cholangiocarcinoma is the use of 192ir wire  this is placed through the tumor  which has been previously intubated  and delivers a high local dose of radiation  the mean survival time in 30 patients treated with intraductal radiation was 16 8 months  an improvement compared to surgical bypass or endoscopic and radiologic drainage procedures  
class4	pneumonia due to legionella micdadei in bone marrow transplant recipients  legionella micdadei has previously been described as a cause of nosocomial pneumonia  particularly in kidney transplant recipients  cell mediated immunity is the principal host defense against this pathogen  a common clinical scenario in the immunocompromised host is that of septic pulmonary embolus  but asymptomatic infections have also been reported  the organism is weakly acid fast in clinical specimens but loses this property when grown on solid media  we report two cases of l  micdadei pneumonia  differing markedly in clinical severity and outcome  in bone marrow transplant recipients  additionally  we note the growth of the organism in liquid culture media with preservation of its acid fast property  
class4	current advances in the diagnosis and treatment of aids  an introduction  significant progress has been made in the diagnosis and treatment of aids  laboratory tests available for assessment of human immunodeficiency virus  hiv  infection include the detection of antibodies to hiv type 1  the direct detection of the virus  the identification of surrogate markers  and the phenotypic analysis of peripheral blood mononuclear cells  clinicians have made great strides in the treatment of tumors  opportunistic infections  and complications associated with aids as well as in the treatment of the infection itself  in selected patients  treatment with interferon alpha has been successful against aids related kaposi s sarcoma  attempts to treat the leukopenia and anemia of patients with aids by the administration of hematopoietic growth factors have resulted in increased white blood cell counts and a decrease in erythrocyte transfusion requirements  in addition to zidovudine  several antiretroviral agents are undergoing testing  including the nucleoside analogues dideoxycytidine and dideoxyinosine  soluble cd4  and the glycosidase inhibitor n butyldeoxynojirimycin  
class4	cytomegalovirus infections in bone marrow transplant recipients given intensive cytoreductive therapy  cytomegalovirus  cmv  infections were studied in 785 bone marrow transplant recipients given intensive cytoreductive therapy  cmv excretion occurred in 24   viremia in 9   seroconversion in 40   and overall active infection in 47   cmv disease was much less common  retinitis  enteritis  and pneumonitis occurred in only one  five  less than 1    and 55  7   of the patients  respectively  allograft recipients were more likely to develop cmv disease than were autograft patients  p    0001  despite comparable rates of active cmv infection  cmv disease was rare after primary infection in both autograft and allograft recipients  0 and 1   respectively   in contrast  cmv disease occurred in 16  of seropositive allograft recipients  among allograft recipients  risk factors for cmv pneumonitis were seropositivity  age greater than 10 years  and acute graft vs  host disease  while the use of cyclosporine as prophylaxis against graft vs  host disease was protective  although active infection rates did not decrease  the rates of cmv pneumonitis in allograft recipients during successive years declined significantly  p less than  001   
class4	detection of bcr abl fusion in chronic myelogeneous leukemia by in situ hybridization  chronic myelogeneous leukemia  cml  is genetically characterized by fusion of the bcr and abl genes on chromosomes 22 and 9  respectively  in most cases  the fusion involves a reciprocal translocation t 9 22  q34 q11   which produces the cytogenetically distinctive philadelphia chromosome  ph1   fusion can be detected by southern  dna  analysis or by in vitro amplification of the messenger rna from the fusion gene with polymerase chain reaction  pcr   these techniques are sensitive but cannot be applied to single cells  two color fluorescence in situ hybridization  fish  was used with probes from portions of the bcr and abl genes to detect the bcr abl fusion in individual blood and bone marrow cells from six patients  the fusion event was detected in all samples analyzed  of which three were cytogenetically ph1 negative  one of the ph1 negative samples was also pcr negative  this approach is fast and sensitive  and provides potential for determining the frequency of the abnormality in different cell lineages  
class4	regulation of gene expression with double stranded phosphorothioate oligonucleotides  alteration of gene transcription by inhibition of specific transcriptional regulatory proteins is necessary for determining how these factors participate in cellular differentiation  the functions of these proteins can be antagonized by several methods  each with specific limitations  inhibition of sequence specific dna binding proteins was achieved with double stranded  ds  phosphorothioate oligonucleotides that contained octamer or kappa b consensus sequences  the phosphorothioate oligonucleotides specifically bound either octamer transcription factor or nuclear factor  nf  kappa b  the modified oligonucleotides accumulated in cells more effectively than standard ds oligonucleotides and modulated gene expression in a specific manner  octamer dependent activation of a reporter plasmid or nf kappa b dependent activation of the human immunodeficiency virus  hiv  enhancer was inhibited when the appropriate phosphorothioate oligonucleotide was added to a transiently transfected b cell line  addition of phosphorothioate oligonucleotides that contained the octamer consensus to jurkat t leukemia cells inhibited interleukin 2  il 2  secretion to a degree similar to that observed with a mutated octamer site in the il 2 enhancer  the ds phosphorothioate oligonucleotides probably compete for binding of specific transcription factors and may provide anti viral  immunosuppressive  or other therapeutic effects  
class4	survey of alabama physicians  use of mammography  1989  in early 1989 we surveyed by questionnaire alabama primary care physicians  n   1800  concerning their attitudes toward and use of mammography  there were 681 respondents  37 8    the majority  83   recommend mammograms for their patients according to the american cancer society guidelines and obtain baseline studies in asymptomatic women between the ages of 35 and 40 years  it appears that the cost of mammograms is decreasing in alabama  a screening study was available for  50 or less to 34  of responding physicians  almost one half  48   of the physician respondents believe that more than 50  of their patients have had at least one mammogram  
class4	preventing colorectal cancer  knowledgeable patients should not die of colorectal cancer  increasing the intake of dietary fiber  decreasing fat consumption  and increasing the use of modern technology to detect adenomatous polyps and early cancer can greatly decrease the mortality associated with colorectal cancer  
class4	synchronous hodgkin s disease and myelofibrosis terminating with granulocytic sarcoma and acute megakaryocytic leukemia  our patient had stage iiiai hodgkin s disease with synchronous myelofibrosis and myeloid metaplasia  a slowly progressive myeloproliferative disease developed over 9 1 2 years and terminated in a painful osteolytic bone disease  spinal extradural granulocytic sarcoma and acute megakaryocytic leukemia  it is likely that this was a result of the myeloproliferative disease rather than a late complication from combination chemotherapy  our case demonstrates the importance of a curative approach to hodgkin s disease even in the face of a coexistent disease with a long or unknown natural history  
class4	adenocarcinoma of the appendiceal stump  we have reported the case of a 58 year old woman with nonspecific abdominal complaints in whom barium enema and subsequent colonoscopy showed a 3 cm lobulated adenocarcinoma within a villous adenoma arising from the appendiceal stump  because such appendiceal malignancies have no specific clinical signs  symptoms  or radiologic features  preoperative diagnosis is extremely difficult  and colonoscopy may be required to clarify radiologically demonstrated irregularities  
class4	trabecular or merkel s cell carcinoma  two cases of trabecular cell carcinoma of the skin are presented  the clinical presentation and behavior  and the histologic findings  of the tumor are described  surgical excision of the primary lesion with regional lymph node dissection  if indicated  is the treatment of choice  distant metastasis is treated by local irradiation  
class4	adenocarcinoma of the colon occurring with intussusception in an adolescent  hydrostatic reduction of intussusception is definitive therapy in most infants with this abnormality  in the older child  adolescent  and adult  a polyp or tumor is often present  operative intervention should be considered earlier in the clinical course both to relieve the intussusception and to define the nature of the lead point  
class4	the predictive value of needle localization mammographically assisted biopsy of the breast  this study was done to review critically the experience at the university of california at san diego in needle localization mammographic biopsy of the breast with regard to use and accuracy in identifying early carcinoma of the breast  ninety seven patients underwent needle localization mammographic biopsy of the breast between 1985 and 1987  indications for this procedure included the presence of microcalcifications or a mass shown on mammographic examination  or both  in conjunction with physical examination which did not define a discrete abnormality in the area  mammographic  demographic  pathologic  hormone receptor data and staging information were recorded and processed on the microvax ii computer  digital equipment corporation   twenty four per cent of lesions with needle localization mammographic assisted biopsy proved to be malignant  sixteen lesions were diagnosed as an infiltrating ductal carcinoma and ten of these had an accompanying intraductal carcinoma  over all  intraductal carcinoma was present in 16 of the 23 specimens diagnosed as malignant  at biopsy  the margins were clear in 17 of 23  and vascular invasion was present in only one patient with an infiltrating lobular carcinoma  five were tumor in situ  12 were stage 1 and five were stage 2  staging information was not available in one instance   hormone receptor data were available in 17 of 23 specimens  estrogen receptors were positive in 13 and progesterone receptors were positive in six  the smallest preinvasive malignant lesion was 4 millimeters  as seen on the mammogram  and the smallest free standing invasive lesion was 8 millimeters  preinvasive lesions  intraductal  presented as microcalcifications in 80 per cent  invasive lesions presented as either a mass  n   9  or as a mass and microcalcifications  n   5  in 81 per cent  all five lesions presenting as both a mass and microcalcifications on mammogram proved to be malignant  multifocal lesions on mammographic examination which proved to be malignant were multifocal pathologically in only 50 per cent  needle localization mammographic biopsy is useful in detecting early carcinoma of the breast  biopsy should be done on lesions presenting on mammogram as both a mass and microcalcifications and not observed  focality of lesions on mammogram does not correlate with focality on biopsy and may be misleading as criteria for operative planning  
class4	focal nodular hyperplasia of the liver  twenty four patients underwent biopsy or resection of the liver for focal nodular hyperplasia  fnh  at memorial sloan kettering cancer center from 1978 to 1988  twenty two of the patients were women  the mean age was 35 years  a history of antecedent oral contraceptive or conjugated estrogen  premarin  use was obtained in 18 of 21 women  there were two men  aged 26 and 37 years  neither gave a history of hormone use  most of the tumors were solitary  22 of 24  and located in the left lobe of the liver  17 of 22   fifteen of the patients had a prior or simultaneous malignant lesion and six had other benign tumors  most of the tumors were resected with a wedge or subsegment of liver  13 of 24   four patients underwent segmentectomy and five required lobectomy for removal of the tumors  two patients had an intraoperative biopsy only  the patients in whom the tumor was diagnosed preoperatively underwent computed tomography and arteriography routinely  scintigraphy of the liver with sulfur colloid was obtained in only three patients  despite its distinct potential for nonoperative diagnosis of fnh  
class4	time to recurrence varies inversely with thickness in clinical stage 1 cutaneous melanoma  the thickness of a tumor has been identified as the principal prognostic factor in cutaneous malignant melanoma  however  time to recurrence has not conclusively been related to thickness  a retrospective study of 216 patients with a primary cutaneous malignant melanoma that recurred was conducted to clarify this relationship and investigate possible independent relationships between age at diagnosis and sex of patients to time to recurrence  the results of analysis of linear regression revealed an inverse linear relationship between thickness and time to recurrence  p less than 0 001   patients more than 50 years of age at the time of diagnosis were shown to relapse sooner than those less than 50 years of age  p   0 014   sex was not a significant factor in predicting time to recurrence  p greater than 0 10   these results suggest that thickness of tumor provides an indication of time to recurrence in those patients destined to recur and stress the need for long term surveillance in patients with a history of malignant melanoma because of the possibility of late relapse even with thin lesions  
class4	repeat hepatic resection for primary and metastatic carcinoma of the liver  during the last 15 years  19 patients underwent repeated hepatic resections for malignant lesions of the liver  the first hepatic resection had been performed four to 40 months earlier for treatment of hepatocellular carcinoma  nine patients  or hepatic metastases  ten patients   eight of which were of colorectal origin  repeat resection was an extensive hepatectomy in six  a segmentectomy in six and a local excision in seven  in one patient  three wedge resections and  finally  hepatic transplantation were subsequently performed after an initial extended right lobectomy  the operative mortality rate was 5 2 per cent  the three year actuarial survival rate was 64 per cent after the second resection  
class4	mediastinal tracheostomy using a pectoralis major myocutaneous flap after resection of carcinoma of the esophagus involving the proximal part of the trachea  an operative procedure of mediastinal tracheostomy using a pectoralis major myocutaneous flap is presented  in this procedure  the terminal portion of the trachea penetrates through the center of a pectoralis major myocutaneous flap and the tracheal wall is completely wrapped with the muscular portion of the flap  between 1981 and 1988  eight patients with carcinoma in the cervicothoracic segment of the esophagus underwent mediastinal tracheostomy after laryngoesophagectomy and extended resection of the proximal part of the trachea through sternal manubrectomy  because of invasion into the trachea  in five of eight patients  a pectoralis major myocutaneous flap was used to construct a tracheal stoma  a skin flap only  or both a skin flap and a muscle flap  was used in the other three  in four of eight patients  tracheal necrosis occurred  and rupture of the brachiocephalic artery occurred in one patient when the tracheal stoma had been constructed using both a skin flap and a muscle flap  however  neither skin breakdown nor bleeding from the major vessels occurred when using the myocutaneous flap  therefore  it is concluded that the construction of the tracheal stoma using a pectoralis major myocutaneous flap is recommended for mediastinal tracheostomy after laryngoesophagectomy with extended resection of the proximal part of the trachea  
class4	the justification for surgical treatment of metastatic melanoma of the gastrointestinal tract  fifty six patients with symptomatic metastatic melanoma of the gastrointestinal tract  git  treated surgically at the sydney melanoma unit between 1974 and 1989 were reviewed  the majority of these patients presented with abdominal pain or symptoms of anemia  the small intestine was the site of metastasis in more than 80 per cent  the mean over all survival time was 11 7 months  range of one to 60 months  after surgical treatment of a first metastasis to the git and 3 6 months  range of zero to 12 months  postoperatively for a second git metastasis  forty four of the patients reported complete relief of their symptoms postoperatively  the results suggest that an aggressive approach to symptomatic git metastases from malignant melanoma is justified both to relieve distressing symptoms and to prolong life  
class4	hepatic resection for advanced hepatocellular carcinoma with removal of portal vein tumor thrombi  in 13 of 398 patients who underwent hepatectomy  tumor thrombi of the remnant portal vein was concomitantly removed by the balloon catheter method in 8  an open method under hepatic vascular exclusion in 1  and resection of the occlusive portal segment followed by portal reconstruction in 4  in 8 of these patients the liver was cirrhotic  the mode of hepatectomy consisted of bisegmetectomy or trisegmentectomy in 11  segmentectomy in one  and partial resection in one patient  two patients died of portal thrombosis or hepatic failure in the hospital  the mean survival in four patients was 12 months  seven are still alive  mean  16 months   in the corresponding period  nine patients with occlusive tumor thrombi of the portal confluence were hospitalized without operation and survived up to 4 months  mean  64 days  after detection of the tumoral occlusion  the causes of death of the nine patients were bleeding esophageal varices  rupture of the tumor  or hepatic failure  it was revealed that removal of tumor thrombi in the remnant portal vein contributes to  1  portal decompression   2  feasibility of arterial embolization  and  3  increase in resectability of the main tumor  at present  this procedure might be regarded as an emergency procedure for the avoidance of the above lethal impendence  but it may open the door to an adjuvant therapy  
class4	decollateralization with silicone rubber sheeting for advanced hepatocellular carcinoma  a preliminary report  a new treatment method  interception of collaterals with a silicone rubber sheet  was applied to three patients with advanced hepatocellular carcinoma in whom arterial chemoembolization was assessed as ineffective because of the developed collateral feeding arteries  this procedure was followed by arterial chemoembolization or intraportal infusion chemotherapy or both  follow up celiac angiography confirmed that the long term decollateralization was achieved by shielding the liver with silicone rubber sheeting  this technique resulted in partial responses without serious complications in all the patients including two who had no responses to chemoembolization before the procedure  the response durations were 5  21  and 27  months  respectively  one patient died of gastrointestinal bleeding 7 months after the decollateralization  the other two patients are still alive  and the survivals after the procedure are 28 and 30 months  respectively  this therapy is considered promising and may be worth choosing as an adjuvant treatment for advanced hepatic malignancies uncontrolled by arterial chemotherapy or chemoembolization  
class4	the role of gastric resection in the management of multicentric argyrophil gastric carcinoids  a patient with pernicious anemia  atrophic non antral gastritis  hypergastrinemia  and widespread hyperplasia of enterochromaffin like cells and manifest enterochromaffin like cell carcinoma was followed up during 39 months  including 15 months after gastric resection  in this case normalization of gastrin levels did not prevent the development of multiple gastric carcinoids in the fundic mucosa  suggesting that factors other than gastrin are of importance in the pathogenesis  
class4	portal vein resection with a new antithrombogenic catheter  curative resection of pancreatic and hepatobiliary tumors is rarely possible because of local invasion  especially into the portal vein  we developed a new antithrombogenic catheter using a heparinized hydrophilic polymer to allow portal vein bypass during resection of tumors invading the portal vein  pancreatectomy or hepatectomy accompanied by portal vein resection was performed for pancreatic or hepatobiliary cancer  with an intraoperative shunt from the superior mesenteric vein to the femoral vein or from the superior mesenteric vein to the intrahepatic portal vein through the umbilical vein or the hepatic hilar portal vein  use of the shunt prevented stasis in the superior mesenteric vein and hepatic ischemia even during prolonged occlusion of the portal vein  and portal vein resection was performed in 81 patients with hepatobiliary and pancreatic disease with greater safety and ease  
class4	adoptive immunotherapy of human pancreatic cancer with lymphokine activated killer cells and interleukin 2 in a nude mouse model  a pancreatic cancer cell line was grown in orthotopic and heterotopic positions in young swiss nih nude mice  which were tested with adoptive immunotherapy  mice were injected with 1 x 10 7  human cancer cells in the subcutaneous tissue and duodenal lobe of the pancreas  the mice were randomly divided into four groups  group ia  lak   il 2   n   25  received 2 x 10 7  human lymphokine activated killer  lak  cells from normal donors by tail vein injection followed by 10 000 units of human recombinant interleukin 2  il 2  given intraperitoneally every 12 hours for 28 days  group ib  il 2   n   27  was given the same dose of il 2 alone  group ic  rpmi 1640   n   18  received a placebo consisting of 1 ml of rpmi 1640 intraperitoneally every 12 hours  and group id  lak   n   14  received 2 x 10 7  lak cells but no il 2  toxicity was significantly higher in group ib  with a mortality rate of 45 5   10 22 animals  versus a 0  mortality  0 25  in group ia  none of the group ia or ib animals died of pancreatic cancer during the experiment  the animals that did not receive il 2 died before 28 days in 14 2  of group ic and in 16 7  of group id  the area under the growth curve of subcutaneous tumors during the course of treatment and the pancreatic tumor weight at the end of treatment were compared in each group  subcutaneous tumors had a reduced rate of growth in group ia animals compared to all the other treatments  pancreatic tumor growth was slowed in group ia  the animals treated with il 2 alone  group ib  showed some slowing of tumor growth that was intermediate between group ia  group ic  and group id  a similar experiment was done with irradiated  375 rad  mice  nine nude mice with tumors were treated with lak   il 2  group iia   eight received il 2 alone  group iib   and seven received placebo  group iic   the antitumor effect of il 2 alone was not present in the irradiated mice  a highly significant difference persisted between group iia and all other groups  there was no difference in the histologic characteristics of tumors in control mice and in mice with inhibited tumor growth treated with il 2 or il 2 and human lak cells  these results show that adoptive immunotherapy with human lak cells and human recombinant il 2 is effective against human pancreatic cancer growing in nude mice  this effect is independent from antitumor activity from il 2 administrations alone  
class4	radiation therapy of early  stages i and ii a  seminoma of testis after initial orchiectomy  with initial orchiectomy and radiation therapy  the prognosis of the patients with early  stages i and ii a  testicular seminoma is nearing almost 100 percent  thirty two patients with stage i and 13 patients with stage ii a seminoma of the testis were treated with initial orchiectomy  this was followed by estimation biochemical markers and radiologic investigations  all the patients with stage i disease received radiotherapy to the ipsilateral pelvic and para aortic nodes  the patients with stage ii a disease also received radiation therapy to the supradiaphragmatic regions  the disease free survival in both groups of patients was found to be 100 percent  
class4	management of superficial g2  pta and pt1  bladder cancer  a total of 143 patients with superficial g2  pta  pt1  bladder cancer  48 g2pta  95 g2pt1  presenting between 1970 through 1987 were reviewed  of 48 patients with g2pta followed for up to eighteen years  g3 recurrence developed only in 1  2 0    and invasive cancer  greater than pt2  developed only in 2  4 2    they both received radiotherapy and have responded completely  there have been no cancer related deaths  in contrast  in the 95 patients in whom the basement membrane had been breached  pt1   higher grade tumor  g3  developed in 11  11 5    and 15  16   had recurrences with invasion of muscle  greater than pt2   among these there were 7  7 3   cancer related deaths  
class4	radiologic staging of chest in testicular seminoma  we investigated the usefulness of chest x ray  cxr   conventional planar tomography  tom   and computerized axial tomography  cat  in evaluating patients with stages i and ii testicular seminoma  all patients had a cxr  and 22 patients had either tom or cat as part of initial staging  no occult pulmonary or mediastinal nodal disease was found during initial staging  and none of the patients manifested recurrence of tumor in these sites as a first event  review of the literature corroborates our finding of a very small thoracic failure rate in early stage seminoma  routine use of cat or tom is not indicated in staging these patients  
class4	oncocytic renal tubular adenoma  so called oncocytoma  in seventeen year old girl  renal tubular neoplasms  adenomas or adenocarcinomas  are rare in children or young adults  herein  we report an oncocytic renal tubular adenoma  so called oncocytoma  that was found in a seventeen year old girl  preoperative evaluation included aspiration of this tumor  and we suggest that preoperative aspiration is an important procedure in the diagnosis and management of suspected renal tumors in children and young adults  
class4	intravesical condyloma acuminatum with progression to verrucous carcinoma  condyloma acuminatum is a common form of venereal disease  most patients with condylomata acuminata suffer from only the local cosmetic and irritative effects of the lesions  few patients have progression to aggressive  regionally distributed lesions that can be life threatening  we describe a forty three year old white woman who had a seventeen year history of scleroderma with extravesical and intravesical condylomata acuminata  during two years of conservative management with transurethral excision  electrocoagulation  and intravesical chemotherapy  the disease progressed to involve the entire bladder and resulted in obstructive renal insufficiency that required anterior exenteration and urinary diversion  the natural history of the disease is described  and the relevant literature is reviewed  
class4	constitutional symptoms in patients with germ cell neoplasms  a patient with a mediastinal germ cell neoplasm evidenced fever  weight loss  pruritus  and painful adenopathy on ingestion of alcohol  retrospective review revealed that 9 percent of 104 patients with advanced germ cell neoplasm evidence constitutional symptoms at presentation  
class4	natural history of cardiac rhabdomyoma in infancy and childhood  although spontaneous regression of cardiac rhabdomyoma has been reported  prognosis is still considered to be poor and surgery continues to be indicated  the experience with rhabdomyoma diagnosed in live infants over a 20 year period was reviewed  diagnosis by angiography or echocardiography was accepted only if multiple tumors were present or if tuberous sclerosis was also diagnosed  nine patients  3 diagnosed prenatally and the remaining 6 at age less than 8 months  were identified as having a total of 24 tumors  measurements in 2 planes demonstrated at least some evidence of regression in 24 patients  100    with 20 of 24 having complete resolution  one patient required delayed surgery for excision of a subaortic ridge that appeared at the site of a resolved tumor  our findings suggest that pediatric cardiac rhabdomyoma is most often a benign condition in which spontaneous regression is the rule  surgery is recommended only for patients with refractory dysrhythmias or severe hemodynamic compromise  
class4	diet and female sex hormone concentrations  an intervention study for the type of fat consumed  a possible mechanism by which dietary fat may influence the development of breast cancer is by influencing the concentration of female sex hormones  this study investigated the effect of alteration in the type of fat consumed on concentrations of female sex hormones in serum  female volunteers were randomly assigned to continue on their usual meat eating diet  change to a vegetarian diet  or change to a diet that was predominantly vegetarian but where fish was consumed at least three times per week  change to the vegetarian or fish diet had little effect on diet total hormone concentrations  however  the amount of estradiol was significantly decreased in the vegetarian group  when nutrient consumption was correlated with hormone concentrations  prolactin was directly associate with fat consumption  sex hormone binding globulin was inversely associated with fat consumption  particularly cholesterol consumption   and the proportion of nonprotein bound estradiol was directly associated with complex carbohydrate consumption  
class4	dietary fat and risk of breast cancer  the relationship between dietary fat and subsequent risk of breast cancer was studied in 3988 initially cancer free finnish women aged 20 69 y  during a follow up period of 20 y  54 breast cancer cases were diagnosed  risk of breast cancer was significantly inversely related to energy intake and nonsignificantly inversely related to absolute fat intake  a positive association between energy adjusted total fat intake and occurrence of breast cancer was also observed  the relative risk in the highest tertile as compared with the lowest tertile was 1 7  95  confidence limits 0 6 4 8   the corresponding relative risks were 1 4  0 5 3 7  for saturated fatty acids  2 7  1 0 7 4  for monounsaturated fatty acids  1 2  0 6 2 8  for polyunsaturated fatty acids  and 2 2  1 0 5 0  for cholesterol intake  adjustment for different potential confounding factors did not alter the results  the present data suggest that breast cancer is associated inversely with energy intake and weakly positively with energy adjusted fat intake  
class4	breast cancer and dietary and plasma concentrations of carotenoids and vitamin a  a case control study of breast cancer was conducted in buffalo  participants completed a food frequency questionnaire and donated a fasting blood sample before definitive workup for breast masses  dietary and plasma concentrations of carotenoids and retinol for 83 women found to have breast cancer were compared with those of 113 women found to be free of breast cancer  control subjects   there were no case control differences in dietary estimates of vitamin a intake or in plasma alpha carotene and lycopene  however  subjects with breast cancer had lower concentrations of plasma beta carotene than did control subjects  p   0 02   there was no overall association between plasma retinol and breast cancer but a positive relationship was observed between retinol and breast cancer in the subgroup with low beta carotene values  these results suggest that low plasma beta carotene is associated with increased risk of breast cancer  other studies will need to determine whether low carotene concentrations are a subtle effect of the disease or might be causally related to breast cancer  
class4	follicular neoplasms of the thyroid in men older than 50 years of age  a dna flow cytometric study the clinical behavior of follicular neoplasms of the thyroid in elderly men can be difficult to predict on histologic grounds alone  to assess the usefulness of dna flow cytometry in predicting the metastatic potential of these tumors  the authors studied 44 primary and metastatic follicular neoplasms of the thyroid by dna flow cytometry of paraffin embedded tissue  the neoplasms were obtained from 44 men ranging in age from 50 to 79 years  mean  60   there were 29 follicular adenomas  11 primary follicular carcinomas  neoplasms with capsular and or vascular invasion   and 4 metastatic follicular carcinomas  follow up information was available on 40 of the 44 patients  the mean follow up was 114 months  twenty five of the 29 follicular adenomas had a diploid dna content  2  7   were tetraploid  and the dna histograms on 2 were not interpretable  all patients with follicular adenomas had no evidence of disease  ned  at last follow up  eight of the 11 primary follicular carcinomas were diploid  six of these patients had ned  one died with carcinoma at 82 months  and no follow up was available on one  three  27   of the primary follicular carcinomas were aneuploid or tetraploid  two of these patients had ned  and the third died with carcinoma 84 months after diagnosis  two of the four metastatic follicular carcinomas were diploid and two  50   were aneuploid or tetraploid  one of the two patients with diploid metastatic follicular carcinomas died with carcinoma  as did one of the two patients with aneuploid metastatic follicular carcinomas  these results suggest the following   1  follicular carcinomas are more likely to be aneuploid or tetraploid than are follicular adenomas   2  follicular neoplasms without capsular or vascular invasion may include a small number of aneuploid or tetraploid tumors  and  3  dna ploidy does not add to the prognostic value of histologic studies alone  
class4	potential value of hormone receptor assay in carcinoma in situ of breast  the estrogen receptor  er  expression of invasive breast cancer has been extensively studied both biochemically and with specific monoclonal antibodies against er  relatively few studies have attempted to characterize er pattern in breast carcinoma in situ  cis  and in other premalignant lesions  in the current study  the authors investigated the pattern of er expression in 62 cases of breast cis  30 of which had a component of invasive cancer  and 36 cases of atypical hyperplasia  paraffin sections of formalin fixed breast tissue underwent enzyme pretreatment to expose nuclear antigenic sites as previously described  breast tissues then underwent estrogen immunocytochemical assay using specific monoclonal antibodies  abbott laboratory  chicago  il   the cases were evaluated for heterogeneity  intensity of staining  and percentage of er positive cells  an attempt was made to study the relation between the pattern of er expression  nuclear pleomorphism  and type of cis  the results of er immunocytochemical assay showed positive nuclear staining for er in 75  of the cis  73  of cis with invasive cancer  and 100  of atypical hyperplasias  er expression in cis agreed with that in the invasive carcinoma in 29 of 30 cases  this study also suggests that comedocarcinoma has a higher incidence of negative er expression than the other types of cis  particularly when it is associated with significant nuclear pleomorphism  there was no significant difference in er tumor heterogeneity between premalignant and malignant lesions  
class4	survey of histologic specimens of human cancer for human papillomavirus types 6 11 16 18 by filter in situ hybridization  histologic specimens  317  of genital and nongenital cancers and normal tissue were analyzed for the presence of the dna of human papillomavirus  hpv  6  11  16  and 18 by filter in situ hybridization performed on paraffin embedded  formalin fixed tissue  histofish   hpv dna was found in 73 of 172  42   anogenital lesions and 17 of 116  15   nonanogenital carcinomas  no hpv dna was found in normal mouse skin  five samples   human autopsy liver  two samples   or kidney  eight samples   or in carcinomas of the breast  three samples   bladder  five samples   or colon  nine samples   of the nongenital tumors  hpv dna was found in the carcinomas of the lung  2 of 5   anus  7 of 18   esophagus  9 of 39   buccal cavity  1 of 5   and larynx  5 of 50   hpv dna was also detected in 2 of 11 histologically normal specimens of the cervix and 1 of 3 human skin lesions  the detection of hpv dna in carcinomas of the lung  larynx  and esophagus as well as in the anogenital region confirms recent suggestions that hpv types 6  11  16  and 18 have a wider association with different types of cancer than previously believed  the study also shows that histofish is a useful method for detecting hpv dna in histologic specimens  
class4	improved flow cytometric determination of proliferative activity  s phase fraction  from paraffin embedded tissue  recent studies suggest that proliferative activity  s phase fraction  spf   may have greater prognostic significance than total nuclear dna content  however  relatively few studies have examined spf from paraffin embedded tissue because of significant contamination of histograms with debris  in this study  cell cycle analysis was performed on 124 matched tissue specimens  fresh tissue was divided into two equal portions  one portion was frozen  whereas the other portion was processed and embedded in paraffin  s phase could be determined for both frozen and paraffin embedded tissue in 81 cases  correlation between spf from frozen and paraffin embedded tissue was demonstrated  r   0 80  when debris was subtracted from histograms with the use of two new subtraction algorithms referred to as multicut and singlecut  unlike other debris subtraction algorithms  the quantity and distribution of debris calculated by these algorithms are dependent on the magnitude and position of histogram peaks  a lesser degree of correlation was demonstrated with the use of a standard exponential debris subtraction algorithm  r   0 67   correlation of spf for aneuploid cases was greater when spf was calculated as a percentage of the aneuploid cell population rather than as a percentage of the entire cell population  this was attributed to the observation that the proportion of aneuploid cells from paraffin embedded tissue was less than that from frozen tissue  the results of this study indicate that spf can be calculated from paraffin embedded tissue with values comparable to those obtained from frozen tissue  the ability to calculate spf reliably from paraffin embedded tissue should allow additional evaluation of this parameter as a prognostic indicator  
class4	demonstration of lipiodol in paraffin sections using a modified silver impregnation technique  to demonstrate postangiographic lipiodol  lip  in hepatocellular carcinoma  hcc  in paraffin sections  direct impregnation of formalin fixed tissue blocks with silver nitrate  agno3  was followed by routine processing  lip appeared as black globules in the sinusoids  ninety four tissue blocks from 13 postangiographic lip hccs and 69 from 8 non lip hccs and 4 fatty livers were studied  seventy two of 73 negative controls and all positive blocks as seen on soft tissue radiographs  strs  were correctly coded  specificity 98 6   sensitivity 100    twenty six of the 44 lip negative areas on strs from lip cases contained scanty globules of less than 10 microns in diameter  fatty change gave no positive readings  thus  modified agno3 impregnation is a simple  accurate means of detecting lip in high quality paraffin sections suitable for tumor diagnosis and  if applied to postangiographic lip  ultrasonographically guided liver biopsy  can verify that a biopsy has reached a suspected tumor focus  
class4	immunophenotypic aberrancy in adult acute lymphoblastic leukemia  some recent reports indicate a high frequency of immunophenotypic aberrancy in acute lymphoblastic leukemia  all   to investigate this issue with regard to adult all  the authors reviewed the immunophenotyping data from 39 cases analyzed in their clinical laboratory  flow cytometric analysis of peripheral blood and or bone marrow was performed with the use of a panel of 21 b cell  t cell  and myeloid monoclonal antibodies  moabs   the surface antigen profiles of the leukemic cells were compared with those of normal bone marrow and thymic counterparts  as defined by current models  twenty six cases were b precursor all  8 were t all  and 3 were b all  burkitt s leukemia   only two cases coexpressed lymphoid and myeloid antigens  in contrast  intralineage aberrancy was quite common  immunophenotypes from 13 of 26 b precursor all cases deviated from normal b lineage marrow cells as defined by a recent classification  the t all cases were also immunophenotypically heterogeneous  this high incidence of aberrant antigen expression in adult all suggests that leukemogenesis also involves aberrant differentiation rather than purely a process of maturational arrest  
class4	microstaging of squamous cell carcinomas  the clinical classification of squamous cell carcinoma  which was established primarily by the international union against cancer  uicc   does not permit optimal estimation of expected metastasis  the authors  results indicate that metastasis can be more accurately estimated on the basis of invasion depth  histopathologic grading  and especially tumor thickness  one essential advantage of these criteria is that they can be established by a histopathologist  it is interesting to note that in the authors  collective no carcinoma less than 2 mm thick metastasized  that is  a relatively high percentage of carcinomas  48   can be graded as no risk carcinomas  the risk of metastasis for undifferentiated carcinomas greater than 6 mm thick that have infiltrated the musculature  the perichondrium  or the periosteum  however  is quite high  tumors between 2 and 6 mm thick with moderate differentiation and a depth of invasion that does not extend beyond the subcutis can be classified as low risk carcinomas  
class4	mucinous adenocarcinoma of the prostate with endobronchial metastasis  endobronchial metastases can manifest clinical symptoms and x ray findings mimicking a centrally located bronchogenic carcinoma  the authors recently encountered a case of endobronchial metastasis from a mucinous adenocarcinoma of the prostate that was originally diagnosed as a primary bronchogenic carcinoma  the correct diagnosis was made on the basis of the morphologic similarities between the primary prostatic lesion and the lung lesion and was corroborated by immunohistochemical analyses  
class4	malignant rhabdoid tumor of the liver  a distinct clinicopathologic entity  a malignant rhabdoid tumor occurring as a primary hepatic neoplasm in a six month old white infant is reported  it was treated by an attempt at total resection involving right hepatic lobectomy and by chemotherapy with cis platinum  vp 16  and adriamycin  despite this  recurrence of the tumor resulted in the girl s death within three months  the neoplasm showed typical light microscopic features of malignant rhabdoid tumor as well as filamentous cytoplasmic inclusions by electron microscopic examination and staining for both cytokeratin and vimentin by immunohistochemistry  the classic clinicopathologic features of this tumor support the concept that malignant rhabdoid tumors similar to those of the kidney may occur in extrarenal sites  
class4	primary malignant melanoma of the lower respiratory tract  report of a case and literature review  the authors report a case of primary bronchial malignant melanoma  occurring in a 34 year old woman presenting with persistent cough  at bronchoscopic examination  a polypoid mass was found to occlude the left mainstem bronchus  biopsies showed a malignant epithelioid tumor resembling an atypical carcinoid  histochemistry  electron microscopic study  and immunohistochemistry confirmed the diagnosis of melanoma  physical examination and additional clinical history to exclude other possible primary sites were negative  the patient underwent thoracotomy with left pneumonectomy  nineteen months after resection she was found to have a histologically similar tumor involving her left adrenal gland  review of the literature shows that melanoma of the lower respiratory tract has been reported only in adults and has a tendency to present as a central polypoid growth that may be responsive to surgical resection  
class4	clinicopathologic features and long term results of alpha fetoprotein producing gastric cancer  during a 10 yr period  24 cases of alpha fetoprotein producing gastric cancer were experienced in our department  the mean age was 62 5 yr  and the sex ratio of males to females was 3 1  borrmann ii and iii types of gastric cancer were predominant  83 3    the prognosis was dismal  most of the patients  including three radically operated cases of early gastric cancer  died from liver metastasis within 2 yr  the 1   3   and 6 yr survival rates were 37 5   8 3   and 8 3   respectively  for all cases and 75 0   25 0   and 25 0  for radically operated cases  the incidences of synchronous and metachronous liver metastasis were 31 8  and 40 9   significantly higher than the incidences of afp negative gastric cancer  p less than 0 91   despite radical gastrectomy  metachronous liver metastasis occurred in 75 0  of the cases  two radical hepatic resections  including extended right lobectomy  were performed in one patient with early gastric cancer who had repeated metachronous liver metastasis  however  the tumor recurred immediately  apparently  radical gastrectomy or hepatic resection alone may not suffice for this particular type of cancer  the methods of treatment and follow up considered should be different from that for other types of gastric cancer  
class4	adenocarcinoma arising in barrett s esophagus after total gastrectomy a 64 yr old japanese male who underwent a partial gastrectomy for a duodenal ulcer at the age of 21  a total resection of the remnant stomach for a stomal ulcer at age 25  and in whom barrett s esophagus was diagnosed at age 47  was found to have a tumor at the distal esophagus and was operated on by thoracic esophagectomy  the tumor was a well to moderately differentiated adenocarcinoma invading down to the muscularis propria  the entire esophageal mucosa in the resected specimen was lined by columnar epithelium  this tumor was thought to derive from the barrett s esophageal epithelium  
class4	granular cell tumor of the esophagus  endoscopic ultrasonographic demonstration and endoscopic removal  a 35 yr old japanese man with a granular cell tumor of the esophagus that was removed by endoscopic polypectomy is presented  radiography and endoscopy showed a 20 x 12 mm sessile protrusion in the distal esophagus  endoscopic ultrasonography demonstrated the hypoechoic mass in the submucosa without continuity to the muscularis propria  the lesion was successfully treated by endoscopic polypectomy without complications  the cross sections of the resected specimen were quite in agreement with the ultrasonographic findings  endoscopic ultrasonography is valuable to assess the exact location and extent of the tumor  and to determine the indication for endoscopic polypectomy  
class4	diffuse hemangiomatosis of the spleen  splenic hemangiomatosis presenting with giant splenomegaly  anemia  and thrombocytopenia  in an elderly patient with oligosymptomatic giant splenomegaly  clinical and laboratory data were nondiagnostic  while nonhomogeneous splenic enlargement was the only finding detected by imaging procedures  splenectomy was performed and diffuse hemangiomatosis of predominantly capillary type found  the failure of imaging techniques to even hint at the nature of the underlying disorder is comprehensible in view of the organ being essentially replaced in toto by the abnormal vascular channels  diffuse splenic hemangiomatosis  a rare condition  may cause hypersplenism  and its diagnosis may be elusive because of misleading patterns on imaging  
class4	a chance to cut is a chance to cure  fifty seven patients underwent local excision of an invasive distal rectal cancer as an initial operative procedure with curative intent  five year survival was 82 5   and the rectal cancer specific mortality rate was only 10 5   the level of wall invasion  vascular permeation  tumor ulceration  mobility  and differentiation were the criteria studied for prognosis  poor prognostic factors included mucinous cell differentiation and full thickness invasion  and in these cases  abdominoperineal resection was recommended  none of the 27 patients without these adverse prognostic factors died from rectal cancer  the other factors did not appear to influence the outcome  and local excision of distal rectal cancer would be the treatment of choice in such selected patients  
class4	ten year prospective study on the development of renal cell carcinoma in dialysis patients  a prospective study was undertaken to investigate the development of renal cell carcinoma in dialysis patients  three renal cell carcinomas were detected among 96 hemodialysis patients in 1979  and screening by computed tomographic  ct  scan was continued yearly until 1989  during this 10 year period  one renal cell carcinoma was found in the second year and another in the ninth year  autopsy performed on seven of 19 patients who died showed one case of small clear cell carcinoma accompanying acquired cystic disease  in 33 males  kidneys were found to have enlarged 2 7     1 7 times over the 10 year follow up due to acquired cysts  while no change in kidney volume was noted in 24 females  native kidneys in nine of 12 patients who maintained functioning grafts were reduced in size  the patient with the largest kidney enlargement  11 5 times  died from retroperitoneal bleeding in 1989  these prospective study results suggest that both the incidence and prevalence of renal cell carcinoma in dialysis patients is high  furthermore  major complications of acquired renal cystic disease seem to occur predominantly in males  
class4	the mutation for medullary thyroid carcinoma with parathyroid tumors  mtc with pts  is closely linked to the centromeric region of chromosome 10  two new morphs  f and g  detected by the centromeric alpha satellite probe p alpha 10rp8 and d10z1 in hinfi digests are linked to the psti polymorphisms of d10z1  confirming their chromosome 10 location  the f and g morphs were in strong linkage disequilibrium with each other but were in weak linkage disequilibrium with the a and b morphs defined in psti digests  data for haplotypes formed by using the a and f morphs improved the lod score for linkage between the disease locus for multiple endocrine neoplasia type 2a  men2a  and d10z1  z   14 06 at theta   0  in the six large families studied by wu et al  furthermore  the locus that codes for a distinct phenotype  medullary thyroid carcinoma  mtc  with parathyroid tumors  pts  and no pheochromocytomas  pheos   referred to as mtc with pts   in one of the families was closely linked to two markers  d10z1 and rbp3  with lodscores of 2 86 and 3 54  respectively  at theta   0  a possible allelic association was noted between disease phenotypes and centromeric haplotypes  the phenotype mtc and pheos with and without pts was associated with the same relatively common centromeric haplotype  a   b f g   in the four families in which all four morphs could be determined  while the phenotype mtc with pts was associated with the rare centromeric haplotype  a b f g   in one family  
class4	a new dna marker  d10s94  very tightly linked to the multiple endocrine neoplasia type 2a  men2a  locus  combined somatic cell hybrid and linkage studies between d10s94 and five pericentromeric loci  fnrb  d10z1  men2a  rbp3  and d10s15  have localized the new dna sequence pcl1 a1s 6 c23 at d10s94 to 10q11 2  no recombinants were observed between d10s94 and d10z1 or men2a  d10s94 maps in proximal 10q11 2 very near to men2a  there are three possible orders for the six loci that we investigated from the centromeric region of chromosome 10  at present the genetic data do not allow us to order men2a with respect to d10z1 and d10s94  the three possible orders are fnrb d10z1 d10s94 men2a rbp3 d10s15  fnrb d10z1 men2a d10s94 rbp3 d10s15  and fnrb men2a d10z1 d10s94 rbp3 d10s15  in view of the fact that no recombinants between d10s94 and men2a or between d10s94 and d10z1 were observed  the combined haplotypes formed from rflps and d10z1 and d10s94 will increase the informativeness and accuracy of genotype prediction for at risk members of the families having the men 2a syndrome  particularly when the affected parent is female  the localization of d10s94 with respect to men2a will prove valuable in experiments directed toward cloning the men2a locus  
class4	the importance of cytogenetic studies in adult acute lymphocytic leukemia  purpose  the prognostic importance of pretreatment bone marrow cytogenetic studies in adults with acute lymphocytic leukemia treated at a single institution  with an identical treatment program  is described  patients and methods  a total of 105 patients with a documented morphologic diagnosis of acute lymphocytic leukemia were reviewed for the purpose of this analysis  all patients had an extensive workup at presentation  and cytogenetic analysis was performed in 103 patients  using the giemsa banding technique with trypsin pretreatment on 24 hour cultured cells  results  the specific cytogenetic classification in the 103 patients who had the karyotypic analysis was as follows  diploid 27   philadelphia chromosome positive 13   hyperdiploid 12   b cell karyotype 6   6q  and 14q  abnormalities 4   pseudodiploid 8   hypodiploid 2   and insufficient metaphases 28   b cell  6q  or 14q   and philadelphia chromosome positive karyotypes tended to correlate with other known negative prognostic factors  patients with diploid  hyperdiploid  pseudodiploid  and hypodiploid karyotypes or with insufficient metaphases could be combined into one group with a favorable prognosis  in this group  the remission rate with induction chemotherapy was 89   the median complete remission duration was 26 months  and the median survival was 25 months  with a 3 year survival rate of 45   patients with philadelphia chromosome positive  b cell  and 6q  or 14q  abnormalities collectively had an unfavorable prognosis  their response rate to induction chemotherapy was 65   the median response duration was 7 months  and the median survival was 8 months  with a 3 year survival rate of less than 10   conclusion  we conclude that the pretreatment bone marrow karyotype is an important part of the evaluation of adults with acute lymphocytic leukemia and provides significant prognostic information  
class4	endometrioma of the liver  hepatic endometriosis is extremely rare  we describe a patient sent to us with epigastric pain as the only symptom and who was found to have associated endometrioma of the liver and left ovary  we suggest a gynecologic evaluation before surgery for hepatic cyst of unknown cause  
class4	hemoperitoneum as a result of coital injury without associated vaginal injury  hemoperitoneum as a result of coital injury without associated vaginal injury is an extremely rare entity  and evidence by only five cases that have been reported in the medical literature to date  we report five additional cases encountered in two medical centers  two of these were ruptured corpus luteum cysts  one was a laceration of the round ligament  another was a laceration of an ovary  and the fifth was rupture of a serous cystadenoma  this diagnosis should be considered in patients with hemoperitoneum after coitus  
class4	management of selected cystic adnexal masses in postmenopausal women by operative laparoscopy  a pilot study  twenty five postmenopausal patients were predicted to have benign masses by screening criteria that included ultrasonographic findings of a cystic adnexal mass less than 10 cm with distinct borders and no evidence of irregular solid parts  thick septa  ascites  or matted bowel  and a normal serum ca 125 value  less than 35 u ml   all 25 masses were accurately predicted to be benign  the size of the cysts on ultrasonography ranged from 3 to 9 cm with a mean of 5 cm  twenty two patients  88   were successfully managed by operative laparoscopy and adnexectomy  mean operative time was 70 minutes and mean postoperative hospital stay was 12 hours  mean time of return to normal activity was 5 days  three patients required laparotomy  we conclude that removal of these cystic adnexal masses by operative laparoscopy is an acceptable alternative in carefully selected postmenopausal women  
class4	ultrasonographic assessment of placental abnormalities  current ultrasonographic techniques offer a novel approach for the identification of a wide variety of placental abnormalities usually described postnatally by the pathologist  placental vascular lesions  placental tumors  and abnormal placentation are potentially associated with perinatal complications and their diagnosis in utero may influence the pregnancy management  an ultrasonographic classification of placental lesions that is based on their location  size  echogenicity  and number is proposed  repeated ultrasonographic examination  together with biologic investigations  is important for the prenatal differential diagnosis of most these lesions and for full understanding of their pathophysiologic characteristics and significance  
class4	preferential mitogenic activity for myoblast like cells can be extracted from uterine leiomyoma tissues  the presence of mitogen s  in leiomyoma extracts stimulating cells with the fibroblast  myoblast  and osteoblast phenotype was documented  mitogenic activity in leiomyoma extracts was acid stable and sensitive to tryptic digestion  reverse phase high performance liquid chromatography successfully separated mitogen s  with preferential activity for myoblast cells from mitogens with a broad type of cell specificity and from inhibitors  this leiomyoma derived preferential activity for myoblasts was absent in identically treated myometrial and endometrial extracts  this suggests that leiomyoma derived substances with preferential growth factor activity for myoblast like cells may play a role in the pathophysiologic characteristics of uterine leiomyomas  
class4	practical aspects of pulsatile gonadotropin releasing hormone administration  pulsatile administration of gonadotropin releasing hormone represents a major advance in the treatment of anovulation in women who fail to ovulate with clomiphene citrate and is an alternative for many women who currently receive human menopausal gonadotropin  four issues must be addressed before administering pulsatile gonadotropin releasing hormone   1  safety   2  efficacy   3  convenience  and  4  cost  each of these issues will be affected by the three major decisions a physician makes with gonadotropin releasing hormone therapy   1  patient selection   2  route of administration  and  3  dose of gonadotropin releasing hormone  the ideal candidate for gonadotropin releasing hormone therapy is a patient with an absence of endogenous pulsatile gonadotropin releasing hormone  as seen in hypothalamic amenorrhea  although women with polycystic ovarian disease can be treated with pulsatile gonadotropin releasing hormone  a decreased ovulation rate should be expected  the route of administration  intravenous or subcutaneous  and the degree of monitoring can be tailored by the physician to fit each patient s needs  pulsatile gonadotropin releasing hormone therapy is a safe  effective  convenient  and economical alternative to human menopausal gonadotropin for ovulation induction in women resistant to clomiphene  
class4	ocular adnexal kaposi s sarcoma in acquired immunodeficiency syndrome  we examined histopathologically 18 ocular adnexal kaposi s sarcoma lesions related to acquired immunodeficiency syndrome  these lesions were classified into three types  type i consisted of thin  dilated vascular channels lined by flat endothelial cells with lumen containing erythrocytes  type ii featured plump  fusiform  endothelial cells  often with a hyperchromatic nucleus and foci of immature spindle cells and occasional slit vessels  type iii was characterized by large aggregates of densely packed spindle cells with hyperchromatic nuclei  occasional mitotic figures  and abundant slit spaces often containing erythrocytes in between  clinically  type i and type ii tumors were patchy and flat  less than 3 mm in height  and of less than four months  duration  type iii tumors were nodular and elevated  greater than 3 mm in height   we describe the clinical and histopathologic types of kaposi s sarcoma that may help in diagnosis  
class4	traumatic enucleation for posterior uveal melanoma  two features of eyes enucleated for posterior uveal melanoma that may serve as indicators for traumatic enucleation and relate to dissemination of tumor cells at the time of enucleation are myelin artifact of the optic nerve head and acute hemorrhage within the tumor  myelin artifact occurs when crushed optic nerve tissue is squeezed into the eye at the time of enucleation  intralesional hemorrhage may occur during surgery and may be correlated with fluctuations in intraocular pressure  we reviewed 519 cases of posterior uveal melanoma treated by enucleation between 1950 and 1970  without knowledge of the follow up data  we examined histologic sections for myelin artifact  intralesional hemorrhage  subretinal hemorrhage  callender cell type  size of tumor  necrosis  and scleral or orbital invasion  neither myelin artifact nor intralesional hemorrhage were independent prognostic risk factors  these findings do not support or refute the hypothesis that excessive trauma during enucleation results in a worse prognosis  
class4	a randomized study of methanol extraction residue of bacille calmette guerin as postsurgical adjuvant therapy of uveal melanoma  a randomized controlled clinical trial of methanol extracted residue of bacille calmette guerin adjuvant treatment of posterior uveal melanoma was undertaken  of 113 patients  34 patients received adjuvant immunotherapy and 79 patients received no treatment  no difference in survival was observed between the adjuvant treated group and the control group of patients  this study found that the size of the tumor was a highly significant risk factor for death caused by metastasis of uveal melanomas  the standard deviation of the nucleolar area of the neoplastic cells was a significant risk factor  even though patients with tumors composed of callender s spindle type cells were not included in the study  
class4	the value of nucleolar organizer regions in uveal melanoma  the collaborative ocular melanoma study group  silver staining of nucleolar organizer regions is an objective method for evaluating the malignancy of a variety of tumors  we studied 126 ciliochoroidal melanomas  three coincidental nevi that occurred in eyes with melanomas  and one magnocellular nevus collected from the collaborative ocular melanoma study to determine the effectiveness of the silver stained nucleolar organizer region technique in assessing the malignant potential of these tumors  malignant lesions demonstrated higher mean silver stained nucleolar organizer region counts  4 347  than benign nevi  1 855   p less than or equal to  0001   among malignant melanomas  mixed cell melanomas had slightly higher counts than spindle cell melanomas  p less than or equal to  0001   but this difference was not important clinically  results were also compared to other histopathologic variables  which disclosed correlation of silver stained nucleolar organizer regions with mitoses and tumor size  comparison with computerized cytomorphometric analyses of prognosis also disclosed significant correlation  this technique may prove to be a useful adjunct in the assessment of malignancy and treatment response of uveal melanomas  
class4	immunohistologic properties of benign and malignant mixed tumor of the lacrimal gland  we studied the immunohistopathologic features of normal lacrimal gland  benign mixed tumor  and malignant mixed tumor of the lacrimal gland  primary antisera were to keratin  muscle specific actin  vimentin  and glial fibrillary acid protein  keratin stained in occasional myoepithelial cells in normal gland  ductal epithelium in normal gland and the tumors  and occasional stromal epithelioid cells in the tumors  muscle specific actin stained in myoepithelium and vascular smooth muscle in normal gland and the tumors  and occasional spindle shaped and clusters of stromal cells in the tumors  vimentin staining was nonspecific  glial fibrillary acid protein stained in occasional myoepithelial cells in normal gland and polyhedral stromal cells in benign mixed tumor  our findings indicate that ductal epithelium develops into the epithelial component  and some cells in the stroma and myoepithelium develop into some cells in the stroma of benign and malignant mixed tumor of the lacrimal gland  
class4	a clinicopathologic study of the eyes in familial adenomatous polyposis with extracolonic manifestations  gardner s syndrome   the eyes of a 51 year old woman with familial adenomatous polyposis and extracolonic manifestations  gardner s syndrome  were obtained postmortem and studied by light microscopy and by transmission and scanning electron microscopy  we found a generalized abnormality in melanogenesis of the retinal pigment epithelium and at least three types of pigmented lesions  the histologic findings in one type of lesion were consistent with congenital hypertrophy of the retinal pigment epithelium or benign pigmented nevus of the retinal pigment epithelium  the other two types of lesion were most consistent with hamartomatous malformations of the retinal pigment epithelium featuring cellular hypertrophy  hyperplasia  and rarely retinal invasion and formation of a minute mushroom shaped tumor  these histopathologic findings indicate a generalized effect of the familial adenomatous polyposis gene on the retinal pigment epithelium  this oncogene  which is responsible for tumor formation in the gastrointestinal tract  soft tissues  bone  and other locations in patients with familial adenomatous polyposis  also leads to a generalized defect in melanogenesis and focal lesions of the retinal pigment epithelium  
class4	increase of beta 1 6 branched oligosaccharides in human esophageal carcinomas invasive against surrounding tissue in vivo and in vitro  the  glcnac beta 1 6man   beta 1 6  branched n glycosidic oligosaccharides expressed on tumor cells have been found to contribute to malignant and metastatic potential in experimental tumor models  phaseolus vulgaris leukoagglutinin  l pha  requires the beta 1 6 linked lactosamine antenna for high affinity binding and was used histochemically to characterize the distribution of these sugar structures in human esophageal squamous cell carcinomas from 42 patients  leukoagglutinin reactive carcinoma cells in the invasive tumors were distributed predominantly on the outer surface of the tumor adjacent to the surrounding tissue  furthermore  when te 1 cells  a human esophageal squamous cell carcinoma line  were cultured in a collagen gel matrix to obtain colonies in a three dimensional form  these colonies exhibited high affinity for l pha binding only in the outer cell layer facing the collagen matrix  unrelated to the cell growth cycle  these findings suggest that the increase in beta 1 6 branched oligosaccharides in esophageal carcinomas is an important trait of the tumor in the invasion into the surrounding tissue  
class4	vimentin is preferentially expressed in high grade ductal and medullary  but not in lobular breast carcinomas  two hundred sixty two invasive breast carcinomas dating from 1979 to 1984 were tested for vimentin and keratin on formaldehyde fixed paraffin embedded sections  none of 26 lobular carcinomas expressed vimentin  vimentin expression in 10  or more of tumor cells was found in 78  of medullary  14 of 18   in 16  of ductal not otherwise specified  nos   35 of 214   and in two of four mucinous carcinomas  a further seven tumors showed vimentin expression in less than 1  to 10  of the cells  vimentin was expressed in tumor cells of 30   28 of 93  of grade iii invasive ductal nos carcinomas versus 7   7 of 105  of grade ii and 0  of grade i carcinomas  0 of 10   vimentin was found to be preferentially expressed in tumors growing in broad  often anastomosing bands or sheets with extensive necrosis  scanty supportive stroma  high nuclear grade  and numerous mitoses  the authors conclude that vimentin is not detected in lobular carcinomas  but is preferentially expressed in medullary and in high grade ductal nos breast carcinomas  
class4	inhibition of angiogenesis and tumor growth in the brain  suppression of endothelial cell turnover by penicillamine and the depletion of copper  an angiogenic cofactor  microvascular proliferation  a hallmark of malignant brain tumors  represents an attractive target of anticancer research  especially because of the quiescent nonproliferative endothelium of the normal brain  cerebral neoplasms sequester copper  a trace metal that modulates angiogenesis  using a rabbit brain tumor model  normocupremic animals developed large vascularized vx2 carcinomas  by contrast  small  circumscribed  relatively avascular tumors were found in the brains of rabbits copper depleted by diet and penicillamine treatment  cdpt   the cdpt rabbits showed a significant decrease in serum copper  copper staining of tumor cell nuclei  microvascular density  the tumor volume  endothelial cell turnover  and an increase in the vascular permeability  breakdown of the blood brain barrier   as well as peritumoral brain edema  in non tumor bearing animals  cdpt did not alter the vascular permeability or the brain water content  cdpt also inhibited the intracerebral growth of the 9l gliosarcoma in f 344 rats  with a similar increase of the peritumoral vascular permeability and the brain water content  cdpt failed to inhibit tumor growth and the vascularization of the vx2 carcinoma in the thigh muscle or the metastases to the lung  findings that may reflect regional differences in the responsiveness of the endothelium  the distribution of copper  or the activity of cuproenzymes  metabolic and pharmacologic withdrawal of copper suppresses intracerebral tumor angiogenesis  angiosuppression is a novel biologic response modifier for the in situ control of tumor growth in the brain  
class4	coexpression patterns of vimentin and glial filament protein with cytokeratins in the normal  hyperplastic  and neoplastic breast  the authors studied by immunohistochemistry the intermediate filament  if  protein profile of 66 frozen samples of breast tissue  including normal parenchyma  all variants of fibrocystic disease  fcd   fibroadenomas  cystosarcoma phylloides  and ductal and lobular carcinomas  monoclonal antibodies  mabs  to cytokeratins included mab ka 1  which binds to polypeptide 5 in a complex with polypeptide 14 and recognizes preferentially myoepithelial cells  mab ka4  which binds to polypeptides 14  15  16 and 19  individual mabs to polypeptides 7  13  and 16  17  18  and 19  and the mab mixture ae1 ae3  the authors also applied three mabs to vimentin  vim   and three mabs to glial filament protein  gfp   selected samples were studied by double label immunofluorescence microscopy and by staining sequential sections with some of the said mabs  an mab to alpha smooth muscle actin  and well characterized polyclonal antibodies for the possible coexpression of diverse types of cytoskeletal proteins  gel electrophoresis and immunoblot analysis also were performed  all samples reacted for cytokeratins with mabs ae1 ae3  although the reaction did not involve all cells  monoclonal antibody ka4 stained preferentially the luminal secretory cells in the normal breast and in fcd  whereas it stained the vast majority of cells in all carcinomas  monoclonal antibody ka1 stained preferentially the basal myoepithelial cells of the normal breast and fcd while staining tumor cell subpopulations in 4 of 31 carcinomas  vimentin positive cells were found in 8 of 12 normal breasts and in 12 of 20 fcd  in most cases  vim reactive cells appeared to be myoepithelial  but occasional luminal cells were also stained  variable subpopulations of vim positive cells were noted in 9 of 20 ductal and in 1 of 7 lobular carcinomas  glial filament protein reactive cells were found in normal breast lobules and ducts and in 15 of 20 cases of fcd  with rare exceptions  gfp reactivity was restricted to basally located  myoepithelial appearing cells  occasional gfp reactive cells were found in 3 of 31 carcinomas  evaluation of sequential sections and double label immunofluorescence microscopy showed the coexpression of certain cytokeratins  possibly including polypeptides 14 and 17  with vimentin and alpha smooth muscle actin together with gfp in some myoepithelial cells  the presence of gfp in myoepithelial cells was confirmed by gel electrophoresis and immunoblotting  our results indicate that coexpression of cytokeratin with vimentin and or gfp is comparatively frequent in normal basal myoepithelial cells of the breast  abstract truncated at 400 words   
class4	a b blood group antigens in tissues of ab heterozygotes  emphasis on normal and neoplastic urothelium  the tissue distribution of the a and b blood group antigens was studied in 41 individuals with the heterozygous ab red blood cell  rbc  phenotype  a total of 134 biopsies from a variety of normal tissues  94 from urothelium and 40 from other tissues  were examined  in addition  changes in the expression of these antigens associated with neoplastic transformation were evaluated in 70 biopsies from transitional cell carcinomas of 19 ab heterozygous patients  there was heterogeneity in the distribution of tissue a and b antigens  depending on the cell type  as well as among cells of the same type  ninety one percent of ab heterozygotes expressed both a and b antigens in normal epithelial cells  with a mosaic distribution clearly apparent in 50  of these individuals  in 21  of these subjects  the a antigen was undetectable in the vascular endothelial cells in all biopsies from several organs  in most  79   transitional cell neoplasms  only one of the two antigens was consistently expressed  the results of this study may have implications for the clonal or specific gene deletion theories of neoplasia  they also demonstrate the existence of a subgroup of ab individuals in whom the a antigen is absent specifically from the vascular endothelium  
class4	flow cytometric analysis of the mechanism of methylmercury cytotoxicity  flow cytometric analysis of murine erythroleukemic cells  melc  exposed in vitro to 2 5 to 7 5 mumol l  micromolar  methylmercury  mehg  reveals a dose dependent decrease in the rate of dna synthesis  rate of passage through the s phase of the cell cycle   manifested as the accumulation of most of the cells in the s phase  and a modest accumulation of cells in the g2 m phase of the cycle  light microscopy reveals a progressive increase in chromosomal damage  condensation  pulverization   at or above 10 mumol l mehg  progression through all the phases of the cell cycle is blocked and mitotic cells are arrested irreversibly in anaphase  with most exhibiting arrangement of chromosomes in a wreathlike ring formation  also the cells exhibit both nuclear propidium iodide  pi  fluorescence  indicative of loss of viability  and concurrent cytoplasmic carboxyfluorescein  cf  fluorescence  viable cells exhibit cf fluorescence and exclude pi   in addition  there is a dose dependent increase in cellular refractive index  90 degrees light scatter   an apparent decrease in cell volume  axial light loss   and progressive resistance to detergent  np 40  mediated cytolysis  resistance to detergent mediated cytolysis is indicative of fixation  protein denaturation  cross linking  and so on  of the plasma membrane cytoplasm complex  our findings indicate that dna synthesis is the primary target of mehg cytotoxicity and that apparent targets and degree of cytotoxicity are a complex function of dose  
class4	expression of aminopeptidase n  cd13  in mesenchymal tumors  for a long time  cd13 molecules have been considered to be restricted to myeloid cells and related neoplasms  meanwhile  however  expression of cd13 has also been detected in some hepatocellular  gallbladder  renal  and lung carcinomas  and even in some fibrosarcomas and malignant melanomas  in this study  expression of cd13 antigen was immunohistochemically examined in non neoplastic mesenchymal cells  along with 33 benign and 83 malignant mesenchymal tumors  met  using cd13 monoclonal antibodies  mab  my7  u71  wm 15  and mou48  in non neoplastic mesenchymal cells  expression of cd13 was restricted to perivascular fibrocytes blasts  tissue histiocytes  osteoclasts  and to the perineurium of peripheral nerve trunks  under neoplastic conditions  cd13 was detectable in some tumors of smooth muscle  fibrous  fibrohistiocytic  synovial  osteogenic  and peripheral nerve sheath origin  and even in some tumors of adipose tissue  tumors of striated muscle origin  of autonomic ganglia  and of cartilage forming tissues were cd13 negative throughout  thus in most but not all tumors studied the pattern of expression of cd13 mirrors the situation found in their cells of origin  these findings enrich the data on expression of leukocyte differentiation antigens in extra hematopoietic tissues  expression of cd13  which meanwhile is known to be identical to aminopeptidase n  an important peptide cleaving enzyme  in only some met might reflect a special functional state of these neoplasms  
class4	immunocytochemical localization of progesterone receptors in endocrine cells of the human pancreas  progesterone receptors  pgr  have been immunocytochemically localized in the nuclei of several  40  to 75   endocrine cells of the human pancreas and in a more variable number of neoplastic cells of 7 of 18 endocrine pancreatic tumors  conversely the exocrine epithelial cells of the pancreas did not exhibit any pgr immunoreactivity in normal as well as in different pathologic conditions  including pancreatic adenocarcinomas  estrogen receptors were not detected in any of the pancreatic samples investigated  double immunocytochemical experiments have documented that pgr immunoreactivity in normal langerhans islets is a consistent feature of most  75   glucagon producing a cells  of approximately 5  to 20  of insulin producing b cells  and of a variable percentage of pancreatic polypeptide  pp  producing cells  ranging from 5  to 70   these figures were not affected by the sex  age  or underlying disease of the patients  the reported findings corroborate previous clinical and experimental evidence indicating that sex steroid hormones may have some regulatory effects on the functional activity of the endocrine pancreas  
class4	immediate versus delayed shoulder exercises after axillary lymph node dissection  a total of 144 evaluable patients with breast cancer were enrolled in a multicenter  randomized  prospective study to establish the role of delayed shoulder exercises on wound drainage and shoulder function after axillary lymph node dissection  patients in group 1  n   78  started active shoulder exercises 1 day postoperatively  patients in group 2  n   66  started on the eight postoperative day  following 1 week of immobilization of the arm  patients in group 2 had 14  less wound drainage volume than those in group 1  600     436 ml versus 701     398 ml   this difference  however  was not significant  also  no differences could be established between the two groups when duration and volume of wound drainage  number and volume of seroma aspirations  wound complication rates  and shoulder function were compared 6 months after surgery  
class4	variations in sensitivity after sectioning the intercostobrachial nerve  the authors present a prospective study of the variations in sensitivity that appear in the armpit and arm after the intercostobrachial nerve has been sectioned in a modified radical mastectomy  of a total of 208 patients studied between 1978 and 1987  the intercostobrachial nerve was sectioned in 139 patients  whereas in 30 it remained intact  in 39 patients only peripheral branches of the nerve were sectioned  the patients were examined at regular postoperative intervals in order to evaluate their sensitivity both to touch and to pain in the axilla and arm  four hundred thirty three examinations were carried out and the 3 operative groups were assessed accordingly  after the nerve was sectioned  there was increasing anesthesia in the armpit and hypoesthesia on the posterointernal face of the arm  while for the patients in whom the intercostobrachial nerve remained intact  these alterations were less intense and long lasting  significant statistical differences between the two groups also exist  in the absence of axillary lymphatic ganglia infiltrated by the tumor  the conservation of the intercostobrachial nerve is recommended  
class4	anaesthetic problems in ex situ resection of the liver  ex situ resection of the liver is a new surgical technique for treatment of liver tumours not amenable to conventional surgery  this paper describes the cardiovascular and metabolic changes that occurred in nine consecutive such patients  no severe haemodynamic or pulmonary complications occurred  specific problems were encountered during the prolonged anhepatic period  which lasted an average of 5 96  sd 1 46  hours  significant metabolic and coagulation disorders occurred 2 to 3 hours after hepatectomy because of complete loss of hepatic function  the predominant findings during the anhepatic period were hypoglycaemia and severe metabolic acidosis  mainly from increased levels of lactic acid  exogenous administration of dextrose 5  at an average rate of 188 ml hour was necessary to maintain normoglycaemia  while correction of metabolic acidosis required 403  sd 159 79  mmol of sodium bicarbonate  supplemented by hyperventilation  tris hydroxymethylaminomethane was used when sodium overload was thought to be a problem  there was a marked decrease of factor v and fibrinogen  a moderate thrombocytopenia and fibrinolysis  the severity of these alterations was dependent on the duration of the anhepatic period and the primary function of the re implanted liver  
class4	anesthesia for craniotomy  a double blind comparison of alfentanil  fentanyl  and sufentanil  using a prospective  randomized  and double blind study design  alfentanil  n   15   fentanyl  n   14   or sufentanil  n   16   in combination with n2o  were administered to patients undergoing craniotomy for supratentorial tumor resection  physicians were given two syringes  one of which was labeled as  load  for the initial loading dose and the other as  maintenance  for continuous infusion  the concentration of drug in each syringe was adjusted to permit administration on a milliliter per kilogram basis  the target loading doses for alfentanil  fentanyl  and sufentanil were 75  10  and 1 microgram kg  respectively  and initial infusion rates were 33 5  2 0  and 0 3 microgram kg 1 h 1  respectively  additional supplementary boluses and changes in maintenance infusion rate were made according to predetermined guidelines  isoflurane  in increasing 0 2  inspired increments  was used only when the maximum allowed opioid dose had been given  i e   supplementary bolus doses equal to 75  of the calculated loading dose or supplementary bolus doses equal to 50  of the calculated loading dose combined with a 50  increase in the maintenance infusion rate   opioid infusions were stopped at the time of bone flap replacement  antihypertensive medications and naloxone were subsequently given at the discretion of the anesthesiologist  group demographics were not different  total volumes of drug were similar among groups indicating equipotent preparations  administration of isoflurane  antihypertensive medications  and naloxone were not different among groups  although decreases in blood pressure seen with induction were similar among groups  alfentanil treated patients received ephedrine more frequently before intubation  thirty minutes after entry into the postanesthesia recovery area  respiratory rate and ph were lowest in sufentanil treated patients  
class4	infection during chronic epidural catheterization  diagnosis and treatment  a potentially serious complication of long term epidural catheterization in cancer patients is infection  the early signs of infection were studied in 350 patients in whom long term epidural catheters were inserted  three areas of the catheter track were found to be involved  exit site and superficial catheter track infection  and epidural space infection  the authors identified the early signs of infection in each area and the progress of the infection from the deep track to include the epidural space in four of these patients  all 19 patients who developed deep track or epidural infections were successfully treated with antibiotics and catheter removal  none of the patients required surgery for spinal cord decompression  catheters were replaced in 15 of the 19 treated patients who requested them after treatment with no recurrent infections  it was concluded that use of long term epidural catheterization is associated with a definable epidural infection rate  the use of epidural opioid analgesia is an effective and safe means of obtaining pain relief for terminally ill patients when patients are monitored for possible infection and receive prompt treatment when the diagnosis is established  
class4	the single breath nitrogen test  mortality  and cancer  the relationship between indices of the single breath nitrogen test and mortality  overall cancer incidence  and respiratory cancer incidence was examined in a cohort of 876 men  46 to 69 yr of age  examined in 1974 and followed until june 1985  closing volume  closing capacity  and slope of phase iii were not related to mortality or cancer  in contrast  fev1 was related to mortality  with an estimated relative mortality risk of 1 37  95  confidence interval  1 11 to 1 70  per liter under the expected fev1  given height  age  and smoking  but fev1 was not related to cancer  inability to perform acceptable single breath nitrogen test tracings was related to mortality with a relative mortality risk of 2 03  1 45 to 2 85   but not to cancer  we conclude that indices of the single breath nitrogen test have no predictive value concerning overall mortality and cancer incidence  
class4	frequency and clinical implications of monoclonal antibody detection of tumor associated antigens in serum of patients with lung cancer  we previously showed that a panel of monoclonal antibodies  mab   5e8  5c7  and 1f10  that detect serum tumor associated antigens  taa  could distinguish patients with lung cancer from those without to a highly significant degree  however  among patients with lung cancer  the frequency and clinical importance of serum taa expression were not established  therefore  we analyzed the serum and initial clinical characteristics of 52 philadelphia va patients with newly diagnosed lung cancer seen over a 13 month period  a modified semiquantitative elisa was employed to determine mab reactivity  our cohort was characterized by a mean age of 65     9 year  sd  and mean karnovsky score of 74     10  marked weight loss was present in 28 subjects  and 39 presented with either stage iii or iv disease  the panel detected taas in 38 of 52 cases  sensitivity 73   95  cl  60 83    including 13 of 22 squamous cell  9 of 12 adenocarcinoma  10 of 11 undifferentiated  and 6 of 7 small cell carcinomas  no significant differences were found between the reactive and nonreactive patients in terms of age  stage at presentation  histologic subtype  performance status  or weight loss  however  1f10 and 5c7 were each associated with a greater risk of early death by cox proportional hazard analysis  p   0 017 and 0 006  respectively  even when other prognostic variables are accounted for  we conclude that specific serum taa can be detected in the majority of lung cancer patients with all major histologic subtypes in a cohort with advanced tumors and poor prognostic indices  
class4	cecal diverticulitis presented as a cecal tumor  seven patients diagnosed as having acute appendicitis were operated on and a cecal wall mass due to cecal diverticulitis was found  in two patients the mass could not be separated from the cecal wall and right colectomy was performed  in five patients  in whom the mass could be separated from the cecum  conservative operations  three diverticulectomies and two wedge resections  were performed  thus avoiding needless  more extensive surgery  
class4	jejunal rectal fistula as a complication of postoperative radiotherapy  we present the case of a patient with an unusual  complex enteric fistula with multiple tracts and associated abscesses  the fistula was a late complication of radiotherapy  administered three years earlier  after resection for carcinoma of the sigmoid colon  most of the small bowel was involved in the radiation induced disease  a wide resection was performed successfully  this report reviews current literature on intra abdominal postradiotherapy injuries  particularly intestinal fistulae  
class4	risk for colon adenomas in patients with rectosigmoid hyperplastic polyps objective  to determine whether hyperplastic polyps found in the rectosigmoid area of the colon are associated with proximal adenomas  and to judge whether patients with distal hyperplastic polyps found during sigmoidoscopy might benefit from full colonoscopy  design  data on patients having colonoscopy collected prospectively according to a set protocol  the size and location of all polyps were noted  and all polyps were biopsied  setting  two university hospitals  patients  one thousand eight hundred and thirty six consecutive patients referred for colonoscopy between 31 december 1987 and 31 august 1989  results  of the 970 patients who met eligibility requirements  274  28 3   had adenomas and 108  11 1   had hyperplastic polyps  the proportion of patients with distal hyperplastic polyps and proximal adenomas  31 9   was similar to the proportion of those without distal hyperplastic polyps  23 0    crude odds ratio  1 57  95  ci  0 77 to 3 06   after adjusting for age and sex  the results were unchanged  adjusted odds ratio  1 53  ci  0 82 to 2 88   patients with distal adenomas  on the other hand  were three times more likely to have proximal adenomas than those without distal adenomas  adjusted odds ratio  3 42  ci  1 99 to 5 88   conclusions  distal hyperplastic polyps are not strong predictors of risk for proximal adenomas  based on the magnitude of the risk difference  we do not believe that finding a hyperplastic polyp during sigmoidoscopy justifies doing a full colonoscopy to search for proximal adenomas  because rectosigmoid adenomas are associated with proximal adenomas  however  small polyps seen during sigmoidoscopy should be biopsied to determine their type  colonoscopy should be reserved for patients who are proved to have adenomas  
class4	tumor cell lines established in vitro  an independent prognostic factor for survival in non small cell lung cancer  objective  to determine the relation between in vitro establishment of tumor cell lines and survival in patients with non small cell lung cancer  design  cohort study  setting  single institution tertiary care center  patients  one hundred twenty three consecutive patients with non small cell lung cancer from whom a viable tumor specimen could be obtained  intervention  tumor tissue was removed at the time of entry into a therapeutic protocol  the tumor tissue was processed in the laboratory for attempted cell line establishment  patients classified as potentially curable  stages i  ii  and iiia  were treated with surgical resection  radiation therapy  or a combination  patients suitable for palliative therapy only  stages iiib and iv  were treated with radiation therapy with or without chemotherapy  chemotherapy was based on in vitro drug sensitivity when available  cell line establishment was correlated to clinical outcome  measurements and main results  univariate analysis of survival was done using the log rank test  multivariate analysis was done by cox modeling step up and step down techniques  cell lines were established from the tumor specimens of 25 patients  20    those patients experienced a median survival of 7 months compared with 18 months in patients from whom cell lines could not be established  p less than 0 001   in the 61 patients with potentially curable disease  8 patients  13   with cell lines established had a median survival of 8 months compared with 32 months for those without cell lines established  p   0 001   in the 62 palliative group patients  the median survival of the 17 patients  27   from whom tumor cell lines were established was 5 months compared with 7 months for those without cell lines  p   0 15   multivariate analysis in both groups showed cell line establishment to be a significant indicator of prognosis  p less than 0 0001 for curable group  p less than 0 01 for palliative group   conclusion  in vitro tumor growth is related to decreased patient survival  which in turn reflects the biologic aggressiveness of cancers giving rise to these tumor cell lines  
class4	the internist in the management of head and neck cancer  the general internist has an important role in the management of head and neck squamous cell cancers  this heterogeneous group of cancers must be accurately diagnosed and staged before planning treatment  curability is directly related to stage at presentation and  because most patients with such cancers present to internists first  these physicians must be familiar with presenting symptoms and must be suspicious enough to refer patients with symptoms for appropriate evaluation  the work up of patients with suspected unknown primary cancer presenting as adenopathy is detailed  and the physician is cautioned not to immediately proceed to open biopsy  as many as 10  of such primary cancers remain undetected  although  with proper therapy  the 5 year survival rate for squamous cell cancer of the head and neck is 60   those patients cured of head and neck cancer still face significant psychosocial and medical problems  including hypothyroidism  xerostomia  and a 20  rate of second primary cancer  head and neck cancer is highly preventable  75  of cases are related to tobacco and alcohol use  smokeless tobacco has gained popularity among young americans and is associated with an increased incidence of head and neck cancer at several sites  education is crucial  and internists must seek strategies to stop patients from using tobacco products  other etiologic factors include industrial carcinogens  epstein barr virus  and diet  retrospective serologic and dietary recall studies of vitamin a suggest an etiologic role of diet  vitamin a analogs have been tested in preneoplastic lesions  to reduce mortality from head and neck cancers  the general internist must play a central role in prevention and early detection  
class4	colorectal cancer  evidence for distinct genetic categories based on proximal or distal tumor location purpose  to examine studies of normal colon and colorectal cancer for evidence that the location of the primary tumor proximal or distal to the splenic flexure of the colon may determine distinct genetic categories of this disease  data identification  studies were identified through a manual search of journals  through medline  and through review of bibliographies in identified articles  study selection  approximately 300 articles were examined  about 150 articles were excluded because tumor location was not reported or was reported in a way that did not permit correlation with results or conclusions  data extraction  articles were selected either because the presentation of data permitted correlation of results with anatomic regions of the colon or because they were relevant to inherited colorectal cancer  results of the analysis  differences were noted in biologic properties of proximal and distal segments of normal fetal and adult colonic epithelium and in the epidemiologic  pathologic  cytogenetic  and molecular features of proximal and distal colorectal cancer  some differences correlated with the features of inherited colorectal cancer  proximal  nonpolyposis or distal  and polyposis forms   conclusions  developmental and biologic differences in proximal and distal colon may reflect differing susceptibilities to neoplastic transformation  differences in proximal and distal colorectal cancer suggest that each may arise through different pathogenetic mechanisms  proximal tumors appear to represent a genetically more stable form of the disease and may arise through the same mechanisms that underlie inherited nonpolyposis colon cancer  distal tumors show evidence of greater genetic instability and may develop through the same mechanisms that underlie polyposis associated colorectal cancer syndromes  
class4	histopathologic grading of salivary gland neoplasms  ii  acinic cell carcinomas  acinic cell carcinomas display varied cytoarchitectural patterns of growth that should allow for formulation of histopathologic grading  grading of these carcinomas may serve to identify subsets whose biologic behavior is more aggressive than the usually accepted low grade behavior of acinic cell carcinomas as a group  to that end  a three level histopathologic grading scheme is presented  
class4	myasthenic thymus and thymoma are selectively enriched in acetylcholine receptor reactive t cells  we compared t cell proliferative responses to acetylcholine receptor  achr  and to purified protein derivative  ppd   of tuberculin  of hyperplastic thymus  thymoma  and blood cells from patients with myasthenia gravis  mg   hyperplastic mg thymus cells gave significantly higher and more consistent responses to achr than parallel cultures of autologous blood cells  whereas responses to ppd showed an opposite trend  thus there was a preferential localization of achr reactive t cells in the hyperplastic mg thymus  furthermore  there was a strong correlation between blood and thymus cell responses to ppd  but not to achr   arguing that the hyperplastic mg thymus contains a sample of sensitized peripheral t cells  by contrast  both achr  and ppd responsive t cells were almost undetectable in thymus from nonmyasthenic patients  which is evidently much less receptive to circulating t cells  cells from mg thymomas showed the highest stimulations by achr but did not consistently react to ppd  however  the uninvolved thymus adjacent to these thymomas behaved almost identically to the hyperplastic samples described above  our interpretation is that achr specific t cells are initially sensitized in the mg thymoma but are selectively trapped in the hyperplastic thymus after being primed elsewhere  
class4	cutaneous t cell lymphoma  parapsoriasis en plaque   an association with pityriasis lichenoides et varioliformis acuta in young children  pityriasis lichenoides et varioliformis acuta  pleva  and pityriasis lichenoides chronica  plc  are related benign disorders without recognized association with cutaneous t cell lymphoma  ctcl   we report the cases of two children with documented pleva evolving into ctcl over several years  one child had the clinical lesions of plc but the dermatopathologic findings of pleva at age 2 years  at age 12 years  he had skin changes of poikiloderma atrophicans vasculare and dermatopathologic findings consistent with parapsoriasis en plaque  the second child presented at age 7 years with scaling dermatitis and dermatopathologic findings of pleva  at age 12 years  the histologic diagnosis was parapsoriasis  monoclonal antibody studies performed on biopsy specimens from both patients revealed 70  to 100  cells staining with cd5  80  to 90  staining with cd4  30  to 50  staining with cd8  and an increase in cd1 staining cells in the papillary dermis  indicating a predominantly helper t cell infiltrate  we believe that plc and pleva may be part of the spectrum of ctcl  furthermore  ctcl may be more common in young children than once thought  
class4	my7 monoclonal antibody for diagnosis of cutaneous t cell lymphoma  infiltrate in cutaneous t cell lymphomas  ctcls  is composed mainly of cd4 helper cells with a phenotype very similar to that of benign cutaneous lymphoid infiltrate  my7  cd13  is a monoclonal antibody that is normally expressed on peripheral granulocytes and monocytes but also cross reacts with an antigen expressed on epidermal basal cells  we studied my7 expression on basal cells of the epidermis and cd4 cell infiltrate in 34 ctcls  11 pseudolymphomas  and 29 other benign cutaneous lesions  an indirect immunofluorescence technique with double labeling and an immunoperoxidase technique were used  we found that in benign inflammatory infiltrate  less than 10  of cd4 cells expressed my7 antigen associated with normal my7 monoclonal antibody labeling of basal cells  whereas in ctcls more than 50  of cd4 tumoral cells in dermis expressed my7 antigens  however  basal cells were my7 negative  thus  it is demonstrated that my7 monoclonal antibody with its double modulation on epidermis  basal cells  and dermis  cd4 cells  has diagnostic value for differentiating ctcls with cd4  my7  tumor cells in dermis and my7 negative basal cells from benign inflammatory lesions with cd4  my7  cells in dermis and my7 positive basal cells  this modulation of my7 labeling could be related to the secretion of epidermal cytokines  
class4	positive results of combined therapy of surgery and intraperitoneal hyperthermic perfusion for far advanced gastric cancer  to evaluate the clinical efficacy of intraperitoneal hyperthermic perfusion  iphp  for far advanced gastric cancer  particularly with peritoneal seeding  we investigated the survival times of 59 patients who underwent distal subtotal gastrectomy  total gastrectomy  or total gastrectomy combined with concomitant resection of some of the remaining intra abdominal organs  in all the 30 patients given iphp  no cancer cells were present posthyperthermically in the lavage from the douglas pouch  the 30 patients given iphp lived longer than the 29 patients not given iphp  p   0 001   with a 1 year survival rate of 80 4  in the former group compared to 34 2  in the latter  with respect to a comparison of survival time of patients with peritoneal seeding  7 patients not given iphp had a 6 month survival rate of 57 1  and did not survive more than 9 months  whereas 20 patients given iphp had 1  and 2 year survival rates of 78 7  and 45 0   respectively  here the difference was significant  p   0 001   the iphp and control groups without peritoneal metastasis included 10 and 22 patients  respectively  and the 1 year survival rates are 85 4  and 45 3   respectively  the survival rates of the former exceeded those of the latter  with p   0 015 by the generalized wilcoxon test  thus this combined therapy offers the promise of extended survival for patients with far advanced gastric cancer  
class4	intrarectal ultrasonography in rectal cancer staging and in the evaluation of pelvic disease  clinical uses of intrarectal ultrasound  accurate preoperative staging of a rectal cancer patient may impact heavily on subsequent management  this study attempts to evaluate the accuracy of intrarectal ultrasonography  irus  in staging rectal cancers compared to clinical and pathologic examination  in addition the accuracy of irus was assessed in a group of patients with uncertain pelvic perirectal disease after a negative physical examination  in a prospective manner  52 cancer patients were staged with digital exam and irus  accuracy rates were 48  and 83   respectively  compared to pathologic evaluation in assessing wall penetration  and irus identified positive lymph nodes in 12 of 17 cases  in patients with pelvic disease  irus corresponded with pathologic diagnosis in 15 of 17 cases and revealed new information in 6 patients  intrarectal ultrasonography appears to be the most accurate imaging technique for staging rectal cancers and demonstrates promise in the evaluation of perirectal pelvic disease  
class4	localization and peptide content of endocrine pancreatic tumors  endocrine pancreatic tumors contain and frequently secret neurohormonal peptides  this phenomenon can be used as a diagnostic and classifying tool  this study analyzes 31 patients operated on because of an endocrine pancreatic tumor  including the diagnostic procedures and the localization methods  in 15 insulinoma cases only 6 patients had a positive arteriography  while all 11 selective pancreatic vein samplings were positive  the immunoreactivity showed that  besides insulin  most tumors also contained other peptides  of four gastrinoma cases the arteriography was positive in three  but the selective vein sampling localized the tumor in all  the tumor s content of peptides showed mixed patterns  in the four glucagonomas  the arteriography was positive in all and the venous sampling performed in three of the cases also was positive  in five pancreatic polypeptide containing tumors  pp omas  the arteriography was positive in four and sampling performed in two was positive in both  in the pp omas the peptide pattern showed that these tumors frequently contain several peptides  we used selective pancreatic vein sampling in 21 cases with positive result in all  in the cases in which arteriography was negative  the sampling results helped the surgeon to find the tumor  the peptide pattern in the tumors varied greatly and most tumors were multihormonal  
class4	localization and surgical treatment of occult insulinomas  management of patients with biochemical evidence of insulinoma and negative preoperative imaging studies  occult  tumors is controversial  varying from primarily medical management to aggressive  blind nearly total pancreatectomy to extirpate the tumor  since 1982  12 consecutive patients with occult insulinoma underwent preoperative portal venous sampling  pvs  for insulin followed by surgical exploration with intraoperative ultrasound  ious   eleven of twelve patients  92   had insulinoma removed and were cured  portal venous sampling correctly predicted the location of the insulinoma in 9 patients  75   and that no tumor would be found in another patient  a fourfold insulin gradient in the pancreatic tail of one patient correctly predicted that a distal pancreatectomy would remove the insulinoma despite the fact that neither palpation nor ious identified any tumor  intraoperative ultrasound was the single best method to identify occult tumors because it correctly identified 10 of 11 insulinomas that were found  including five pancreatic head tumors that were not palpable  palpation identified five insulinomas  of the 10 tumors that were identified during operation by palpation or ultrasound  ious identified significantly more  100  versus 50   p   0 03  and guided the successful enucleation of each  the results support the strategy of preoperative pvs and operation with ious to localize and remove insulinoma in patients with occult tumors  most tumors  75   will be correctly localized to a specific pancreatic region by preoperative pvs and identified by ious  83    allowing simple enucleation and biochemical correction of hypoglycemia  morbid blind pancreatic resections are no longer indicated and long term medical management of hypoglycemia should be reserved for the occasional patient  8   who fails preoperative pvs and operation guided by ious  
class4	surgical management of pheochromocytoma with the use of metyrosine  despite recommended preoperative preparation with alpha adrenergic blockers  severe hemodynamic instability may occur during operations to resect pheochromocytoma  we combined the alpha blocker phenoxybenzamine with the tyrosine hydroxylase inhibitor metyrosine in an attempt to better manage the hypertension of patients with pheochromocytoma undergoing surgical resection  this report reviews the cases of 25 consecutive patients undergoing surgery for known intra abdominal pheochromocytoma  each patient had elevated serum or urine levels of catecholamines or their metabolites  nineteen patients were prepared before operation with phenoxybenzamine and metyrosine and six patients were given phenoxybenzamine alone  there were no significant differences in maximum  minimum  or mean blood pressure before or after tumor resection between patients who received metyrosine and those who did not  however careful review suggested that those who received metyrosine had more severe disease as judged by biochemical criteria  study of selected patients matched for age and severity of disease suggested that the intraoperative blood pressure management of patients prepared with phenoxybenzamine and metyrosine was facilitated  in addition metyrosine prepared patients lost less blood and required less volume replacement during surgery than did non metyrosine prepared patients  there were no apparent differences in postoperative fluid requirements  although the study is not a prospective randomized trial  a retrospective review of patients managed with the combination of phenoxybenzamine and metyrosine suggests that surgery to resect pheochromocytoma can be better performed with both drugs than with phenoxybenzamine alone  the combination regimen appears to result in better blood pressure control  less blood loss  and the need for less intraoperative fluid replacement than does the traditional method of single agent alpha adrenergic blockade  
class4	strategy for lymphadenectomy in lung cancer three centimeters or less in diameter we have surgically treated 221 patients with a primary lung cancer 3 0 cm or less in diameter  there were 8 patients with a tumor 1 0 cm or less in diameter  group a   84 with a tumor 1 1 to 2 0 cm in diameter  group b   and 129 with a tumor 2 1 to 3 0 cm in diameter  group c   the incidence of n0  n1  and n2 disease was 100   0   and 0   respectively  for patients in group a  83   5   and 12  in group b  and 62   12   and 25  in group c  n0 versus n2  p less than 0 01   for the 63 patients with regional lymph node involvement   skipping  metastasis was present in 28 6   the 5 year survival rate was 80  for group a  74  for group b  and 51  for group c  group b versus group c  p less than 0 01   of the 121 patients who underwent complete resection and were followed up for 5 years  41  had recurrence  8  with local recurrence and 33  with distant metastasis  therefore  it is important to do as complete a resection as possible together with mediastinal lymphadenectomy  efforts to detect systemic spread should be made at the time of preoperative evaluation  even when the lung tumor is small  
class4	surgical management of pulmonary metastatic leiomyosarcoma with gross endobronchial extension  metastatic leiomyosarcoma occasionally is seen with gross endobronchial extension without invasion of the bronchial wall  these patients have major airway obstruction and partial or total atelectasis of the lung  precise bronchoscopic assessment coupled with intraoperative bronchotomy allows the surgeon to determine the origin of the tumor and to save uninvolved pulmonary parenchyma  our experience with 4 such patients illustrates the possibility of saving lung tissue despite total bronchial obstruction  
class4	giant chest wall tumor resulting from tissue reaction to foreign bodies  three patients are reported in whom chest wall tumors developed 19 to 28 years after thoracoplasty and increased in size with time  the tumors could be removed operatively with good results  all tumors were composed of hematoma and necrotic material  and in all cases they revealed foreign bodies microscopically  diagnosis and possible etiological factors are discussed  
class4	thoracoscopic treatment of spontaneous pneumothorax using carbon dioxide laser  in an effort to improve the success rate of the previously described thoracoscopic electrocautery ablation technique of spontaneous pneumothorax  the carbon dioxide laser was evaluated in 12 patients  the recurrent  5 patients  or persistent  7 patients  spontaneous pneumothoraces were caused by rupture of  1  blebs in 6 patients   2  intrapulmonary apical type ii bullae in 3 patients  and  3  diffuse bullous emphysema  type iii  in 3  the air leaks were successfully sealed in all but 1 patient with ruptured type ii bulla  surgical specimen from this single failure suggested that the entire inner lining of the bullae must be thermocoagulated  this technical modification led to successful outcome in 2 subsequent cases  with the use of carbon dioxide laser  it was possible to treat not only small blebs but all types of bullae causing spontaneous pneumothorax  laser thoracoscopy is effective and safe in treating spontaneous pneumothorax  
class4	vagal schwannoma  a patient with a benign encapsulated intrathoracic vagal schwannoma is presented and the literature is reviewed  the right paratracheal tumor was identified incidentally on a chest film and excised using a right thoracotomy  although rare  vagal schwannomas should be considered for any mediastinal mass along the vagus nerves especially when the paratracheal tumor produces minimal or no respiratory symptoms suggesting a slow growing  encapsulated process  
class4	successful fontan type operation for a nonresectable right ventricular tumor  a large intracavitary right ventricular tumor in a 24 year old patient was considered nonresectable because it involved the interventricular septum  the free ventricular walls  and the tricuspid valve  surgical palliation consisted of closure of the tricuspid and pulmonary valves  and the right atrium was anastomosed to the pulmonary artery bifurcation  the patient is asymptomatic 7 years after operation  and the neoplasm  a rhabdomyoma  has not increased in size  
class4	mediastinal hibernoma  a rare tumor  hibernoma is an uncommon soft tissue tumor that is derived from the remnants of fetal brown fat  review of the world medical literature revealed 90 cases  6 of which were intrathoracic  we present the seventh case of intrathoracic hibernoma  in this case  the hibernoma was within the mediastinum without direct invasion of other structures  
class4	acute hypercalcemic crisis after an open heart operation  acute hyperparathyroidism developed in a previously normocalcemic 64 year old woman during the first week after a coronary operation  prolonged qt interval in the electrocardiogram and hypercalcemia were documented on the fourth postoperative day  neck exploration on the fifth postoperative day revealed a lower right parathyroid adenoma  parathyroidectomy resulted in rapid and dramatic improvement of the clinical picture and normalization of laboratory values  
class4	long term results of operation for non small cell lung cancer in the elderly  we surgically treated 185 patients with non small cell lung cancer who were 70 years old or older  the operative mortality rate was 3   and the 5 year survival rate was 48   the mortality and prognosis were similar to those in younger patients  the number of elderly patients who smoked heavily or who had ventilatory defects was high  but the incidence of pneumonectomy was low  there were no differences based on age in regard to histological type  tnm classification  and curability  pulmonary complications occurred in 21  of the elderly patients and were correlated with preoperative pulmonary function and smoking habits  when the elderly are to undergo elective pulmonary resection for lung cancer  the preoperative evaluation of pulmonary function should be thorough  and both preoperative and postoperative physical therapy should be given  if postoperative pulmonary function is predicted to be less than 0 8 l m2 of vital capacity and 0 6 l m2 of forced expiratory volume in 1 second  a limited resection or nonsurgical therapy should be considered  
class4	congenital tracheoesophageal fistula associated with carcinoma of the lung in an adult  a rare case of adult congenital h type tracheoesophageal fistula was diagnosed  subsequently  at operation  large cell  undifferentiated carcinoma of the right middle lobe with extension to the right lobe and adherence to the diaphragm was documented  the diagnosis  surgical intervention  and 4 year follow up are presented  
class4	bronchial anomaly of the right upper lobe  this case report presents a rare anomaly of right upper lobe bronchial anatomy  during routine right upper lobe resection for carcinoma  a common right upper and middle lobe bronchus was found  the resection was completed as a right upper and middle bilobectomy  knowledge of this uncommon variant was beneficial in performing the pulmonary resection  a review of the literature is presented  
class4	squamous carcinoma metastatic to the sternum  a 63 year old man had a 10 x 16 cm sternal mass 18 months after a second aortocoronary bypass operation  the resected lesion was a metastatic tumor of squamous histology  no primary tumor was found  the diagnostic work up and treatment options are presented  
class4	malignant thymoma presenting as intracardiac tumor and superior vena caval obstruction  a case of malignant thymoma with intracardiac infiltration and intrinsic superior vena caval obstruction due to the tumor is reported  intracardiac invasion by a thymoma is rare and for this reason is believed worthy of a report  
class4	empiric treatment of fungal infections in the neutropenic host  review of the literature and guidelines for use  persistent fever that is refractory to broad spectrum antibacterials is common in neutropenic patients undergoing induction chemotherapy of acute leukemia  clinical experience suggests that many of these patients are infected with fungi  until recently  data supporting the role of empiric antifungal therapy in this setting were limited to small groups of patients or postmortem reports  evolving evidence in larger patient populations supports data from smaller series  febrile neutropenic patients who have failed to respond to a 4  to 7 day course of broad spectrum antibacterials may benefit from the early initiation of antifungal therapy  patients with fungal colonization or pulmonary infiltrates and adult patients who have not received previous fungal prophylaxis may especially benefit from the early use of antifungal drugs  amphotericin b has been the  gold standard  for empiric antifungal therapy  although the newer azoles may be useful in certain situations  
class4	systemic therapy in metastatic colorectal cancer  fluorouracil based chemotherapy regimens have been utilized in metastatic colorectal cancer for more than 30 years  early attempts at defining an optimal treatment schedule and use in combination with other drugs failed to significantly improve results  in contrast  the clinical effectiveness of fluorouracil has been improved by continuous infusion administration and modulation with folinic acid  both approaches have increased the response rate compared with results achieved with traditional bolus schedules  the effect on survival has been less significant  unfortunately  expense and  in some instances  toxicity have also been increased  which detracts from their overall usefulness  clinical studies that evaluate fluorouracil chemotherapy in combination with biological response modifiers are ongoing and will be areas of intense research during the next few years  
class4	acute renal failure in obstructive jaundice in cholangiocarcinoma  this study was aimed at defining the natural history of renal failure in obstructive jaundice due to cholangiocarcinoma  which is an important health problem in northeastern thailand  sixty four patients among a total of 130 patients with obstructive jaundice secondary to cholangiocarcinoma who developed acute renal failure were studied retrospectively  analysis was made with respect to clinical features  laboratory findings  and outcome  the development of renal failure before surgery was observed in all patients  it was nonoliguric in 80  and was associated with severe jaundice  gram negative infection  42    hypotension  31    hypoproteinemia  30    hyponatremia  56    and hypokalemia  63    the mean duration of renal failure was 2 weeks  all patients underwent surgery for the relief of jaundice  seventy seven percent of the patients survived and had recovery of renal function after the relief of jaundice  twenty three percent of the patients died of infection  clinical data highlight the higher serum bilirubin levels and the frequent occurrence of hyponatremia  hypokalemia  and hypotension in renal failure  their possible roles in contributing to the development of renal failure are discussed  
class4	medical comorbidity of major depressive disorder in a primary medical practice  despite much speculation about the relationship between depression and medical comorbidity in primary care settings  few investigators have examined this issue empirically  using a two stage screening procedure  we assessed 618 patients aged 18 to 64 years in an academic general medicine clinic  forty one patients  6 6   suffered from a current episode of major depressive disorder  mdd   we compared this group with a 20  random sample of nondepressed patients  while patients with mdd were younger  mean age  41 1 vs 47 2 years   they were assessed by the duke university severity of illness scale as having more severe medical illness  patients with mdd were more likely to have malignant tumors and  ill defined conditions  than nondepressed patients  the 18 patients with mdd  44   who were correctly diagnosed by their physicians had less severe medical illness than those whose depression was clinically undetected  a logistic regression model predicting mdd group membership included female gender  younger age  higher duke university severity of illness scale score  and more frequent inactive ill defined diagnoses  these findings are consistent with assertions   1  patients with mdd have more physical illness than nondepressed patients and or  2  somatic symptoms and disability caused by mdd add to the burden of physical illness  
class4	pheochromocytoma presenting as rhabdomyolysis and acute myoglobinuric renal failure  we report the case of a previously healthy young woman who presented with the sudden onset of rhabdomyolysis and myoglobinuric renal failure  requiring hemodialysis for 3 weeks  common causes of rhabdomyolysis were ruled out  as renal function returned  severe hypertension was noted and a pheochromocytoma was diagnosed  we suggest that pheochromocytoma causes rhabdomyolysis and myoglobinuria via catecholamine mediated vasoconstriction and skeletal muscle ischemia  
class4	lower extremity weakness as the initial manifestation of lung cancer  published erratum appears in arch phys med rehabil 1991 jan 72 1  61  a 55 year old woman had progressive lower extremity weakness  she had an 80 pack per year history of cigarette smoking  electromyographic findings were consistent with the lambert eaton myasthenic syndrome  despite a normal chest x ray  normal laboratory studies  and negative bronchoscopy  investigation for lung cancer was pursued  the final thoracotomy and pathology reports indicated a diagnosis of oat cell carcinoma  after treatment with chemotherapy and radiation therapy  clinical and electrophysiologic findings have resolved  two years after diagnosis  the patient remains in good health without evidence of recurrence  
class4	needle localized mammographic lesions  results and evolving treatment strategy  from january 1981 to december 1987  932 needle localization breast biopsies were performed at our institution for mammographically detected abnormalities  we reviewed 531 needle localization breast biopsy procedures performed during two periods  january 1981 to june 1984  n   311  and january to august 1987  n   220  to compare results and treatment patterns  and to determine the prevalence of the missed lesions  mammographic abnormalities detected on routine screening accounted for a larger proportion of needle localization breast biopsies in the later series  94  30   of 311 vs 94  43   of 220   however  the rate at which carcinoma was identified remained constant at 29  as did the percentage of cancers that were invasive  46  vs 51    overall  the rate of malignant diagnoses after needle localization breast biopsy was lowest in asymptomatic women undergoing routine screening mammography  44  24   of 188  and significantly higher in women undergoing mammographic follow up of the contralateral breast after treatment for breast cancer  28  43   of 65   there were seven missed lesions in 531 needle localization breast biopsies  necessitating a second procedure in six and interval mammograms in one  
class4	hepatic vein reconstruction for preserving remnant liver function  hepatic malignancies often infiltrate to the major hepatic vein  recently  we performed hepatic resection combined with hepatic vein reconstruction for preserving remnant liver function in three such patients  one patient had a saphenous vein graft  postoperative liver function of the patients who underwent hepatic vein reconstruction was compared with those of eight patients who underwent hepatic resection of segments vii and viii  the right hepatic vein in four of them was resected and in the remaining four was preserved by skeletalization using an ultrasonic aspirator  although four patients with right hepatic vein resection showed severe lowering of liver function after surgery  the postoperative course of patients with preservation or reconstruction of the right hepatic vein maintained good liver function  liver regeneration of three patients with hepatic vein reconstruction was good on computed tomography  besides this report  to our knowledge  there is no other report of hepatic vein reconstruction for preserving the remnant liver function  problems with hepatic resection combined with hepatic vein reconstruction are discussed  we conclude that hepatic vein reconstruction is one of the means for extending indication of the malignant tumor resection of the liver  
class4	primary malignant peritoneal mesothelioma  a report of seven cases and a review of the literature  mesothelioma of the peritoneum is a rare malignant neoplasm easily mistaken by both surgeon and pathologist for one of the more common neoplasms of the abdomen  review of our records from metropolitan area hospitals for the past 15 years identified seven patients with primary peritoneal mesotheliomas  their diagnosis  management  and survival is analyzed  we report a case of an extended survivor  7 years  and one of a long term survivor  15 years   as well as what we believe to be the only case in the literature presenting with a coexistent malignant neoplasm  prevention of this commonly fatal neoplasm is linked to avoiding occupational exposure to asbestos  long term survival for a few patients may be achieved with correct identification of the neoplasm and aggressive management  this report includes a review of the literature  
class4	management of perineal wounds following abdominoperineal resection with inferior gluteal flaps  our experience treating perineal wounds secondary to abdominoperineal resection  either for inflammatory bowel disease or cancer  is presented  a total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection  all wounds were closed using the inferior gluteal myocutaneous flap  fifteen of 16 patients have achieved healing  eight of whom had no complications  only minor revisions or local wound care were required in the remaining patients  with only one patient failing to heal  our results compare favorably with previous reports of treatment of this difficult problem  
class4	the papillary cystic neoplasm of the pancreas  an increasingly recognized clinicopathologic entity  the clinical course of the papillary cystic neoplasm of the pancreas is contrasted with that of the pancreatic ductal adenocarcinoma  the former occurs predominantly in young women  has a low malignant potential  and is highly curable with surgical treatment  three cases are reported that illustrate the typical clinical features and the indolent nature of the tumor  one case was discovered after blunt abdominal trauma resulted in rupture of the tumor and hemoperitoneum  all cases were treated by pancreatic resection with preservation of the spleen  an important consideration in younger patients  all patients were free of disease at long term follow up  increasing awareness of this tumor has resulted in the reclassification of several tumors and should lead to better recognition by surgeons caring for patients with pancreatic diseases  
class4	retrovirus from human t cell leukemia virus type i associated myelopathy is the same strain as a prototype human t cell leukemia virus type i  a retrovirus was isolated from a t cell line that was established from lymphocytes in the cerebrospinal fluid of a patient with human t cell leukemia virus type i associated myelopathy  ham   and its genome was sequenced  the nucleotide sequence of the 3  half of the total genome was identical in 99 5  of the nucleotides to that of the prototype human t cell leukemia virus type i that was derived from a patient with adult t cell leukemia  these results indicate that the same retrovirus human t cell leukemia virus type i is associated with both a neurological disease  ham  and a lymphoproliferative disease  adult t cell leukemia  
class4	molecular phenotype of a pediatric small round cell tumor  molecular probes were used to characterize an unusual small round cell abdominal tumor arising from the fallopian tube of a 15 year old girl  dna and rna extracted from the tumor and adjacent normal tissue was subjected to southern and northern blot analysis using a variety of different probes  n myc oncogene rna was greatly expressed in the tumor  but was not expressed in normal tissue or amplified in chromosomal dna  insulin like growth factor ii rna was similarly overexpressed in the neoplasm  but not in normal tissue  while histopathologic studies could not distinguish between a neuroectodermal neoplasm and wilms  tumor  electron microscopy and the pattern of gene expression was most consistent with wilms  tumor  
class4	decrease in cerebral metabolic rate of glucose after high dose methotrexate in childhood acute lymphocytic leukemia  we measured changes in the regional cerebral metabolic rate of glucose  rcmrglu  using 18f fluorodeoxyglucose and positron emission tomography for the assessment of neurotoxicity in childhood acute lymphocytic leukemia treated with high dose methotrexate  hd mtx  therapy  we studied 8 children with acute lymphocytic leukemia  mean age  9 6 years  treated with hd mtx  200 mg kg or 2 000 mg m2  therapy  cmrglu after hd mtx therapy was most reduced  40   in the patient who had central nervous system leukemia and was treated with the largest total doses of both intrathecal mtx  it mtx  and hd mtx  cmrglu in the whole brain after hd mtx therapy was reduced by an average of 21   p less than 0 05   the reductions of cmrglu in 8 patients were correlated with total doses of both it mtx  r   0 717  p less than 0 05  and systemic hd mtx  r   0 784  p less than 0 05   cmrglu of the cerebral cortex  especially the frontal and occipital cortex  was reduced more noticeably than that of the basal ganglia and white matter  we suggest that the measurement of changes in rcmrglu after hd mtx therapy is useful for detecting accumulated mtx neurotoxicity  
class4	photodynamic therapy with chloroaluminum sulfonated phthalocyanine  to study the vascular effects of a new photosensitizing agent independent of the influence of tumor growth  a cutaneous wound model was used  six week old harlan sprague dawley  fuzzy  rats were surgically wounded in a standard fashion  the animals were then divided into three groups  the first group received chloroaluminum sulfonated phthalocyanine only  the second group was treated with light only  and a third group was treated with both chloroaluminum sulfonated phthalocyanine and light  photodynamic therapy with chloroaluminum sulfonated phthalocyanine had a direct effect on the neovasculature of a healing wound  the vasodilatation that was seen in the wound neovasculature that occurred 12 hours after the completion of chloroaluminum sulfonated phthalocyanine photodynamic therapy may have indicated a therapeutic  window  at which other therapies can be employed to improve clinical efficacy  
class4	photodynamic therapy in the treatment of squamous cell carcinoma of the head and neck  photodynamic therapy is an experimental modality for tumor treatment based on the combined action of the tumor localizing agent  ie  hematoporphyrin derivative  and red light  from 1985 through 1989  26 patients were treated using hematoporphyrin derived drugs and 630 nm light delivered by a tunable dye laser  all patients had biopsy proved squamous cell carcinoma of the head and neck  and they had either failed the traditional treatment modalities or refused conventional therapies  histological complete responses were achieved in 20  77   of 26 patients and partial responses in 5  19   of 26 patients for periods up to 48 months  only minimal toxic reaction was noted in the group  as a guide to treatment planning for a patient group with large tumors  we used an optical dosimetry model based on tissue optics  the rate of complete responses to this treatment was 8  73   of 11  our data indicate that photodynamic therapy is capable of inducing significant clinical and histological responses in the majority of those treated  and in some patients a prolonged response is produced  in certain select head and neck malignancies  photodynamic therapy has an important role as a treatment modality  
class4	leiomyosarcoma of the sinonasal tract  a clinicopathologic study of nine cases  the clinicopathologic features of nine cases of sinonasal tract leiomyosarcoma  sntl  referred to the armed forces institute of pathology  washington  dc  during the period from 1970 through 1988 are described  this report represents the largest study to date on sntl  and our results are compared with the 21 previously reported cases of sntl  of the nine cases described  patients ranged in age from 22 to 86 years  mean  55 years   the most frequent clinical presentation was nasal obstruction unilaterally  the neoplasms were limited solely to the nasal cavity in four cases  44   and involved both the nasal cavity and paranasal sinuses in the remaining five cases  light microscopic  immunocytochemical  and ultrastructural features served to characterize these tumors as malignant neoplasms of smooth muscle origin  in contrast with previous studies  immunocytochemistry was employed to differentiate sntl from other spindle cell malignancies of the region  using newly available monoclonal antibodies to smooth muscle antigens  treatment was surgical  radiotherapy or chemotherapy did not appear to affect the progression of the disease  furthermore  no relationship was found between the aggressiveness of sntl and morphologic parameters  eg  mitotic count and tumor size   instead  prognosis was dependent on the distribution of disease at presentation  of all 30 patients with sntl described to date  10 had the neoplasm confined solely to the nasal cavity  the 10 neoplasms did not recur  we conclude that sntl may best be regarded as a locally aggressive neoplasm with only limited metastatic potential and that it could be curable by complete surgical excision  
class4	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  
class4	improving diagnostic accuracy of cervical metastases with computed tomography and magnetic resonance imaging  elective neck dissection in patients with head and neck cancer continues to be controversial  the management of these patients would be greatly facilitated by improvements in predicting cervical metastases  recent investigations have suggested that computed tomography and magnetic resonance imaging are more sensitive in detecting cervical metastases than physical examination  the department of otolaryngology at the ohio state university hospitals  columbus  undertook a prospective study to compare the preoperative sensitivities of physical examination  computed tomography  and magnetic resonance imaging with pathologic findings in 27 patients undergoing neck dissections for head and neck cancer  the results indicate that computed tomography and magnetic resonance imaging were more sensitive  84  and 92   respectively  than physical examination  75    although the results did not achieve statistical significance  the sensitivity of combined computed tomography and magnetic resonance imaging was 90   
class4	the in vivo biologic effect of interleukin 2 and interferon alfa on natural immunity in patients with head and neck cancer  given the association of deficient natural immunity with the risk of metastatic disease  the ability to activate natural killer cell function may have a therapeutic significance  the effect of continuous infusion of interleukin 2 plus intramuscular interferon alfa on natural immune status was  therefore  analyzed in eight patients with head and neck cancer  also evaluated was the effect of interleukin 2 interferon alfa therapy on lymphokine activated killer cell activity as well as total lymphocyte count  percent of lymphocyte subsets  and levels of both circulating immune complexes and antibody classes  both the percent and absolute number of natural killer cells  ie  cd56  cd3  lymphocytes  within peripheral blood as well as natural killer cell activity against k562 targets increased significantly with treatment  the remaining immune parameters were not significantly altered  the demonstrated capacity to modulate natural immune function supports the potential use of interleukin 2 containing regimens as a preventive measure against metastatic disease in patients with head and neck cancer  
class4	metastasizing pleomorphic adenoma of the nasal septum  pleomorphic adenoma is the most common benign tumor of glandular tissue occurring in the head and neck region  there have been several reports of metastasis of this benign appearing tumor from the salivary glands to distant sites  suggesting hematogenous spread and implantation  although occurrence of pleomorphic adenoma on the nasal septum has been described  to our knowledge this is the first reported case of recurrent septal pleomorphic adenoma with histologically benign tissue in an enlarged metastatic ipsilateral submandibular lymph node  suggesting lymphatic spread  the literature concerning the subject is reviewed  wide septal excision and modified neck dissection is the recommended treatment  
class4	chondrosarcoma of the larynx  diagnosis with magnetic resonance imaging and computed tomography  chondrosarcomas are the most common sarcomas of the larynx  they are generally slow growing lesions with insidious onset of symptoms  we are presenting a case of chondrosarcoma that recurred 10 years after excision of a presumed chondroma  computed tomographic and magnetic resonance imaging  mri  scans were performed  both studies delineated the lesion nicely  to the best of our knowledge  this is the first report on mri characteristics of chondrosarcoma of the larynx  a review of the literature regarding the use of computed tomography in the management of chondrosarcoma is presented  the mri characteristics are discussed and the two scanning modalities are compared  computed tomography is an excellent study in its ability to demonstrate the extent of the lesion within the laryngeal skeleton  furthermore  it is more highly sensitive than plain roentgenograms in the detection of calcifications that are highly suggestive of chondrosarcoma  alternatively  mri can also demonstrate the lesion within the larynx but it has the added advantage of superior contrast resolution of the tumor and paralaryngeal tissues  when the three dimensional imaging capacity of mri is considered as well  mri seems to be the superior study  
class4	reliability of colposcopy and directed punch biopsy a group of 118 women underwent laser cone biopsy  data were collected routinely on proforma case notes and entered into a computerized database  the histology of the cone biopsies was compared with that of previous  colposcopically directed punch biopsies  with the cytology of smears taken in the clinic and with the colposcopic diagnosis  the punch biopsy had a 54  false negative rate and neither of the two microinvasive carcinomas biopsied in this way were detected by the biopsy  ten of 24 women with negative punch biopsies had cin iii in the cone  when the punch biopsy showed cin ii or worse  the cone biopsy confirmed the presence of cin in 86   there was some evidence of false negative cone biopsies  the data suggest that management should not be based solely upon the punch biopsy result but should include consideration of the cytology and colposcopy findings  excisional methods of treatment are more likely to reveal early invasion and adenocarcinoma in situ  
class4	the management of primary fallopian tube carcinoma  the outcome of 30 patients with primary fallopian tube carcinoma is described  treatment varied over the 22 year period of accrual and included combinations of surgery  radiotherapy and chemotherapy  there was an apparent increase in stage at treatment with time which was probably related to more precise staging at laparotomy and the greater use of computerized tomography  the median survival for all patients was 28 months and the 5 year survival was 18   ten patients received postoperative chemotherapy for residual disease with an overall response rate of 80  and median progression free and overall survival times of 14 and 21 months respectively  the pattern of relapse was similar to that seen in ovarian carcinoma  with all but one patient having the pelvis or abdomen as the main site of recurrence  primary fallopian tube carcinoma has a response to treatment and a tumour biology similar to that of ovarian carcinoma  it is recommended that the management of this uncommon malignancy should continue to be along the lines of ovarian carcinoma  with initial treatment by cytoreductive surgery followed by chemotherapy or radiotherapy for residual disease  
class4	interleukin 6  il 6  is an intermediate in il 1 induced proliferation of leukemic human megakaryoblasts  we have examined the in vitro effects of recombinant human  rh  interleukin 1  il 1  on the growth of purified megakaryoblasts obtained from patients with acute megakaryoblastic leukemia  we demonstrate that both il 1 alpha and il 1 beta treatment of these cells led to stimulation of dna synthesis  as shown by increase of 3h thymidine incorporation up to 35 fold  and also resulted in colony formation of leukemic megakaryoblasts  however  the stimulatory effect of il 1 was dependent on endogenous production of il 6  because addition of neutralizing monoclonal antibody  moab  to il 6 abrogated the stimulatory activity of il 1  in contrast  neutralizing moabs to granulocyte  g  colony stimulating factor  csf   granulocyte macrophage  gm  csf  and macrophage  m  csf failed to counteract the growth enhancing effects of il 1  leukemic megakaryoblasts accumulated il 6 mrna and released il 6 protein into their culture supernatant when exposed to rh il 1 but failed to disclose transcripts for g   gm   and m csf under these conditions  analysis of il 6 receptor  il 6r  transcript levels demonstrated that megakaryoblasts constitutively expressed il 6r mrna and that these transcripts are down regulated to undetectable levels upon exposure to il 1 and il 6  increase of 3h thymidine incorporation by megakaryoblasts could be duplicated by exogenous il 6 that could be blocked by neutralizing moab to il 6  in conclusion  our results suggest that leukemic megakaryoblasts could produce and secrete il 6  and express il 6r  and that the growth enhancing effect of il 1 on these cells is indirect  via production of il 6 by leukemic cells  
class4	induction of in vitro graft versus leukemia activity following bone marrow transplantation for chronic myeloid leukemia  we studied the in vitro effects of lymphokine activated killer  lak  cells from the peripheral blood of chronic myeloid leukemia  cml  patients after allogeneic and syngeneic bone marrow transplantation  bmt   lak cells were generated by incubating peripheral blood mononuclear cells from patients post bmt with recombinant interleukin 2  il 2   500 u ml  in 10  ab serum for 7 days  they were phenotyped and tested for activity in a standard 4 hour 51cr release assay  n   37  and in a cfu gm assay  n   24   we found that the lak cells were mainly activated natural killer cells  but some were cd3  t cells  in the 51cr release assay lak cells from 20 of 33  61   allogeneic and 2 of 4 syngeneic recipients killed recipient cml cells and in 22 of 37  60   cases also killed the hla disparate cml cells  in the cfu gm assay the lak cells incubated together with the cml cells in liquid culture before plating inhibited  p less than  05  colony growth in 16 of 22 allogeneic and 2 of 2 syngeneic recipients  cell cell contact was necessary for optimal effect  there was little or no inhibition of proliferation of donor marrow cfu gm  this in vitro graft versus leukemia  gvl  effect could also be demonstrated after lak effectors were depleted of cd3  t cells  it was inducible in recipients of both t cell depleted and t cell replete donor marrow and in recipients with or without graft versus host disease  these results suggest that a major histocompatibility complex unrestricted gvl effect is inducible following allogeneic and syngeneic bmt  the use of il 2 lak cells after bmt could reduce the risk of relapse  
class4	deletion of the human retinoblastoma gene in primary leukemias  as an initial step in evaluating the role of tumor suppressor genes in leukemogenesis  we surveyed primary leukemia cells from 130 patients for possible deletion of the retinoblastoma susceptibility  rb  gene by southern blot analysis  two of them clearly showed homozygous deletion of rb alleles  the first patient was a pre b acute lymphoid leukemia  all  associated with a cytogenetic translocation  t 14 16  q24 q22   the deletion was located at the 3  portion of the rb gene  very close to the site of rb gene deletion recently identified in an all cell line  the absence of rb110 protein was further confirmed by western blot analysis  the second patient was a chronic myelomonocytic leukemia  cmmol   terminated in acute blastic transformation  deletion of the 5  portion of rb gene was found in leukemic cells in the chronic stage  the results indicated that inactivation of the rb gene occurred in certain cases of leukemia  its significance warrants further study  
class4	expression of p glycoprotein in adult t cell leukemia cells  we have examined the expression of p glycoprotein  p gp  in adult t cell leukemia  atl  samples from 25 patients  based on immunoblotting with a monoclonal antibody against p gp  c219  8 of 20 atl patients were p gp positive at the initial presentation  all 6 patients at the relapsed stage were p gp positive  and refractory to chemotherapy  the expression of mdr1 mrna in p gp positive atl cells was increased at the relapsed stage of one patient  p gp of this patient was photolabeled with  3h azidopine and the labeling was inhibited with nimodipine  vinblastine and progesterone  these results suggest that p gp expressed in atl cells from patients at relapsed stage has the same binding site s  for the drugs as that in multidrug resistant cells  and is correlated with the refractory nature of the cells to chemotherapy  
class4	association of bcl 1 rearrangements with lymphocytic lymphoma of intermediate differentiation  previous studies using classical cytogenetics have demonstrated the presence of the t 11 14   q13 q32  chromosomal translocation in some cases of lymphocytic lymphoma of intermediate differentiation  idl   a distinct type of low grade b cell lymphoma  this finding suggested that the bcl 1 region  located at band q13 of chromosome 11  might be involved in this neoplasm  using a genomic probe from the major breakpoint area of the bcl 1 locus  we identified rearrangements of the bcl 1 region in 10 of 19 cases  2 of which comigrated with a rearranged allele of the immunoglobulin heavy chain gene joining region  in contrast  bcl 1 rearrangements were not found in other types of low grade b cell lymphoma  specifically in 36 cases of chronic lymphocytic leukemia small lymphocytic lymphoma  cll sll  and 27 cases of follicular lymphoma  fl   to further assess the molecular pathology of idl  we analyzed these cases for rearrangements of the bcl 2 proto oncogene  which is associated primarily with follicular lymphomas  none of the 19 cases of idl had rearrangements  furthermore  none of the 36 cases of cll sll showed bcl 2 rearrangements  whereas  as expected  21 of 27 cases of fl had rearrangements of the bcl 2 locus  our findings demonstrate an association between a rearranged bcl 1 region with approximately 50  of idls and suggest that abnormalities of this locus may be important in the pathogenesis of idl  
class4	psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial objectives  to assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon s opinion or the patient s choice  to determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial  design  prospective  multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer  setting  12 district general hospitals  three london teaching hospitals  and four private hospitals  patients  269 women under 75 with a probable diagnosis of stage i or ii breast cancer who were referred to 22 different surgeons  interventions  surgery and radiotherapy or adjuvant chemotherapy  or both  depending on the individual surgeon s stated preferences for managing early breast cancer  main outcome measures  anxiety and depression as assessed by standard methods two weeks  three months  and 12 months after surgery  results  of the 269 women  31 were treated by surgeons who favoured mastectomy  120 by surgeons who favoured breast conservation  and 118 by surgeons who offered a choice of treatment  sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery  and 43 of these chose breast conserving surgery  the incidences of anxiety  depression  and sexual dysfunction were high in all treatment groups  there were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy  a significant effect of surgeon type on the incidence of depression was observed  with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons  p   0 06   there was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose  most of the women  159 244  gave fear of cancer as their primary fear rather than fear of losing a breast  the overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the cancer research campaign breast conservation study  at 12 months 28  of women who underwent mastectomy in the present study were anxious compared with 26  in the earlier study  and 27  of women in the present study who underwent lumpectomy were anxious compared with 31  in the earlier study  in both the present and earlier study 21  of women who underwent mastectomy were depressed  and 19  of women who underwent lumpectomy in the present study were depressed compared with 27  in the earlier study   conclusions  there is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy  women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological  sexual  or social problems from those women who are treated for breast cancer outside a clinical trial  
class4	chronic anaemia  hyperbaric oxygen and tumour radiosensitivity  anaemia is an important factor in the response of some human tumours to radiotherapy  the outcome is also influenced by whether the treatment is given in air or high pressure oxygen  hpo   the present study examined the relationship between anaemia and tumour response to radiation given in air or hpo in c3h mice transplanted with a mammary adenocarcinoma using a growth delay assay to assess the radiation response  chronic anaemia was induced by the use of a low iron diet and was characterized by a significant reduction in host haematocrit and whole blood viscosity  in addition  anaemia was associated with a right shift in the oxyhaemoglobin dissociation curve and an increase in the volume doubling time of the tumour  but there was no change in the concentration of 2 3 diphosphoglycerate in the red cells  radiation studies with these anaemic mice demonstrated that the tumour radiosensitivity was decreased when treatment was given in air  hpo was successful in overcoming the increased radioresistance associated with anaemia  this result suggested that tumours grown in anaemic mice have a higher hypoxic fraction than those grown in control mice  changes in host physiology with chronic anaemia may contribute to the benefit seen with hpo but such alterations per se may be inadequate to maintain tumour oxygenation when treatment is given in air  
class4	lipiodol computerized tomography  how sensitive and specific is the technique in the diagnosis of hepatocellular carcinoma  computerized tomography  ct  following the intra arterial injection of lipiodol  lipiodol ct  was performed on 60 patients suspected of having a hepatocellular carcinoma  hcc   four main patterns of uptake of the lipiodol within the liver were seen on ct  of the 14 well circumscribed lesions with dense homogeneous uptake of lipiodol  13 were confirmed to be hccs  of the 25 lesions with dense patchy uptake of lipiodol at the periphery and or in the centre  19 were confirmed to be hccs  in 18 patients  in whom only ill defined faint patchy uptake of lipiodol was present in the liver  or in whom no hepatic uptake was present at all  only one patient was found later to have an hcc  of the three hypodense lesions in the liver with no lipiodol uptake  one was found to be necrotic hcc  one a cholangiocarcinoma and one a regenerative nodule  in the diagnosis of hcc  lipiodol ct had an overall sensitivity of 97 1   an accuracy of 88 3  and a specificity of 76 9   of the 34 patients with hcc  only 23 were solitary at diagnosis  the size of the hccs ranged from 0 8 cm to 11 cm in diameter with the median size at 2 2 cm  eleven of 34 hccs  32 3   were resectable  we conclude that  as part of a screening programme for high risk patients  lipiodol ct is useful in the early detection of hccs  the technique also plays an important role in determining whether the tumour should be resected or managed with chemotherapy  by detecting hccs while still small  the resectability rate can also be improved  
class4	choroid plexus cysts and chromosomal defects during a 4 year period  83 pregnant women with fetal choroid plexus cysts were investigated in our unit  abnormal karyotypes were found in 20 fetuses  including trisomy 18  n   16   trisomy 13  n   1   triploidy  n   1  and translocation down s syndrome  n   2   all fetuses with chromosomal defects had structural malformations in addition to the choroid plexus cysts  
class4	clinical management of port wine stain in infants and young children using the flashlamp pulsed dye laser  the flashlamp pulsed dye laser  flpdl  at 585 nm  a wavelength well absorbed by oxyhemoglobin  causes highly selective vascular injury  in addition  the 450 microsecond pulse duration produced by this laser approximates the thermal relaxation time for dermal blood vessels thereby confining the energy to the target  this new laser effects excellent lightening of port wine stain  pws  in infants and young children without the adverse complications of hypertrophic scarring  permanent pigmentation abnormality  or textural changes  complications often seen with conventional laser systems  the flpdl now permits treatment of this patient population expected to gain the most benefit from early laser therapy in a much safer manner  before the psychological complications of being a  marked  person develop  the purpose of this report is to   1  describe the theoretical considerations behind achieving selective removal of pws that can be understood and used by a nonsurgically oriented practitioner  and  2  describe the practical application of the device used in the clinical management of infants and young children  
class4	predictive value of congenital hypertrophy of the retinal pigment epithelium as a clinical marker for familial adenomatous polyposis  one hundred forty eight members of 53 kindreds with familial adenomatous polyposis  fap  were examined for congenital hypertrophy of the retinal pigment epithelium  chrpe  and extracolonic manifestations  ecm  to assess the value of chrpe as a predictive marker for fap  based on eye examination results  the families were divided into 2 groups  in a first group of 34 families  all 61 members diagnosed as having polyps and 13 of the 33 patients at risk had 4 or more lesions distributed in both eyes  by contrast  in a second group of 18 families  all 32 polyposis patients and all 18 members at risk had less than 4 lesions  extra colonic manifestations were present in 26 of 34 families in the first group and in 11 of 18 families in the second group  data on one family with ambiguous ancestry were reviewed separately  the existence of 4 or more chrpe lesions distributed in both eyes seems to be a congenital marker for fap  present in 65 4 percent of families  when present in a family  1  it is found in all diagnosed patients in that family  2  can therefore be considered predictive for the development of polyps in other family members who carry the trait  and 3  if confirmed by longer follow up  may possibly preclude members without the trait from further evaluation and surveillance  
class4	effects of preoperative radiotherapy on rectal cancer  preliminary report on combining radiation with intratumor injections of peplomycin and bromodeoxyuridine  between 1976 and 1983  61 patients with advanced rectal cancer underwent miles  operation at the authors  institution  all lesions were located 10 cm or less from the anal verge  of these patients  25 were treated by surgery alone and 36 were given preoperative radiotherapy  the total dose was 42 6 gy   30 6 gy  1 8 gy fr x 5 week   delivered to the entire pelvis plus an additional 12 gy  3 0 gy fr x 4 week  delivered to the primary tumor  of 36 patients  21 were administered intratumor injections of peplomycin and bromodeoxyuridine at the time of boost radiation and 15 were treated without intratumor injections  during the follow up period  3 to 9 years   in the groups of patients who underwent radiation  there was only one local failure  2 8 percent   in contrast  in the group of patients treated by surgery alone  eight local failures occurred  32 percent   the intratumor injection significantly enhanced the effect of radiation on tumor regression  the incidence of positive lymph nodes was higher in patients in the surgery alone group than it was in the groups treated with radiation  there was no difference in the rate of distant metastasis among the three treatment groups  the five year survival rate for the radiation with intratumor injection group  radiation alone group  and surgery alone group  was 77 8  69 2  and 56 0 percent  respectively  no severe complication was experienced  
class4	erythrocyte stearic acid desaturation in patients with colorectal carcinoma  the erythrocyte stearic oleic acid ratio  saturation index  was investigated as a means of differentiating between control subjects  n   146  and patients with benign  n   48  and malignant  n   117  colorectal disease and patients undergoing postoperative follow up after curative resection  n   49   erythrocyte fatty acid profiles were determined by gas liquid chromatography  neither age  sex  dukes  stage  nor degree of differentiation of the tumors had a significant effect on the erythrocyte saturation index  the erythrocyte saturation index was lower in patients with primary and recurrent colorectal cancer compared with control subjects and patients with inflammatory bowel disease or benign colonic polyps  p less than 0 0001   the erythrocyte saturation index was not found to be useful in the postoperative follow up of these patients  using both saturation index and age as a means of differentiating between patients with primary colorectal cancer and control subjects gave a sensitivity of 67 percent and a specificity of 81 percent  
class4	nitrite from inflammatory cells  a cancer risk factor in ulcerative colitis  elevated levels of luminal nitrite and a lowered luminal ph were found in 77 percent of patients with acute ulcerative colitis  no luminal nitrite was found in healthy control subjects  nitrites are a secretory product of activated macrophages and neutrophils of the lamina propria  whereas the lowered luminal ph is due to diminished bicarbonate formation by impaired colonocytes  a hypothesis is put forward that nitrites  lowered ph  and bacterial amines are conducive to formation of carcinogenic n nitroso compounds  which reflect a cancer risk in patients with ulcerative colitis dependent on the type and extent of inflammatory cell activation as well as metabolic impairment of colonic epithelial cells  
class4	passage of a colon  cast  after anoabdominal rectal resection  report of a case  the authors report a case of the passage of a total colonic j pouch  cast  per anus after anoabdominal rectal resection and colonic j pouch anal anastomosis  this occurred without development of cuff abscess and was not due to occlusion of the inferior mesenteric artery  this was successfully treated  with preservation of anal function  with resection of the colonic j pouch by transanal approach  
class4	characterization in vitro of a human tumor necrosis factor binding protein  a soluble form of a tumor necrosis factor receptor  tumor necrosis factor  tnf  is a pleiotropic mediator of inflammatory responses  a cysteine rich  highly glycosylated 30 kd tnf binding protein  tnf bp  purified from urine may have a role in regulation because it protects in vitro against the biological effects of tnf  the cytotoxic effect of tnf on the fibrosarcoma cell line wehi 164 was inhibited by 50  at a 10 fold excess of tnf bp  the binding of tnf to the receptor was partially reversed after the addition of tnf bp  results from biosynthetic labeling of cells with 35s cysteine followed by immunoprecipitation with anti tnf bp indicated that tnf bp is formed and released at the cell surface by cleavage because no corresponding cellular polypeptide was observed  a cellular 60 kd polypeptide  which was immunoprecipitated with anti tnf bp  may correspond to the transmembrane tnf receptor molecule and be the precursor of tnf bp  thus  tnf bp appears to be a soluble form of a transmembrane tnf receptor  moreover our results demonstrate that the production of tnf bp is increased when the tnf receptor is downregulated in cells by treatment with tnf or by activation of protein kinase c with phorbol esters  tnf bp may be an important agent that blocks harmful effects of tnf  and  therefore  useful in clinical applications  
class4	whole body lipolysis and triglyceride fatty acid cycling in cachectic patients with esophageal cancer  whole body lipolytic rates and the rate of triglyceride fatty acid cycling  reesterification of fatty acids released during lipolysis  were measured with stable isotopic tracers in the basal state and during beta adrenergic blockade with propranolol infusion in five cachectic patients with squamous cell carcinoma of the esophagus  five cachectic cancer free  nutritionally matched control patients  and 10 healthy volunteers  resting energy expenditure and plasma catecholamines were normal in all three groups  the basal rate of glycerol appearance in blood in the patients with cancer  2 96     0 45 mumol kg 1 min 1  was similar to that in the nutritionally matched controls  3 07     0 28 mumol kg 1 min 1   but 48  greater than in the normal weight volunteers  2 00     0 16 mumol kg 1 min 1   p   0 028   the antilipolytic effect of propranolol and the rate of triglyceride fatty acid cycling in the patients with cancer were also similar in the cachectic control group and approximately 50  greater than in the normal weight volunteers  but the differences were not statistically significant because of the variability in the data  we conclude that the increase in lipolysis and triglyceride fatty acid cycling in  unstressed  cachectic patients with esophageal cancer is due to alterations in their nutritional status rather than the presence of tumor itself  increased beta adrenergic activity may be an important contributor to the stimulation of lipolysis  
class4	potent toxicity of 2 chlorodeoxyadenosine toward human monocytes in vitro and in vivo  a novel approach to immunosuppressive therapy  lymphoid cells were thought to be uniquely susceptible to excess 2  deoxyadenosine  dado   when exposed to inhibitors of adenosine deaminase  ada   however  we now find that human monocytes are as sensitive as lymphocytes to dado or to the ada resistant congener 2 chloro 2  deoxyadenosine  cldado   monocytes exposed in vitro to cldado  or to dado plus deoxycoformycin rapidly developed dna strand breaks  both the dna damage and the toxicity of cldado or dado toward monocytes were blocked by deoxycytidine  but not by inhibitors of poly adp ribose  polymerase  a partial decrease in rna synthesis and a gradual decline of cellular nad were early biochemical events associated with monocyte dna damage  low cldado concentrations  5 20 nm  inhibited monocyte phagocytosis and reduced the release of interleukin 6  higher cldado concentrations led to a dose  and time dependent loss of monocyte viability  circulating monocytes disappeared within 1 wk in patients with cutaneous t cell lymphoma or with rheumatoid arthritis during continuous cldado infusion  the marked sensitivity of human monocyte function and survival to cldado in vitro  together with the monocyte depletion in patients receiving cldado chemotherapy  suggests that cldado or other dado analogues offer a novel therapeutic strategy for chronic inflammatory and autoimmune diseases characterized by inappropriate monocyte deployment or function  
class4	elevated insulin receptor content in human breast cancer  the growth of breast cancer cells is under the regulation of hormones  growth factors  and their receptors  in the present study  we have employed a new  sensitive  and specific radioimmunoassay for the direct measurement of insulin receptors in surgical specimens of breast cancers  in 159 specimens the insulin receptor content was 6 15     3 69 ng 0 1 mg protein  this value was more than sixfold higher than the mean value found in both 27 normal breast tissues obtained at total mastectomy  0 95   0 68  p less than 0 001  and in six normal specimens obtained from reduction mammoplasty  0 84     0 78  p less than 0 001   the insulin receptor content in breast cancer tissues was also higher than in any normal tissue investigated including liver  pezzino  v   v  papa  v  trischitta  a  brunetti  p a  goodman  m k  treutelaar  j a  williams  b a  maddux  r  vigneri  and i d  goldfine  1989  am  j  physiol  257 e451 457   the insulin receptor in breast cancer retained its ability to both bind insulin and undergo insulin induced tyrosine kinase activation  immunostaining of the specimens revealed that the insulin receptor was present in malignant epithelial cells  but was not detected in stromal and inflammatory cells  univariant analysis revealed that the insulin receptor content of the tumors correlated positively with tumor size  p   0 014   histological grading  p   0 030   and the estrogen receptor content  p   0 035   there were no significant correlations between insulin receptor content and the age  body weight  menopausal status  and nodal involvement of the patients  these studies indicate  therefore  that the insulin receptor content is increased in breast cancers and raise the possibility that the insulin receptor may have a role in the biology of these tumors  
class4	epidermal growth factor regulates the in vitro sensitivity of human ovarian carcinoma cells to cisplatin  cisplatin  ddp  is the most effective drug for the treatment of human ovarian cancer  but the mechanisms that determine sensitivity to the cytotoxic action of ddp are not well understood  treatment of two human ovarian carcinoma cell lines with epidermal growth factor  egf  simultaneously increased sensitivity to ddp and caused a persistent change in morphology in the absence of any mitogenic effect  sensitization to ddp was shown to be dependent on both egf concentration and egf receptor number in c127 mouse fibroblasts expressing the human egf receptor after transfection with a pbpv plasmid construct containing the human egf receptor gene under control of the transferrin receptor 3  inducible regulator  sensitization of human ovarian carcinoma cells to ddp was not blocked by inhibition of protein synthesis  egf did not enhance sensitivity to ddp or alter morphology in ddp resistant human ovarian carcinoma cells despite the presence of functional egf receptors on these cells  these results showed that elements of the signal transduction pathway activated by egf determined cellular sensitivity to ddp  and that a ddp resistant phenotype is associated with a defect in this signal transduction pathway  
class4	a phosphatase activity present in peripheral blood myeloid cells of chronic myelogenous leukemia patients but not normal individuals alters nuclear protein binding to transcriptional enhancers of interferon inducible genes  cytoplasmic protein from peripheral blood myeloid cells of chronic myelogenous leukemia  cml  patients altered the electrophoretic mobility of complexes formed between nuclear proteins and interferon inducible transcriptional enhancers  immature myeloid marrow cells  blasts and promyelocytes  have a higher level of this activity than do mature myeloid marrow cells  bands and polys   this activity  which is not detectable in the peripheral blood cells of normal individuals  is at least 50 fold higher in cml marrow blasts and promyelocytes than that found in marrow blasts and promyelocytes of normal individuals  this activity was inhibited by in vivo incubation of immature myeloid cells with the phosphatase inhibitor  sodium orthovanadate  0 2 mm   and by adding orthovanadate  20 mm  directly to cytoplasmic proteins of myeloid cells  interferon alpha  1 000 u ml  reduced the effects of the cml myeloid cell cytoplasmic protein on the electrophoretic mobility of nuclear protein dna complexes  these data suggest that a unique phosphatase may be involved in the abnormalities in cml which are modulated by interferon alpha  
class4	quality control practices in centralized tumor registries in north america  a survey of quality control practices was mailed to 73 central registries in the u s  and canada  the response rate was 88   with respondents representing a wide range of registry characteristics and reporting strategies  while registries expressed different priorities in data use  80  of respondents felt quality control data were important in the identification of problems  the most common method of quality control was acceptance sampling  used by 97  of respondents   and took the form of visual review  recoding and edit checking  computer based edit checks were almost universally used  95    process control methods of any sort were used by only 22  of respondents with less than 4  of registries reporting formal quantitative criteria  sixty one percent of respondents reported conducting one or more designed studies  e g  reabstracting or casefinding studies  but only 20  of those made the results public  greater emphasis should be placed on development of quantitative process controls  experimental design of quality control studies  and formal analyses and reporting of study results  
class4	adverse mortality experience of a southwestern american indian community  overall death rates and underlying causes of death in pima indians  as part of an ongoing epidemiologic study  the death rate and causes of death during 1975 through 1984 were determined in pima indians who resided in the gila river indian community  gric  in 1965 and later  death certificates were available for 677 of the 681 deaths  in 78  of the deaths  the underlying cause recorded on the death certificate agreed with the cause determined after review of all available relevant records  the age  and sex adjusted average annual death rate for the gric population  1639 100 000  was 1 9 times  95  ci 1 7 2 0  the 1980 rate for the u s  all races  878 100 000   in pima males  whose death rate was substantially higher than that of pima females  the age adjusted death rate was 2 3 times that in u s  males  all races  moreover among males 25 34 years of age  the pima death rate was 6 6 times that for the u s  all races  diseases of the heart and malignant neoplasms caused 59  of u s  deaths in 1980  but only 19  of gric deaths  by contrast  the age  and sex adjusted mortality rate in the gric pima was 5 9 times the rate of the u s  all races for accidents  6 5 times for cirrhosis  7 4 times for homicide  4 3 times for suicide  and 11 9 times for diabetes  tuberculosis and coccidioidomycosis were important causes of death in the pima  for whom infectious diseases was the tenth leading cause of death  the findings indicate that programs to improve the adverse mortality experience of the gric population should emphasize factors related to fatal accidents  alcoholic cirrhosis  homicide  suicide  diabetes mellitus  and infectious diseases  young pimas  especially the males  should be the primary focus of such preventive efforts  these findings and recommendations probably apply to many native american populations  
class4	shortcut method to calculate the sample size in trials of screening for chronic disease  one of the first questions arising in the planning of a randomized trial to evaluate mortality reduction by screening concerns the sample size of the trial required to detect an expected mortality reduction in the study group for given significance level alpha  and power 1   beta  if estimates exist of the underlying average annual incidence rate of the disease ra and the annual mortality rate delta a or survival data for patients in the population under consideration before screening started  then a simple formula for the probability of dying from the disease within t years after entry into the trial can be given for the control group  standard formulas may then be used for sample size calculations in randomized trials  which compare the risk of death from the disease in the control and the study group accrued at t years after entry  a simple correction for loss of follow up  due to mortality from other causes or  for instance  migration is possible  
class4	atheroemboli to the lower urinary tract  a marker of atherosclerotic vascular disease  a case report  atheroemboli to the lower genitourinary tract may serve as a marker for disseminated atheroembolic disease  a highly lethal condition  a case presentation and review of our institional experience is presented  
class4	family cancer syndrome  a study of the kindred of a man with osteogenic sarcoma of the mandible  several familial cancer syndromes have been identified  the syndrome of sarcomas  breast cancer and other neoplasms  known as li fraumeni syndrome  is characterized by several different neoplasms presenting at young ages with autosomal dominant transmission and a high incidence of second primaries  in this paper  we studied six generations  51 people  of the family of a 24 year old man with osteogenic sarcoma of the mandible  twelve malignancies in 11 people  including several rare tumors  were revealed  mean age of presentation was 24 years old  nine of the 11 patients died of disease  one developed a second primary  two tumors presented in the head and neck  transmission was autosomal dominant  the karyotypes of two family members were normal  identification of li fraumeni syndrome in a family is important in determining appropriate follow up for the patient and family  such families are models for studying carcinogenesis  
class4	chondrosarcoma of the head and neck  chondrosarcoma is a malignancy rarely encountered in the head and neck  in an attempt to define this tumor s characteristics and response to therapy  all cases of chondrosarcoma treated at the university of michigan over the past 25 years were retrospectively studied  fourteen cases originating in the nose and paranasal sinuses  mandible  temporal bone  and larynx were reviewed  aggressive surgical resection was the mainstay of treatment  and resulted in an overall survival of 70   with an average follow up of 3 5 years  survival was highest in primary temporal bone lesions  and lowest in paranasal sinus lesions  unresectable lesions were not cured by other modalities  this study  therefore  continued to support the crucial role of wide surgical resection in the treatment of head and neck chondrosarcoma  but conservative resection  when needed to preserve important structures  has resulted in long term survival  
class4	the melanocyte and melanoma  this paper reviewed some of the interesting biological aspects of melanocytes and their relationship to the nevus and to melanoma  it also proposed a rationale for  adequate  surgery in the management of melanoma according to level  depth  margins  and trends in treatment  these propositions were derived from an analysis of 995 cases of melanoma of the head and neck  
class4	a palmar dermatosis linked to occult carcinoma of the upper thorax  head and neck  bazex s syndrome and tripe palm  an unusual  persistent  corregated to honeycombed thickening of the palms accompanied by tenderness around the fingernails was found to be a cutaneous marker for internal malignancy  this combination of signs and symptoms has been reported under two clinical entities  bazex s syndrome and tripe palm  this paraneoplastic syndrome is of interest to head and neck surgeons due to the location of the primary tumor  the site of metastatic disease  and the ability to cure the cutaneous disease by surgical removal of the primary tumor  in our patient  a squamous cell carcinoma of the lung not detectable on chest x ray presented as a cervical mass accompanied by cutaneous changes on the palms and fingernails  recognition of the relationship of the dermatologic changes to malignancy of a specific body region eventually led to the detection of the primary tumor  the characteristics of these paraneoplastic syndromes were reviewed in this report  
class4	the cancer prevention reminder system  the cancer prevention reminder system is a computer based system designed to increase the delivery of periodic health maintenance procedures  the program provides printed reminders that identify patients  overdue procedures  prints summary reports of the percentage of patients who are eligible and overdue for a procedure  and prints mailing labels for patients  we performed a randomized  controlled trial in which the effects of computer based reminders were compared with those of two other interventions among residents in a university based group practice  
class4	prophylaxis of aphakic cystoid macular edema without corticosteroids  a paired comparison  placebo controlled double masked study  prior investigations have reported that topical nonsteroidal anti inflammatory drug  nsaid  therapy prevents the development of postoperative angiographic signs of angiographic cystoid macular edema  cme   however  these studies include concurrent use of corticosteroids  the current study reports therapeutic efficacy for ketorolac ophthalmic solution  an nsaid  in the prophylaxis of angiographic aphakic cme  acme  after cataract surgery without concurrent corticosteroids for the first time  fifty patients with bilateral cataracts were enrolled in this placebo controlled  paired comparison  double masked study  eleven patients had evidence of angiographic acme on postoperative day 40  two of these patients demonstrated bilateral acme  one patient had acme in the nsaid treated eye  and eight patients demonstrated acme in the placebo treated eye  this is a statistically significant difference favoring drug treatment  the signs of anterior ocular inflammation were greater in the eyes with acme  this study suggests prophylactic treatment of acme may be possible without the risks of concurrent corticosteroid toxicity  in addition  a higher incidence of acme in black patients  22   is observed in this study than has been recognized previously  
class4	ki 67 immunostaining in uveal melanoma  the effect of pre enucleation radiotherapy  the reactivity of 33 choroidal and ciliary body melanomas with monoclonal antibody ki 67  which recognizes a proliferation associated nuclear antigen  has been assessed and compared with clinicopathologic parameters  in 23 cases  8 gy irradiation was given 2 days before enucleation  nonirradiated melanomas had a significantly higher proliferation rate as defined by staining with monoclonal antibody ki 67 as compared with irradiated tumors  p   0 007   similarly  a strong relationship was found between pre enucleation irradiation and low mitotic activity  p   0 001   there was no significant correlation between the presence of ki 67 positive nuclei and histologic classification  largest tumor diameter  localization of the tumor  age  sex  scleral invasion  pigmentation  and lymphocytic infiltration  the relevance of ki 67 immunohistochemistry for the assessment of the life prognosis of patients with uveal melanoma has to be studied prospectively  
class4	immunoblastic t cell lymphoma presenting as an eyelid tumor  a 59 year old white man presented with an ulcerating mass of the left upper eyelid of 6 months  duration  a biopsy specimen of the tumor was diagnosed as an immunoblastic t cell malignant lymphoma  the lesion completely regressed after 4000 cgy of cobalt 60 radiation therapy  in the ensuing 33 months  multiple  widespread skin nodules of the same neoplasm developed including a right upper eyelid tumor  to the authors  knowledge  this is the first reported case of an immunoblastic t cell lymphoma initially manifesting as an eyelid neoplasm  
class4	emergent signs of cancer  recognizing them early in the office or er  primary care physicians have a crucial role in recognition of potentially emergent conditions in patients with known or suspected cancer  this task presents a significant challenge because the initial manifestations of these conditions are usually nonspecific  in most cases  therapy is far more effective when diagnosis is made at the earliest possible point  thus  physicians should become familiar with conditions commonly seen in cancer patients  such as superior vena cava syndrome  malignant pericardial effusion  spinal epidural metastasis  and altered mentation from brain metastases  metabolic encephalopathy  or hypoglycemia  
class4	585 nm for the treatment of port wine stains  although the flashlamp pulsed dye laser has been successfully used for the treatment of port wine stains  pws  at 577 nm  a number of adult patients had incomplete clearance of their birthmarks with this treatment modality because of residual vessels lying beyond the 0 75 mm penetration depth of 577 nm irradiation  fifteen adult patients  of whom nine were previously treated with limited success at 577 nm  group a   and six untreated patients  group b  were included in the study  for the group a patients  treatment with 585 nm produced successful clearance of the birthmark  for the six patients in group b  parallel treatment of different sites of the same lesion coupled with skin biopsies and histologic examination revealed that a change in the wavelength from 577 to 585 nm allowed the laser light to penetrate from the midreticular dermis into the subcutaneous fat  this explained the clearance achieved at 585 nm and not at 577 nm  
class4	reasons why mastectomy patients do not have breast reconstruction  breast reconstruction after mastectomy is valuable  yet only a small percentage of eligible patients ever have reconstruction  little has been done to determine why so few patients proceed with reconstructive surgery  a homogeneous population of mastectomy patients  some of whom underwent breast reconstruction while others did not  were surveyed regarding their attitudes about breast reconstruction  a total of 245 women were surveyed  one hundred and fifty eight  64 percent  responded  71 of whom had been reconstructed while 87 had not  comparison of the responses of the two groups suggests factors that play a role in determining whether the mastectomy patient will accept or decline the option of breast reconstruction  considerations that made it less likely that a woman would pursue reconstruction included advanced age at the time of mastectomy  concern about complications from further surgery  uncertainty about outcome  and fear about the effect of reconstruction on future problems with breast cancer  marital status  receiving chemotherapy  or knowing a patient who had a bad result from reconstruction did not affect the decision  an awareness and understanding of these factors may be helpful to physicians in counseling patients and in increasing the number of women who enjoy the benefits of breast reconstruction  
class4	mammographic measurements before and after augmentation mammaplasty  thirty five augmented women underwent mammography using both the standard implant compression technique and  when possible  the implant displacement technique  all had preaugmentation film screen mammography available for evaluation  the area of mammographically visualized breast tissue before and after augmentation mammaplasty was measured using a transparent grid  patients with subglandular implants had a mean decrease of 49 percent of measurable tissue area with compression mammography and a 39 percent decrease with displacement mammography  patients with submuscular implants had a 28 percent decrease in measurable tissue area with compression mammography and a 9 percent decrease with displacement mammography  anterior breast tissue was seen better with displacement mammography  posterior breast tissue  with compression mammography  most patients had some degree of parenchymal scarring and lower image quality after augmentation  state of the art mammography was not possible in most patients augmented with silicone gel filled implants  
class4	combined tensor fasciae latae musculocutaneous flap and sartorius musculocutaneous flap for the repair of wide defects of the lower leg  the tensor fasciae latae musculocutaneous flap has great advantages for reconstruction of the abdominal wall  but the medial border of its territory is limited to the thigh  in order to expand the territory  a combined tensor fasciae latae musculocutaneous flap and sartorius musculocutaneous flap was devised  this flap was successfully used to resurface a large defect in the lower leg as a distally based musculocutaneous flap  the advantages of this flap are its extremely large territory  the fact that total necrosis of the flap cannot occur  and that as a proximally or distally pedicled flap it is suitable for large defects in the abdominal wall  lower leg  and gluteal region  
class4	metabolism of human gliomas  assessment with h 1 mr spectroscopy and f 18 fluorodeoxyglucose pet localized hydrogen 1 magnetic resonance  mr  spectroscopy and fluorine 18 fluorodeoxyglucose  fdg  positron emission tomography  pet  were employed to obtain metabolic information from intracranial gliomas  advantages and difficulties associated with comparison of results from the two modalities were realized  forty patients were studied with h 1 mr spectroscopy  mr signal intensities from lactate  n acetylaspartate  naa   choline  and creatine from a volume of interest containing the tumor and a contralateral volume were obtained and evaluated  naa signal intensities were generally decreased in the tumor spectra  and choline signal intensities were elevated  h 1 mr spectroscopy was unsuccessful in eight patients  and fdg pet scans were not obtained in four of the patients with successful mr spectroscopic examinations  lactate signal intensity was detected in 10 of the 28 patients who had successful h 1 mr spectroscopic and fdg pet studies  lactate signal intensities were observed in lesions shown at fdg pet to be hypermetabolic  as well as in lesions found to be hypometabolic  
class4	chemical shift imaging of human brain  axial  sagittal  and coronal p 31 metabolite images  multivoxel magnetic resonance  mr  spectroscopy and novel data analysis techniques were developed to obtain high quality phosphorus 31 metabolite images from the human brain and to overlay each metabolite distribution directly onto corresponding hydrogen 1 mr images  the p 31 mr spectroscopic data were acquired by means of three dimensional chemical shift imaging  phase encoding in three spatial dimensions  on a 1 5 t clinical instrument equipped with a specially designed quadrature p 31 birdcage coil constructed in the authors  laboratory  axial  sagittal  and coronal metabolite images based on the area for any one of five peak regions  phosphodiester  phosphocreatine  gamma  alpha  and beta adenosine triphosphate  were generated from 8 x 8 x 8 or 12 x 12 x 8 csi arrays with voxel sizes of 27 cm3 and 12 cm3  respectively  the positions of these images were aligned with anatomic features by means of the voxel shifting capability of the fourier transform  direct overlays of these metabolite images on corresponding proton images demonstrated excellent correlation with anatomy  factors indicating the utility of this technique for viewing p 31 metabolite levels in all areas of the brain simultaneously  
class4	rhabdomyosarcomas in the head and neck  mr imaging evaluation  to determine the typical magnetic resonance  mr  signal intensity characteristics of rhabdomyosarcomas  short repetition time  tr  short echo time  te   t1 weighted  and long tr  proton density and t2 weighted  images of 13 patients with rhabdomyosarcomas of the head and neck were retrospectively reviewed  seven patients received gadopentetate dimeglumine injections  the most common mr appearance was that of a homogeneous mass  hyperintense to both muscle and fat on long tr long te images and isointense or minimally hyperintense to muscle on short tr short te images  all lesions of the patients who received gadopentetate dimeglumine enhanced markedly  two lesions had intratumoral hemorrhage  and six were markedly heterogeneous in signal intensity  similar mr signal intensity patterns have been described for lymphomas and nasopharyngeal carcinomas  the forte of mr imaging lies in its ability to delineate precisely the extent of the rhabdomyosarcoma  
class4	mucocele of the cystic duct remnant in eight liver transplant recipients  findings at cholangiography  ct  and us  the case histories and radiologic studies of eight liver transplant recipients who developed a mucocele of the allograft cystic duct remnant were retrospectively evaluated  all patients had clinical and or laboratory evidence of biliary obstruction or cholangitis from 2 weeks to 3 3 years following transplantation  cholangiographic  ultrasound  us   and computed tomography  ct  images were available for review in eight  five  and four patients  respectively  cholangiograms demonstrated an extrinsic mass compressing the common hepatic duct in seven of eight patients  us and ct showed fairly well  to well defined round fluid collections adjacent to the common hepatic duct in three and two patients  respectively  the findings of this study suggest that the detection at cholangiography of an extrinsic mass compressing the common hepatic duct appears to be specific for a mucocele of the allograft cystic duct remnant  ct and us images may offer confirmatory evidence  
class4	colorectal tumors  an in vitro study of high resolution mr imaging  to study the potential utility of magnetic resonance  mr  imaging in staging colorectal tumors  15 resected colonic segments containing 17 elevated lesions were examined on a 1 5  or 1 9 t superconductive mr system  the whole intestinal wall was apparent as three or five layers on images obtained with a short repetition time  tr  and short echo time  te  and as six or eight distinct layers  including the intestinal wall proper as well as an adherent mucus layer and an outer layer of pericolonic fat  on the long tr te images  in cases of colonic carcinoma  mr images correlated well with the pathologic findings  including the macroscopic growth pattern  depth of mural invasion  and the presence of foci of calcific tumor necrosis and pools of extracellular mucin  colloid   these features suggest that mr imaging may be valuable in the clinical evaluation of colorectal tumors  
class4	colonic stenoses  use of oral barium when retrograde flow is completely obstructed on barium enema studies  forty patients with complete obstruction to retrograde barium flow on barium enema examinations  without clinical or radiographic evidence of obstruction  were studied further with orally administered barium in the same session  all patients had undergone aborted double contrast barium enema studies and had received antispasmodics intramuscularly before the examination  the authors describe the technique  as well as the clinical and radiologic findings  that allows the safe ingestion of oral barium in patients with stenotic lesions of the colon  in all patients  oral barium passed through the small bowel and the stenotic site in an average of 148 minutes  with no complications  in seven patients  there were synchronous lesions in the colon and small bowel  and the findings were determined better with oral barium studies in 19 patients  if a barium enema study is done and retrograde passage of barium is obstructed by a lesion in the left side of the colon  additional diagnostic information can be obtained by giving the patients oral barium  this practice is safe if precise criteria are applied  
class4	hepatic tumors  signal enhancement at doppler us after intravenous injection of a contrast agent  experiments were carried out to detect and establish the origin of doppler and echo signal enhancement in small vessels of the systemic circulation and of tumors after intravenous injection of a contrast agent  eight woodchucks  marmota monax  were studied  each woodchuck had naturally occurring hepatocellular carcinoma  injections of 0 1 4 0 ml of air filled human serum albumin microspheres were administered into a hind limb or jugular vein  ultrasound  us  examination included transabdominal duplex scanning  color doppler imaging  placement of a doppler transducer on the exposed tumor  and surgical implantation of pulsed doppler cuffs  doppler signals were assessed by recording color doppler images and results of spectral analysis  while subjective echo level was unaffected within the tumors  dramatic doppler signal enhancement was recorded in both normal and tumor vessels  at optimum dose levels  a signal gain of approximately 10 db was recorded from the tumor  analysis showed that the echo enhancement was due to the presence of the contrast agent in branches of the hepatic artery  these results suggest that tumor detection may be enhanced by intravenous administration of a us contrast agent  
class4	receptor imaging  application to mr imaging of liver cancer  a new contrast agent for magnetic resonance  mr  imaging  directed to asialoglycoprotein  asg  receptors on hepatocytes  was used for detection of liver cancer in rats  ultrasmall superparamagnetic  mean size  12 nm  particles of iron oxide  uspios  were targeted to asg receptors by coating particles with arabinogalactan  ag   liver t2 relaxation times decreased more effectively after a single intravenous administration of ag uspio than after an equal dose of a conventional superparamagnetic liver mr contrast agent  ami 25  mean size  72 nm   receptor affinity studies demonstrated that receptor mediated attachment and subsequent cellular endocytosis do not occur in primary malignant  hepatocellular carcinoma  or metastatic  adenocarcinoma  tumors  because the surface asg receptors are lost during malignant dedifferentiation  in vitro relaxation and in vivo mr imaging experiments of liver tumors show that targeting uspio to hepatocytes rather than to the mononuclear phagocytic system allows a considerable dose reduction  increases tumor liver contrast  and potentially allows distinction of asg positive  benign hepatocellular  and asg negative  malignant hepatocellular  tumors  
class4	hilar malignancy  treatment with an expandable metallic transhepatic biliary stent  an expandable metallic transhepatic biliary endoprosthesis was used to treat 20 patients with hilar malignancy and isolated right and left intrahepatic ducts  in 12 patients  only one intrahepatic ductal system was drained  in eight patients  both systems were drained  in five patients  both systems were drained through a single transhepatic track by arrangement of two stents in a t configuration  the initial technical success rate in placing the stents and achieving internal drainage was 100   complications necessitating further intervention occurred in two of the 20 patients  short term clinical follow up was available for 19 of the 20 patients  two months after stent insertion  two patients complained of persistent jaundice  two patients died without jaundice  and 15 patients were free of symptoms of biliary obstruction  a variety of geometric configurations are possible with this endoprosthesis  the relative merits of these stent arrangements are discussed  and a new technique for placing the stents in a t configuration is described  
class4	invasive papillary carcinoma of the breast  mammographic appearance  the mammographic findings in 18 patients with invasive papillary carcinoma were studied retrospectively  the mammograms of 10 patients showed a multinodular pattern  and seven patients had solitary nodules  one patient had an irregular  ill defined mass in the retroareolar region  two patients were found to have carcinoma in the contralateral breast  and two patients had intraductal carcinoma adjacent to the invasive papillary carcinoma  the varied mammographic features that may occur with this rare breast malignancy are discussed  
class4	mixed form  diffusely scattered calcifications in breast cancer with apocrine features diffusely scattered calcifications visible with mammography are almost always benign  certain patterns  however  should arouse concern  for example  extensive comedocarcinoma is associated with large areas of mammographically visible calcium deposition  the authors identified 10 women in whom calcifications were visible throughout large volumes of breast tissue at mammography  the calcifications did not resemble those typical of extensive comedocarcinoma  yet they were associated with extensive breast cancer  their mammographic pattern was characterized by a strikingly wild  chaotic appearance with profuse deposition of calcium  as in many cancers  the particles were heterogeneous  but unlike in most carcinomas  many deposits had a typically benign morphology  histologic examination showed that even these typically benign calcifications were associated with malignant cells  the authors believe that the apocrine features displayed by many of the cancer cells in these 10 patients may explain the unusual profusion of calcium deposits  
class4	cystic rheumatoid arthritis  description of a nonerosive form  in a study of patients with rheumatoid arthritis  ra   9   n   70  were found to have a cystic form  at radiologic examination of these patients with cystic ra  the first abnormality seen consisted of periarticular intraosseous cysts without erosions  the cysts were distributed symmetrically  most often located at the proximal side of the joints and predominantly around the proximal interphalangeal  metacarpophalangeal  and wrist joints of the hands and the first interphalangeal and metatarsophalangeal joints of the feet  computed tomographic scans showed the peripheral intraosseous location of the cysts  magnetic resonance images showed that the cysts may contain fluid  inflamed synovia  or both  cysts can be an important feature in the diagnosis of ra and a supplement to the criteria of the american rheumatism association  osteoporosis  joint space narrowing  and joint destruction occurred less frequently in patients with cystic ra than in patients with classic ra  of the patients with cystic ra  54  were male  and 50  were seronegative  this study is a supplement to and an enlargement on earlier descriptions of cyst predominance in ra  
class4	widespread inflammatory response to osteoblastoma  the flare phenomenon  a case of vertebral osteoblastoma caused a diffuse  reactive inflammatory infiltrate in two vertebrae  adjacent ribs  and the paraspinous soft tissues  the authors call this the flare phenomenon  on magnetic resonance images the diffuse inflammatory response caused a misleading appearance that simulated a malignant process  lymphoma or ewing sarcoma   a computed tomographic myelogram was diagnostic  
class4	small cell lung cancer  staging with mr imaging  small cell lung cancer is an aggressive neoplasm  metastases are detected in two thirds of patients at diagnosis with use of conventional staging  which includes bilateral bone marrow biopsy  bone scintigraphy  and computed tomography  ct  of the head and abdomen  in 25 patients  small cell lung cancer was staged prospectively with both conventional staging and a magnetic resonance  mr  imaging protocol that included 1 5 t mr imaging of the pelvis  abdomen  spine  and brain  according to conventional staging  14 patients had extensive disease and 11 patients had limited disease  according to staging with mr  19 patients had extensive disease and six had limited disease  all metastatic disease sites seen with conventional staging were identified on mr images  mr images showed additional metastatic involvement in bone  four patients  and liver  three patients  not detected at conventional staging  a low attenuation hepatic lesion on a ct scan was identified as a hemangioma on mr images  these preliminary data suggest that small cell lung cancer may be accurately staged with use of a single mr imaging study  
class4	small nodular lesions in the lung periphery  new approach to diagnosis with ct  to evaluate relationships between lesions in the lung periphery and surrounding structures  particularly vessels and bronchi  axial multiplanar reconstruction  ampr  computed tomography  ct  was used to study 26 patients who underwent surgical resection of pulmonary nodules less than 3 cm in diameter  findings at ampr ct  conventional ct  and digital radiographic tomography were compared with findings obtained at evaluation of the resected specimen with regard to the ability to display the relationships between vessels  bronchi  and lesions  ampr ct was significantly superior to conventional ct and digital radiographic tomography in detecting involvement of pulmonary vessels  p less than  001   involvement of pulmonary veins was seen in all lung cancers  whereas such involvement was seen in only one of eight nonneoplastic lesions  thus  involvement of pulmonary veins is strongly suggestive of malignancy  ampr ct permits three dimensional visualization and morphologic assessment of pulmonary nodules  
class4	retroviral recombination and reverse transcription  recombination occurs at a high rate in retroviral replication  and its observation requires a virion containing two different rna molecules  heterodimeric particles   analysis of retroviral recombinants formed after a single round of replication revealed that  i  the nonselected markers changed more frequently than expected from the rate of recombination of selected markers   ii  the transfer of the initially synthesized minus strand strong stop dna was either intramolecular or intermolecular   iii  the transfer of the first synthesized plus strand strong stop dna was always intramolecular  and  iv  there was a strong correlation between the type of transfer of the minus strand strong stop dna and the number of template switches observed  these data suggest that retroviral recombination is ordered and occurs during the synthesis of both minus and plus strand dna  
class4	germ line p53 mutations in a familial syndrome of breast cancer  sarcomas  and other neoplasms familial cancer syndromes have helped to define the role of tumor suppressor genes in the development of cancer  the dominantly inherited li fraumeni syndrome  lfs  is of particular interest because of the diversity of childhood and adult tumors that occur in affected individuals  the rarity and high mortality of lfs precluded formal linkage analysis  the alternative approach was to select the most plausible candidate gene  the tumor suppressor gene  p53  was studied because of previous indications that this gene is inactivated in the sporadic  nonfamilial  forms of most cancers that are associated with lfs  germ line p53 mutations have been detected in all five lfs families analyzed  these mutations do not produce amounts of mutant p53 protein expected to exert a trans dominant loss of function effect on wild type p53 protein  the frequency of germ line p53 mutations can now be examined in additional families with lfs  and in other cancer patients and families with clinical features that might be attributed to the mutation  
class4	biopsy of the breast for mammographically detected lesions  we prospectively studied 718 women who underwent biopsy of the breast for suspicious  mammographically detected mammary lesions in an attempt to identify key clinical risk factors  as well as roentgenographic characteristics associated with the appearance of early carcinoma of the breast  patients with a benign outcome had an average age of 55 years versus 63 years for patients with carcinoma of the breast  seventy six per cent of these patients had no previous history of mammary problems  20 per cent had a positive family history for carcinoma of the breast  58 per cent were premenopausal and 21 per cent had used birth control pills  except for age  p less than 0 001   the distribution of clinical risk factors was equal among patients with benign or malignant outcomes  suspicious mammographic findings included mass lesions  53 per cent   calcifications  36 per cent  and the association of both  11 per cent   the predominant wolfe pattern on mammography was p1  36 per cent   no relationship was observed between wolfe pattern and malignant conditions  in this group of patients  mammography was poorly specific  however  the positive predictive value increased with age and is related to the age specific prevalence of carcinoma of the breast  eight hundred and twenty five lesions were removed  twenty five per cent  n   203  of the specimens taken at biopsy contained carcinoma  stellate mass lesions were highly suggestive of a malignant growth  p less than 0 0001   no relationship between the size of the suspicious mammographic mass and the malignant lesion was observed  a marked correlation  chi square test with yate s correction  was observed between malignant tumor and lesions with a linear or branching pattern  more than 15 calcifications  or small sized calcifications  the presence of a mass with calcifications was associated with carcinoma in 34 per cent  the incidence of invasive carcinoma was much higher for mass lesions  81 per cent  than for suspicious calcifications  56 per cent   p less than 0 0001   
class4	trends in conserving treatment of invasive carcinoma of the breast in females  this population based study presents trends in the treatment of node negative invasive carcinoma of the breast in females during the 1980s in the detroit metropolitan area  it was done to determine whether or not there has been a significant shift toward conservation of the breast from 1980 to 1987  trend analyses of surgical treatment  tumor size  node status  year of diagnosis  age and race were performed for 13 217 patients drawn from the metropolitan detroit cancer surveillance system  a significant increase in the use of conserving the breast was observed  with younger women receiving this treatment option more often than older women  implications for a continuing shift in the biologic findings and treatment of carcinoma of the breast are discussed  
class4	correlation between hyperthermoradiosensitivity and clinical effect in carcinoma of the esophagus  the correlation between hyperthermoradiosensitivity evaluated by an in vitro succinate dehydrogenase inhibition  sdi  test and the histopathologic effects of hyperthermochemoradiotherapy  hcr therapy  were investigated in 43 patients with carcinoma of the esophagus  the succinate dehydrogenase  sd  activity of tissue fragments taken at biopsy was assayed after exposure to heat  43 degrees c   and radiation  6 grays  was done  the sensitivity to radiation plus heat treatment was estimated by the percentage of sd activity of the treated cells  compared with that of the control cells  the 43 patients were divided into three groups according to the degree of sd activity after exposure to radiation plus heat treatment  the sd activity was less than 50 per cent in group 1  highly sensitive   between 50 and 70 per cent in group 2  moderately sensitive   more than 70 per cent in group 3  less sensitive   eighteen of 20 in group 1  11 of 17 in group 2 and two of six in group 3 were classified as being histopathologically  effective  for hcr therapy  the two year survival rate for groups 1  2 and 3 were 55 5  34 9 and zero per cent  respectively  while there were no statistical differences with regard to prognostic factors  these data suggest that in vitro activities of sd correlate well with the clinical effectiveness of hcr therapy  therefore  it is recommended that a sd inhibition test be included among the guidelines for clinical management  
class4	neoplastic changes in the stomach after gastrectomy  partial gastric resection for benign ulcer disease has been associated with an increased incidence of mucosal dysplasia and invasive adenocarcinoma  particularly 15 to 20 years after resection  these remnant carcinomas are particularly virulent with little hope of resection or cure once symptoms occur  using a planned protocol of routine endoscopic surveillance with biopsy  the goal was to identify early markers of neoplasia  that is  dysplasia  and a diagnosis of adenocarcinoma of the gastric remnant  while both resection and cure were possible  between july 1980 and august 1988  yearly flexible gastroscopic examination and random biopsy have been performed on 163 patients at least ten years after gastrectomy for benign ulcer disease  all biopsy results were interpreted for findings of dysplasia and early gastric adenocarcinoma  results of this ongoing screening program revealed dysplasia of the gastric remnant in nine patients with eventual findings of adenocarcinoma in four of this group  these patients underwent total gastrectomy with findings of limited disease  five patients with mucosal dysplasia continue to be observed at six month intervals  three additional gastric carcinomas were found on initial gastroscopic screening  while one patient had adenocarcinoma diagnosed during a third yearly gastroscopic examination  these eight asymptomatic patients with adenocarcinoma in the gastric remnant had a postgastrectomy interval which ranged from 15 to 29 years  mean of 26 5 years   the results of this study support the concept of neoplastic change in the gastric remnant as a function of time from initial gastric resection  findings of dysplasia on random biopsy indicate a greater likelihood of development of carcinoma of the gastric remnant and identify a subset of patients requiring aggressive endoscopic surveillance  
class4	therapeutic dilemmas associated with antenatally detected ovarian cysts  fifteen instances of ovarian cysts detected antenatally are reported  seven cysts more than 5 centimeters in diameter were treated surgically because of clinical signs  such as palpable abdominal mass  vomiting and abdominal distension  seven cysts less than 5 centimeters in diameter  and one cyst more than 5 centimeters in diameter began to regress spontaneously within six months after birth  because the pathophysiologic nature of neonatal ovarian cysts has not been elucidated and because the borderline between physiologic and pathologic factors is still unclear  we propose a more conservative approach in the management of neonatal ovarian cysts to avoid unnecessary operations  
class4	intraoperative pressure profile measurement and continence mechanism adjustment in the indiana pouch urinary reservoir  we have described herein a simple pressure transducer system which helps the surgeon to tailor suture placement and achieve a continent ileocecal reservoir  it seems that fewer lembert sutures than previously recommended are necessary to create a continent reservoir  although further study is needed  
class4	magnetic resonance imaging of experimental rat brain tumors  histopathological evaluation  using rg c6 glioma transplanted rats  we studied precontrast and postcontrast magnetic resonance imaging  extravasation of evans blue  and histology  in all rats  tumor was enhanced with gadolinium diethylenetriaminepentaacetic acid  gd dtpa   the necrotic portion in the tumor  however  was not enhanced  hemorrhage and hydrocephalus were clearly visualized on both the precontrast and postcontrast images  blood brain barrier disrupted areas stained with evans blue and areas enhanced with gd dtpa on magnetic resonance imaging were nearly consistent  it is suggested that the mechanism of brain tumor enhancement with gd dtpa on magnetic resonance imaging is simply related to the degree of alteration of the blood brain barrier  the gd dtpa enhanced magnetic resonance imaging  even with low magnetic field  is useful for the evaluation of size  shape  and location of experimental rat brain tumors  
class4	third ventricle cavernous angioma  report of two cases  cavernous angioma arising in the third ventricle is an extremely rare disease  we have reviewed five cases previously reported  as well as our own two cases  and discuss the clinical characteristics of and surgical approach to cavernous angioma at this site  the bifrontal craniotomy and interhemispheric translamina terminalis approach minimize the damage to the brain and allow for an approach to the third ventricle in a wide operative field with minimal compression of the brain itself  we have found this approach to be suitable for surgery on angiomas of the anterior half of the third ventricle  
class4	magnetic resonance imaging of vertebral osteoblastoma  a report of two cases  two patients with vertebral osteoblastoma evaluated with computed tomography and magnetic resonance imaging are presented  a literature review revealed that cases of osteoblastoma originating within the vertebral body are exceedingly rare  
class4	aqueductal  pencil  glioma presenting as neurogenic pulmonary edema  a case report  a case of neurogenic pulmonary edema due to hydrocephalus  without initial neurological deficit  is described  computed tomography demonstrated a ring enhancing lesion in the tectum of the mesencephalon obstructing the aqueduct of sylvius  the lesion  on autopsy  was a rare mesencephalic glioma described in the literature as a  pencil glioma  of the aqueduct  
class4	computed tomography and bronchoscopy in chest radiographically occult main stem neoplasm diagnosis and nd yag laser treatment in 8 patients  we studied 8 adult patients with variable symptoms of cough  dyspnea  stridor  wheezing  or hemoptysis  fiberoptic bronchoscopy in all showed complete or nearly complete endobronchial obstruction of a main stem bronchus by neoplasm with a mean bronchial diameter of 1 9 mm     1 6 mm  mean     standard deviation   in 4 patients  a lobar bronchus was also completely obstructed  no mass was visible on chest radiographs of any patient  however  computed tomography in each showed main stem endobronchial obstruction  lobar obstruction  4 instances in 3 patients   and in 6 patients hypoperfusion of the involved lung  computed tomographic scan showed additional abnormalities that were unsuspected on viewing chest radiographs or at bronchoscopy  including mediastinal adenopathy in 3 patients and an extraluminal tumor component in 4  after therapy with nd yag laser  main stem airway diameter increased to a mean of 9 6 mm     1 0 mm  p less than  05  and pulmonary functions improved  results suggest the complementary role of computed tomography and fiberoptic bronchoscopy in the detection and laser treatment planning of chest radiographically occult severe neoplastic obstruction of the main stem bronchus  
class4	correlation of free phenytoin to serum albumin in cancer patients  the objectives of this study were to compare the total and free phenytoin serum concentrations of cancer patients with hypoalbuminemia with those of cancer patients with normal serum albumin and to correlate the percentage of free phenytoin with the albumin concentration  a total of 22 patients were studied  13 with normal albumin concentration and 9 with low albumin  the mean free phenytoin in the normal albumin group was 9 9      1 3  percent and 17 6      4 6  percent in the low albumin group  with the groups combined  the mean free phenytoin was 13 1 percent  range 8 3 22 2  with the albumin range of 20 45 g l  there was a significant negative correlation  r    0 9  p less than 0 001  between the percentage of free phenytoin and the measured serum albumin  in cancer patients  the serum albumin concentration appears to be the key factor that determines the percentage of free phenytoin  in cancer patients with low serum albumin concentration  the total and free phenytoin concentration should be measured for adequate assessment of phenytoin therapy  
class4	fine needle aspiration cytology and flow cytometry of intracystic papillary carcinoma of breast to define criteria for cytologic diagnosis of intracystic papillary carcinoma  icpc   the authors retrospectively reviewed the fine needle aspiration  fna  cytologic specimens of eight cases of histologically proven icpc of breast  the patients were five black and three white women  56 87 years of age  the fna specimen was cyst fluid in four cases  bloody in three  clear in one   all the aspirates showed cellular smears with small and large clusters of cells with papillary and or cribriform configurations and numerous single epithelial cells  the cells were cuboidal to columnar with minimal atypia  icpc was suggested by fna in each case  and all the patients underwent surgical excision or mastectomy  flow cytometry  performed on fresh fna specimen in one case and on paraffin embedded surgical tissue in all eight cases  showed seven tumors to be aneuploid and one to be diploid  the authors contend that icpcs of breast have distinct cytomorphologic features that can be recognized by fna  because icpc may present in cyst fluid  either bloody or clear  all breast cyst fluids from postmenopausal women should be examined cytologically  flow cytometric demonstration of an aneuploid population may assist in confirming malignancy in this lesion  
class4	ki67 index and s phase fraction in human breast carcinomas  comparison and correlations with prognostic factors  in a prospective study of 148 consecutive breast adenocarcinomas  proliferative indices of the same surgical tumor sample were performed by immunohistologic staining  ki67 index  with the use of the ki67 monoclonal antibody  which binds to a nuclear antigen only expressed in cycling cells  and by flow cytometry derived s phase fraction  spf   measurable ki67 and spf indices were obtained in 142 cases and 99 cases  respectively  and in 96 cases by both methods  in aneuploid tumors  a significant but low  p less than 0 05  r   0 3  relationship was observed between ki67 index and spf  when compared with clinical  pathologic  and biochemical parameters these two proliferative indices were shown to be associated with nuclear grading and mitotic index  additionally  correlations were observed between ki67 index and node involvement  p less than 0 02  and between spf and estrogen receptors  p   0 002   these results show that  1  proliferative indices are obtained in 96  of surgical samples with ki67 versus 67  with spf and that  2  ki67 index and spf may provide complementary data with respect to prognosis  
class4	cytologic features of poorly differentiated  insular  carcinoma of the thyroid  as revealed by fine needle aspiration biopsy  the authors report on the cytologic features of six cases of poorly differentiated  insular  carcinoma  ic  of the thyroid  a recently described variety of thyroid tumor intermediate between well differentiated and anaplastic neoplasms  it is characterized by trabecular and or alveolar growth patterns  merging with follicular areas  and by the absence of pleomorphism in the tumor cells  fine needle aspiration biopsy  fnab  materials  both smears and cell block preparations  from six patients were reviewed after the diagnosis of ic was confirmed on the surgical specimen  the following cytologic features were consistently found  high cellularity and necrotic background  low grade of atypia  trabeculae and or clusters  possibly associated with microfollicles  of cells with poorly defined cytoplasm  and cytoplasmic vacuoles containing thyroglobulin  nuclear inclusions and grooving of the nuclear surface were additional features  preoperative diagnosis suggestive of ic might be of value for planning surgical treatment and subsequent therapy  
class4	diagnosis and localization of prostate carcinoma by fine needle aspiration cytology and correlation with histologic whole organ sections after radical prostatectomy  twenty nine patients with clinical stage t1 2  no  mo prostate carcinoma were treated by retropubic radical prostatectomy  diagnosis was made by fine needle aspiration biopsy from six to eight separate sectors of the prostate  at the time of biopsy  diagrams of the palpated organ were drawn  depicting the location of the lesion and the site of each biopsy  without the examiners  knowledge of cytologic data  extirpated prostate glands were examined with whole organ histologic sections  and carcinomas were scored according to the method of gleason  the location and extent of all typical and malignant foci were mapped on a standard diagram  the results of preoperative cytologic examination were compared with postoperative histopathologic findings  showing a tendency toward underestimation of both the extent and degree of differentiation of the carcinomas during cytologic examination  in no case were these parameters overestimated during cytologic examination  the gleason score correlated well with the presence of capsular and seminal vesicle invasion  
class4	immunocytochemical profile of benign and carcinomatous effusions  a practical approach to difficult diagnosis  one of the great challenges in the cytodiagnosis of effusions is the distinction between reactive mesothelium histiocytes and cancer cells  this is notably true in patients having undergone radiation and or chemotherapy  to establish whether monoclonal antibodies  moabs  could be used as reliable diagnostic adjuvants  the authors retrospectively and blindly studied 60 cases diagnosed by standard cytologic criteria  malignant  benign  and equivocal   with a panel of seven readily available moabs  cytokeratins  vimentin  ema  b72 3  alpha cea  hmfg 2  and leu m1  and the lectin ulex europaeus i  all 18  100   malignant cases showed reactivity with ema and hmfg  whereas 17  95   and 11  61   reacted with b72 3 and alpha cea  respectively  combinations of  1  ema   b72 3   2  ema   alpha cea  and  3  ema   alpha cea   b72 3 displayed positivity in 17  95    11  61    and 10  56   malignant cases  respectively  of the 18 benign cases  7 reacted with hmfg and 2 each with ema and b72 3  only one case  5 5   reacted with both ema and b72 3  based on these results  the 24 equivocal cases were regrouped into 14 malignant and 10 benign cases  follow up effusions obtained within the ensuing three months in all these patients allowed the authors to unequivocally confirm the diagnosis in all but five  the combination of ema and b72 3 moabs detected malignant cells in 95  of the cases  with a 3 5  incidence of false positive cases in this study  a panel of ema  b72 3  and alpha cea moabs should prove the most useful and simple approach to the correct diagnosis in most questionable effusions  some of the potential pitfalls are discussed  
class4	unusual variants of adrenal pseudocysts with intracystic fat  myelolipomatous metaplasia  and metastatic carcinoma  five previously unreported cases of adrenal pseudocysts are described that demonstrate a wider range of histologic appearances than has been previously recognized in these lesions  one pseudocyst removed from an asymptomatic 59 year old female contained intracystic nests of cytologically malignant cells of unknown origin  workup revealed a left breast mass  which on biopsy showed an infiltrating ductal carcinoma with neoplastic cells that were cytologically similar to those found within the cyst contents  four other pseudocysts are described with variable numbers of intracystic vascular structures and benign adrenal cortical cells  in addition  intracystic mature adipose tissue was observed in all four cases  with myelolipomatous metaplasia found in one  awareness of the wide histologic variability of these lesions should improve diagnostic accuracy and allow distinction from adrenocortical neoplasia and myelolipoma  
class4	secondary t cell lymphoproliferation after marrow transplantation  secondary lymphoproliferative syndromes in immunosuppressed patients have been characterized as polyclonal or monoclonal b lineage disorders nearly always associated with epstein barr virus  ebv  infection  the authors now report three patients with a distinctly different lymphoproliferative syndrome  two patients with common acute lymphoblastic leukemia antigen  calla   cd10  positive acute lymphoblastic leukemia and one patient with acute myelogenous leukemia  respectively  received high dose chemoradiotherapy followed by marrow transplantation from either an hla identical sibling or hla mismatched parent  all three patients developed severe graft versus host disease  gvhd   requiring immunosuppressive treatment with corticosteroids  a secondary malignant t cell lymphoproliferation occurred 2  21  and 43 months  respectively  after marrow transplantation  in all three cases the lymphoid cells expressed t cell surface antigens and were morphologically and immunophenotypically distinct from the malignant cells present before transplantation  one tumor was of host cell origin  one was probably of donor origin  and the tumor origin in the third case could not be determined  the authors were unable to find any evidence for ebv  human t cell lymphotropic virus type i or ii  human immunodeficiency virus  or human herpesvirus 6  
class4	primary lymphoma of the central nervous system in two children with acquired immune deficiency syndrome  postmortem examination disclosed central nervous system non hodgkin s lymphoma in two children who died of acquired immune deficiency syndrome  aids  at 6 and 14 months of age  respectively  systemic signs of lymphoma were not present  the b cell origin and clonality of the neoplastic cells were established by immunohistochemistry in one case and by molecular analysis of immunoglobulin gene rearrangement in the other  moreover  in the latter case the neoplastic cells were characterized by the presence of a single episomal ebv genome  according to these data  the monoclonal b cell proliferation occurred after ebv infection  thus suggesting a possible pathogenetic role of ebv in the early stages of lymphomagenesis  
class4	strategy for breakpoint cluster region analysis in chronic myelocytic leukemia in a routine clinical laboratory  despite the increasing reliance on breakpoint cluster region  bcr  determinations in diagnosis of chronic myelocytic leukemia  cml   few reports have dealt with the practical aspects of specimen analysis  in the setting of a routine molecular diagnostics laboratory  samples from 68 patients with active cml were evaluated for bcr rearrangements  with the use of a variety of enzymes and two probes  the data have been used to develop an efficient strategy for bcr screening and breakpoint determination  screening with the universal bcr  ubcr  probe on xba i and bgi ii digests yielded bcr rearrangements in 100  of the ph1 positive patients and three of the seven ph1 negative patients  giving bcr analysis a sensitivity of 100   a single enzyme screen using the ubcr probe would have resulted in a false negative rate of 10   the false negative rate was determined during the breakpoint site analysis from additional digests hybridized to both the 3  and ubcr probes  the false negative rate for the 3  probe was 26 5   because of deletions or 5  rearrangements  the method of breakpoint site determination was dependent on screening results  in 78  of cases  one additional hybridization with two enzyme digests was required  during breakpoint site analysis  a rare false negative result was also demonstrated with bam hi and eco ri  this screening strategy has made bcr analysis competitive with cytogenetic analysis at the authors  institution  although turnaround time may be slightly longer  bcr analysis can yield information  such as detecting bcr positive ph1 negative patients and determining breakpoint site  that cannot be obtained by cytogenetics  
class4	angiocentric lymphoma with histologic features of neoplastic angioendotheliomatosis presenting with predominant respiratory and hematologic manifestations  report of a case and review of the literature neoplastic angioendotheliomatosis  nae  is a rare fatal disease characterized by widespread intravascular proliferations of neoplastic mononuclear cells  clinically  dermatologic and bizarre neurologic manifestations usually predominate  the origin of the neoplastic cells remains still undetermined  the authors report a patient with nae peculiar with respect to the following points   1  the patient predominantly manifested respiratory symptoms and hematologic findings and lacked cutaneous or neurologic manifestations  and  2  immunohistochemical and molecular genetic studies showed the b cell nature of the neoplastic cells  although previous cases with predominant respiratory or hematologic manifestations were reported to be of endothelial origin  despite the rarity  this type of nae or angiocentric lymphoma should be recognized because it is easily confused with other disorders  particularly vasculitis or thrombotic thrombocytopenic purpura  
class4	myofibroblastoma of the tongue  an immunohistochemical  ultrastructural  and flow cytometric study  a case of myofibroblastoma arising in the tongue of a 77 year old man is described  the patient presented with a submucosal tongue mass without other associated symptoms  the tumor was 2 cm in diameter  well circumscribed  and composed of uniform spindle cells arranged in fascicles  electron microscopic examination and immunohistochemistry demonstrated a myofibroblastic origin for the tumor cells  dna flow cytometric analysis showed a diploid dna content of this tumor  to the authors  knowledge  this is the first report of myofibroblastoma occurring in the tongue  
class4	multiple myeloma and acute megakaryoblast leukemia in spent phase polycythemia vera  the spontaneous and simultaneous occurrence of multiple myeloma and megakaryoblast leukemia with myelodysplastic features in a case of spent phase polycythemia vera is well documented  in support of the morphologic characteristics of the bone marrow  immunocytologic studies show proliferation of monoclonal plasma cells and megakaryoblasts  the cytogenetic findings of 20q  and unbalanced t 1 7  are consistent with myelodysplastic and leukemic transformation of the bone marrow  these transformations expand observations on variable and spontaneous lineage commitments as the consequence of alterations of the hematopoietic stem cell clone  these data are in support of the changing insights in hematopoiesis as a process of ordered commitment of the stem cell with sequential lineage potentials  
class4	patency rate of implantable devices during long term intraarterial chemotherapy  intraarterial implantable drug delivery systems have been considered as an alternative method for treating patients with unresectable liver malignancies  however  catheter problems with external implanted devices have resulted in limited application of chemotherapy  the introduction of subcutaneous devices offers an opportunity for long term locoregional chemotherapy  twelve external intraarterial catheters were implanted into 12 patients and 52 subcutaneously placed devices into 51 patients  all with various hepatic malignancies  retrospective analyses comparing those two intraarterial systems were conducted taking into account the function and complication rate  hepatic artery thrombosis  infection  leaking  hemorrhage  and dislocation   the follow up time for the external system was two to eight months  median five weeks   the thrombosis rate 33 3   and the infection rate 25   one instance of severe bleeding from the hepatic artery occurred during chemotherapy  one catheter dislocated  for the subcutaneously implanted intraarterial devices the follow up time was five to forty one months  median sixteen months   the thrombotic complication rate 17 3   and the infection rate 7 6   all patients with simultaneous bowel surgery   catheter dislocation one year later required reimplantation  in 1 patient therapy had to be discontinued because of a catheter leak  the overall function rate was 71 3  with a median follow up time of eight months  anticoagulation therapy for subcutaneously implanted devices starting from the beginning of intraarterial chemotherapy is recommended to achieve long term patency  no implantation should be preformed simultaneously with bowel surgery  the subcutaneously placed intraarterial devices had a higher function rate and were available for a longer period as compared with external implanted catheters  
class4	intraocular lens complications  the authors implanted intraocular lenses  iol  in 780 eyes and considered complications of this surgery  dividing the complications into intraoperative and postoperative  the latter early and late  the most frequent intraoperative complications were  hyphema  vitreous injury  pupil deformation with an iol in the anterior chamber  ac   and hyphema and corneal lesions with an iol in the posterior chamber  pc   among the early postoperative complications of an iol in the ac the authors noticed striate keratopathy and uveal flare and postoperative transitory ocular hypertension and striate keratitis with an iol in the pc  moreover  in late postoperative complications in ac implantation they observed  cystoid macular edema  bullous keratitis  retinal detachment  late uveitis  opacification of posterior capsule  eccentric displacement of the iol  and less frequently  cystoid macular edema in pc implantations  the authors prefer iol implantation in the pc after extracapsular cataract extraction  since this surgery causes less problems in the cornea  vitreous  and retina  
class4	effect of bleomycin on hematoporphyrin derivative phototherapy of solid tumors  hematoporphyrin derivative phototherapy  hpd pt  has been successfully used to localize and treat superficial squamous cell cancers  bleomycin sulfate is a glycopeptide antibiotic that has antineoplastic properties against squamous cell cancers  because both hpd pt and bleomycin chemotherapy are accepted forms of treatment for squamous cell cancer and their cytotoxicity is mediated by singlet oxygen and oxygen radicals  we studied the possibility of enhancing the response of solid tumors to hpd pt by combining this modality with systemic bleomycin chemotherapy in a murine tumor model  bleomycin did not enhance hpd pt significantly  also  we are not confident that hpd pt alone or in combination with other agents can eradicate solid tumors  it certainly did not in this syngeneic murine tumor model  
class4	endoscopic management of early supraglottic cancer  an initial endoscopic surgical approach to early supraglottic cancer provides the surgeon with the ability to accurately stage these lesions  avoiding possible undertreatment while allowing for a valuable treatment option for those supraglottic cancers with histologically incontrovertibly superficial disease  early invasion of the preepiglottic and paraglottic spaces can be determined accurately without altering or delaying any treatment option  open surgical excision  radiotherapy  or chemotherapy   the tendency of supraglottic cancers to transgress the natural foramina of the epiglottis is well established  and the concern about this depth of invasion is reflected by the 1977 revised staging criteria  which required assessment of the preepiglottic space  pes   along with the microscope and the carbon dioxide laser  the adjustable supraglottiscope facilitates the determination of pes invasion and facilitates en bloc excision of superficial supraglottic cancers  the resulting morbidity typically is no different from that with routine direct endoscopy and biopsy  
class4	the association of selected cancers with service in the us military in vietnam  ii  soft tissue and other sarcomas  the selected cancers cooperative study group as part of a series of investigations into the health of vietnam veterans  we conducted a population based  case control study of soft tissue and other sarcomas between 1984 and 1988  all men born between 1929 and 1953 and diagnosed in an area covered by eight cancer registries were considered eligible  controls were selected by random digit dialing  analyses of 342 men with pathologically confirmed sarcoma and 1776 controls showed that vietnam veterans had a relative risk of 1 0 for sarcoma in comparison with men who did not serve in vietnam  95  confidence interval  0 6 to 1 6   restriction of the analysis to the 254 men with soft tissue sarcoma yielded a relative risk of 0 9  95  confidence interval  0 5 to 1 6   several attributes of military service in vietnam  eg  branch  duration of service  military region  and other characteristics that may have been associated with the use of agent orange  were examined  and none was associated with an increased risk for the development of sarcoma  furthermore  no morphologic type of sarcoma was overrepresented among vietnam veterans  results were unchanged if vietnam veterans were compared with  1  other veterans or  2  men who never served in the military  this study  which had 97  power to detect a relative risk of 2 0 for all sarcomas  provides no evidence that the risk for the development of soft tissue or other sarcomas is increased among veterans 15 to 25 years following service in vietnam  
class4	the association of selected cancers with service in the us military in vietnam  iii  hodgkin s disease  nasal cancer  nasopharyngeal cancer  and primary liver cancer  the selected cancers cooperative study group as part of a series of investigations into the health of vietnam veterans  we conducted case control studies involving 310 men with hodgkin s disease  48 with nasal carcinoma  80 with nasopharyngeal carcinoma  130 with primary liver cancer  and 1776 controls between 1984 and 1988  all men born between 1929 and 1953 and diagnosed in an area covered by eight cancer registries were considered eligible as cases  controls were recruited by random digit dialing  whereas the study had excellent power  96   to detect a twofold increase in risk for hodgkin s disease among vietnam veterans  its ability to detect a similarly elevated risk in the other cancers was limited  ranging from 38   nasal carcinoma  to 75   primary liver cancer   analyses showed that risks among vietnam veterans relative to other men were 1 1  hodgkin s disease   0 7  nasal carcinoma   0 5  nasopharyngeal carcinoma   and 1 2  primary liver cancer   none of these relative risks was significantly different from 1 0  similar results were obtained if vietnam veterans were compared with  1  other veterans or  2  men who never served in the military  an examination of several attributes of military service in vietnam  eg  branch  duration of service  and other characteristics that may have been associated with the use of agent orange  failed to identify any groups of veterans who were at increased risk for hodgkin s disease  small numbers limited further analyses of nasal  nasopharyngeal  and liver cancer  these results provide no evidence that  15 to 25 years following service in vietnam  the risk of these malignant neoplasms is higher among veterans  
class4	lymphomatoid granulomatosis presenting as ulcerodestructive gastrointestinal tract lesions in patients with human immunodeficiency virus infection  a new association  we describe cases of severe odynophagia  extensive oral ulcerations  and bowel perforation in patients with human immunodeficiency virus infection that were caused by lymphomatoid granulomatosis  such presentations in human immunodeficiency virus infected individuals are usually ascribed to other causes and may be incorrectly treated on an empiric basis  in addition  deep tissue specimens obtained at the margin of ulcerative lesions are often necessary for definitive diagnosis  we review our limited treatment experience with zidovudine  interferon alfa  and h2 blockers in our patients  based on the markedly increased frequency in which lymphomatoid granulomatosis is being diagnosed at our institution in the post human immunodeficiency virus era  we postulated an association between these two entities  
class4	the dichotomous distribution of gastrinomas  our experience with 47 sporadic gastrinomas suggests that no less than 85  of these tumors are located to the right of the superior mesenteric artery  this finding is unexpected because approximately 75  of insulinomas and glucagonomas are located to the left of the superior mesenteric artery  all of our extrapancreatic gastrinomas have been located to the right  these observations prompted us to determine if other extrapancreatic gastrinomas were also predominantly located to the right side  we searched the world s literature and found 10 cases of ovarian gastrinomas and one case of a renal gastrinoma  nine of these remote extrapancreatic gastrinomas were located on the right side  this distribution of remote extrapancreatic gastrinomas is similar to our experience with peripancreatic gastrinomas  this unexpected right sided preponderance of both remote and peripancreatic gastrinomas suggests a common origin for both  
class4	generation of human monoclonal antibodies against colon cancer  lymphocytes from regional lymph nodes of patients with colon cancer were fused with a human lymphoblastoid cell line with or without in vitro immunization  the efficacy of these two protocols for the generation of human monoclonal antibodies against colon cancer was investigated  the hyperplastic lymph nodes adjacent to the tumor were the best source of b lymphocytes  fusion frequency and the number of tumor reactive clones were markedly increased when the in vitro immunization protocol was applied prior to fusion  as a stimulant in in vitro immunization  the supernatant of pokeweed mitogen stimulated t lymphocytes was superior to the supernatant of mixed lymphocytes culture  carcinoembryonic antigen at 20 micrograms l seemed to be the optimal dose for in vitro immunization  the reactivities of human monoclonal antibodies thus generated were measured by enzyme linked immunosorbent assay and confirmed by immunoperoxidase staining  combining in vitro immunization with lymphocytes of cancer patients may lead to the successful production of clinically useful human monoclonal antibodies  
class4	detection of primary colorectal cancer with indium 111 monoclonal antibody b72 3  b72 3 is a murine monoclonal antibody of the immunoglobulin subclass igg1 directed against tag 72  a cell surface antigen present on colorectal carcinoma cells  we investigated the utility of scanning with indium 111 labeled b72 3 in 16 patients with a high clinical suspicion of or biopsy proven primary colorectal cancer  each patient received 1 or 2 mg of b72 3 monoclonal antibody labeled with 152 mbq of indium 111  patients underwent scanning 2 to 3 days and 7 days after infusion by planar and emission computed tomography  nineteen lesions were confirmed in 12 patients  three patients with benign polyps had true negative monoclonal antibody scans  indium 111 labeled imaging of b72 3 detected nine of 19 lesions  unsuspected tumor sites were identified by monoclonal antibody scan in three patients  by detection of additional abdominal disease and extra abdominal spread  indium 111 labeled scanning of b72 3 directly affected treatment in 18  of patients  
class4	metastatic ciliary body carcinoid tumor  a 50 year old man with a history of systemic carcinoid had decreased right eye vision and a darkly pigmented cilio choroidal mass  results of ultrasonographic and fluorescein angiographic examinations were consistent with a malignant melanoma  fine needle aspiration biopsy of the lesion identified it as a carcinoid metastasis  the patient refused both radiation and enucleation  complete excision with a cyclochoroidectomy was performed  histopathologic examination showed a carcinoid neoplasm covered by marked hyperplasia of the retinal pigment epithelium that produced the pigmented appearance of the lesion  
class4	a study of immunoglobulin g in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the log igg index  a comparison and diagnostic applications  cerebrospinal fluid and serum immunoglobulin g from 1007 patients with suspected neurological disease were analysed by 2 methods  isoelectric focusing for the detection of oligoclonal banding  and quantitative measurement of igg and albumin for the formulation of a log igg index  a comparison of the 2 methods in the detection of local synthesis of igg showed that isoelectric focusing not only gave a much higher yield overall  with 282 patients showing local synthesis versus 225 for the log igg index  but also a higher specificity  with a false positive rate of 0  versus 3 5   in addition  of the 282 patients positive by isoelectric focusing only 163  58   were positive by the log igg index  of the 1007 patients studied  206 had multiple sclerosis  ms   and isoelectric focusing showed local synthesis in 95  of clinically definite cases  with a 90  detection rate overall  the log igg index was positive in only 67  of clinically definite cases  with an overall 59  detection rate  thus with the exceptions noted above  local synthesis of igg as defined by isoelectric focusing is confined to demyelinating  inflammatory  infectious and postinfectious disorders  our results compare very favourably with the published sensitivities of magnetic resonance imaging in the detection of abnormalities in multiple sclerosis  and better than those for evoked potentials  where both these investigations are readily available isoelectric focusing provides a useful adjunct  for the majority of physicians and neurologists who do not have ready access to magnetic resonance imaging  isoelectric focusing is an excellent alternative  we would also recommend that it become the standard for the measurement of igg abnormalities in the cerebrospinal fluid and that the use of quantitative data be abandoned for routine purposes  
class4	oral contraceptives and breast cancer  review and meta analysis  to evaluate the relation between use of oral contraceptives and the incidence of breast cancer  the authors reviewed the epidemiologic literature and used quantitative methods to summarize the data  study results for any use of oral contraceptives were pooled using a model that accounted for both interstudy and intrastudy variability  the authors also explored interstudy variability and modeled a duration effect relation between oral contraceptive use and breast cancer  case control and follow up studies were considered separately  overall  the authors observed no increase in the risk of breast cancer for women who had ever used oral contraceptives  even after a long duration of use  these results were consistent across study design  however  data combined from case control studies revealed a statistically significant positive trend  p   0 001  in the risk of premenopausal breast cancer for women exposed to oral contraceptives for longer duration  this risk was predominant among women who used oral contraceptives for at least 4 years before their first term pregnancy  relative risk   1 72  95  confidence interval   1 36 to 2 19   additional study is required to determine whether this finding in a subgroup of exposed women is confirmed and whether the risk remains increased with advancing age  
class4	predictive value of tumor estrogen and progesterone receptor levels in postmenopausal women with advanced breast cancer treated with toremifene  the predictive value of estrogen receptor  er  concentrations was evaluated in a group of 113 postmenopausal patients with estrogen receptor positive  er greater than 7 fmol mg protein  advanced breast cancer  in 103 patients  tumors were also sampled for progesterone receptor  pgr  determination  all patients were treated with toremifene  a novel antiestrogen  60 mg daily  the median er in 51 responders was 78 fmol mg protein  and in 62 nonresponders  51 fmol mg protein  the median pgr levels were 40 and 37 fmol mg protein  respectively  the response rate in patients with er less than 50 fmol mg protein was 38   and 51  in the group with er greater than 50 fmol mg protein  not significant  ns    the response rate in patients with pgr less than 10 fmol mg protein was 42   and in patients with greater than 10 fmol mg protein  44   the duration of response in patients with er greater than 50 fmol mg protein was significantly longer than with lower er levels  p   0 002   pgr was not associated with the duration of response  in cox s multiple regression analysis  er was an independent prognostic factor  p   0 005  for response duration  thus  the er concentration of tumor tissue predicts the duration of response but not the response rate to toremifene in patients with advanced breast cancer  the pgr status does not predict the response rate or the duration of response  
class4	combined modality therapy for locally advanced non small cell lung carcinoma  multi modality treatment consisting of cisplatin  vp 16  and 5 fluorouracil chemotherapy given concomitantly with external beam radiation was used to treat 64 patients with locally advanced stage iii non small cell lung carcinoma  this regimen was used in a preoperative fashion for four cycles in patients considered surgically resectable and with curative intent for six cycles in the remainder of patients  the clinical response rate for the entire group was 84  and the overall local control rate was 74   the median survival was 13 months with a median follow up for live patients of 19 months  the actuarial 3 year survival and disease free survival rates were 30  and 23   respectively  histologic complete response was 39  and appeared to predict for survival  the 3 year actuarial survival and disease free survival rates for 23 resected patients were 69  and 45   respectively  with the complete histologic responders having a disease free survival of 78   the pattern of first recurrence did not appear to differ by histology or presence of lymph nodes in this subset of patients  the actuarial 3 year survival and disease free survival rates for inoperable patients receiving six cycles of treatment were 18  and 23   respectively  the local control was 67  with the majority of these patients having stage iiib disease  the mountain international staging system appeared to predict for operability  local recurrence  and survival  this concomitant treatment regimen is feasible  with the major toxicities being leukopenia  nausea  and vomiting  
class4	low dose preoperative radiation postpones recurrences in operable rectal cancer  results of a randomized multicenter trial in western norway  a randomized  multicenter clinical trial was conducted in western norway to study the effectiveness of preoperative radiation therapy in operable rectal cancer  given at a dosage of 3150 cgy in 18 fractions  2 to 3 weeks before radical surgery  three hundred nine patients were entered into the trial between may 1976 and december 1985  after radiation no tumor was seen in 4 5  of the patients  there was no increased morbidity or mortality at surgery  the 5 year survival for evaluable patients was 57 5  in the control group and 56 7  in the radiotherapy group  for patients operated on for cure the 5 year survival was 60 9  and 64 2  in the control group and radiotherapy group  respectively  radiation significantly delayed both local and distant recurrences in patients in the radiation group who had curative resection from 13 3 months in controls to 27 1 months  the local recurrence rate in the corresponding groups was 21 1  and 13 7   respectively  we conclude that higher preoperative radiation doses should be used in new trials as a higher dosage may transform the observed positive effects into a survival benefit  
class4	comparison of lymphangiography and computed tomography scanning in evaluating abdominal disease in stages iii and iv hodgkin s disease  a southwest oncology group study  the authors reviewed the records of 139 patients who had laparotomy plus computed tomography  ct  and or lymphangiograms  lag  as part of a their staging workup for hodgkin s disease  in accordance with southwest oncology group  swog  protocol 7808  they evaluated the relative ability of ct and lag to detect disease in the abdomen  two regions of the abdomen were designated  the upper and the lower  to further examine the capabilities of ct and lag in the lower abdomen and ct in the upper abdomen  a lag was more sensitive  p less than 0 05  than ct in detecting positive lower abdominal nodes  in the upper abdomen  ct scan had low sensitivity for detecting positive nodes  liver  or spleen  this study suggests that lag of the lower abdomen provided more information than ct  and therefore should not be abandoned as a valid method for detecting nodal disease  
class4	piroxicam decreases postirradiation colonic neoplasia in the rat  this study evaluated the effects of the nonsteroidal antiinflammatory agent piroxicam on chronic radiation proctitis in the rat  forty female wistar rats received a 2250 cgy dose of irradiation to the distal 2 cm of the colon  twenty received piroxicam 8 0 mg kg orally 30 minutes before exposure and 24 hours after exposure  20 rats served as irradiated controls  all animals were evaluated by colonoscopy 1 and 3 weeks postexposure and every third week until death or killing at 1 year  at killing  colons were removed for light microscopic examination  one year postirradiation results showed no differences in mortality  vascular changes  acute inflammation  colitis cystica profunda  or rectal stricture between the control and piroxicam treated groups  however  at 1 year postirradiation the control group demonstrated neoplasia in 15 of 19 animals compared with eight of 20 animals in the piroxicam treated group  the first endoscopic appearance of colonic neoplasm occurred at 15 weeks postirradiation in one control irradiated rat whereas the first evidence of endoscopic neoplasm in the piroxicam treated group did not occur until 36 weeks postirradiation  histologic examination documented a tendency toward a greater presence of adenocarcinomas in the control group compared with the piroxicam treated group  the authors conclude that piroxicam treatment significantly decreased the incidence of colonic neoplasia in general as well as delayed the endoscopic appearance of colonic neoplasia in rats after pelvic irradiation  
class4	diffuse sclerosing variant of papillary carcinoma of the thyroid  clinical importance  surgical treatment  and follow up study  a diffuse sclerosing variant is not very rare among papillary carcinomas of the thyroid when the patients are female and younger than 30 years of age  the variant is characterized by diffuse involvement of one or both thyroid lobes  with dense sclerosis  patchy lymphocytic infiltration  and abundant psammoma bodies  controversy still exists concerning its prognosis  we reviewed our experience with 14 patients treated between 1958 and 1988  all patients were young females  their age being from 10 to 28 years with a mean of 19 6  hashimoto s thyroiditis had been suspected in nine patients before they came to our clinic  nowadays the diagnosis of this cancer is possible when we have this entity in mind and detect abundant psammoma bodies either by ultrasonography or by soft tissue roentgenography of the neck  total thyroidectomy with modified neck dissection was carried out in eight patients  subtotal thyroidectomy with neck dissection in five  and lobectomy with neck dissection in one  all of them are alive and well without distant metastasis at a mean follow up of 16 years  because most of the patients with this variant of papillary carcinoma are young women and the prognosis is favorable  a complete resection without causing later recurrence  but also cosmetic and complication free surgery  should be considered  
class4	can internal mammary chain treatment decrease the risk of death for patients with medial breast cancers and positive axillary lymph nodes  the effect of internal mammary chain treatment on each type of malignant death related event was analyzed in 1195 patients with operable breast cancer and histologically involved axillary lymph nodes  a group of 135 patients who had no internal mammary chain treatment was compared with a control group of 1060 patients who were treated by surgery and or postoperative radiation therapy  in a multivariate analysis taking into account age  clinical size of the tumor  histoprognostic grading  and the number of positive axillary lymph nodes  quantitative interaction tests were used to determine whether the effects of internal mammary chain treatment on each type of malignant event were significantly different for patients with a lateral tumor compared with those with a medial tumor  the authors found that the effects of this treatment on the risks of distant metastases and of secondary breast cancer were not the same for the patients with a medial tumor as for those with a lateral tumor  for the untreated patients with a medial tumor  the risks of distant metastases and second breast cancer were  respectively  1 6  p   0 02  and 2 9  p   0 02   compared with the treated patients  conversely  for women with lateral tumor  no difference between the two treatment groups was observed  thus  internal mammary chain treatment may improve long term survival rate in patients with a medial tumor and positive axillary lymph nodes essentially by decreasing the risk of development of distant metastases  mainly brain  distant lymph nodes  multiple simultaneous metastases  and or a secondary breast cancer  
class4	superficial esophageal carcinoma  surgical treatment and the results  we report 92 patients treated with esophagectomy for superficial esophageal carcinoma  sec  9 1  of all resected esophageal cancers at our institution   the operative mortality rate was 5 4   in 24 cases  cancer invasion was limited to the mucosa  and in 68 to the submucosa  twenty three patients in the former group had no lymph node involvement  whereas 24 patients  35 3   of the latter group had lymph node metastases  the 5 year survival rate after surgery for patients with sec limited to the mucosa was 83 5   which was significantly better than that for carcinoma invading the submucosa  54 9    no recurrent disease occurred in patients with lesions limited to the mucosa  in conclusion  an esophagectomy with wide lymphadenectomy is necessary to provide a better prognosis for sec invading the submucosa  whereas a less extensive treatment may be considered for sec limited to the mucosa  
class4	the concept of locally advanced gastric cancer  effect of treatment on outcome  the gastrointestinal tumor study group  in previous gastrointestinal tumor study group  gitsg  reports  gastric cancer patients with locally unresectable disease  treated with combined radiation and chemotherapy had a shorter median survival  40 weeks  but more remained alive at 4 years  18   when compared to those randomized to receive chemotherapy alone  76 weeks and 6   respectively   to further test the concept that combined modality therapy might increase the number of long term survivors  a second protocol was designed  but with three major modifications  a course of chemotherapy would precede the 5 fluorouracil potentiated radiation therapy  doxorubicin would be added to the 5 fluorouracil plus methyl ccnu combination  radiation therapy would be given as a single course of 4320 cgy  with 5 fluorouracil given daily for 3 days at the beginning and end of the course  median survival of 46 patients treated with chemotherapy alone was 59 weeks  with 11  alive after 3 years  following combined modality therapy  median survival was 62 weeks  but only 7  lived 3 years  although the problem of early deaths in the combined modality group was resolved  long term survival with combination therapy was not demonstrated in this study  
class4	lack of relationship between perioperative blood transfusion and survival time after curative resection for gastric cancer  to better comprehend the relationship between perioperative blood transfusion and survival time after curative gastrectomy for advanced gastric cancer  the authors reviewed retrospectively data on 568 patients treated in their clinics from 1965 to 1983  of these 568  195  34 3   required no blood transfusion and 373  65 7   required transfusions within the perioperative period  univariate analysis indicated that the survival time of the transfusion recipients was significantly less than that of the patients who had no transfusions  p less than 0 01   in subgroups of the authors  patients stratified to adjust for stage of disease  there was  however  no significant difference between the survival rates  subsequently  multivariate analysis  using the cox regression analysis  which adjusted for sex  age  and other covariates  indicated that perioperative blood transfusion was not a useful factor for predicting survival time  multivariate analysis suggested that tumor size  p less than 0 01   degree of invasion into the gastric wall  p less than 0 01  and status of lymph node metastasis  p less than 0 01  were the most important covariates after curative gastrectomy for advanced gastric cancer  the authors  findings revealed the lack of any relationship between perioperative blood transfusion and survival time of patients who underwent curative resection for advanced gastric cancer  
class4	transrectal ultrasonography of rectal carcinoma  preoperative transrectal ultrasonographic staging of 38 patients with known adenocarcinoma of the rectum was performed  six of these patients had preoperative radiation therapy  of the 32 without radiation therapy  transrectal ultrasonography  trus  correctly staged disease limited to the rectum in 90   18 of 20  and transmural extension in 50   6 of 12   for a sensitivity for evaluating transmural extension of 50   specificity of 90   positive predictive value of 75   and a negative predictive value of 25   nineteen patients had positive nodes  the sensitivity and specificity of detecting nodal metastases by trus were 63  and 85   the positive and negative predictive values were 86  and 61   respectively  trus was slightly superior to digital rectal examination in staging patients because of its superior ability to detect adenopathy  adjacent organ involvement was correctly evaluated in five of six patients  peritumoral fibrosis was misinterpreted as tumor extension into uterus and ovary in one woman  tumor shrinkage in all patients undergoing radiation therapy was identified  but fibrosis and edema made staging by trus unreliable in those patients  
class4	the effect of dietary omega 3 fatty acids  fish oil  on azoxymethanol induced focal areas of dysplasia and colon tumor incidence  maxepa  ma   a fish oil high in omega 3 fatty acids  was combined with various levels of corn oil  co   rich in omega 6 fatty acids  and fed to female cf1 mice  the three fish oil blends with co and the two co levels of the diets studied were as follows  16 0  co   4 4  ma  diet 1   10 2  co   10 2  ma  diet 2   4 4  co   16 0  ma  diet 3   20 4  co  diet 4   and 4 4  co  diet 5   the diets were provided 2 weeks before weekly subcutaneous injection of saline or azoxymethanol  aom   studies of epithelial cell proliferation and the incidence of focal areas of dysplasia  fad  involved six weekly aom injections  one week after the last aom injection and 1 hour before killing  mice were injected with tritiated thymidine  3htdr   no differences in any proliferative parameters were found among the five groups of saline treated mice  among the aom treated animals  those fed diet 3 showed significantly fewer cells per crypt and significantly fewer labeled cells gland than co diets 4 and 5  additionally  the distribution of s phase cells in crypts of aom treated mice fed diet 3 most closely resembled that of the saline controls  the greatest alteration in the distribution of proliferative cells was observed in the high co diet  diet 4  and the lowest ma level  diet 1   mice fed diets 2 and 3 had significantly fewer fad 500 microns of distal colonic serial sections than those fed the high co diet  diet 4   mice involved in chronic tumor incidence studies received only three weekly injections of the same dose of aom  regardless of diet  approximately 88  of all tumors arose in the distal colon  a significantly larger tumor bearing population was observed in both the high co diet 4 and the lowest maxepa  ma  diet  diet 1  compared with the incidence in ma diets 2 and 3 and the low co diet 5  a diet with a ratio of omega 6 to omega 3 fatty acids of approximately 1 0 apparently prevented the development of an adenoma type proliferative pattern thereby reducing fad numbers and subsequent tumor incidence  
class4	aneuploidy in pancreatic insulinomas does not predict malignancy  nuclear deoxyribonucleic acid  dna  ploidy studies with paraffin embedded archival material from 14 pancreatic insulinomas were performed by flow cytometry  clinical follow up  2 to 17 years  mean  8 years  was obtained for all patients  half of the tumors had a normal dna histogram and half exhibited an abnormal dna profile consistent with dna aneuploidy  six of the seven patients with aneuploid tumors are alive and disease free  2 to 5 years postresection   and one is alive with metastatic disease  of the seven patients with tumors showing normal dna profiles  five are alive and disease free  one is dead of disease  and one is alive with metastatic disease  these data suggest that dna ploidy analysis is unlikely to provide useful prognostic information for patients with insulinomas  
class4	comparative study of cutaneous t cell lymphoma and adult t cell leukemia lymphoma  clinical  histopathologic  and immunohistochemical analyses  an important disease entity distinct from cutaneous t cell lymphoma  ctcl  in japan is adult t cell leukemia lymphoma  atl   which usually shows the same phenotype as ctcl  i e   a helper inducer t cell phenotype  cd4 cd8    and usually involves the skin  clinically  both ctcl and atl are heterogeneous in nature  in this study  we demonstrated differences between ctcl and atl in terms of clinical and immunopathologic cell surface features  in patients with atl  the predominant clinical findings were peripheral lymph node involvement  skin lesions  hepatosplenomegaly  leukemic manifestations  and an aggressive course  in patients with ctcl  by contrast  only skin lesions predominated at the onset of the disease and a relatively good prognosis was demonstrated  phenotypic heterogeneity of atl in the skin  i e   cd4 cd8   cd4 cd8   and cd4 cd8   was demonstrated  expression of leu8  cd7  leu9   and cd45ra  2h4  was high in both the skin infiltrating atl cells and peripheral blood and lymph node atl cells compared with that in the skin infiltrating ctcl cells  expression of cd25  il 2r   cd71  okt9   hla dr  and hla dq was higher in the skin infiltrating atl cells than in ctcl cells  expression of cd29  4b4  was high  and that of cd45ra  2h4  was low in both the skin infiltrating atl and ctcl cells compared with the peripheral blood and lymph node atl cells  expression of cd45ro  uchl 1  was not significantly high in the skin infiltrating ctcl cells compared with that in atl cells  the most significant phenotypic difference between atl cells and ctcl cells was the expression of leu8  lymph node homing receptor   cd7 and cd25 antigens on the cell surface  and the main phenotypic difference between skin infiltrating atl and ctcl cells and peripheral blood and lymph node atl cells was the expression of cd29 and cd45ra  these findings confirm that the difference in antigen expression on the cell surface might reflect the clinical features of atl and ctcl  and suggest that the predominant phenotype of peripheral blood and lymph node atl cells is that of naive  relatively immature or activated t cells  and that ctcl cells are previously activated  memory  t cells  in other words  ctcl cells do not share the same origin as atl cells  these observations support the concept that atl is a disease distinct from ctcl  
class4	von willebrand factor in head and neck cancer  laboratory abnormalities in blood coagulation factors are common in patients with cancer but the significance is unknown  twenty eight patients with head and neck cancer were studied at the time of diagnosis  twenty five were advanced stage  iii or iv  patients  levels of clotting factors  antithrombin iii  and plasminogen were normal  levels of von willebrand factor  vwf   both antigenic and functional  ristocetin cofactor   were elevated  this group of patients were followed for a minimum of 41 months  median  48 months   fifteen patients died within the follow up period  von willebrand factor levels were significantly higher in these 15 than the 13 survivors  extreme elevation of ristocetin cofactor  greater than 300 u dl  was seen in six of the 15 patients who died and in none of the survivors  plasma vwf is elevated in head and neck cancer and the level measured at the time of diagnosis may have prognostic and potentially therapeutic implications  
class4	tumor factors predicting for prognosis in metastatic breast cancer  the presence of p24 predicts for response to treatment and duration of survival  fifty one patients with metastatic breast cancer were investigated to determine tumor parameters with prognostic significance  investigations included determinations of p24 content by immunocytochemical means using a monoclonal antibody to p24 protein  immunocytochemical analysis of estrogen and progesterone receptors  ploidy analysis by flow cytometry  and histologic grading  there were significant correlations between the presence of p24 and estrogen receptor  between histologic grade and p24 expression  and between estrogen and progesterone receptors  of the tumor factors investigated only p24 protein was  however  of prognostic significance  patients with p24 positive tumors had a significantly higher rate of response to treatment as well as more prolonged duration of response and duration of survival from diagnosis of metastatic disease  none of the other variables investigated were significantly predictive of outcome  p24 protein may be a useful predictor of prognosis in metastatic breast cancer  
class4	clinicopathologic features of hepatocellular carcinoma in young patients  to investigate clinicopathologic characteristics of hepatocellular carcinoma  hcc  in young adults  excised tumors from 21 patients younger than 45 years  young group  were compared with findings in tumors from 204 patients older than 45  old group   in the young group hcc showed  1  a high incidence of positive hepatitis b virus surface antigen  hbsag   young 71 4  versus old 20 1     2  relatively well preserved hepatocellular function  indocyanine green test  young 10 7     8 8  versus old 20 6     10 8     3  low incidence of histologically verified concomitant cirrhosis  young 52 4  versus old 78 4    and  4  a more advanced stage of the disease in tnm classification  stage iii  young 52 4  versus old 18 1    with respect to survival rates achieved by surgery  there was no statistically significant difference between the two groups  thus  hepatitis b virus may relate to the occurrence of hcc in the young patients  despite the advanced stage in the young group  survival rate after surgery was comparable with that achieved in the old group  these observations mean that a close periodic surveillance of young adults with a positive hbsag is required to detect hcc at an early stage  treatment of patients with hbsag using interferon or vidarabine and hepatitis b vaccine should be made to convert hbsag to negative in these individuals  
class4	angiocentric immunoproliferative lesion t cell non hodgkin s lymphoma and the acquired immune deficiency syndrome  a case report and review of the literature  the lesions known as lymphocytic vasculitis  polymorphic reticulosis  midline malignant reticulosis  lethal midline granuloma   lymphomatoid granulomatosis  and angiocentric lymphoma form what have been collectively termed the angiocentric immunoproliferative lesions  ail   because of recent reports demonstrating clonal rearrangements of the t cell receptor in these lesions  the ail are now thought to represent a continuous spectrum of post thymic t cell non hodgkin s lymphoma  nhl   nhl associated with the acquired immune deficiency syndrome  aids  represents intermediate or high grade b cell malignancies in hiv infected patients that may be etiologically related to the epstein barr virus  ebv   there have been reports of ebv associated t cell nhl  ail  and large granular lymphocyte  lgl  proliferations  as well as hiv associated t cell neoplasia  lgl t cell proliferations  and ail  we describe a case of polymorphic reticulosis  lethal midline granuloma  arising in an hiv infected individual  who later progressed to aids  and review the literature on hiv associated and ebv associated t cell neoplasia  lgl t cell proliferations  and ail  the etiology of this ail t cell nhl  especially in relation to ebv and hiv  is discussed  
class4	disseminated strongyloidiasis with central nervous system involvement diagnosed antemortem in a patient with acquired immunodeficiency syndrome and burkitts lymphoma  a 45 year old man presented with central nervous system involvement as the initial manifestation of disseminated infection with strongyloides stercoralis  several concurrent clinical factors contributed to this event  all related to the patient s immunosuppression  including high grade lymphoma  corticosteroid therapy  and acquired immunodeficiency syndrome  this is only the third case of cns involvement in disseminated strongyloidiasis diagnosed antemortem  
class4	abnormal vitamin b6 status in childhood leukemia  vitamin b6 is involved in many biological processes of potential relevance to carcinogenesis and tumor growth  including dna synthesis and maintenance of immunocompetence  yet very little information exists on b6 nutritional status in childhood leukemia  using a radioenzymatic assay  the authors measured plasma pyridoxal 5  phosphate  plp   the biologically active form of b6  in 11 newly diagnosed untreated children with leukemia and 11 age matched controls  the children with leukemia had significantly lower plp levels than the controls  in 26 additional leukemia patients and 26 additional controls  a high performance liquid chromatography assay also demonstrated lower plasma plp levels in childhood leukemia compared with controls  these differences were significant for both acute lymphoblastic leukemia  all  and for acute nonlymphoblastic leukemia  anll   the plp values did not correlate with indices of leukemia cell burden  but did correlate with reported b6 intake  suggesting that illness related diet changes are at least partially responsible for the low plp levels  before any chemotherapy  overall nutritional status was suboptimal in 53  of all cases and 57  of anll cases  newly diagnosed children with leukemia have suboptimal overall nutrition as well as suboptimal vitamin b6 status  
class4	simultaneous hepatoblastoma in identical male twins  identical male twin infants who in 1987 presented with hepatoblastoma at the age of 7 months are reported  twin b was admitted for investigation due to enlarged liver and spleen  he was found to have an inoperable hepatoblastoma of fetal type and was treated with chemotherapy and local irradiation  however  7 months after the chemotherapy the tumor recurred  the asymptomatic twin a was examined because of the known familial cases  and he proved to have an identical tumor  he was successfully radically operated on and 2 years after the chemotherapy is still doing well with no evidence of tumor  as the mother and the maternal grandmother had polyps in the colon  quite probably the hepatoblastomas of the twins were associated with familial adenomatous polyposis  
class4	melanoma and soft tissue sarcoma in seven patients  seven patients with both melanoma and sarcoma were seen at the dana farber cancer institute  boston  ma  over a 4 year period  three had additional malignant neoplasms  one of these patients also had the hereditary cutaneous malignant melanoma  dysplastic nevus syndrome  these observations suggest the possibility of a biologic relationship between melanoma and sarcoma  the nature of which remains unknown  
class4	the epidemiology of cancer among hispanic women  the experience in florida  to explore cancer incidence among hispanic women living in dade county  florida  data were analyzed from the statewide cancer registry  for all but three sites  hispanics had lower rates of the 15 most prevalent cancers than non hispanics  however  higher rates of cancer among hispanics were noted for cancers of the gallbladder  liver  and heart and soft tissue  subgroups of women had significantly higher rates of cervical cancer and thyroid cancer  lower rates among hispanics were observed for cancers of the esophagus  vagina  breast  colon  buccal cavity and pharynx  and malignant melanoma  these data suggest that most cancer sites traditionally higher among us latino women were not higher among dade hispanics  and that sites more common among non hispanics have not yet shown an increased incidence among hispanic women in dade county  
class4	increasing incidence of cecal and sigmoid carcinoma  data from the connecticut tumor registry  we have studied both the distribution and incidence of colorectal cancer using the connecticut tumor registry  the oldest tumor registry in the united states  during the time period 1973 to 1985  left sided colon cancers accounted for 63  of the cancers  right sided cancers 33   and cancers with unspecified sites 4   indeed  this pattern of distribution has remained constant for 25 years  for the period 1935 to 1985  we calculated the sex specific  age adjusted  normalized to the 1970 u s  census  incidence  age adjusted incidence of rectal cancer has remained stable for 50 years  for men  22 8 cases 100 000 year  and for women  13 9 cases 100 000 year  during these 50 years  the age adjusted incidence of cecal carcinoma for men has increased from 3 6 to 16 7 cases 100 000 year  while for women  it has increased from 4 9 to 14 2 cases 100 000 year  sigmoid carcinoma for men has increased from 8 8 to 18 7 cases 100 000 year  and for women  it has increased from 7 7 to 12 8 cases 100 000 year  the incidence of colon cancer at each site has been and continues to be increasing at a constant rate  age adjusted incidence for all colorectal cancers has increased from 35 2 to 70 2 cases 100 000 year for men and from 32 1 to 49 2 cases 100 000 year for women  thus  distribution of colorectal cancers by site in connecticut has remained stable for 25 years  more importantly  however  the age adjusted incidence of colon cancer has continued to increase for 50 years  whereas that of rectal cancer has remained relatively stable  
class4	rapid diagnosis of lung cancer from palpable metastases by needle thrust  this study encourages the use of percutaneous fnb to diagnose and stage advanced lung cancer in patients with palpable metastases in supraclavicular lymph nodes or soft tissues  percutaneous fnb of metastases is much easier to learn than transthoracic needle aspiration  the superficial target is anchored and sampled with multiple passes using a short needle grasped directly in the fingers  it is fast  accurate  economical and nearly free of risk and pain  the technique saves time and money because it is the only procedure needed by many patients with palpable disease in stage iiib and iv  bronchoscopy  transthoracic needle aspiration and open surgical biopsy thus can be avoided in most patients with palpable metastases  prompt diagnosis by fnb of metastases speeds palliation for patients with urgent need  tumor cell type from fnb correlated with cytologic findings from sputum samples  bronchoscopy specimens and autopsy results  
class4	elevated prostaglandin e2 levels in bronchoalveolar lavage fluid of patients with bronchogenic carcinoma  understanding local pulmonary immunoregulatory mechanism s  in patients with carcinoma of the lung is an important step towards the development of innovative methods of treatment  prostaglandin e2 plays an integral role in immunoregulation  therefore  we evaluated pge2 concentrations in balf from 18 patients with bronchogenic carcinoma  compared to that from six patients with pulmonary diseases other than carcinoma and ten normal smokers of similar age  the level of pge2 in patients with lung carcinoma  158 1     88 7 pg ml  was significantly  p less than 0 001  higher than the other two groups  16 2     6 9 and 4 4     3 4 pg ml   levels of pge2 also varied among patients with carcinoma of different cell types  patients with sqca had significantly  p less than 0 001  higher levels of pge2  242 7     29 4 pg ml  than patients with adca or scca  82 3     27 9 and 66 3     15 2 pg ml  respectively   furthermore  there was a marked difference in pge2 concentration between carcinomatous lung and clinically noninvolved lung in patients with sqca and adca  further study is warranted to determine the interactions between pge2 and other cytokines  interleukin 1  il 2  and tumor necrosis factor   as well as the activity of cytolytic lymphocytes  lak cells  in the lungs of patients with bronchogenic carcinoma  
class4	bronchogenic carcinoma in situ on the carina eradicated by endobronchial biopsy  squamous cell carcinoma in situ of the bronchus is a rare disorder in an isolated clinical setting  we present a case of carcinoma in situ located on the carina with excisional biopsy via a fiberoptic bronchoscope and no recurrence after five years  to our knowledge  this represents the only case of carcinoma in situ treated solely with excisional biopsy  this case further emphasizes the importance of securing biopsy specimens for all mucosal abnormalities and raises the possibility of limited excision as sole therapy for carcinoma in situ  
class4	11 beta hydroxyandrostenedione  a marker of adrenal function in hirsutism  to assess the role of the adrenal glands in the development of hirsutism  levels of 11 beta hydroxyandrostenedione  11 beta oha   17 alpha hydroxyprogesterone  17 ohp   dehydroepiandrosterone sulphate  dheas   androstenedione  delta 4a   and free and total testosterone  t  were measured in 63 hirsute females and 30 control patients  six of the hirsute patients had basal levels of 11 beta oha and 17 ohp and responses to adrenocorticotropic hormone that were significantly greater than these values in controls and the other hirsute women  these women were designated as having an adrenal source for their hirsutism  women with polycystic ovarian syndrome and idiopathic hirsutism had normal values of 11 beta oha and 17 ohp  levels of total and free t  dheas and delta 4a were significantly higher than control values in all of the hirsute women  this study demonstrates that 11 beta oha can be used as a marker to assess the adrenal contribution to hirsutism  
class4	neodymium  yag laser hysteroscopy in large submucous fibroids  the preoperative use of a potent  subcutaneously injected gonadotropin releasing hormone agonist  gnrh a  was evaluated in a series of 60 women with large submucosal fibroids  myomectomy by hysteroscopy and nd yag laser was easily performed  in 12 cases  the largest portion of the myoma was not inside the uterine cavity and myomectomy was carried by a two step hysteroscopy  in women who wished to become pregnant  a pregnancy rate of 66  was achieved  advantages of preoperative use of a gnrh a are  1  the significant decrease of the fibroid size   2  a lower fluid absorption  and  3  the restoration of a normal hemoglobin concentration  
class4	enteric neuronal autoantibodies in pseudoobstruction with small cell lung carcinoma  severe gastrointestinal dysmotility is a newly recognized paraneoplastic syndrome that occurs with small cell lung carcinoma  thirty four patients with small cell carcinoma  of whom 5 had chronic intestinal pseudoobstruction and 29 had no digestive symptoms  were studied serologically  four of the 5 patients with gut dysmotility had immunoglobulin g antibodies reactive with neurons of the myenteric and submucosal plexuses of jejunum and stomach in an indirect immunofluorescence assay  antibodies of this type were not found in any of the 29 patients who had no gut dysmotility  nor were they found in patients with chronic idiopathic intestinal pseudoobstruction  n   8   ovarian cancer  n   20   or epilepsy  n   4  or in normal subjects  n   9   in 4 of the patients with paraneoplastic pseudoobstruction  antibodies in highly diluted serum  1 4000 1 8000  bound selectively to nuclei and cytoplasm of neuronal elements in the gut  this novel autoantibody activity suggests that intestinal pseudoobstruction occurring in patients with small cell carcinoma may have an autoimmune basis  from a clinical standpoint  serological testing offers a simple means for determining which patients with gut dysmotility syndromes may have associated small cell carcinoma  thereby enabling earlier diagnosis and treatment of the tumor  
class4	clinical application of ras gene mutation for diagnosis of pancreatic adenocarcinoma  most pancreatic adenocarcinomas are known to have ras gene  oncogene  mutations  the site of the mutations is localized in codon 12 of k ras gene  such high incidence and localization of the ras gene mutations have not been observed in any other human malignancies  polymerase chain reaction and direct sequencing method enabled us to analyze dna sequence around codon 12 of k ras gene in small quantities of specimens obtained from needle biopsies and aspirate samples for pathological diagnosis  all the materials obtained from 12 patients with pancreatic adenocarcinoma showed the mutations  whereas those obtained from 6 patients with chronic pancreatitis showed no mutations  in several cases using the mutations of k ras gene as a marker  this analysis supplemented conventional pathology and cytology in making the diagnosis of pancreatic adenocarcinoma  the analysis of ras gene mutations was useful for the clinical diagnosis of pancreatic adenocarcinoma  
class4	expression of class ii molecules on intestinal epithelial cells in humans  differences between normal and inflammatory bowel disease  expression of class ii antigens on human intestinal epithelial cells was assessed using a sensitive avidinbiotin peroxidase technique  hla dr was present predominantly in the normal small bowel with diminished but evident expression in the colon  hla dp staining was less prominent  and hla dq was absent  in inflammatory bowel disease the expression of both hla dr and hla dp was increased  but that for hla dq remained absent  suggesting an inherent defect in the ability of intestinal epithelial cells to express hla dq  in related experiments  an interferon gamma treated malignant epithelial cell line t84 also failed to stain for hla dq and hla dp despite the presence of hla dr  isolated rnas for all three subclasses of hla d were detectable by slot blot analysis  suggesting that the lack of hla dq expression relates to posttranscriptional defects in intestinal epithelium  these and other differences with conventional class ii antigen positive accessory cells  macrophages b cells  may help to explain the unique properties of intestinal epithelial cells as antigen presenting cells  
class4	screening colonoscopy in asymptomatic average risk persons with negative fecal occult blood tests  colonoscopy was performed on 210 asymptomatic average risk persons  aged 50 75 years  who had negative fecal occult blood test results  colonoscopy was complete to the cecum in 209 subjects  fifty three subjects  25   had adenomas and two had cancer  all of the adenomas greater than or equal to 1 cm in size and both cancers occurred in subjects aged greater than or equal to 60 years  fifty one percent of subjects with adenomas and one with cancer had no neoplasms distal to the sigmoid descending colon junction  one subject had a major postpolypectomy hemorrhage that stopped spontaneously  screening colonoscopy  therefore  has a high yield for detection of neoplasms in asymptomatic average risk persons aged greater than or equal to 60 years with negative fecal occult blood test results  the yield is low in persons aged 50 54 years and intermediate in persons aged 55 59 years  
class4	modified van nes rotationplasty for osteosarcoma of the proximal tibia in children above knee amputation has been the traditional treatment for osteosarcoma of the proximal tibia  recent advances in chemotherapy have encouraged the development of limb salvage techniques  van nes rotationplasty for malignant lesions of the distal femur has increased in popularity as a reconstructive technique  but no similar procedure has been described for lesions of the proximal tibia  we have developed a modified rotationplasty for this lesion and have performed it in four children  the surgical technique  postoperative management and results of the procedure are described  two patients had delayed wound healing  no other complications have developed and our patients were disease free at follow up  while the appearance of the leg was well accepted by the patients and their parents  this procedure is a useful addition to the armamentarium of the tumour surgeon for the treatment of malignant lesions of the proximal tibia  
class4	parosteal osteosarcoma  treatment by wide resection and prosthetic replacement  we have reviewed 20 cases of parosteal osteosarcoma treated by wide local resection and prosthetic replacement and followed up for six to 17 years  limb function was excellent in 85   one patient with grade iii histological disease developed pulmonary metastases  four patients had local recurrences  which were related to repeated preliminary biopsies  inappropriate siting of biopsy and vascular encroachment by the tumour  after this mode of treatment  the outcome was not related to medullary invasion by the tumour  
class4	marjolin s ulcer  a review and reevaluation of a difficult problem  the formation of an epidermoid carcinoma in nonhealing scar tissue  a marjolin s ulcer  is a well described neoplasm  these lesions are  however  frequently overlooked and often inadequately treated  this paper reviews six cases of scar tissue carcinoma  all lesions were secondary to various kinds of burns  four of the marjolin s ulcers were well differentiated squamous cell carcinomas  one was a moderately differentiated squamous cell carcinoma  and one was a malignant melanoma  the average age at presentation was 59 years  and the mean interval from time of burn injury to appearance of neoplasm was 36 8 years  the lesions varied in anatomic location and involved the upper extremities  lower extremities  and scalp  in addition to the case studies  this paper reviews the literature and provides a logical treatment plan for a patient with a marjolin s ulcer  because these lesions can be very aggressive  a well thought out treatment plan is necessary to optimize care and assure patient survival  
class4	embryologic fusion planes and the spread of cutaneous carcinoma  a review and reassessment  it has long been held that embryologic fusion planes influence the spread of skin cancer  embryologic fusion planes have been implicated in the depth of invasion  horizontal spread  and recurrence of cutaneous carcinoma  however  these structures have never been studied in detail  a review of the surgical literature reveals considerable confusion regarding the exact nature  location  and tumor interactions of these fusion planes  we review the gross and microscopic development of sites of embryologic fusion  we examine histologic sections through fusion sites in normally developed adult and fetal fresh cadaver specimens  our studies  supported by our review of developmental anatomy  indicate that fusion planes do not persist as identifiable anatomic structures that would influence tumor spread  
class4	effect of the topical anesthetic emla on the efficacy of pulsed dye laser treatment of port wine stains  emla cream  eutectic mixture of local anesthetics  is a new topical anesthetic composed of 25 mg lidocaine and 25 mg prilocaine in an oil in water emulsion cream  it has been found to be very effective for local anesthesia prior to venepuncture  minor surgical procedures  and pulsed dye laser  pdl  therapy for port wine stains  pws  in children  however  since emla may cause vasoconstriction of cutaneous vessels  we tried to determine whether pretreatment with emla decreases the efficacy of subsequent pdl treatment  we report eight patients between the ages of 4 and 32 years with pws who received two test site treatments prior to pdl treatment  one site was pretreated with emla cream under occlusion for 60 minutes and then left unoccluded for 15 minutes prior to pdl test treatment  the other site  in the same area of the pws and patient s body  was not pretreated with emla  the test sites were compared 6 8 weeks later to determine whether emla decreased the degree of lightening of the pws compared to the non emla treated site  we conclude that emla is an effective topical anesthetic for pdl treatment of pws and does not adversely affect the efficacy of the treatment  
class4	use of mohs micrographic surgery to establish quantitative proof of heightened tumor spread in basal cell carcinoma recurrent following radiotherapy  we compared 27 basal cell carcinomas  bccs  recurrent following radiotherapy and subsequently excised by mohs micrographic surgery to a control group of bccs recurrent following other treatment modalities and similarly excised  mohs technique permitted precise  quantitative tumor assessment  obtained via a novel method utilizing three parameters  the number of surgical stages required for complete excision  the percentage increase between clinical preoperative tumor area and final postoperative defect area  and the presence of deep subcutaneous tissue invasion  figures for the postradiation group were larger in all three categories  with the latter two revealing statistically significant differences versus the nonradiation group  this study gives strong  direct quantitative support to the clinical impression that bcc recurrent following radiotherapy is a uniquely aggressive  invasive subset of recurrent bcc  
class4	congenital midline nasal masses  diagnosis and management  congenital midline nasal masses  cmnms  are rare lesions most commonly caused by dermoids  hemangiomas  nasal gliomas or encephaloceles  we report a case of nasal glioma and discuss the embryologic development  evaluation  and management of such cmnms  
class4	complete spontaneous regression of multiple basal cell carcinomas in the basal cell nevus syndrome  the possible role of transepithelial elimination  a 36 year old latin american man with the basal cell nevus syndrome had multiple  soft  hairless  depressed scars of the face  scalp  neck  and back  ranging in size from 0 3 x 0 5 cm to 3 5 x 3 9 cm  these areas had never been treated and previously were sites of basal cell carcinomas that underwent complete spontaneous regression 4 5 years from the date of onset  pathology of these spontaneously regressed sites was consistent with the criteria established by curson and weedon  1979   type iii transepithelial elimination was demonstrated for a basal cell carcinoma  type iii transepithelial elimination may play a role in the spontaneous regression of basal cell carcinomas  
class4	new primary basal cell carcinomas arising in skin flaps following mohs micrographic surgery for primary and recurrent basal cell carcinoma  two patients developed new primary basal cell carcinomas  bccs  in skin flaps used to reconstruct wounds that followed an earlier primary bcc and a recurrent bcc treated by mohs micrographic surgery  criteria for distinguishing a new primary bcc arising in a skin flap or full thickness skin graft at a previous treatment site for bcc from a truly recurrent bcc are presented  the distinction between a new primary bcc and true tumor recurrence is important for accurate clinical assessment and may have a dramatic impact on the type of subsequent treatment  in addition  there may be less medicolegal liability in the case of a new primary bcc arising at the site of a previously treated bcc than for a bcc that is determined to be recurrent  
class4	oral diseases in older adults  clinical conference  in the case presented  a 65 year old man with multiple dental  medical  and social problems benefited from interdisciplinary assessment and treatment  despite his poor oral health status and oral health behaviors upon admission  patient education and dental therapy resulted in improved daily oral hygiene  elimination of oral diseases  and improved oral function  the overall quality of life of any individual  particularly an older one  can be enhanced through oral disease prevention  health promotion  and  when indicated  dental therapy  this patient was treated in a hospital environment with a well established team approach to geriatric care  however  regardless of the care setting  the physician can play a key role in improving the oral health status and quality of life of older adults by including an oral screening examination as part of the periodic comprehensive geriatric assessment  recognizing oral pathology  requesting dental consultations and encouraging appropriate dental service utilization  
class4	the gastrin hypothesis  implications for antisecretory drug selection  newer potent and long acting inhibitors of acid secretion  such as the proton pump inhibitor omeprazole  are becoming available for general use  these drugs promise to control acid peptic disease effectively in patients who do not respond adequately to conventional short acting h2 receptor antagonists  the safety of chronic administration of these drugs has come into question  however  lifelong profound inhibition of acid secretion in rats induced by superpotent inhibitors of acid secretion or subtotal fundectomy is associated with the development of carcinoid tumors of enterochromaffin like  ecl  cells in the gastric corpus  available evidence supports a role of gastrin  which becomes chronically elevated in animals subjected to prolonged and profound hypochlorhydria  in humans  hypergastrinemic states such as zollinger ellison syndrome and atrophic gastritis are associated with an increased risk of ecl cell carcinoid tumors  such observations have raised concern that humans may also be susceptible to carcinoid tumor formation in response to potent inhibitors of acid secretion  to date  however  no cases of carcinoid tumor have been attributed to the use of omeprazole in humans  if achlorhydric doses are not used  significant hypergastrinemia can be avoided while effectiveness of treatment is maintained  such measures should minimize any risk of ecl cell carcinoid tumors in humans taking potent long term antisecretory drugs  
class4	epitope mapping of human thyroglobulin  heterogeneous recognition by thyroid pathologic sera  thyroglobulin is the major ag of the thyroid gland involved in autoimmune pathologies  epitope mapping was carried out with a rabbit polyclonal immune serum against fusion proteins expressed in prokaryotic cells  after screening of an initial human thyroglobulin cdna library and subcloning of immunoreactive clones  seven epitopes were characterized and localized on the human thyroglobulin monomeric molecule  one was close to each extremity of the molecule  and five others were concentrated in the middle  covering a sixth of this 2748 amino acid chain  the immunoreactivities of 18 autoimmune sera from different thyroid pathologies were tested against the seven previously characterized epitopes  those from hashimoto s thyroiditis were the most immunoreactive  immune responses were heterogeneous for sera from different pathologies as well as for those from the same pathology  the central epitopes and the near c terminal epitope  however  were the epitopes most often recognized by the immune sera  these findings show that some autoepitopes overlap accurately with some heteroepitopes characterized by a polyclonal immune serum directed against the mature protein  
class4	growth factor dependent differentiation along the myeloid and lymphoid lineages in an immature acute t lymphocytic leukemia  bone marrow cells from a child with an immature  cd2   cd5   cd7   acute t lymphocytic leukemia  t all  were cultured in the presence and absence of human ril 2  il 3  or granulocyte macrophage  gm  csf  cells cultured without growth factors failed to divide and those initiated in the presence of il 2 or gm csf underwent maturation and terminal t lymphoid or myelomonocytic differentiation  respectively  in contrast  a permanent growth factor dependent cell line  designated tall 103 3  was established upon culture in il 3  the tall 103 3 cells gradually lost the t cell specific markers and acquired a myeloid phenotype  cd15   cd33    switching of the il 3 dependent cells at an early passage to medium containing only human ril 2 resulted in the establishment of a subline  named tall 103 2  with a t lymphoid phenotype  cd3   cd8   tcr gamma delta    cd7    the tall 103 2 cells strictly require il 2 for growth  are irreversibly committed to the lymphoid lineage  and cannot survive in the presence of any other hemopoietic growth factor tested so far  in contrast  the il 3 dependent tall 103 3 cells could be adapted to grow in synthetic  serum free  medium also in the presence of either gm csf or il 5  in which they retain a myeloid phenotype  interestingly  after 18 mo in culture in il 3  the tall 103 3 cells can still be phenotypically converted to the lymphoid lineage upon addition of il 2  thus maintaining its bipotentiality  despite the marked phenotypic differences  the tall 103 2 and tall 103 3 cell lines show the same karyotypes with multiple abnormalities present in the primary malignant clone and have identical rearrangements of the tcr gamma and  delta loci  thus confirming their derivation from a common precursor cell  together  these findings indicate that the phenotype of immature t all cells can be drastically modified by the presence of specific hemopoietic growth factors in the environment  leading to either lymphoid or myeloid lineage commitment while leaving their karyotype and genotype intact  
class4	antigen induced cross linking of the ige receptor leads to an association with the detergent insoluble membrane skeleton of rat basophilic leukemia  rbl 2h3  cells  cross linking of the ige receptor on the surface of rat basophilic leukemia cells by multivalent ag  dnp bsa  causes a rapid conversion to a detergent insoluble form  there is a concurrent increase in the amount of filamentous actin associated with the plasma membrane  both the degree of receptor detergent insolubility and the rise in f actin content are rapid with a half maximal response of less than 1 min and can be rapidly reversed by the addition of monovalent ag  dnp lysine   these two early steps in the triggering of rat basophilic leukemia cells can be dissociated from each other by pretreatment of the cells with either cytochalasin or sodium azide  these reagents block the increase in f actin but have no effect on receptor detergent insolubility  this indicates that microfilaments are not responsible for detergent insolubility of the receptor and that it may be the membrane skeleton that is interacting with the complex  this was further confirmed by the finding that cross linking of the ige receptors on the surface of purified plasma membranes also leads to detergent insolubility of the receptor  therefore  all of the components necessary for detergent insolubility of the receptor are present in the plasma membrane  and cytoplasmic components are not needed  these results suggest that detergent insolubility and immobility of the cross linked receptors are caused by multivalent interaction with the membrane skeleton  actin filaments may then interact with these receptor membrane skeletal complexes in order to produce large scale clustering and capping  the membrane skeleton may therefore be acting as an intermediate structure between the cell surface receptors and microfilaments  
class4	mapping the site of interaction between murine ige and its high affinity receptor with chimeric ig  we have investigated the interaction of mouse  m  ige with its fc epsilon ri on rat basophilic leukemia cells using a set of chimeric ig that were constructed by exchanging homologous h chain c domains between human  hu  igg1 and mige  binding affinities were examined with equilibrium and kinetic measurements  and we found that epsilon c gamma 3  mige with c epsilon 4 replaced by c gamma 3  was indistinguishable from mige  the huigg1 and the other chimeric ig  which did not contain both c epsilon 2 and c epsilon 3  did not bind detectably to rat basophilic leukemia cells  ka less than 10 6  m 1   the ability of these chimeric ig to stimulate a cellular response  degranulation  in the presence of multivalent ag was also tested  the epsilon c gamma 3 was indistinguishable from mige in eliciting a high level of degranulation  whereas the other chimeric ig stimulated no response even when they were preaggregated to enhance their binding avidity  these results demonstrate that c epsilon 4 may be replaced by c gamma 3 without affecting the binding and cell activating properties of mige  the lack of binding by the other chimeric ig indicates that both c epsilon 2 and c epsilon 3 are necessary for the binding interaction  
class4	ige receptor mediated phosphatidylinositol hydrolysis and exocytosis from rat basophilic leukemia cells are independent of extracellular ca2  in a hypotonic buffer containing a high concentration of k   in isotonic buffer  ige receptor mediated exocytosis from rat basophilic leukemia cells is dependent on extracellular ca2   with half maximal degranulation requiring 0 4 mm ca2   no significant exocytosis occurs in the absence of extracellular ca2   this absolute requirement for ca2  is eliminated by suspending the cells in a hypotonic buffer containing 60 to 80 mm k   na  cannot substitute for k   optimal ca2    independent exocytosis occurs in a buffer containing 20 mm dipotassium pipes  ph 7 1  40 mm kcl  5 mm glucose  7 mm mg acetate  0 1  bsa  and 1 mm egta  the cells maintain this ca2    independent exocytosis even if they are preincubated with 1 mm egta for 40 min at 37 degrees c before triggering  exocytosis is eliminated as isotonicity is approached by adding sucrose  nacl  kcl  or potassium glutamate to the buffer  quin 2 fluorescence measurements reveal only a very small rise in  ca2  i when the cells are triggered in hypotonic buffer in the absence of extracellular ca2  and the presence of 1 mm egta  in isotonic buffer  degranulation does not occur under conditions that lead to such a small rise in  ca2  i  sustained ige receptor mediated phosphatidylinositol hydrolysis  which is also ca2  dependent in isotonic buffer  becomes independent of ca2  in the hypotonic buffer  in fact  the rate of phosphatidylinositol hydrolysis in hypotonic buffer in the absence of ca2   and presence of 1 mm egta  is twice that observed in isotonic buffer in the presence of 1 mm ca2   these data show that in hypotonic buffer  the requirement of ige receptor mediated pi hydrolysis for extracellular ca2  is eliminated  and degranulation proceeds with a  ca2  i of 0 1 microm  the baseline level of  ca2  i found in resting cells  these results are consistent with the hypothesis that  in isotonic buffer  the ca2  requirement for mast cell degranulation is for the generation of second messengers via hydrolysis of membrane phosphatidylinositols  
class4	primary intratemporal tumours of the facial nerve  diagnosis and treatment  benign primary tumours of the facial nerve are uncommon  a slowly progressive facial palsy should be considered the result of a nerve tumour until proven otherwise  improvements in diagnostic imaging techniques of the temporal bone have increased the possibility of a correct pre operative diagnosis but facial nerve tumours remain a frequently ignored or misdiagnosed entity as a consequence of their subtle and protean clinical manifestations  a series of 12 cases of primary facial nerve tumours is presented  the clinical features  diagnostic modalities and treatment are discussed in relation to a review of the literature  
class4	technetium 99m v  dimercaptosuccinic acid planar scintigraphy in head and neck cancer  clinical  scintigraphic and radiological study  technetium 99m  tc99m  v  dimercaptosuccinic acid  dmsa  is an imaging agent which has been proposed as a scintigraphic marker for head and neck squamous cell carcinoma  fifty four patients were studied of whom 51 had a head and neck tumour  all patients were examined and then imaged using tc99m v  dmsa scintigraphy and computerized tomography  scintigraphy was less sensitive than clinical examination in the detection of patients with cancer  patients with primary tumours and patients with metastatic neck disease  ct was as sensitive and as accurate as clinical examination but more sensitive than tc99m v  dmsa in detecting patients with cancer and with primary tumours  ct was more sensitive and more accurate than both clinical examination and tc99m v  dmsa scintigraphy in predicting which patients had metastatic neck disease  although tc99m v  dmsa is accumulated by squamous cell carcinoma  its inability to detect low volume disease and apparent low specificity means it has no role to play in the management of patients with head and neck squamous cell carcinoma  
class4	monomorphic adenomas of the major salivary glands  clinicopathological study of 44 cases  we report 44 cases of monomorphic adenoma  ma  of the major salivary glands observed during the years 1979 1989  all of these tumours were reviewed and classified on the basis of the world health organisation  who  criteria  histological type  site  sex and age were considered  34 cases of adenolymphoma were observed  all of them located in the parotid glands  10 ma without lymphoid stroma were located in both parotid and submandibular glands  distinctive histological and clinico pathological features of the latter group of tumours are discussed  as well as the diagnostic criteria in distinguishing these tumours from pleomorphic adenoma and adenoid cystic carcinoma  
class4	tumefactive fibroinflammatory lesions of the head and neck  the term  tumefactive fibroinflammatory lesion  has been used to describe a fibrosclerosing disorder which has a locally destructive nature but is characterized by a benign histological appearance  we report five patients  over a five year period  with such a lesion  the clinical behaviour and surgical findings suggest the lesion to be an invasive malignancy  however  the histological appearance of an admixture of chronic inflammatory cells and fibrosis is consistent with a benign condition  we recommend surgical excision of the lesion as the mainstay of treatment  other studies report the use of steroids and radiotherapy  
class4	osteoma of the middle ear  osteomas involving the middle ear and causing a functional disturbance are rare  we report a case of a patient with an osteoma arising from the lateral semicircular canal  the main symptom was vertigo and to halt this the defect of the canal was obliterated with a bone chip and fibrin glue after removal of the tumour  
class4	auro nasopharyngeal polyp and cholesteatoma  we report the association of an auronasopharyngeal polyp arising in a congenitally abnormal middle ear and eustachian tube  subsequently  ten years after removal of the polyp and insertion of a ventilation tube  there was recurrence of the polyp in association with cholesteatoma of the middle ear  
class4	giant enterocystoma within an infant s tongue  a rare developmental cyst within the tongue and submandibular triangle of a male infant containing heterotopic gastric and intestinal epithelium  enterocystoma  is described and its derivation discussed  this cyst was of such a size as to cause feeding difficulties and partial airway obstruction during sleep  following c t  scanning  total obstruction necessitated an emergency tracheostomy  successful enucleation via a median labiomandibulotomy was performed without further complication and two years later there is no sign of recurrence  
class4	direct extension of laryngeal carcinoma to the skin of the neck  invasion of the skin of the neck by laryngeal carcinoma is relatively uncommon  twelve cases of cancer of the larynx fungating through the cervical skin are presented  they mostly followed initial treatment by deep x ray therapy or partial laryngectomy  a high tracheostomy was also considered to be a contributing cause for the occurrence of such a mishap  the management and follow up of these patients is described  
class4	late development of a squamous carcinoma in a reconstructed pharynx  we report a case in which a squamous cell carcinoma was found to have arisen from a delto pectoral skin flap used in pharyngeal reconstruction  the flap had been forming a neo pharynx for 24 years  no other signs of recurrent disease had developed in this period  this raises the possibility of tumour induction in heterotopic skin used for oropharyngeal reconstruction  
class4	haemangiosarcoma of the maxillary antrum  angiosarcomas are extremely rare in the head and neck and the histological diagnosis is often difficult  we present a case of a haemangiosarcoma of the maxillary antrum in a 33 year old male  the histological diagnosis and subsequent management are discussed  
class4	enhanced hepatic drug clearance in patients with cystic fibrosis  to examine whether hepatic drug metabolism is altered in patients with cystic fibrosis  cf   we evaluated the pharmacokinetics of three model pharmacologic substrates  antipyrine  a marker of hepatic oxidative metabolism  lorazepam  a marker of hepatic glucuronosyltransferase activity  and indocyanine green  icg   a marker of hepatic blood flow and biliary secretion  in 14 patients with cf  14 6 to 29 2 years of age  and in 12 children and adolescents with cancer  7 2 to 19 4 years of age   which was treated with only surgery and radiation  each study subject received a single intravenous dose of the combined model substrates  0 03 mg kg lorazepam  10 mg kg antipyrine  and 0 5 mg kg icg  for 5 minutes  followed by repeated blood sampling  n   10  during a 24 hour postinfusion period  patients with cf had a significantly greater plasma clearance of lorazepam  56 5     5 2 vs 25 9     1 9 ml min m2  and icg  892 5     176 4 vs 256 5     41 7 ml min m2  but not of antipyrine  27 2     3 8 vs 20 7     2 0 ml min m2  in comparison with control subjects  the apparent steady state volume of distribution for lorazepam  icg  and antipyrine was significantly higher in the patients with cf  2 0   3 1   and 1 4 fold  respectively  than in control subjects  clearance of the model substrates did not correlate with standard biochemical markers of hepatic function  similarly  no significant relationships were observed between the clearance or steady state volume of distribution of the compounds and the national institutes of health prognostic scores for the patients with cf  these data demonstrate that the plasma clearance of lorazepam and icg is increased in patients with cf and suggest that hepatic glucuronosyltransferase activity and biliary secretory capacity are enhanced in this disease  
class4	vaginal removal of the pedunculated submucous myoma  historical observations and development of a new procedure  a new method of vaginal removal of submucous fibroids was attempted on 151 patients  the procedure involves dilation of the cervix with laminaria tents and removal of the submucous fibroid by grasping with appropriate instruments  myomas were removed successfully in 92  of the patients  hysterectomy and abdominal myomectomy were avoided in all but four of them  perforation occurred in two patients  morbidity was minimal  the four patients who desired pregnancy conceived  
class4	laser therapy for vaginal intraepithelial neoplasia after hysterectomy  in recent years there has been a marked increase in the number of reported cases of vaginal intraepithelial neoplasia  vain  after hysterectomy  until about 10 years ago radiation or surgery had been the therapeutic modality mostly used for this disease  more recently  topical drugs  such as bleomycin and 5 fluorouracil cream  have been used  but they are often ineffective and poorly tolerated  for the last 14 years we have used the co2 laser for the treatment of vain and have treated a total of 143 patients  our use of a combination of wire sutures through the vaginal mucosa and the introduction of fluids into the underlying submucosal areas allows retraction and ballooning of the recesses and scars and permits us to place the vaginal mucosa at right angles to the laser beam to allow complete treatment  
class4	the cytobrush for evaluating routine cervicovaginal endocervical smears  while the conventional wooden spatula cotton tipped applicator has remained the method of obtaining papanicolaou smears for most clinicians at the university of california at los angeles  the student health service  shs  adopted the zelsmyr cytobrush as its sole method of obtaining cervical samples in late 1986  a study was done to define changes in both the adequacy of sampling and the detection rate for both squamous and glandular epithelial abnormalities with the cytobrush  to accomplish this goal  1 000 cytobrush and 244 conventionally obtained smears were analyzed prospectively  and 3 864 shs samples obtained in 1986 prior to the change in method were reviewed retrospectively  as compared to cervical samples obtained by conventional methods  the cytobrush smears contained significantly more endocervical cells and had fewer drying artifacts  both methods obtained equivalent squamous samples and had similar final class distributions  no case of endocervical adenocarcinoma carcinoma in situ or invasive adenocarcinoma was detected  shs patients who had initial  no endocervical cells  samples but whose repeat sample did contain endocervical cells retained the same class in more than 75  of cases  this study confirmed that the cytobrush technique produces papanicolaou smears with improved sampling of the squamocolumnar junction but questioned whether that results in an increased detection rate for cervical pathology  
class4	carcinosarcoma and spindle cell carcinoma of the lung  clinicopathologic and immunohistochemical studies  we examined pulmonary carcinomas with prominent sarcoma like lesions both clinicopathologically and immunohistochemically  grossly  two tumors had predominantly endobronchial growths  four bulky parenchymal growths  and two endobronchial  parenchymally mixed growths  in these eight patients  six tumors were completely resected  one patient was given irradiation only  and one patient died in the early postoperative period  on the basis of specific differentiation of the sarcoma like lesions  the tumors were separated into three groups  two with  true  sarcoma differentiated into soft tissues such as striated muscle or osteoid tissue  three with a fibromatous sarcoma resembling atypical pseudosarcomatous stroma  and three with spindle cell carcinoma with evidence of epithelial differentiation  the prognosis was poor  and tumors with specific differentiation into rhabdomyosarcoma  chondrosarcoma  or spindle cell carcinoma progressed more rapidly than did those with a fibromatous sarcoma  because the fibromatous sarcoma like lesions were found to relate to a longer survival time for the patients  we wish to emphasize that a distinction of sarcomatous components should be made with regard to assessing the prognosis of pulmonary carcinoma with sarcoma like lesions  
class4	utility of frozen section evaluation of lymph nodes in the staging of bronchogenic carcinoma at mediastinoscopy and thoracotomy  we conducted a retrospective analysis of the utility of frozen section diagnoses in determining lymph node status at mediastinoscopy in 122 consecutive patients with bronchogenic carcinoma  thirty five of 122 patients had one or more lymph nodes with frozen section evaluation positive for metastatic carcinoma  subsequent nodal sections not in the original frozen section study revealed metastatic carcinoma in two additional patients  the false negative rate was 1 6   sensitivity was 94 6   predictive value of negative frozen section evaluation results was 97 7   because there were no false positive frozen section results  specificity and predictive value for positive results of frozen section evaluation were 100   the statuses of individual lymph nodes from these 122 patients were also evaluated  six hundred twenty lymph nodes were sampled from the mediastinum at mediastinoscopy  frozen sections in 47 lymph nodes were positive  subsequent nodal sections not in the original frozen sections examination revealed metastatic carcinoma in four additional lymph nodes  the false negative rate was 0 6   sensitivity was 92 2   predictive value of negative results from frozen section evaluation was 99 3   because there were no false positive frozen section results  specificity and predictive value for positive results of frozen section examination were 100   we conclude that frozen section evaluation of lymph nodes at mediastinoscopy reliably indicates lymph node status  thus enabling the physician to decide whether to proceed to thoracotomy  thus staging of the carcinoma and definitive surgery can be accomplished during a single anesthetic procedure  combining mediastinoscopy and thoracotomy with frozen section diagnostic control also reduces both the length and cost of hospitalization  
class4	diagnostic significance of carcinoembryonic antigen in the differential diagnosis of malignant mesothelioma  the histologic and cytologic distinction of malignant mesothelioma from carcinomas metastatic to the pleura or peritoneum is often problematic  for this reason immunologic methods are being increasingly used as diagnostic adjuncts  this review summarizes 40 studies on the expression of carcinoembryonic antigen in mesotheliomas and in lung and other carcinomas involving the pleura or peritoneum  carcinoembryonic antigen was identified immunohistochemically in 11  of mesotheliomas and in 84  of carcinomas examined and immunocytochemically  in serous effusions  in 4  and 58   respectively  in serum and in pleural or ascitic fluid  significantly elevated levels of carcinoembryonic antigen are commonly associated with  lung  carcinomas but rarely with mesotheliomas  thus  together with identification of the antigen in serum  pleural fluid  or ascitic fluid  immunohistochemical and immunocytochemical techniques for detecting carcinoembryonic antigen provide a valuable aid for distinguishing malignant mesothelioma from metastatic carcinomas  
class4	primary osteosarcoma of the lung  report of two cases and review of the literature  two cases of primary osteosarcoma of the lung are presented  in one case  the radiologic  clinical  and cytologic findings led to a preoperative diagnosis of undifferentiated carcinoma of the lung  in the second case  a lung nodule was discovered during postchemotherapy follow up in a patient with lymphoma  fine needle aspiration in the second case showed lymphoma  and further chemotherapy was instituted  however  persistent growth of the nodule prompted a resection  microscopic examination of the resected tumors in both cases revealed histologic features of high grade osteosarcoma  flow cytometric analyses of the primary tumors showed abnormal hyperdiploid deoxyribonucleic acid populations in accordance with those seen in high grade malignant neoplasms  immunohistochemical studies supported a mesenchymal origin for these tumors  these tumors shared clinical features with other reported cases of primary osteosarcoma of the lung such as large size at diagnosis  occurrence in older individuals  and aggressive behavior  
class4	common nonvenereal genital lesions  there are a wide variety of local and systemic skin diseases that produce lesions in the genitoanal region  these lesions may resemble those produced by sexually transmitted microorganisms  the purpose of this article is to make physicians aware of the common skin diseases that produce lesions on the genitalia to avoid the inappropriate diagnosis of a sexually transmitted disease  
class4	human recombinant gm csf in allogeneic bone marrow transplantation for leukaemia  double blind  placebo controlled trial  in a randomised  double blind trial 20 patients with leukaemia received human recombinant granulocyte macrophage colony stimulating factor  gm csf  and 20 received placebo  for 14 days after allogeneic  matched sibling  bone marrow transplantation  the neutrophil count recovered to 0 5 x 10 9  l 3 days earlier in the gm csf group than in the placebo group  not significant   and the median neutrophil count at 14 days was significantly higher in the gm csf group  1 90 vs 0 46 x 10 9  l   the lymphocyte count was significantly higher in the gm csf than in the placebo group between days 10 and 15 after transplantation  but this difference was not associated with a higher incidence of graft versus host disease  there was no evidence that gm csf was associated with a greater incidence of leukaemic relapse  the gm csf group had lower haemoglobin concentrations and platelet counts and higher plasma urea  creatinine  and bilirubin than the placebo group  the duration of hospital stay was the same for both patient groups  further studies are now indicated to assess the overall effect of gm csf on outcome after allogeneic bone marrow transplantation  
class4	paraneoplastic pemphigus  an autoimmune mucocutaneous disease associated with neoplasia  background and methods  we describe five patients with underlying neoplasms in whom painful mucosal ulcerations and polymorphous skin lesions developed  usually with progression to blistering eruptions on the trunk and extremities  histologic examination showed vacuolization of epidermal basal cells  keratinocyte necrosis  and acantholysis  immunofluorescence testing revealed atypical pemphigus like autoantibodies in perilesional epithelium and serum from all five patients  we studied the antigenic specificities of the autoantibodies by indirect immunofluorescence and immunoprecipitation  using extracts of 14c labeled human keratinocytes  igg purified from the serum of one patient was passively transferred to four neonatal mice to test for pathogenicity  results  immunofluorescence testing showed that the autoantibodies bound to the surface of tissues containing desmosomes  including complex and simple epithelia  and myocardium  an identical and unique complex of four polypeptides with molecular weights of 250  230  210  and 190 was immunoprecipitated by all serum samples  the 250 kd polypeptide comigrated with desmoplakin i  a protein found in the desmosomes of all epithelia   and the 230 kd antigen comigrated with the antigen of bullous pemphigoid  cutaneous blisters  a positive nikolsky s sign  and epidermal and esophageal acantholysis developed in all mice into which the autoantibody was injected  electron microscopy showed epidermal acantholysis similar to lesions of experimentally induced pemphigus vulgaris  conclusion  these five patients with cancer had a novel acantholytic mucocutaneous disease characterized by autoantibodies that were pathogenic after passive transfer  the autoantibodies from these patients reacted with an antigen complex composed of desmoplakin i and the 230 kd antigen of bullous pemphigoid and two as yet unidentified epithelial antigens  we suggest the term  paraneoplastic pemphigus  for this disease  
class4	synthetic analogues of fumagillin that inhibit angiogenesis and suppress tumour growth  neovascularization is critical for the growth of tumours and is a dominant feature in a variety of angiogenic diseases such as diabetic retinopathy  haemangiomas  arthritis and psoriasis  recognition of the potential therapeutic benefit of controlling unabated capillary growth has led to a search for safe and effective angiogenesis inhibitors  we report here the synthesis of a family of novel inhibitors that are analogues of fumagillin  a naturally secreted antibiotic of aspergillus fumigatus fresenius  we first isolated this fungus from a contaminated culture of capillary endothelial cells  purified fumagillin inhibited endothelial cell proliferation in vitro and tumour induced angiogenesis in vivo  it also inhibited tumour growth in mice  but prolonged administration was limited because it caused severe weight loss  synthesis of fumagillin analogues yielded potent angiogenesis inhibitors   angioinhibins   which suppress the growth of a wide variety of tumours with relatively few side effects  
class4	hippocampal sclerosis can be reliably detected by magnetic resonance imaging  two independent blinded observers reported the preoperative mris in a series of 81 consecutive patients with intractable temporal lobe epilepsy who were undergoing temporal lobectomy  we then compared the nature and lateralization of the mri abnormalities with the pathologic diagnosis and the side of lobectomy  the mri criteria of hippocampal sclerosis were an increased t2 weighted signal and the signal s confinement to a unilaterally small hippocampus  imaging was performed in coronal and axial planes  specially orientated along and perpendicular to the long axis of the hippocampal body  we found diagnostic mri abnormalities in 25 of the 27 cases with pathologically proven hippocampal sclerosis  sensitivity 93   specificity 86    in addition  we detected all 13 foreign tissue lesions on mri  overall  we detected lateralized lesions on mri that correctly predicted the side of the epileptogenic temporal lobe in 72 cases  89    with 2 possible errors  a learning effect in appreciating the relatively subtle mri changes of hippocampal sclerosis was apparent in our later cases  as shown by an improved correlation between the 2 observers  this study demonstrates that hippocampal sclerosis can be identified on mri with a high degree of sensitivity and specificity  
class4	large cystic optic glioma  a 5 1 2 year old boy developed a huge cyst in his chiasmal glioma 4 years after radiation therapy  the cyst produced obtundation but was successfully treated  
class4	purification and characterization of an inhibitor  soluble tumor necrosis factor receptor  for tumor necrosis factor and lymphotoxin obtained from the serum ultrafiltrates of human cancer patients  serum ultrafiltrates  suf  from human patients with different types of cancer contain a blocking factor  bf  that inhibits the cytolytic activity of human tumor necrosis factor alpha  tnf alpha  in vitro  bf is a protein with a molecular mass of 28 kda on reducing sodium dodecyl sulfate polyacrylamide gel electrophoresis  sds page   the active material was purified to homogeneity by a combination of affinity chromatography  page  and high pressure liquid chromatography  amino acid sequence analysis revealed that bf is derived from the membrane tnf receptor  purified bf blocks the lytic activity of recombinant human and mouse tnf alpha and recombinant human lymphotoxin on murine l929 cells in vitro  however  bf inhibits the lytic activity of tnf alpha more effectively than it does that of lymphotoxin  the bf also inhibits the necrotizing activity of recombinant human tnf alpha when coinjected into established cutaneous meth a tumors in balb c mice  the bf may have an important role in  i  the regulation and control of tnf alpha and lymphotoxin activity in cancer patients   ii  interaction between the tumor and the host antitumor mechanisms  and  iii  use of systemically administered tnf alpha in clinical trials with human cancer patients  
class4	epstein barr virus small nuclear rnas are not expressed in permissively infected cells in aids associated leukoplakia  epstein barr virus  ebv  dna structure and gene expression were analyzed in tissue specimens from oral hairy leukoplakia  hlp   a mucocutaneous lesion that develops in patients infected with human immunodeficiency virus  hiv   the structure of the terminal restriction enzyme fragments of ebv revealed that hlp is a permissive infection without a predominant  detectable population of ebv episomal dna  in rna preparations from this uniquely permissive infection  ebv replicative mrnas could be identified by northern analysis  however  the virally encoded small nuclear rnas  the ebers  were not detected in most hlp rna preparations  in situ hybridization detected eber expression in very rare cells  these data indicate that unlike other viral small nuclear rnas  the ebers are not expressed during viral replication and must participate in the complex maintenance of latent ebv infection  
class4	overexpression of normal and mutated forms of hras induces orthotopic bladder invasion in a human transitional cell carcinoma  recent studies have shown that orthotopic  transurethral  transplantation of human bladder cancer cell lines into nude mice permits tumor growth that accurately reflects their clinical malignant status in the original host  thus  such a system allows a unique opportunity to analyze the genetic events involved in the conversion of low grade bladder cancer  the vast majority of which are curable  to the high grade life threatening form of the disease  since 5 10  of transitional cell carcinomas  tccs  have been shown to contain a mutated hras gene  and protein expression levels of all forms of hras have been correlated with tcc progression  we chose to study the contribution of the hras oncogene in bladder tumor progression  we evaluated the effects of transfection of normal or mutated hras genes into a human tcc  called rt 4  that behaves as a superficial noninvasive papillary tumor after transurethral orthotopic inoculation into athymic nude mice  we found that overexpression of either transfected normal or mutated hras genes converted rt 4 cells to express an invasive phenotype remarkably similar in nature to the clinical behavior of high grade bladder carcinomas  these results suggest a role for overexpressed normal or mutated ras genes in human bladder carcinoma progression  and highlight the importance of using orthotopic inoculation systems for evaluation of the contribution of oncogenes to malignant tumor progression  
class4	congenital biliary tract disease  jaundice in the pediatric patient requires prompt and directed evaluation  this dictum is highlighted in infants with biliary atresia  in whom the progressive sclerosing process results in complete obliteration of patent but microscopic hilar biliary structures by 4 months of age  kasai s operation  if done before that time  will re establish bile drainage in 90  of infants  one fourth to one third of patients achieve long term jaundice free survival  complications of cholangitis  portal hypertension  and fat malabsorption are experienced by many patients  in children with early or late operative failure  liver replacement now offers legitimate hope for extended survival  choledochal cyst is a conglomerate of pancreaticobiliary anomalies consisting of a choledochal cyst  a common channel type pancreaticobiliary junction  intrahepatic cystic disease  and partial obstruction of the distal common bile duct  many patients have one or more of these malformations  it is now widely accepted that the preferred treatment of choledochal cyst is total excision of the diseased biliary duct with reconstruction by roux en y choledochojejunostomy   internal  excision avoids injury to other structures in the hepatoduodenal ligament  particularly if pericystic inflammation is present  congenital perforation of the common bile duct responds in most cases to simple peritoneal drainage of the perforation  retention of the tube cholecystostomy is useful for subsequent cholangiographic follow up  tube cholecystostomy may also be useful for irrigation of the biliary tract in infants with inspissated bile syndrome  
class4	cholangiocarcinoma  the diagnosis of cholangiocarcinoma can now be made with greater rapidity and accuracy  in the clinical setting of obstructive jaundice  a ct scan or sonogram may suggest cholangiocarcinoma if dilated intrahepatic ducts are seen with a nondilated extrahepatic biliary tree  the diagnosis is confirmed by cholangiography  and the tumor is staged by the combination of cholangiography and angiography  if the tumor extensively involves both lobes of the liver or involves the main portal vein or hepatic artery  the lesion is considered unresectable  these patients are best palliated nonoperatively  but they should still have an attempt at a tissue diagnosis  as various other lesions can masquerade as cholangiocarcinoma  in comparison  if the tumor is confined to or is distal to the hepatic duct bifurcation  extends into only one lobe of the liver  or involves only the right or the left portal vein or hepatic artery  the lesion may be resectable  and exploration is indicated  as many as half of all patients explored with curative intent will have a successful resection  various surgical options are appropriate for patients undergoing tumor resection  depending on the site and extent of the lesion  similarly  several surgical options are possible for palliation in patients with unresectable cholangiocarcinoma  the role of radiotherapy in the management of cholangiocarcinoma is uncertain  our results  like those of many other retrospective analyses  suggest that radiotherapy prolongs survival after curative resection as well as after palliative stenting  however  further data from randomized studies are necessary to support or refute this impression  further studies of adjuvant chemotherapy or hormonal therapy will also be necessary to improve patient survival  
class4	lithiumogenic disorders of the thyroid and parathyroid glands as surgical disease  little notice has been paid in the surgical literature to problems with psychoeffective lithium  which by interfering with adenylate cyclase affects thyroid and parathyroid function  causing hypercalcemia  hyperparathyroidism  and hypothyroidism  seven patients with lithiumogenic hyperparathyroidism occurring after years of lithium therapy underwent treatment and manifested osteoporosis  n   2   hypertension  n   2   nephrolithiasis  n   1   coma  n   1   rising hypercalcemia  n   1   goitrous myxedema  n   4   nephrogenic diabetes insipidus  n   2   renal failure  n   2   and hyperlipidemia  n   1   disease directed parathyroidectomy  without morbidity  was curative  unique laboratory findings included normal serum phosphorus and reduced urinary calcium and cyclic adenosine monophosphate values  three separate cases of thyroid carcinoma after long term lithium therapy were also treated  being preceded by myxedema  n   2  and concurrent with hyperparathyroidism  n   1   there has been only one previous report of lithium associated thyroid carcinoma  all patients taking lithium should undergo surveillance for thyroid and parathyroid dysfunction and neoplasia  and appropriate surgical and medical treatment should be considered in each situation  although hyperparathyroidism may be reversible with lithium discontinuance  such therapy may be obligatory for patient well being  thus dictating parathyroidectomy  
class4	multiple parathyroid adenomas  report of thirty three cases  an increasing number of patients with primary hyperparathyroidism are found to have two or three enlarged parathyroid glands  of 865 patients successfully operated on by one surgeon  j n a    multiple enlarged parathyroid glands  adenomas  were found and resected in 33 cases  3 8    with resulting normocalcemia lasting from 1 to 22 years  mean 5 8   twenty nine patients had two adenomas and four had three adenomas  in 28 patients the multiple adenomas were synchronous  twenty five patients underwent removal of all of the enlarged parathyroid glands in one operation  in three patients one adenoma was removed  reoperation for persistent hypercalcemia was performed  and a second adenoma was resected with cure  in five patients one adenoma was removed  normocalcemia ensued for 3 to 18 years  and a second  metachronous  adenoma occurred and was resected successfully  although 10 of 70 enlarged parathyroid glands removed were labeled hyperplasia  cure in all but one of our patients by selective resection of only enlarged parathyroid glands emphasizes the unreliability of histologic criteria in differentiating between parathyroid adenoma and hyperplasia  based on this study  we support the existence of multiple adenomas and advocate removal of only macroscopically enlarged parathyroid glands in patients with primary hyperparathyroidism  
class4	endosonography in the localization of parathyroid tumors  a preliminary study  a preoperative transesophageal exploration of the parathyroids by endosonography was performed on 23 patients with primary hyperparathyroidism  the system used was a 7 5 mhz transducer mounted on the tip of an endoscope with an external diameter of 13 mm  the field of visualization was 360 degrees  a retrograde exploration was done moving up from the aortic arch to the upper esophageal sphincter  all patients underwent surgery afterward  and adenomas were found  in 12 cases the adenoma was visualized  all 12 adenomas were posteriorly located on the right side  four cases  and left side  eight cases  of the esophagus  nine of these 12 tumors were on the posterior face of the thyroid lobes  with six tumors in the middle one third of the thyroid lobe and three in the lower one third of the thyroid lobe  the other three tumors were located below the lower pole of the thyroid lobes in the upper posterior mediastinum  mean tumor weight was 1165 mg  of the 11 tumors that could not be visualized  eight tumors were anteriorly located  three of these tumors were on the anterior and lateral surface of the lower pole of the thyroid  and five were in the thyrothymic tracts  the remaining three tumors were located on the back of the thyroid lobes  two of these tumors were at the upper esophageal sphincter  and one was on the side of the pharynx  mean tumor size was 1334 mg  localization of parathyroid tumors by endosonography appears possible but only if lesions are located posteriorly  close to the esophagus  endosonography is not indicated before routine cervical exploration for primary or secondary hyperparathyroidism  as in other such studies  endosonography could be useful in cases of persistent or recurrent hyperparathyroidism  
class4	function in athymic nude mice of parathyroid heterografts from patients with primary hyperparathyroidism and secondary hyperparathyroidism  heterotransplantation of adenomatous parathyroid glandular tissue from humans with primary hyperparathyroidism into athymic nude mice creates a unique animal model of this disease  the mice manifest high concentrations of both midregion c terminal human parathyroid hormone and biologically active intact human parathyroid hormone relative to either mice with no implants or mice that received normal human parathyroid tissue  secretion of these substances is maintained in most mice for at least 9 to 13 months after implantation  in addition  animals that have experienced implantation exhibit other characteristics associated with human primary hyperparathyroidism including relative hypercalcemia and increased renal 25 hydroxyvitamin d 1 alpha hydroxylase activity  we also measured these parameters in a group of nude mice that received transplantation of a similar mass of hyperplastic parathyroid tissue that was obtained from patients with uremic secondary hyperparathyroidism  although we hypothesized that the level of human parathyroid hormone secretion from these implants would fall over time in response to the normal host environment  hormone levels remained as high as those in recipients of adenomatous heterografts  even after 9 to 13 months  moreover  similar biologic effect of the excess parathyroid hormone  i e   relative hypercalcemia  hyperphosphatasemia  and increased 1 25 dihydroxyvitamin d biosynthesis  were detected  these animal models should prove extremely useful in supplementing our understanding of hyperparathyroid disorder in man  
class4	effects of tamoxifen and somatostatin analogue on growth of human medullary  follicular  and papillary thyroid carcinoma cell lines  tissue culture and nude mouse xenograft studies  the knowledge that  1  the normal thyroid contains somatostatin   2  polypeptide growth factors influence thyroid cell function  and  3  thyroid cells contain steroid hormone receptors prompted us to add somatostatin analogue no  201 995  sms   5 ng ml  and or tamoxifen citrate  tam   5 mumol l  to 7 day monolayer cultures  50 000 cells well  of three separate human thyroid carcinoma cell lines  dr081  medullary   wr082  follicular   and npa 87  papillary   results  tabulated as cell numbers well  x10 5  on day 7  revealed that tam inhibited growth of medullary and follicular cells and that tam plus sms inhibited growth of papillary cells  in vivo studies of subcutaneous tumor cell xenografts in nude mice have documented that tam  5 mg subcutaneous pellet  significantly inhibits the growth of medullary implants  flow cytometric dna studies of medullary cell cultures demonstrated a reduced g2   m phase with tam treatment  for papillary cell implants  tam plus sms  5 micrograms subcutaneously  twice daily  did not suppress tumor growth  all three cell lines were negative for estrogen receptor  addition of estradiol  5 ng ml  to medullary cell cultures neither stimulated replication nor reversed the inhibitory effects of tam in vitro  we conclude that  1  tam slowed the growth of a cell line of human medullary carcinoma  both in vitro and in vivo   2  this effect was not reversed by estradiol   3  tam plus sms inhibited replication of a papillary carcinoma cell line in vitro  but not in vivo  and  4  tam alone and tam plus sms inhibited replication of cultures of a human follicular thyroid carcinoma cell line  tam and sms may be useful in treatment of some human thyroid carcinomas  
class4	management of cushing s syndrome secondary to adrenal adenoma during pregnancy  this report discusses our experience with two patients who had unilateral adrenalectomy during pregnancy as treatment for cushing s syndrome secondary to an adrenal adenoma  previously only five patients with this clinical problem who underwent unilateral adrenalectomy during pregnancy had been reported  we have reviewed the world literature on cushing s syndrome in pregnancy secondary to an adrenal adenoma  a total of 19 patients who had unilateral adrenalectomy for this problem after the completion of pregnancy were identified  the review of world literature and the two patients who are the subject of this report were the basis of our analysis of fetal death  neonatal complications  and maternal complications in seven pregnancies during which unilateral adrenalectomy was performed  group 1  compared to the 19 pregnancies that were associated with unilateral adrenalectomy at the completion of pregnancy  group 2   of the seven pregnancies in group 1  one fetal death and no neonatal complications occurred  but fetal death and neonatal complications occurred in 12 of the 19 pregnancies in group 2  four of the seven mothers in group 1 had complications  16 of the 19 mothers in group 2 had complications  this study suggests that adrenalectomy during pregnancy should be considered as a therapeutic option in the management of cushing s syndrome secondary to an adrenal cortical adenoma  
class4	the role of adrenalectomy in cushing s syndrome  forty four patients with cushing s syndrome were treated by adrenalectomy between 1975 and 1989  twenty patients had adrenal adenomas  13 with obvious cushing s syndrome and 7 whose disease was subclinical  detected after evaluation of an incidentally discovered adrenal mass  es   twelve patients underwent bilateral adrenalectomies for cushing s disease after failed transsphenoidal explorations and pituitary irradiation  six patients had primary adrenal hyperplasia  five as manifestations of carney s complex  two others underwent bilateral adrenalectomies for ectopic adrenocorticotropic hormone from carcinoid tumors  four patients had adrenocortical carcinoma treated with transabdominal adrenalectomy  three are alive from 8 years to 5 months  there was one postoperative death  2 3   caused by coagulopathy and multiple organ failure and three  7   minor postoperative complications  follow up showed good to excellent results in 95  of patients  it is concluded that adrenalectomy provides prompt relief from the severe morbidity of cushing s syndrome regardless of the cause  it is the treatment of choice for adrenal adenomas  carcinomas  primary hyperplasia  and selected patients with cushing s disease  
class4	time to recovery of the hypothalamic pituitary adrenal axis after curative resection of adrenal tumors in patients with cushing s syndrome  the recovery time of the hypothalamic pituitary adrenal  hpa  axis after curative resection of adrenal tumors in patients with cushing s syndrome is poorly documented  eight consecutive patients were treated with a standardized hydrocortisone replacement strategy after curative resection of a cortisol secreting tumor and the time to recovery of the hpa axis was determined  hypercortisolism was documented by elevated 24 hour urinary free cortisol levels  cure was documented by undetectable postoperative morning serum cortisol levels  each patient received replacement hydrocortisone after surgery and was reevaluated every 3 to 6 months with an adrenocorticotrophic hormone  acth  stimulation test  each patient was also monitored carefully for symptoms and signs of adrenal insufficiency  which was defined as symptoms consistent with this diagnosis that responded to increases in hydrocortisone levels  after surgical resection  each patient was cured of hypercortisolism  subsequently  despite replacement hydrocortisone  each patient had symptoms of hypocortisolism  and in four of eight patients the dose of hydrocortisone was increased to relieve the symptoms  patients required a median time of 15 months  range  9 to 22 months  to recover a normal acth stimulation test and 19 months  range  12 to 24 months  to allow discontinuation of replacement doses of hydrocortisone  the results suggest that surgical resection of a cortisol secreting adrenal tumor will result in rapid cure of hypercortisolism  but complete recovery of the hpa axis and discontinuation of replacement steroids will require between 1 and 2 years  normal adrenal function  as assessed by the cortisol response to acth  returns despite replacement doses of hydrocortisone  and replacement doses of hydrocortisone can be tapered rapidly or discontinued after a normal acth stimulation test  
class4	posttranslational gastrin processing depends on tumor morphology  extracellular matrices have recently been demonstrated to alter cell morphology in culture  altered cell morphology has been associated with changes in gene transcription and translation  but it is not known whether it also affects posttranslational processing  using tyrosine o sulfation as a marker of processing  we studied the effects of various substrates on biologically active gastrin  irg  production and sulfation in gastrin containing tumor cells  gt cells   dispersed gt cells were plated onto different substrates and then incubated  culture media from days 4  7  and 28 were assayed with specific antibodies that recognize total irg and nonsulfated irg  cells cultured on plastic and dried films of laminin  collagen  and matrigel  collaborative research inc   lexington  mass   flattened and formed monolayers of gt cells  cells cultured on a porous membrane and hydrated gels of collagen and matrigel did not flatten but formed spheroids of gt cells  the monolayer cultures showed an increase in sulfation with time but a decrease in irg production  the spheroid cultures maintained a constant level of sulfation over time and  with the exception of matrigel  gel   also showed a decrease in irg production  these results indicate that the level of sulfation was unchanged from that of the original tumor when cells were grown in spheroids but increased when cultured as monolayers  it appears that alteration of the cellular milieu alters colony morphology  which in turn alters gastrin processing  
class4	the utility of circulating levels of human pancreatic polypeptide as a marker for islet cell tumors  the measurement of plasma levels of human pancreatic polypeptide  hpp  has been reported to be clinically useful in predicting the existence of pancreatic islet cell neoplasms in patients with familial multiple endocrine neoplasia type 1  fmen i  and the possible presence of metastatic disease in patients with islet cell tumors  however  these studies have not been prospective and involve small numbers of patients  in this study  fasting plasma samples from 36 patients with biopsy proved islet cell tumors were analyzed for hpp by radioimmunoassay and compared with age matched control subjects  of 13 patients with fmen i who had islet cell tumors  7  54   had elevated plasma hpp levels before surgery  after resection of all islet cell tumors  4 of 12 patients evaluated after surgery still had elevated levels  fifteen patients had islet cell tumors that were localized  seven insulinomas and eight gastrinomas   but none of these patients had elevated hpp levels  either before or after surgery  nine patients  including one with fmen i  with metastatic islet cell tumors to the liver were studied  three with more advanced disease had elevated hpp levels before surgery  each of the nine patients underwent resection of all gross disease and the three patients with elevated preoperative levels had normal postoperative hpp levels  our results indicate that basal plasma levels of hpp were not clinically useful  the hpp levels did not reliably predict the presence of islet cell tumors in patients with fmen i  because 46  of patients with tumors did not have elevated plasma levels  and in those with elevated values hpp levels did not reliably predict the resection of all tumor  plasma levels of hpp have no utility in patients with localized sporadically occurring islet cell tumors and limited utility  33   in predicting the presence of metastatic islet cell tumors to the liver  
class4	extraadrenal retroperitoneal paragangliomas  natural history and response to treatment  extraadrenal retroperitoneal paragangliomas  rp  are uncommon tumors  because of their rarity  little is known of their natural history or response to treatment  we reviewed 22 patients with rp who were seen at our center between 1949 and 1990  the distribution of male and female patients was nearly equal  and the mean age was 42  most patients were admitted with pain or a mass  and eight of 22 tumors were functional  no significant difference was noted in duration of symptoms  size of the tumor  or survival between functional and nonfunctional tumors  eleven of 22  50   rp metastasized and were therefore classified as malignant  five year and 10 year disease free survival rates were 19  and 19  for tumors not resected and 75  and 45  for those completely resected  once metastases occurred  the 5 year survival rate was 36   but no patient survived beyond 76 months  predictors of survival included complete resection of the tumor but not size or functional status  although some patients who received chemotherapy or radiotherapy had clinical responses  a survival benefit could not be shown  rp have a high rate of malignant behavior and should be treated aggressively with operation  late metastases are not uncommon  and prolonged follow up is necessary  once metastases have occurred  some patients may have prolonged survival  
class4	the effect of somatostatin on 5 hydroxytryptamine release from a carcinoid tumor  one of the major manifestations of the carcinoid syndrome is secretory diarrhea thought to be due to overproduction of 5 hydroxytryptamine  5 ht   synthetic somatostatin analogues have proved to be clinically effective in controlling this diarrhea  we have established a continuous cell line from a human pancreatic carcinoid tumor that secretes 5 ht  we examined the ability of the somatostatin analogue  sms 201 995  to inhibit 5 ht release in vitro  tumor cells were exposed to sms 201 995  10  6  mol l   pentagastrin  10  9  mol l   acetylcholine  10  5  mol l   and isoproterenol  10  5  mol l  alone and in combination  5 ht release was assayed with high pressure liquid chromatography  we found that pentagastrin  6 43     0 64 ng ml   isoproterenol  20 24     2 17 ng ml   and acetylcholine  12 39     1 10 ng ml  each stimulated release of 5 ht compared to control values  4 38     0 42 ng ml   sms 201 995 significantly reduced release of 5 ht in response to isoproterenol and acetylcholine but did not inhibit the effect of pentagastin  these data suggest that different agents do not act through the same pathway to stimulate 5 ht release from human pancreatic carcinoid cells  
class4	intraatrial extension of thyroid cancer  technique and results of a radical surgical approach  an occlusion of the superior vena cava by a tumor thrombus extending into the right atrium was diagnosed in three patients with a follicular thyroid cancer  all patients showed the typical clinical picture of the superior vena cava syndrome  a right parasternal thoracotomy was performed for preparation of the major vessels  the superior vena cava was opened and the entire intravascular tumor thrombus was removed  the cavotomy was closed directly in two patients  in the third patient the left brachiocephalic trunk was resected and reconstructed with a vascular  polytetrafluoroethylene  graft  this patient had bone and brain metastases and an occlusion of the graft 3 months after surgery after anticoagulation was stopped  the other two patients were clinically symptom free without local recurrence 13 and 50 months after surgery  an aggressive surgical approach is justified in grossly invasive thyroid cancer to decrease local recurrence and death rates  to correct the disturbing clinical symptoms of superior vena caval occlusion  and to prevent tumor embolism and the development of distant metastases  by reducing tumor mass  an even better basis for radioiodine treatment can be prepared  
class4	the intraoperative incidence of detectable bilateral and multicentric disease in papillary cancer of the thyroid  this is a prospective study to determine the incidence of grossly detectable multicentric and bilateral cancer at operation in patients who  before surgery  were believed to have a unilateral lesion  the opposite lobe was inspected at the time of operation and the surgeon made a determination as to whether there was bilateral and or multicentric disease present  a total thyroidectomy was then carried out and the accuracy of the surgeon s judgment was established by permanent section pathologic examination  fifteen of the 44 patients were assessed to have gross bilateral disease  thirteen of these were confirmed by pathologic examination  one case of microscopic bilateral disease was not recognized by the surgeon  seventeen patients were thought to have unilateral multicentric disease  fifteen of these cases were confirmed by microscopy and an additional seven cases were documented to have secondary foci  it is obvious from this study that most disease that is called microscopic disease is actually palpable  a review of the literature confirms this  it was very unlikely for a patient who did not have unilateral multicentric disease to have a contralateral focus of carcinoma  the incidence of bilateral disease was 32   and the incidence of multicentric disease was 50   the surgeon was very accurate in assessing this  we believe that surgeons who advocate lobectomy as the primary treatment for thyroid cancer are recognizing grossly detectable disease in a significant number of patients and thus are doing total thyroidectomies in most patients with bilateral disease  
class4	intraoperative decision making during thyroid surgery based on the results of preoperative needle biopsy and frozen section  prognostic factors in well differentiated thyroid cancer are age of the patient and grade  size  distant metastasis  and extracapsular spread of the disease  however  the surgeon is often not sure about the pathologic diagnosis of thyroid nodules  the accuracy of preoperative studies  such as ultrasonography and thyroid scanning  is limited  the most cost effective test is fine needle aspiration  the accuracy of which exceeds 80  in most series  however  a large group of nodules exist for which aspiration cytologic studies are considered to be either suspicious or indeterminate  the decision about the extent of thyroidectomy may be difficult in these patients  intraoperative frozen section may help the surgeon to distinguish benign from malignant lesions  but as in fine needle aspiration  the major problem is the distinction between follicular adenoma and follicular carcinoma  the frozen section diagnosis of follicular adenoma was changed to follicular carcinoma in one third of the cases  13 of 38 cases   the decision about the extent of thyroidectomy in patients with follicular adenomas was based on other prognostic factors  such as age and sex of the patient and the size of the nodule  the accuracy of frozen section diagnosis was 95   our experience suggests that decisions regarding the extent of thyroidectomy can best be made by preoperative fine needle aspiration with confirmation by frozen section diagnosis in equivocal cases  
class4	prognostic significance of nondiploid dna determined by flow cytometry in sporadic and familial medullary thyroid carcinoma  to clarify the role of dna measurements in predicting outcome after surgical treatment of medullary thyroid carcinoma  mtc   we performed flow cytometric analysis in nuclear suspensions of 119 mtc tumors  of the 119 patients  63  53   patients had sporadic tumors and 56  47   patients had familial tumors  survivors were followed for a mean of 13 years  dna content was normal in 92  77   patients and abnormal  nondiploid  in 27  23   patients  ten year cause specific mortality rates were 12   42   and 49  with diploid  tetraploid polyploid  or aneuploid tumors  p   0 0009  and were greater with nondiploid tumors both in the sporadic  p   0 012  and multiple endocrine neoplasia  familial  cases  p   0 114   none of 27 patients with tnm stage i disease died of mtc  in patients with tnm stages ii  iii  and iv disease  dna nondiploid tumors were associated with increased deaths from mtc  in a cox proportional hazards model involving all 119 patients and adjusted for disease stage and inheritance pattern  nondiploid dna was independently associated with increased deaths from mtc  p   0 008   in an identical cox model restricted to the 92 dna diploid tumors  an s phase fraction of 15 0  or more remained a significant variable  p   0 034  after adjustment for stage and inheritance pattern  we therefore conclude that dna measurements do have a role to play in predicting outcome after surgical treatment of mtc  
class4	clinicopathologic and flow cytometric dna study of medullary thyroid carcinoma  sixty one patients with medullary thyroid carcinoma were investigated to establish relationships between the neoplasm s dna content  other clinicopathologic factors  and patient survival  at least 5 years  follow up   there were 26  42 6   familial and 35  57 4   sporadic carcinomas  forty two neoplasms  68 8   were diploid and 19  31 2   were aneuploid by flow cytometric assessment  in univariate analysis  age  hereditary background  dna content  calcitonin immunoreactivity  and type of surgery were strong predictors of clinical outcomes  in multivariate regression analysis  none of these factors was an independent prognosticator  patients  gender  clinical stage  histologic subtype  and amyloid content of the tumor did not influence survival  
class4	actin architecture of cultured human thyroid cancer cells  predictor of differentiation  the actin cytoskeleton is important for cell structure and motility  a disordered actin architecture has been correlated with a high metastatic potential in melanoma  fibrosarcoma  and colon cancer models  thyrotropin is known to induce growth and differentiation in cultured thyroid cells  whereas the carcinogenic phorbol ester 12 o tetradecanoylphorbol 13 acetate  tpa  causes dedifferentiation and malignant transformation in many cell lines  we therefore assessed the effect of thyrotropin and tpa on the actin architecture of ftc 133 human follicular thyroid cancer cells in continuous culture  staining of filamentous actin with rhodamine phalloidin showed that 1 mu ml or 30 mu ml thyrotropin induced actin polymerization was detectable at 1 hour but more notable at 24 hours  similarly tpa  0 008 to 10 mumol l  caused rapid actin fiber disruption and redistribution to the cell periphery  secondary antibody staining for alpha actinin  a protein that binds and crosslinks actin  was more prominent after treatment with thyrotropin but decreased after tpa  these findings indicate that the actin cytoskeleton has a dynamic response to trophic factors  thyrotropin promoted actin polymerization  but tpa caused depolymerization  these effects may correlate with cellular alpha actinin levels  actin architecture may therefore reflect the state of differentiation of thyroid tumor cells  
class4	n ras 61 oncogene mutations in hurthle cell tumors  mutations of ras oncogenes are believed to play an important role in the initiation or progression of human tumors  in thyroid tumors the incidence of ras activation by specific point mutations has been reported to range from 33  in follicular adenomas up to 60  in anaplastic carcinomas  because of our long standing interest in hurthle cell tumors  we began a study of 70 such cases to determine the incidence of ras mutations and their clinical correlates  analysis of n ras sequences at condon position 61  with the polymerase chain reaction method and oligonucleotide probe hybridization  showed point mutations of the normal codon caa  in eight tumor samples  one was a mutation from caa to aaa  one from caa to cta   and six from caa to cga  these mutations would result in amino acid substitutions of lysine  leucine  or arginine for the normal glutamine at position 61 in the n ras protein  identical ras mutations in two tumors and some of their surrounding thyroid tissue may indicate that activating ras point mutations are an early event in carcinogenesis  the incidence of mutations was 1 of 24  4   of the histologically benign tumors  5 of 34  15   of the intermediate tumors  with vascular or capsular permeation   and 2 of 12  17   in the malignant group  four of these eight patients died of metastatic thyroid disease and four are alive without evidence of recurrence  
class4	posterior mediastinal teratoma with abdominal extension  posterior mediastinal benign teratomas are uncommon neoplasms in infancy  nine cases have been reported so far  a one month old baby was found to have a benign posterior mediastinal teratoma infiltrating the lower oesophagus from the level of the carina through the oesophageal hiatus into the upper abdomen  partial oesophagectomy provided a successful outcome  
class4	are three substages of clinical b prostate carcinoma useful in predicting disease free survival  the b1 nodule  a 1 5 cm area of induration surrounded on at least two sides by prostatic tissue of normal consistency  was defined by jewett in 1968 as the stage of prostatic cancer best suited for treatment and cure by radical prostatectomy  rp   the area of prostatic induration suitable for rp was subsequently extended to less than one lobe  stage b1   this extension of induration was supported by the study of walsh and jewett in 1980 showing a 51 percent survival free of disease at fifteen year follow up  subsequently  clinical staging systems evolved which substaged clinical b into three categories of induration  b1n   less than 1 5 cm nodule  b1   greater than 1 5 cm but less than one lobe  and b2   one lobe or both lobes  to determine if digital assessment of these progressively greater degrees of induration would translate into different intervals to first progression  whether local or distant  we reviewed prostate diagrams and descriptions of all stage b patients treated by iodine 125 interstitial implant and external beam radiation therapy between 1974 and 1985 at our institution  forty six patients had b1 nodules  78 patients b1  less than one lobe   and 52 patients b2  one lobe or greater   mean follow up was fifty five months  we found b1n  which was also associated with well differentiated grade and a normal acid phosphatase  to have the longest interval to progression  
class4	radical prostatectomy versus expectant primary treatment in stages i and ii prostatic cancer  a fifteen year follow up  a fifteen year follow up of a prospective  randomized study comparing placebo with radical prostatectomy as the primary treatment of early prostatic cancer is presented  a total of 111 patients with clinical stage i or ii prostatic cancer  normal acid phosphatase levels  and negative findings on skeletal x ray film were evaluable  thirty stage i patients and 20 stage ii patients received placebo only  31 stage i and 30 stage ii patients underwent radical prostatectomy  the survival status for 95 patients  86   was established at the fifteen year follow up  no significant differences in crude survival occurred in either stage or in both stages combined  moreover  the survival curves closely followed reference curves based on expected u s  mortality for men of comparable ages and races  a statistically significant association between a high gleason histologic score and poor survival was established  in this study  initial treatment with radical prostatectomy did not yield longer survival than initial placebo treatment alone  however  the findings should be interpreted with caution  since sample size was small and staging procedure was simplified  
class4	epididymal metastasis from prostatic adenocarcinoma mimicking adenomatoid tumor  a case of epididymal metastasis from prostatic carcinoma is presented  the initial histologic findings were suggestive of adenomatoid tumor  but a diagnosis of metastatic adenocarcinoma of prostatic origin has been established by prostatic acid phosphatase and prostate specific antigen immunoperoxidase staining  
class4	femoral mononeuropathy after radical prostatectomy  femoral mononeuropathy is a recognized complication following abdominal and vaginal hysterectomy  retractor injury and lithotomy position were postulated mechanisms  we report a femoral nerve lesion following a radical perineal prostatectomy  
class4	testicular calcifications and neoplasia in patient treated for subfertility  a subfertile male with a history of left cryptorchism underwent scrotal ultrasound that revealed stippled calcifications  without associated mass  in the right testicle  six months later  while on a regimen of clomiphene citrate  a testicular tumor became palpable  this was sonographically confirmed to be surrounding the calcifications  testicular calcifications are most commonly associated with benign conditions  we review the literature regarding their relationship to neoplasms and the significance of the ultrasonic findings  furthermore  this is the sixth reported case of testicular tumor developing during hormonal treatment for oligospermia  although these cases may be circumstantial  closer surveillance and screening ultrasound may be indicated for subfertile males taking clomiphene citrate  
class4	papanicolaou smear cell recovery techniques used by primary care physicians  nine hundred tennessee based internists  family physicians  and obstetrician gynecologists were randomly selected and surveyed to identify papanicolaou smear cell recovery methods used in their practices  this 16 item survey also requested typical laboratory reporting procedures on papanicolaous smears  the most frequently reported cell sampling technique was the combination cotton tipped applicator and spatula  which was used by 47 percent of all physicians  use of the cervical cytobrush for papanicolaou smears  which has been shown to improve the detection of cervical dysplasia  was used alone or in combination by 19 percent of those surveyed  of whom 72 percent were gynecologists  cervical sampling should contain cells from the transformation zone as evidenced by an adequate number of endocervical cells on the smear  laboratories reporting the presence of endocervical cells were significantly different  p less than 0 05  among the specialties  with 26 percent of the internists   18 percent of the family physicians   and 15 percent of the obstetricians  laboratories not providing this information in their reports  reporting inadequate smears is a necessary first step toward improved sampling technique  without this information  physicians risk missing pathology through reports of false negative papanicolaou smears  
class4	malignant melanoma presenting as nasal obstruction  mucosal melanomas arising in the nasal cavity are rare tumors comprising less than 1 percent of all melanomas  often  the common clinical symptom is nasal obstruction  grossly  they may or may not be pigmented and frequently attain large sizes  histologic diagnosis of these tumors may be difficult  requiring immunohistochemical or electron microscopic confirmation  aggressive surgical management is the treatment of choice in clinical stage i disease  subsequent surveillance for recurrence is mandatory  markers such as 5 s cysteinyldopa may prove useful in staging  prognosticating  and postoperative surveillance for early recurrence  but their exact role has yet to be delineated  ultimate prognosis is poor  
class4	parental age in sporadic hereditary retinoblastoma  of 104 children with sporadic hereditary retinoblastoma born between 1945 and 1970  we studied the age of their parents at the birth and compared this age with the mean age of parents at the birth of their children during the same period in the netherlands  the mean age of fathers at the birth of their children with sporadic hereditary retinoblastoma  33 7 years  was significantly higher than the mean age of fathers at the birth of their children in the general population  32 5 years   p less than  05  one sided   similarly  the mean age of mothers at the birth of their children with sporadic hereditary retinoblastoma  31 2 years  was significantly higher than the mean age of mothers at the birth of their children in the general population  29 5 years   p less than  05  one sided   we further analyzed this parental age factor by measuring the relative risk of age groups and comparing the incidence of sporadic hereditary retinoblastoma in the various parental age groups with the incidence of sporadic hereditary retinoblastoma in the total population  mothers 35 years of age or older had a relative risk of 1 7 to have a child with sporadic hereditary retinoblastoma compared with mothers in the population in general  p    006  one sided   similarly  fathers 50 years of age or older had a relative risk of 5 0 to have a child with sporadic hereditary retinoblastoma compared with fathers in the population in general  p    04  one sided   no parental age effect was found in children with nonhereditary retinoblastoma  we conclude that a high paternal and a high maternal age are significant risk factors for sporadic hereditary retinoblastoma  
class4	capillary haemangioma presenting as a lung pseudocyst  a girl who developed a lung cyst at 24 hours of age during gentle ventilation for respiratory distress syndrome is reported  instead of resolving as expected of a pseudocyst it continued to expand  resection at 1 year of age showed a cyst entirely surrounded by capillary haemangioma  aspiration of this cyst would have been dangerous  
class4	indomethacin responsive hypercalcaemia associated with a renal sarcoma  an infant presented with a non metastatic renal spindle cell sarcoma and hypercalcaemia  which resolved after treatment with indomethacin  there was in vivo and in vitro evidence that hypercalcaemia was mediated by circulatory prostaglandins  
class4	surgical strategy in thyroid disease  over the past 8 years  311 patients have undergone surgical treatment by the senior authors for thyroid disease  over 80  of the cases were performed by the head and neck surgical service at olive view county hospital  sylmar  calif  with the remainder performed at ucla affiliated institutions  this service is an important source of thyroid surgical training for ucla head and neck residents who rotate through this major affiliate  the purpose of this communication is to review our experience with these cases  to describe our overall surgical strategy  and to detail the specifics of our surgical procedure  which we have developed to safely train residents in the treatment of these challenging cases  this article deals with the specific problems of preservation of the recurrent nerve  the parathyroid glands  and the techniques for reimplantation of injured parathyroid glands  the management of larger  substernal thyroid glands  and our techniques for partial thyroid surgery  in addition  the difficult decisions in the management of thyroid cancer  such as completion thyroidectomy  the management of lymph node mestastases  and how tracheal  esophageal  or laryngeal invasion should be managed are discussed  an initial section describing the general preoperative examination of these patients is also included  so that the proper surgical strategy can be developed prior to entering the operating room  
class4	carotid body tumors  the surgical management of carotid body tumors requires identification and preservation of neural and vascular structures without compromising resection of the neoplasm  fifteen patients were examined and treated for carotid body tumors at the cleveland  ohio  clinic foundation from 1979 through 1987  the benchmark of diagnosis is bilateral carotid angiography  when neural structures are free of tumor  meticulous dissection facilitates their preservation  large tumor size increases risk for arterial resection necessitating reconstruction  the use of a vascular shunt minimizes the risk of cerebral ischemia  postoperative intravenous digital subtraction angiography allows for evaluation of arterial repair  a retrospective review of 15 carotid body tumor resections performed in 14 patients revealed no evidence of tumor recurrence  no mortality associated with surgical intervention  no postoperative cerebrovascular accident  and limited morbidity associated with unavoidable sacrifice of neural elements  
class4	unknown primary squamous cell carcinoma metastatic to the neck  we analyzed retrospectively 157 cases of metastatic neck squamous cell carcinoma from unknown primary sites  treated with surgery  radiotherapy  excisional biopsy  and combined modalities  median follow up was 74 months  and overall actuarial survival was 55  at 5 years  the surgery treated group  despite a higher rate of manifesting primary tumors  had significantly better survival at 5 years compared with those receiving radiation therapy  of whom 23  had residual disease after treatment  primary tumors were discovered during follow up in 16  overall  different treatments yielded comparable results in lower staged neck disease  nx  n1  n2a   while surgery appeared more effective in controlling advanced disease  n2b  n3a   factors that affected survival include neck stage  connective tissue invasion  and presence of recurrent or residual disease after treatment  
class4	oncogene amplification in squamous cell carcinoma of the head and neck  cellular oncogenes appear to be involved in the control of normal cell growth and differentiation  the abnormal activation of these genes in naturally occurring and experimentally induced cancers may have an important role in the expression of the malignant phenotype in cancer cells  mechanisms for the activation of these genes include chromosomal translocation  point mutation  and dna amplification  the amplification of specific oncogenes correlates with clinical prognosis in several human malignancies  including breast cancer and neuroblastoma  we examined 21 fresh frozen human squamous cell carcinomas of the aerodigestive tract for amplification of 10 known cellular oncogenes  c myc  n myc  l myc  n ras  h ras  k ras  erb b  erb b2  raf  and int 2   using southern blotting techniques  eleven of 21 tumors demonstrated a two fold to 11 fold amplification of the int 2 oncogene  one member of a family of genes related to basic fibroblast growth factor  amplification of c myc  a gene that codes for a dna binding protein involved in the regulation of cell growth  was seen in two tumors  none of the other eight genes studied were amplified in any of the tumor specimens  
class4	intraoperative radiation of canine carotid artery  internal jugular vein  and vagus nerve  therapeutic applications in the management of advanced head and neck cancers  as a step in the application of intraoperative radiotherapy  iort  for treating advanced head and neck cancers  preliminary information was obtained on the radiation tolerance of the canine common carotid artery  internal jugular vein  and vagus nerve to a single  high dose electron beam  both sides of the neck of eight mongrel dogs were operated on to expose an 8 cm segment of common carotid artery  internal jugular vein  and vagus nerve  one side of the neck was irradiated  using escalating doses of 2500  3500  4500  and 5500 cgy  the contralateral side of the neck served as the unirradiated control  at 3 and 6 months after iort  one dog at each dose level was killed  none of the dogs developed carotid bleeding at any time after iort  light microscopic investigations using hematoxylin eosin staining on the common carotid artery and internal jugular vein showed no consistent changes that suggested radiation damage  however  the masson trichrome stain and hydroxyproline concentration of irradiated common carotid artery indicated an increase in the collagen content of the tunica media  marked changes in the irradiated vagus nerve were seen  indicating severe demyelination and loss of nerve fibers  which appeared to be radiation dose dependent  four patients with advanced recurrent head and neck cancer were treated with surgical resection and iort without any acute or subacute complications  the role of iort as a supplement to surgery  external beam irradiation  and chemotherapy in selected patients with advanced head and neck cancer needs further exploration  
class4	use of the levator scapulae muscle flap in head and neck reconstruction  there are numerous techniques available for reconstruction of defects following composite resection of oral cavity and oropharyngeal tumors  no single technique is applicable in all situations  the levator scapulae muscle flap is well known for its application in carotid protection  little attention is paid to its usefulness in other aspects of head and neck reconstruction  we have been using the levator scapulae muscle flap for a variety of reconstructive problems  the flap is useful for buttressing intraoral suture lines  closing intraoral defects  and providing soft tissue to fill in dead spaces and bulk out lateral and anterior oral defects  the levator flap was found to be easy to elevate  safe  and reliable with a minimum of wound complications  a review of 18 patients  representative case studies  and a discussion of surgical technique and relevant anatomy and blood supply is presented  
class4	parotid duct communicating with a labial pit and ectopic salivary cyst  labial pits are usually described as blind epidermal invaginations of lip mucosa with occasional drainage of minor salivary gland secretions  a case of an aberrant parotid duct in communication with both a unilateral  commissural labial pit and an interposed salivary cyst is presented  a 7 year old boy who had experienced lifelong clear drainage from a congenital pit at his right oral commissure developed fever  pain  and a submucosal mass of the right cheek over a 6 week period  a preoperative sialogram through the pit demonstrated a communication between the oral commissure fistula  an intervening salivary cyst  and a proximal tract from the cyst to the parotid gland  an en bloc resection of the pit  fistula tract  and cyst was performed through a transoral approach  the dissection was medial to the buccinator muscle  there has been no recurrence of the cyst after 1 year follow up  a description of labial pits and parotid duct anomalies is presented  however  to our knowledge  this combination of anomalies has not been previously described  
class4	intraventricular diamorphine via an ommaya shunt for intractable cancer pain  we describe two patients in whom diamorphine was administered into the intraventricular space via an ommaya reservoir  producing excellent pain relief  the use of this technique for long term administration of analgesia is reviewed  
class4	radiobiological studies in the naevoid basal cell carcinoma syndrome  the naevoid basal cell carcinoma syndrome is described in a 43 year old male  the response of dividing fibroblasts from this patient to the lethal effects of ionizing radiation was indistinguishable from that of a normal control  mean inactivation dose  d    1 74 gy and 1 68 gy  respectively  however  these cells were defective in the repair of potentially lethal damage  d   2 36 gy and 3 26 gy  respectively   the response to radiation of go t lymphocytes derived from the patient was similar to that of the control  the frequency of mutant circulating t lymphocytes resistant to 6 thioguanine was 17 x 10  6  which was elevated when compared with age matched controls  these results suggest an abnormality in the response of the fibroblasts to ionizing radiation damage  
class4	the significance of leu 8 negative t cells in lymphoid skin infiltrates  malignant transformation  selective homing or t cell activation  the expression of leu 8 was studied on skin biopsies from a large group of patients with benign and malignant skin disorders and correlated with the expression of t cell differentiation antigens and activation markers  the effect of in vitro stimulation of peripheral blood t cells and t cell subsets on the expression of leu 8 antigen was also determined  in all the skin diseases studied an inverse relationship was found between the proportions of cells expressing leu 8 and hla dr  a deficiency of leu 8 positive cells was not specific for mycosis fungoides  but was also found in several reactive dermatoses  stimulation of peripheral blood cells with phytohaemagglutinin  pha   concanavalin a  con a   and anti cd3 pma resulted in a considerable decrease of leu 8 antigen expression on day 3 in both cd4  and cd8  t cells  these data suggest that the low proportion of leu 8  t cells in mycosis fungoides and several reactive skin disorders is not related to malignant transformation or selective homing of leu 8  t cells  but probably results from local t cell activation  
class4	pachyonychia congenita complicated by hidradenitis suppurativa  a family study  a family is described in which five of the six members with the jackson lawler type of pachyonychia congenita also had varying degrees of hidradenitis suppurativa  we suggest an association between this type of pachyonychia congenita and hidradenitis suppurativa  
class4	leukaemia complicating treatment for hodgkin s disease  the experience of the british national lymphoma investigation  objective  to determine the incidence of and risk factors for the development of secondary acute leukaemia and myelodysplasia in patients treated in british national lymphoma investigation s studies of hodgkin s disease since 1970  patients  2676 patients entered into hodgkin s disease studies between february 1970 and november 1986  data accrued up to november 1988 were analysed  ensuring a minimum follow up period of two years  design  retrospective analysis of multicentre trial data by case control and life table methods  results  17 cases of secondary leukaemia were recorded in this group of 2676 patients  giving an overall risk at 15 years of 1 7   the risks of leukaemia after chemotherapy alone and chemotherapy with radiotherapy were not significantly different  the risk of leukaemia increased sharply with the amount of treatment given as measured by the number of attempts at treatment  the 15 year risks of leukaemia were 0 2   2 3   and 8 1  for patients receiving one  two  or three or more attempts at treatment  the highest risk  22 8  at 15 years  was observed in patients treated with lomustine  ccnu   and a case control study suggested that this was an independent risk factor  the risk of secondary leukaemia was largely related to the overall quantity of treatment  although exposure to lomustine seemed to be an important risk factor  treatment with both drugs and radiation was not more leukaemogenic than treatment with drugs alone  the greatest risk of secondary leukaemia was seen in multiply treated patients who were unlikely to be cured of hodgkin s disease  conclusions  avoidance of secondary leukaemia should be a minor factor in the choice of treatment for hodgkin s disease  
class4	dilatation in the duplex kidney  3 unusual cases  dilatation in the upper limb of a duplex ureter is usually secondary to obstruction and may be associated with a ureterocele  by contrast  vesicoureteric reflux is the usual cause of a dilated lower moiety ureter  we report 3 cases in which unusual or complex causes of dilatation of 1 limb of a duplex ureter were demonstrated  
class4	surgical approach to the retrocrural lymph nodes  removal of retrocrural lymph nodes requires an approach other than the infradiaphragmatic retroperitoneal access generally used in the surgical management of testicular tumours  the transperitoneal route given access  at best  to the origin of the superior mesenteric artery  but advanced testicular tumours occasionally require retrocrural node dissection  we describe a useful surgical approach to these nodes and the underlying anatomy  
class4	nonpigmented congenital iris stromal cyst  a nonpigmented iris stromal cyst was observed in the right eye of a 6 week old girl  there was no past history of trauma or use of topical miotics  and the remainder of the ocular examination was normal  the pathophysiology and management of this rare developmental anomaly are controversial  
class4	the patterns of care outcome study for cancer of the uterine cervix  results of the second national practice survey  this report summarizes the outcome results of the patterns of care study  pcs  of cancer of the uterine cervix from 565 patients treated in 1978  the 5 year survival with no evidence of disease was  stage i  74   stage ii  56   and stage iii  33   the 5 year local in field failure rate was  stage i  12   stage ii  27   and stage iii  51   extent of parametrial involvement  unilateral versus bilateral  may be important in determining survival and local failure  the four year actuarial survival was 58  for unilateral involvement versus 47  for bilateral  p   0 06   and the local failure rate was 32  for unilateral versus 45  for bilateral  p less than 0 05   when analyzed by stage  patients with stage iib disease with unilateral parametrial involvement showed a trend toward improved survival and decreased local failure compared with those with bilateral stage iib cancers  p   0 1   the use of intracavitary irradiation significantly improved survival and reduced local failures  furthermore  the number of intracavitary applications was important  when two or more intracavitary applications were used compared with one application  local in field failure was significantly reduced  29  versus 17  at 4 years  p less than 0 001   and four year survival was improved  60  versus 73   p   0 01   the four year actuarial rate of major complications depended on the stage  stage i  8   stage ii  15   and stage iii  13   there was a statistically significant increase in major complications in patients undergoing laparotomy for staging versus no laparotomy 23  versus 11  at 4 years  p less than or equal to 0 01  and a trend toward increased major complications in patients who were thin or had prior abdominal surgery  this study confirmed the stage dependent outcome of treatment of cancer of the uterine cervix with radiation and indicated that further division of stage iib to indicate prognostic significance of unilateral or bilateral parametrial involvement may be warranted  this study also confirmed the importance of intracavitary radiation in optimizing control established by the 1973 pcs  it further suggests that where possible  two intracavitary insertions may yield better results than one insertion  
class4	the influence of autologous lymphokine activated killer cell infusions on the toxicity and antitumor effect of repetitive cycles of interleukin 2  twenty patients with refractory malignancies were treated with a protocol evaluating the addition of ex vivo activated autologous lymphokine activated killer  lak  cells to a clinically tolerable interleukin 2  il 2  regimen  four weekly cycles of human recombinant il 2 at 3 x 10 6  u m2 day by continuous infusion for 4 days week   sixteen patients completed their induction month of therapy  two had a partial response  six had stable disease  and eight had progressive disease  four patients had clinical toxicity preventing completion of the induction month of therapy  and one of these patients died during therapy  significant clinical toxicities included decreased performance status  weight gain  catheter related thromboses  infectious complications  fever  hypotension  and dyspnea or hypoxemia requiring oxygen  thus  the addition of lak cell infusions to this il 2 regimen did not cause a noticeable change in antitumor response rate but did not cause more severe toxicity  
class4	carboplatin in childhood brain tumors  a children s cancer study group phase ii trial  between october 1985 and march 1988  children s cancer study group institutions entered 95 patients with recurrent brain tumors into a phase ii trial of carboplatin 560 mg m2 every 4 weeks  complete or partial responses were observed for one of 19 evaluable children with brainstem glioma  two of 14 with ependymoma  six of 19 with medulloblastoma or central nervous system primitive neuroectodermal tumor  pnet   and none of 15 with high grade astrocytoma  of 33 children with medulloblastoma  ependymoma  or central nervous system pnet  five of 12 with no prior cisplatin exposure had responses  and two of 21 with prior cisplatin exposure had responses  p   0 03   thirty four percent of patients had absolute neutrophil count nadirs less than 500 microliters  and 37  had platelet count nadirs less than 25 000 microliters  sixteen percent had moderate to severe otoxicity  10  had nausea and vomiting  and none had nephrotoxicity  
class4	interferon alpha 2a and 5 fluorouracil for advanced colorectal carcinoma  assessment of activity and toxicity  preclinical data showed that the cytotoxic effects of 5 fluorouracil  5 fu  are augmented by interferon  ifn   in a small study  13 of 17 patients with advanced colorectal cancer responded to a regimen of 5 fu with ifn  using the same dose and schedule as in this pilot study  38 previously untreated patients with metastatic colorectal carcinoma were treated with continuous intravenous  iv  infusion of 5 fu 750 mg m2 daily for 5 days  followed by weekly bolus 5 fu at 750 mg m2 and subcutaneous ifn at 9 million units three times per week  of 35 evaluable patients  nine  26   had a partial response  95  confidence limit  11  to 41    with a median response duration of 7 5 months  range  4 4 to greater than 11 7 months   seven patients  20   had a minor response  and ten  28   had stable disease  the most common toxicities observed were stomatitis  52   and diarrhea  43    neurotoxicity was seen in 34  of patients and consisted of gait disturbance  dizziness  confusion  memory loss  and dementia  because of toxicity  84  of patients required a reduction of the ifn dose by at least 50   and 63  required reduction of the 5 fu dose by at least 25   although the combination of 5 fu and ifn in patients with advanced colorectal carcinoma has some activity  the regimen was toxic  and the observed response rate  26   was not substantially superior to alternative 5 fu programs  
class4	conservative surgery and radiation therapy for soft tissue sarcoma of the wrist  hand  ankle  and foot  seventy eight patients with soft tissue sarcoma  sts  arising in the distal extremities  wrist  hand  finger  ankle  foot  and toe  who were treated with conservation surgery and radiation therapy were studied retrospectively with respect to survival  local recurrence  functional limb preservation  complications  and distant metastasis  after a median follow up of 7 9 years  actuarial 5 year and 10 year survival rates were 80  and 69   respectively  and disease free rates were 61  and 51  at the same times  actuarial local control rates were 80  and 74  at 5 and 10 years  respectively  fifteen patients  19   had local recurrence  but 12 of these were salvaged  ultimately  53 patients  68   retained a normal or fairly normal extremity  six  8   needed amputation for complications  and 13  17   needed amputation to control recurrent disease  the functional outcome was significantly better for patients with upper extremity lesions than for those with lower extremity tumors  even for the latter  this treatment strategy was preferable to amputation  the incidence of hematogenous metastases from distal extremity sarcomas depends on the size of the primary tumor  it was concluded that conservation surgery and radiation therapy  xrt  is an acceptable treatment strategy for sts arising in distal extremities  it yielded a high rate of disease control and functional limb preservation  
class4	multiagent chemotherapy in relapsed acute lymphoblastic leukemia in children  twenty seven evaluable children with early first bone marrow relapse of acute lymphoblastic leukemia were treated with an intensive induction consolidation and ongoing maintenance therapy  induction therapy consisted of a 35 day course of daunomycin  vincristine  and prednisone  immediately followed by teniposide  cytosine arabinoside  ara c   and l asparaginase  intrathecal methotrexate  hydrocortisone  and ara c were given through the induction consolidation phase  twenty three of 27 patients achieved remission by the end of induction consolidation  maintenance with the same drugs in a modified dosage schedule continued for approximately 2 years  a small subgroup of patients who were m3 at day 35 but m1 at day 56  end of induction consolidation  and had a cumulative event free survival  efs  of only 0 40 at 6 months  all had relapsed by 15 months  however  the efs for m1 patients by day 35 and maintained on chemotherapy was 0 64 at 12 months and 0 32 at 30  36  and 48 months  respectively  although good reinduction and remission duration rates at 12 to 24 months were achieved and an apparent plateau in survival occurs at 30 months  fall off in survival would not be unexpected with probably less than 20  alive after 5 years  
class4	a standard dose of radiation for  microscopic disease  is not appropriate  elective irradiation of sites of potential occult tumor spread is often part of a patient s radiation therapy program  the required radiation dose  d  depends on the probability that occult disease exists  p occ    the number of sites at risk  a   the number of tumor clonogens present  ni   their radiation sensitivity  and the desired control rate  an exponential model of cell survival is used to quantify the importance of these factors  control probability    1   pocc x  1   e ni x  sf2 d 2  a  sf2   surviving fraction after 2 gy  implications for clinical radiation therapy include  1  since the number of clonogens in an occult site may vary from 10 degrees to 10 8   ni is the major determinant of the required dose  the intrinsic radiation sensitivity of the clonogens  sf2  is also extremely important in determining the dose  other factors are less influential since they vary less  2  the variability of ni  8 logs  is larger than the variation in cell number seen with gross disease  1 cm3 versus 1000 cm3  3 logs   when ni approximately 10 8   the required dose approaches that needed for small volume gross disease  10 9  cells  1 cm3   3  the dose prescribed to elective sites should reflect the risk of occult disease based on the primary tumor site  stage  and grade  4  regions where clinicoradiologic evaluation is difficult  e g   pelvis and obese neck  require higher doses because macroscopic tumor deposits may exist  5  relatively low doses  10 to 30 gy  are often thought to be inadequate for microscopic tumor  however  similar doses have been reported to sterilize microscopic tumor in ovarian  rectal  bladder  breast  and head and neck carcinomas  relatively low doses should not be discounted since they may be useful in select cases when normal tissue tolerances and or previous irradiation treatment limit the radiation dose  
class4	primary central nervous system lymphoma in a pediatric patient with acquired immune deficiency syndrome  treatment with radiation therapy  primary central nervous system  cns  lymphoma  an otherwise rare pediatric tumor  has been reported with increasing frequency in children with acquired immune deficiency syndrome  aids   with current therapy  the outcome of this disease is invariably fatal  the authors present a case of primary cns lymphoma in a 3 5 year old girl with aids who received treatment with total brain irradiation  after treatment  the patient s mental status improved  the seizures resolved  and she had no further progression of her neurologic symptoms until she died of pneumonia 6 months later  the autopsy revealed a necrotic mass at the site of the original tumor  the brain stem and spinal cord  unirradiated  contained lymphomatous lesions  the patient had extensive fibrinoid necrosis and leukoencephalopathy that were consistent with radiation induced cns damage  coexisting aids encephalopathy also contributed to the patient s cns injury  effective palliation of cns lymphoma in children with aids may be obtained with cranial irradiation  pediatric aids patients may show more severe tissue effects from irradiation than unaffected children  
class4	131i treatment of thyroid papillary carcinoma in a patient with renal failure  procedures for 131i ablation in renal failure are not known  in one patient receiving dialysis  detailed dosimetry and health safety aspects were obtained  the results showed insignificant contamination of equipment  but a surprisingly significant reduction in biologic half life of 131i due to efficient dialysis extraction  the data indicate that 131i ablation can be done safely and easily during dialysis but that much higher 131i doses must be used to achieve equivalent results to those obtained in patients with normal renal function  
class4	the interplay of local and distant control in the cure of cervical cancer  from 1978 to 1986  183 women with cervical cancer received definitive radiation therapy after extraperitoneal surgical staging  relapse free rates were strong functions of pelvic lymph node metastases and cervical size  the recurrence distribution consisted of 4  isolated local  13  isolated distant  and 17  combined local and distant failures  with the assumption of independent local and distant failure probabilities  suit et al  s method was extended to assess potential improvement in cure attainable with perfect local and distant control  yielding local  lsa  and distant  dsa  survival advantages of 17  and 28   various subsets of clinical stage  cervical size  pelvic node metastases  periaortic metastases  and peritoneal metastases had lsa from 12  to 27  and dsa from 12  to 71   for any prognostic group  lsa never exceeded dsa  showing that effective systemic therapy would have a greater impact on improving survival than would advances in local and regional tumor control  therapeutic implications and limitations of the extended lsa dsa model are discussed  this form of analysis can be used to guide the intensity of local and distant treatment to maximize the cure of the patient with cancer  
class4	the role of elective lymph node dissection in the management of patients with thick cutaneous melanoma  a retrospective search of patients seen at the duke melanoma clinic from 1970 to 1986 identified 308 clinically stage i patients  with 4 0 to 10 0 mm cutaneous melanomas  five year and ten year survival was 56  and 43   respectively  elective lymph node dissection  elnd  was done in 116 patients  37 7    there was no difference in disease free interval  dfi  or survival between these patients versus patients treated with wide excision only  p   0 9   thirty two patients  27 6   had pathologically positive nodes on elnd  these patients had a shorter dfi  p   0 05  and survival  p   0 03  compared with patients with negative node dissections  when further divided by breslow s thickness  this difference persisted in patients with 4 0 to 6 0 mm lesions  p   0 01   however  for thicker lesions  greater than 6 0 mm   there was no difference in survival between the node negative and node positive groups  p   0 9   the mean follow up was 7 1 years  elective lymph node dissection was not done in 192 patients  78 of these recurred first in the regional nodes  these 78 patients were compared with the 32 patients who had pathologically positive nodes by elnd to see if patient survival was improved by early removal of nodal disease  there was no difference in dfi  p   0 5  or survival  p   0 3  between these two groups  it is concluded that elnd may provide prognostic information for patients with thick cutaneous melanomas  however  there was no change in dfi or ultimate survival when patients were followed  and nodes removed when clinically positive  the authors do not recommend elnd for patients with thick melanomas because the risk of distant metastases outweighs any benefit of regional node dissection  
class4	endoscopic and radiographic evaluation of the murine colon  endoscopic and radiographic techniques have not been widely applicable in the evaluation of chemically induced murine colon cancer  the authors investigated methods of cleansing the rat colon and refined endoscopic and radiographic techniques  they compared total colonoscopy  tc  and air contrast  acbe  and single contrast barium enema  scbe  findings with those obtained at necropsy in rats with 1 2 dimethylhydrazine  dmh  induced colon cancer  gastrograffin enemas with bisacodyl suppositiories showed complete evacuation of solid feces  sprague dawley rats treated with dmh had their colons cleansed and then underwent tc  5 0 mm olympus bronchoscope  and either scbe or acbe  colonoscopy and acbe were equally sensitive  81 5  and 76 3   respectively   although scbe was significantly insensitive in identifying lesions  p less than 0 001   this study demonstrates that   1  mechanical cleansing of the rat colon is feasible   2  tc and barium radiology can be done routinely after mechanical cleansing  and  3  tc and double contrast be are sensitive in identifying colon lesions  these techniques will provide a means for manipulation of murine tumors and in vivo surveillance  
class4	immunohistochemical differentiation of basal cell epithelioma from cutaneous appendages using monoclonal anti glycoprotein antibody tnkh1  its application in mohs  micrographic surgery  tnkh1  which was primarily developed to detect differentiated melanocytic tumor cells  was found to recognize basal keratinocytes of hair follicle and some basal keratinocytes of human epidermis  thus  tnkh1 decorated the basal cells of following structures  epidermis  39 of 54  only part of each specimen  opes    upper hair follicle  one of 24  opes   lower hair follicle  21 of 21  very high rate of each specimen  vhes    sebaceous duct  14 of 15  vhes   sebaceous gland  ten of 14  germinative cells near duct   eccrine duct  three of 19  opes   epithelial tumors  considered to be derived from or differentiating toward hair follicle such as trichilemmoma  one of one  vhes  and basal cell epithelioma  bce   32 of 32  vhes  were labeled not only in the peripheral cells but in their entirety  on the other hand  epidermal tumors  such as seborrheic keratosis  ten of 11  opes   actinic keratosis  two of three  opes   and squamous cell carcinoma  one of two  opes   showed an irregular peripheral basal cell staining as in normal epidermis  the apocrine sweat apparatus and eccrine secretory portion were negative  eccrine ductal tumors such as syringoma  two tested   eccrine acrospiroma  one   and eccrine carcinoma  two  were tnkh1 negative  taking advantage of this total labeling of bce versus peripheral labeling of the hair follicle  the authors could distinguish bce tissue from other structures clearly  among confusing structures the upper hair follicle and the eccrine duct were excluded easily because of their negative staining with tnkh1  the lower hair follicle was tnkh1 positive but only in the outer basal layer  whereas the bce was tnkh1 positive in its entire basaloid cells  the result indicated that tnkh1 will be a useful antibody in mohs  micrographic surgery  
class4	immunohistochemical demonstration of the placental form of glutathione s transferase  a detoxifying enzyme in human gliomas  expression of the human placental form of glutathion s transferase  gst pi  in human gliomas was investigated by immunohistochemical methods  and the result was compared with that of normal human glial cells  the gliomas in this study were composed of five benign astrocytomas  grade 2   ten anaplastic astrocytomas  grade 3   and 16 glioblastomas  grade 4   normal human glial cells showed only a weak immunostaining response for gst pi in the cytoplasm or some nuclear membranes  all of benign astrocytomas had diffusely weak gst pi immunostaining  resembling that of normal glial cells  with increasing grade  gliomas showed a strongly positive reaction for gst pi  the positive reactions were remarkable especially in the gemistocytes and giant cells in the high grade gliomas  these results suggest that cells of gliomas have some detoxifying function and the expression of this detoxifying enzyme  gst pi  is related to the degree of malignancy of the gliomas  
class4	helicobacter pylori and gastric carcinoma  serum antibody prevalence in populations with contrasting cancer risks  this investigation examined the correlation between helicobacter pylori  hp  infection  as reflected in immunoglobulin g serum antibodies  and the risk of gastric cancer  serum samples were obtained from populations with contrasting gastric cancer risks  the highest prevalence of hp infection  93   was observed in the adult population at highest gastric cancer risk  the residents of pasto  colombia  in the lower risk colombian city of cali  a 63  overall prevalence rate was found  both children and adults were sampled in new orleans  louisiana  where gastric cancer rates are high for blacks but not for whites  the prevalence of hp infection was significantly higher in black than in white adults  70  versus 43   p   0 0001  a higher prevalence was also detected in black compared with white children  49  versus 32   p   0 01  however  an even greater disparity was noted when comparing children from two hospitals  regardless of race  which serve different socioeconomic groups  a prevalence rate of 54  was found at charity hospital compared with 24   p   0 0001  at children s hospital  our findings indicate that socioeconomic conditions  known to influence gastric cancer risk  are also important determinants of hp infection  
class4	expression of placental alkaline phosphatase in gastric and colorectal cancers  an immunohistochemical study using the prepared monoclonal antibody  the authors developed monoclonal antibodies  moab  against human placental alkaline phosphatase  plap   four specific moab reacting only with plap and two nonspecific moab reacting equally with isozymes of alkaline phosphatase  hepatic  intestinal  and placental  were obtained  immunohistochemical staining with the specific moab showed that the cell membrane and cytoplasm of cancer cells were stained in gastric and colorectal carcinoma  the incidence of plap positivity was 23   25 of 107  of all gastric carcinomas  among gastric carcinomas  the 42   13 of 31  positivity of highly differentiated carcinoma  papillary adenocarcinoma and well differentiated tubular adenocarcinoma  was a significantly higher rate than that found in poorly differentiated carcinoma  poorly differentiated adenocarcinoma and signet ring cell carcinoma  five of 41  12    the incidence of plap positivity was 11   four of 35  in colorectal carcinoma  in contrast  gastric adenoma  intestinal metaplasia  and noncancerous tissue adjacent to cancer did not show staining  these results indicated that expression of plap was apt to occur in more highly differentiated gastric carcinoma and was highly specific for carcinoma in the gastrointestinal tract  although its incidence was not high  
class4	prognostic significance of type iv collagen and laminin immunoreactivity in urothelial carcinomas of the bladder  invasion of a carcinoma involves the degradation and penetration of the subepithelial basement membrane  bm   this phenomenon might be used for histopathologic evaluation of neoplasms of the bladder  the authors studied the clinicopathologic data and tissue specimens of 125 cases of urothelial carcinomas collected prospectively  penetration of the bm was evaluated by immunohistochemical staining of the bm components laminin and type iv collagen  the use of this parameter as a prognostic indicator in bladder cancer was assessed  the 5 year survival rate of patients having tumors with an interrupted or absent bm was significantly lower than that of patients having tumors with an intact bm  the rate of progression was greater in tumors with an interrupted or absent bm than in tumors with an intact bm  no association was found between bm status and recurrence  however  a significant correlation between tumor stage and bm staining was found  a correlation was also found between ploidy and bm staining as well as between histologic grade and bm staining pattern  when evaluating histologic grade  stage  ploidy  age  and bm score as prognostic parameters  the stage of bladder carcinomas turned out to be the most important factor in predicting the survival rate and the progression free survival  however  bm staining was found to be of value for early identification of microinvasion and is helpful for correct staging of urothelial carcinomas  
class4	primary breast lymphoma  an immunohistologic study of 20 new cases  primary malignant lymphomas of the breast  pbl  are uncommon  the authors report the clinical  histologic  and immunoperoxidase findings on 20 cases recorded at the alberta cancer registry over the last 23 years  these cases were then added to material on 257 cases abstracted from the literature and analyzed  it was found that there are two clinicopathologic types of pbl  the first affects pregnant or lactating women with bilateral  diffuse disease  is rapidly fatal  and corresponds histologically to a burkitt s type lymphoma  the second is unilateral at presentation and afflicts a broad age range  but primarily older women  this has a variable course only part of which is predicted by histologic grade and stage  tumor size  treatment  and side of presentation were not found to be significant prognostic factors  histologically  these tumors can be grouped into large cell b cell lymphomas  monocytoid b cell lymphomas  mbcl   and undifferentiated  some of which may be t cell  evidence suggesting that the mbcl of breast are the equivalent of the malignant lymphomas of the mucosa associated lymphoid tissues  malt  is reviewed  the breast is a hormone dependent member of the malt and therefore it is interesting that two of these tumors were strongly positive for estrogen receptors  
class4	estrogen receptor localization in normal and neoplastic epithelium of the uterine cervix  to investigate the estrogen receptor  er  status of cells during carcinogenesis of the uterine cervix  the immunohistochemical reactivity for a monoclonal anti er antibody  h 222  was studied in 26 normal cervical specimens  21 cases of cervical intraepithelial neoplasia  cin   and 21 cases of invasive cervical carcinoma  in addition  the presence of human papillomavirus  hpv  dna  types 6 11  16 18  or 31 33 35  was analyzed by in situ hybridization  in the normal cervix  basal cells of the squamous epithelium  metaplastic cells  and endocervical glandular cells were er positive  in contrast  neoplastic cells of cin  17 of 21 cases  and invasive carcinoma  19 of 21 cases  were er negative  the remaining four cases of cin and two cases of invasive carcinoma were focally er positive  the hpv dna analysis revealed that hpv dna in er negative cases was either types 16 18 or undetectable  but all er positive neoplasms contained hpv dna types 31 33 35  these results suggest that most neoplastic cells in cin and invasive cervical carcinoma lose their er expression and that this may be related to the hpv dna types which they possess  
class4	cancer antigen 125  carcinoembryonic antigen  and carbohydrate determinant 19 9 in ovarian tumors  the authors studied data of combination assays of tumor markers  because simultaneous elevation of different types of tumor markers in the serum was puzzling  they interpreted such phenomena regarding cancer antigen 125  carcinoembryonic antigen  and carbohydrate determinant 19 9 in ovarian tumors  the tissue expression of the antigens was compared with preoperative serum levels  several different factors were found to cause the simultaneous elevation of two or three of these markers in the serum  furthermore  even when the levels of some of the tumor markers were raised in the serum  the ovarian tumor did not always produce the marker by itself  this study indicates that immunohistochemical identification of a marker in tumor tissue is prerequisite to the use of that marker in the serum to monitor disease status  
class4	chondrolipoangioma  a cartilage containing benign mesenchymoma of soft tissue  the clinical and pathologic features of four cases of benign mesenchymoma in which mature cartilage represented the predominant component are reported  the distinctive histologic feature in all four cases was a lobular proliferation of cartilaginous tissue exhibiting a spectrum of hyaline cartilage  fibrocartilage  myxoid cartilage  and cartilage with ossification and even bone marrow formation  intimately associated with mature adipose tissue and vascular elements  the localization of these tumors was in the proximity of a bone  but not attached to the periosteum or in continuity with a joint  because these lesions may be mistaken for other cartilaginous neoplasms of soft tissue  recognition of this entity has potentially important diagnostic and therapeutic implications in that mutilating surgery may be avoided  
class4	dentofacial development in long term survivors of acute lymphoblastic leukemia  a comparison of three treatment modalities  ninety seven children who were diagnosed with acute lymphoblastic leukemia before 10 years of age and treated with chemotherapy alone  chemotherapy plus 1800 cgy cranial irradiation  rt   or chemotherapy plus 2400 cgy rt were evaluated for effects of therapy on dentofacial development  all patients were seen at least 5 years postdiagnosis  dental abnormalities were determined from panoramic radiographs  and craniofacial evaluations were made from lateral cephalometric radiographs  ninety one  94   of all patients and 41  100   of patients younger than 5 years of age at diagnosis had abnormal dental development  the severity of these abnormalities was greater in children who received treatment before 5 years of age and in those who received rt  observed dental abnormalities included tooth agenesis  arrested root development  microdontia  and enamel dysplasias  craniofacial abnormalities occurred in 18 of 20  90   of those patients who received chemotherapy plus 2400 cgy rt before 5 years of age  mean cephalometric values of this group showed significant deficient mandibular development  the results of this study suggest that the severity of dentofacial developmental abnormalities secondary to antileukemia therapy are related to the age of the patient at the initiation of treatment and the use of cranial rt  
class4	clinical and prognostic assessment of patients with resected small peripheral lung cancer lesions  one hundred fifteen patients with small  less than or equal to 2 cm in diameter  peripheral lung cancer lesions underwent surgical treatment in the department of surgery  the research institute for chest diseases and cancer  tohoku university  miyagi prefecture  japan  the authors investigated several prognostic factors of these cases  the 5 year survival rate of these 115 patients was 70   various factors such as histologic type  nodal involvement  pleural involvement  pathologic stage  and curativity of the operation were revealed to affect survival significantly  in patients with and without nodal involvement  there was no significant difference between the survival rate of patients with lung cancer lesions smaller than 2 cm and those with lesions 2 1 to 3 cm  however  the rate of lymph node metastasis was significantly different in the group with lesions smaller than 2 cm compared with those with lesions 2 1 to 3 cm  21  versus 43   respectively   
class4	choroid plexus tumors in the breast cancer sarcoma syndrome  choroid plexus neoplasms are rare epithelial tumors of the central nervous system  a carcinoma of the choroid plexus occurred in a child from a family with the breast cancer sarcoma syndrome  li fraumeni or sbla syndrome   an inherited condition characterized by the development of diverse neoplasms  sarcoma  breast cancer  brain tumors  leukemia  adrenal cortical carcinoma  and others   choroid plexus carcinomas were identified in two kindreds previously reported with the syndrome  the literature contains reports of choroid plexus neoplasms occurring in families and in individuals with multiple primary tumors  choroid plexus neoplasm may be a manifestation of the inherited proclivity to tumor development in the breast cancer sarcoma syndrome  
class4	fallopian tube cancer  the roswell park experience  sixty four patients with primary fallopian tube cancer treated at roswell park memorial institute from 1964 to 1987 underwent retrospective clinicopathologic review  in 40 patients fallopian tube cancer was the only primary  but in 24 patients primary fallopian tube cancer was part of a multifocal upper genital tract malignancy  of the 40 patients with unifocal fallopian disease  the median survival was 28 months  only 15  of patients were alive and disease free with follow up ranging from 22 to 141 months  median  90 5 months   survival was not associated with stage of disease  tumor histology  grade  or depth of invasion in this series  fourteen patients who received cisplatin based chemotherapy were evaluable for response  three patients  21   responded  two complete and one partial  twelve patients without clinical evidence of disease underwent second look procedures  ten laparotomy and two laparoscopy  four of ten second look laparotomies were negative  secondary debulking was done in three of four patients with gross disease  one of which had a negative third look laparotomy  negative laparotomy  second look or third look  was associated with improved survival  p   0 016   one of the two laparoscopies was negative  but the patient recurred  in the remaining 24 patients cancer of the fallopian tube was part of a multifocal upper genital tract malignancy  in 12 patients tubal disease was invasive  and in 12  it was in situ  separate primaries occurred in the ovaries  n   20   uterus  n   7   and cervix  n   2   this represents 1 3  of ovarian malignancies treated at roswell park memorial institute during the study period  fallopian tube cancer seems as virulent as ovarian cancer with few long term survivors  it is frequently associated with other sites of upper genital tract malignancy  second look laparotomy is an important predictor of survival  second look laparoscopy may be useful if positive  
class4	true hermaphrodite with bilateral ovotestes  bilateral gonadoblastomas and dysgerminomas  46 xx 46 xy karyotype  and a successful pregnancy  the first case  to the authors  knowledge  is reported of a true hermaphrodite with bilateral ovotestes  bilateral gonadoblastomas and dysgerminomas  a 46  xx 46 xy karyotype  and a successful pregnancy  the true hermaphroditism was diagnosed during infancy  the patient was subsequently found to have a gonadoblastoma and a microscopic dysgerminoma in the gonad diagnosed as an ovotestis and excised during infancy  the successful pregnancy occurred when the patient was 29 years old  a year later a large gonadal tumor affecting the remaining gonad was excised  the gonad was found to be an ovotestis  and the tumor was a dysgerminoma arising from a gonadoblastoma  this case further emphasizes the malignant potential of the y chromosome in patients with abnormal gonads  
class4	extrahepatic metabolism of morphine occurs in humans  the pharmacokinetics of morphine was studied in six patients in whom a radiologic localization of an insulinoma was to be performed under general anesthesia  sampling was done in the peripheral artery  the mesenteric vein in five of the six patients  the hepatic vein  and the peripheral vein  as well as in urine  hepatic blood flow was estimated by an indocyanine green infusion technique at the end of the radiologic procedure  morphine terminal half life was 92     9 minutes  total body clearance was 1260 ml min 1  and the hepatic extraction ratio was 0 65     0 11  no concentration gradient was observed between the artery and the superior mesenteric vein  showing that no gut wall metabolism of morphine occurred  the total body clearance exceeded the hepatic clearance by 38   it was concluded that the extrahepatic extraintestinal clearance of morphine probably occurred through the kidney  
class4	insulin like growth factor binding protein secretion by breast carcinoma cell lines  correlation with estrogen receptor status  breast tumor cell lines have been shown to secrete several distinct polypeptide growth factors  although conflicting results exist for the insulin like growth factors  igfs   in contrast a limited number of breast tumor cell lines have definitely been shown to secrete the high affinity igf binding proteins  igfbps  that modify igf actions  to characterize the types of igfbps that are secreted by breast tumor cell lines  conditioned medium was collected from seven separate tumor cell lines  three of which were estrogen receptor  er  negative  and four of which were er positive  all three of the er negative cell lines  mda 231  mda 330  and hs578t  secreted binding proteins of 49 000 and 43 000 mr  igfbp 3  as well as 29 000  igfbp 1  and 24 000 mr  in contrast  all four er positive cell lines secreted 34 000  igfbp 2  or 24 000 mr forms  and none secreted the 49 000 and 43 000 or 29 000 mr forms  bt 20  a cell line that is positive for er messenger rna  mrna  but negative for er protein  secreted predominantly a 34 000 mr protein  the amount of total igfbp activity released in 24 h ranged between 0 4 and 5 6 nm equivalents of igfbp 1  and there was no significant difference between the er positive and negative cell lines  the mcf 7 cells that produced predominantly 34 000 and 24 000 mr forms showed a 1 8 fold increase in igfbp secretion after estrogen stimulation  immunoblotting and a specific ria for igfbp 1 showed that only the er negative lines mda 330  mda 231  and hs578t secreted this form  northern blotting analysis for the mrna encoding this protein showed that both mda 330 and mda 231 contained a single 1 6 kilobase mrna species that hybridized with an igfbp 1 complementary dna  cdna  probe  immunoblotting analysis of the other cell lines showed that only the 34 000 mr form secreted by the er positive cell lines reacted with igfbp 2 antisera  exposure of the conditioned media from the three er negative cell lines to n glycanase revealed that the 49 000 and 43 000 mr forms of igfbp were glycosylated and therefore probably represent igfbp 3  we conclude that er negative cell lines secrete three forms of igfbps  igfbp 1  igfbp 3  and a 24 000 mr form  in contrast  the er positive cell lines secrete predominantly igfbp 2 and the 24 000 mr form but do not secrete igfbp 3 or 1  abstract truncated at 400 words   
class4	a simple and sensitive microtiter plate estrogen bioassay based on stimulation of alkaline phosphatase in ishikawa cells  estrogenic action of delta 5 adrenal steroids  we have developed an estrogen bioassay using the ishikawa human endometrial adenocarcinoma cell line growing in 96 well microtiter plates  alkaline phosphatase enzyme activity  alkp  in these cells is markedly stimulated by estrogens  and this enzyme can be easily quantified in situ using a chromogenic substrate  these cells are very sensitive to estrogens  estradiol induces alkp at levels as low as 10  12  m  antiestrogens completely block the action of estradiol  various estrogens stimulate alkp with potencies comparable to those achieved in vivo  the induction of alkp is specific for estrogens  no other type of steroid  including androgens  progestins  mineralocorticoids  or glucocorticoids produce this effect  the stimulation of alkp in ishikawa cells is specific for estrogens  is highly reproducible and sensitive  and permits large numbers of samples to be assayed with ease  we have used this assay to investigate the estrogenic action of the adrenal delta 5 3 beta hydroxysteroids  while pregnenolone is inactive  dehydroepiandrosterone and its sulfate ester induce alkp slightly  however  the c19 steroid  5 androstene 3 beta  17 beta diol is considerably more estrogenic in this assay  although it stimulates ishikawa alkp with a potency of 1 30 000 that of estradiol  the stimulation by 5 androstene 3 beta 17 beta diol is inhibited by antiestrogens  but it is not blocked by the delta 5 3 beta hydroxysteroid isomerase dehydrogenase inhibitor  cyanoketone  or by the aromatase inhibitor  4 hydroxy androstenedione  thus  neither conversion to a delta 4 3 ketone nor aromatization is required for the action of this unusual estrogen  
class4	alterations in opioid parameters in the hypothalamus of rats with estradiol induced polycystic ovarian disease  the distribution and density of selectively labeled mu   delta   and kappa opioid binding sites were examined by in vitro radioautography in the hypothalamus of normal  estradiol valerate  ev  injected  and estradiol  e2  implanted female rats  hypothalamic beta endorphin concentration was also examined by ria in these three groups of animals  quantitative analysis of film radioautographs demonstrated a selective increase in mu opioid binding in the medial preoptic area of ev treated  but not of e2 implanted rats  however  both these estrogenized groups exhibited a reduction in the density of delta opioid binding in the suprachiasmatic nucleus  statistically significant changes between either estrogenized groups were not observed for kappa opioid binding  results on the hypothalamic concentration of beta endorphin indicated a marked reduction in ev injected animals with respect to controls  in contrast  the e2 implanted animals exhibited beta endorphin concentrations similar to controls  the present results confirm the increase in opioid receptor binding previously reported in the hypothalamus of ev treated rats and further demonstrate that this increase is confined to the medial preoptic area and exclusively concerns mu opioid receptors  the concomitant reduction in beta endorphin levels observed in the same group of animals suggests that the observed increase in mu opioid binding could reflect a chronic up regulation of the receptor in response to compromised beta endorphin input  given the restriction of this effect to the site of origin of lhrh neurons and the demonstrated inhibitory role of opioids on lhrh release  it is tempting to postulate that such up regulation could lead to the suppression of the plasma lh pattern that characterizes polycystic ovarian disease in the ev treated rat  
class4	rapid inactivation and phosphorylation of pyroglutamyl peptidase ii in y 79 human retinoblastoma cells after exposure to phorbol ester  pyroglutamyl peptidase ii  ec 3 4 19     a membrane bound metalloproteinase  is a highly specific trh degrading enzyme  exposure of y 79 human retinoblastoma cells to 12 0 tetradecanoyl phorbol 13 acetate  tpa  decreased the activity of this enzyme in a time  and concentration dependent manner  ic50 5 x 10  9  m   after 15 min of tpa treatment  only 10  of pyroglutamyl peptidase ii activity remained  tpa treatment did not affect the activity of the cytosolic enzyme pyroglutamyl peptidase i  ec 3 4 19 3  or the membrane bound enzyme dipeptidyl peptidase iv  ec 3 4 19 3   pretreatment of the cells with the protein kinase c inhibitors h 7 or sphingosine prevented the inactivation of pyroglutamyl peptidase ii by tpa  the time course of the tpa mediated effect paralleled the time course of translocation and activation of protein kinase c in this cell line  immunoblot analysis demonstrated that inactivation of pyroglutamyl peptidase ii was not due to dissociation or internalization of this enzyme molecule  incubation of tpa activated y 79 cell membranes with gamma  32p  atp followed by immunoprecipitation revealed a time dependent phosphorylation of a 48 kilodalton subunit of pyroglutamyl peptidase ii  these studies indicate that the phorbol ester effect is mediated by protein kinase c  and reveal a mechanism of potentiation of the action of trh at its target sites  
class4	squamous cell carcinomas often produce more than a single bone resorption stimulating factor  role of interleukin 1 alpha   several cultured human squamous cell carcinoma cell lines  scc 4  scc 12b2  scc 12f2  ec gi 10  and ben  and one normal keratinocyte line  epy 1  were investigated for the production of bone resorption stimulating activity  brsa   conditioned medium  cm  from each of the six cell lines stimulated bone resorption in neonatal mouse calvariae in culture  the brsa of scc 12f2 and ec gi 10 was inhibited completely by antibody to interleukin 1 alpha  il 1 alpha   whereas the brsa in cm from the ben  scc 4  scc 12b2  and epy 1 cell lines was only partially inhibited by anti il 1 alpha  addition of indomethacin to the calvarial cultures also partially inhibited the brsa from ec gi 10  scc 4  scc 12b2  and epy 1 cells  the brsa from ben and scc 12f2 cells was inhibited completely by indomethacin  camp production by calvariae was determined after a 60 min incubation with cm  cm from ec gi 10  ben  scc 4  and epy 1 stimulated camp production by bone  preincubation of cm from ben  ec gi 10  scc 4  and epy 1 cells with two antisera against pth related protein  pthrp  one specific for two pthrp  1 141   the other recognizing both pthrp  1 40  and pthrp  1 141   completely inhibited the camp stimulating activity  using specific enzyme linked immunosorbent assays for il 1 alpha and il 1 beta  il 1 alpha was measured in cm of the scc 4  scc 12b2  scc 12f2  and epy 1 cell lines  il 1 beta was undetectable  less than 0 1 ng ml  in cm from all cell lines  our findings indicate that the brsa secreted by scc 12f2 cells can be accounted for largely or entirely by il 1 alpha  while the activity produced by scc 12b2 includes il 1 alpha and another unknown factor s   the brsa produced by ec gi 10  ben  scc 4  and epy 1 cells includes both il 1 alpha and pthrp  we conclude that il 1 alpha may be a more prevalent and biologically significant component of the brsa produced by sccs than previously recognized  
class4	autoradiographic evaluation of monoclonal antibodies  access to melanoma associated antigens in melanoma xenografts  autoradiography of nude mice bearing human malignant melanoma xenografts was performed to characterize the distribution pattern of radioiodinated anti melanoma monoclonal antibodies  moab  and fragments in macroscopic tumor nodules  non uniformity of radioactivity distribution was seen in all moab xenograft combinations  the predominant patterns were marked deposition of radioactivity either in the periphery of nodules or in sharply delimited intra tumoral foci  these patterns were generated by limitations in the accessibility of melanoma tissue rather than gross necrosis or heterogeneity of antigen expression  computer aided densitometry of autoradiograms was used to elaborate the difference of accumulation in intra tumoral hot spots versus cold areas  it was found that increasing uniformity was achieved by increasing the dose of moab  i e   intact igg  injected  whereas a reduction in the size of moab  igg greater than f ab  2 greater than fab  showed no such effect  
class4	ability of circular extrachromosomal dna molecules to carry amplified mycn proto oncogenes in human neuroblastomas in vivo  amplification of the proto oncogene mycn  also known as n myc  in neuroblastomas has been shown to correlate with both disease stage and prognosis  yet little is known about the dna structures that carry amplified mycn genes in neuroblastomas in vivo  we have used dna irradiation and pulsed field gel electrophoresis to analyze mycn amplification structures in eight neuroblastomas from separate patients  four primary tumors and four metastatic lesions exhibiting mycn amplification   six of the eight neuroblastomas  three primary tumors and three metastatic lesions  exhibited mycn dna irradiation profiles consistent with the presence of circular extrachromosomal dna amplification structures  five neuroblastomas possessed amplification structures within the size range of double minute chromosomes  and one contained smaller dna circles  two neuroblastomas exhibited mycn dna irradiation patterns consistent with larger  presumably chromosomal  amplification structures  multiple sizes of dna circles were observed in the neuroblastomas of four different patients  implying in vivo multimerization of amplification structures  the presence of circular mycn amplification structures in six of eight neuroblastomas examined suggests that circular dna molecules are important structures in in vivo gene amplification  
class4	history of cigarette smoking and risk of leukemia and myeloma  results from the adventist health study  the risks of leukemia and myeloma associated with cigarette smoking were evaluated in a cohort study of 34 000 seventh day adventists  although seventh day adventists do not smoke by church proscription  many are adult converts who smoked cigarettes prior to their baptism into the church  in comparison with those who never smoked  ex smokers experience a relative risk of 2 00  95  confidence interval   1 01 3 95  for leukemia and 3 01  95  confidence interval   1 13 8 05  for myeloma  risks increased in a dose response fashion with increasing numbers of cigarettes smoked daily for both leukemia  trend p    009  and myeloma  trend p    005   also  the risks of both leukemia and myeloma increased with the total duration of cigarette smoking  the cigarette smoking leukemia relationship was strongest for myeloid leukemia  for which ex smokers experienced a relative risk of 2 24  95  confidence interval   0 91 5 53   these data lend support to the hypothesis that cigarette smoke may induce malignant degeneration in bone marrow and its products  
class4	glycolysis as primary energy source in tumor cell chemotaxis  the energy requirements via glycolytic pathways were directly measured in migrating tumor cells  motility in the metastatic human melanoma cell line a2058  stimulated by insulinlike growth factor i  igf i   depends on glycolysis in the presence of glucose as its principal source of energy  motility in glucose free medium was 75  reduced and utilized mitochondrial respiration  inhibited by oligomycin   with increasing  physiologic  glucose concentrations  there was a dramatic shift to anaerobic glycolysis as the energy source and 93  elimination of the oligomycin inhibition of motility  oxamate  an inhibitor of glycolysis  inhibited motility at all glucose concentrations  co2 production from glycolysis and from the hexose monophosphate shunt was measured in migrating tumor cells  the time course and glucose dose dependence of glycolytic co2 production correlated directly with motility  in contrast  mitochondrial co2 production was inversely related to glucose concentration  a monoclonal antibody for the igf i receptor inhibited both motility and glycolytic co2 production  indicating that both processes are receptor mediated  
class4	influence of organ environment on extracellular matrix degradative activity and metastasis of human colon carcinoma cells orthotopic implantation of human colon carcinoma cells is useful for studying the behavior of metastatic subpopulations  we observed that the parental line and variants of human colon carcinoma km12 cells were all tumorigenic following implantation into the subcutis or cecal wall of balb c nude mice  their ability to metastasize to distant organ sites varied  however  with the site of growth  subcutaneous  sc  tumors did not produce visceral metastases  whereas cecal tumors metastasized to the regional mesenteric lymph nodes and to the liver  to examine the influence of organ environment on the extracellular matrix degrading activity of the tumors  we inoculated human colon carcinoma cells into the subcutis or cecal wall and after 7 weeks isolated and cultured the tumors in serum free medium  the conditioned media of sc tumors contained very low levels of type iv collagenase  gelatinase  and heparanase  heparan sulfate specific endo beta d glucuronidase   whereas the media of the cecal wall tumors contained high levels of both  zymograms of the media revealed that the intracecal human colon carcinomas secreted more than three times the amount of latent and active forms of 92 kd type iv collagenase than did the sc tumors  moreover  only the conditioned media of intracecal tumors contained latent and active forms of 64 kd type iv collagenase  histochemical analysis using rabbit antiserum raised against the synthetic peptides of 72 kd procollagenase type iv showed type iv collagenase in the intracecal tumors  human colon carcinoma growing sc  however  were not stained significantly  these results suggest that factors in the organ environment may affect production and secretion of tumor extracellular matrix degrading enzymes  and these factors may modify the metastatic behavior of human colon carcinoma cells in nude mice  
class4	bolus versus infusion regimens of etoposide and cisplatin in treatment of non small cell lung cancer  a study of the north central cancer treatment group in an effort to test clinically the hypothesis that the duration of cellular exposure to etoposide  vp 16  and cisplatin  cddp  is an important determinant of cytotoxicity  we performed a phase iii randomized trial comparing an outpatient bolus regimen of combined vp 16 and cddp with a sequential infusion over 72 hours of these same two drugs  all patients had stage iv non small cell lung cancer  and survival was the primary end point  of 113 patients randomly allocated to the study  108 were assessable for response  survival  and toxicity  a major response was observed in 20  37   of 54 patients on the bolus regimen and in 16  30   of 54 patients receiving infusion therapy  the median time to progression was 61 and 88 days for bolus and infusion therapy  respectively  the median survival time was 148 and 157 days  respectively  p    71   study results were not consistent with the possibility that infusion therapy could be associated with a 50  improvement in median survival  i e  from 5 months to 7 1 2 months  toxicity was primarily myelosuppression and was significantly greater with the infusion regimen  we conclude that infusion therapy as tested in this protocol with vp 16 and cddp does not offer any advantage in response rate  time to disease progression  or survival as compared with bolus therapy  in addition  infusion therapy is associated with a greater degree of neutropenia and more treatment related deaths  
class4	mechanism of antitumor activity of tumor necrosis factor alpha with hyperthermia in a tumor necrosis factor alpha resistant tumor  cells from a radiation induced fibrosarcoma  rif 1  are exceedingly resistant to tumor necrosis factor alpha  tnf alpha  in vitro  we tested whether the addition of mild hyperthermia  42 5 degrees c  30 minutes  could enhance tnf alpha activity against rif 1 tumors growing in syngeneic hosts  c3h mice   tnf alpha was administered intratumorally  tumor cell killing essentially was not measurable following tnf alpha  hyperthermia  or a combination of the two  single modality treatments also had no effect on tumor growth delay or on the x ray dose  given 24 hours after the primary treatment  required to sterilize 50  of the tumors  the combination of tnf alpha and hyperthermia  however  resulted in a marked increase in tumor doubling time and a highly significant reduction in the x ray dose required to sterilize the tumors  syngeneic lymph nodal lymphocytes and blood leukocytes did not appear to mediate the action of tnf alpha on rif 1 cells in vitro  necrosis and hemorrhage were the most prominent histopathological alterations in the treated tumors  electron microscopic studies 6 hours after therapy showed increased damage to capillary endothelial cells and accumulation of neutrophils in the capillaries of tumors treated with tnf alpha with or without heat  suggesting that neutrophils may mediate the endothelial cell injury  these observations indicate a greater than additive tumoricidal effect of tnf alpha with hyperthermia  furthermore  they support the concept that the interaction between the two agents damages the vasculature  compromising the microcirculation and ultimately causing ischemic tumor necrosis  
class4	segregation analysis of breast cancer from the cancer and steroid hormone study  histologic subtypes the segregation pattern of breast cancer in white families from the cancer and steroid hormone study was investigated  families were categorized into four groups based on the histologic type of breast cancer in the probands ductal cancer  lobular cancer  adenocarcinoma  and medullary cancer  the ductal cancer sample was further split into a premenopausal proband and a postmenopausal proband subset  results for six complex segregation analyses are presented  the findings suggest heterogeneity in the transmission of breast cancer  for all analyses  there was no evidence for a multifactorial component in the mixed model  ie  a major locus plus other transmission  genetic and or cultural  interpretation of the medullary cancer  adenocarcinoma  and lobular cancer analyses does not permit discrimination among the major locus models  segregation of breast cancer in the entire ductal sample was consistent with autosomal recessive transmission  in the ductal subanalyses  a recessive gene was sufficient to explain the breast cancer distribution when the proband had postmenopausal breast cancer  in contrast  when the proband had premenopausal breast cancer  the transmission model was consistent with a dominant major gene  with sporadic cases of disease  
class4	results of stereotactic brachytherapy used in the initial management of patients with glioblastoma  recent studies have shown a survival benefit for patients with recurrent glioblastomas treated with stereotactic brachytherapy  on the basis of these encouraging results  we began a prospective study in 1987 to evaluate the use of brachytherapy in patients with newly diagnosed glioblastoma  patients were considered eligible for this study if they met the following criteria  karnofsky performance status 70  or greater  tumor size not greater than 5 cm in any dimension  a radiographically well delineated  supratentorial lesion not involving the ependymal surfaces  and pathologically confirmed glioblastoma  we treated 35 such patients between 1987 and 1990 with stereotactic brachytherapy as part of their initial therapy  the treatment protocol involved surgery  partial brain external beam radiotherapy  59 4 gy in 33 fractions   and stereotactic brachytherapy with temporary high activity iodine 125 sources giving an additional 50 gy to the tumor bed  chemotherapy was not used in the initial management of these 35 patients  to compare our results with those obtained in a matched control group  we identified 40 patients with glioblastoma treated with surgery and external radiotherapy  with or without chemotherapy  between 1977 and 1986 at our institution  these patients had clinical and radiographic characteristics that would have made them eligible for the brachytherapy protocol  survival rates at 1 and 2 years after diagnosis were 87  and 57   respectively  for patients receiving brachytherapy versus 40  and 12 5   respectively  for the controls  p less than  001   we conclude that stereotactic brachytherapy improves the survival of patients with glioblastoma when it can be incorporated into the initial treatment approach  unfortunately  only about one in four patients with glioblastoma are suitable candidates for brachytherapy at the time of initial presentation  
class4	lipolytic factors associated with murine and human cancer cachexia  we have identified a lipolytic factor in extracts of a cachexia inducing murine carcinoma  mac16  that shows characteristics of an acidic peptide and appears to be composed of three fractions of apparent molecular weights corresponding to 3 kd  1 5 kd  and 0 7 kd  as determined by exclusion chromatography  material with identical chromatographic and molecular weight characteristics was also present in the serum of patients with clinical cancer cachexia but absent from normal serum  even under conditions of starvation  the mac16 lipid factor  when injected into animals bearing the non cachexia inducing tumor mac13  was capable of inducing weight loss without a significant reduction in food intake  similar lipolytic material  although in lower concentration  was also found in the mac13 tumor extracts  these findings suggest that cachexia may arise from the enhanced expression of a lipolytic factor associated with tumor cells  
class4	effects of fudr on primary cultured colon carcinomas metastatic to the liver  hepatic arterial infusion of fluorodeoxyuridine  fudr  has demonstrated efficacy in the treatment of metastatic colorectal carcinoma of the liver  in this study  the direct cytotoxic effect of fudr was measured on ten metastatic and two primary site colorectal carcinomas in a primary culture assay system  overall  clinically achievable concentrations of fudr  0 4 to 4 microm  induced partial cell kill in 75  of tumors  including a greater than 50  reduction in viable tumor cell number in only two tumors and less than 50  in the remaining seven  total cell kill was not observed in any tumor  three tumors were resistant to these fudr concentrations  tumor sensitivity correlated with the size of the tumor growth fraction  increasing the exposure time to fudr from 3 to 7 days approximately doubled the magnitude of the response  5 flurouracil and cisplatin  at clinically achievable concentrations  were more toxic to metastatic tumor cells than fudr  because of the limited chemosensitivity of metastatic colorectal tumor cells to fudr in vitro  we postulate that other mechanisms besides direct cytotoxicity contribute to the clinical efficacy of fudr in vivo  
class4	recurrence of resected esophagogastric adenocarcinoma  results of re resection  isolated local recurrence following potentially curative resection for carcinoma of the esophagus or esophagogastric junction does not necessarily imply pending systemic disease and early demise  while radiation alone or in combination with chemotherapy is standard treatment for such patients  resection is another available option  resection may also be a consideration should localized disease persist after non operative therapy in the absence of metastases  a 5 year retrospective review was performed examining 204 resections performed prior to 1989  only 5 patients underwent resection of locally recurrent esophagogastric  eg  adenocarcinoma during this period  no squamous carcinoma recurrences were resected  one patient is well 15 months later while another died at 18 months of other causes without recurrence  recurrence after re resection occurred at 8  11  and 24 months in the 3 other patients  although there were no postoperative deaths  major complications occurred in 4 patients  all 5 patients swallowed normally after operation  
class4	cryoprobe as a  handle  for resection of metastatic liver tumors  resection of metastatic liver tumors can be a difficult and risky procedure  using a cryoprobe as a  handle  can greatly facilitate resection by providing a taut surface for transection and improving visualization of ductal and vascular structures  in addition  this technique may decrease the risk of contaminating surrounding tissues with cancer cells  and may inhibit tumor recurrence within the margins of resection  
class4	extended neck dissection  from the time crile described radical neck dissection in 1906  this surgical procedure became popular in the management of metastatic cancer in the neck  over the past two decades  the modified neck dissection has been effectively utilized for conservation of function and cosmesis while achieving the same oncologic goals  however  there are several instances where the above standard procedures are not adequate for resection of malignant tumors  although there is a definite trend toward conservation procedures  extended neck dissection is often necessary especially in patients with n2 and n3 disease  apart from the standard structures removed in radical neck dissection  the other structures removed in extended neck dissection include skin  the digastric muscle  hypoglossal nerve  vagus nerve  sympathetic chain  ramus mandibularis  carotid artery  tracheo esophageal nodes  etc  over the past seven years  we have performed 40 extended neck dissections  all the patients had n2 or n3 disease in the neck  nine patients had unknown primaries  thirteen patients had their primary tumors in the oral cavity and 11 in the laryngopharynx  five patients had primary tumor in the salivary glands and two patients had metastatic melanoma  patients who underwent extensive skin excision had pectoralis myocutaneous flap reconstruction  all patients received postoperative radiation therapy  one patient died of cardiac problems 4 weeks after operation  local control was achieved in 70   the most difficult region for local control was the disease behind the mastoid process  and the most difficult problems were patients with involvement of the subdermal lymphatics  our data suggests that there are definite situations where extended neck dissection is indicated with satisfactory local control of the nodal disease  
class4	immune competent cells of regional lymph nodes in colorectal cancer patients  ii  immunohistochemical analysis of leu 7  cells  distribution of leu 7  cells in cancer tissues and regional lymph nodes was immunohistochemically examined to estimate the role of nk cells in colorectal cancer patients  leu 7  cells were rarely observed both in the primary and distant metastatic lesions  but the number of these cells was large in the germinal center of the lymph nodes  studies of leu 7  cell population in the lymph node indicated that intermediate nodes in n0 and n1 groups showed significantly higher values than those in the control group  comparative study of the population in identical patients revealed a significantly higher rate in the intermediate nodes than in the paracolic nodes both in n0 and n1 groups  these data suggest that leu 7  cells might be related to the defense mechanism of regional lymph nodes against tumor  
class4	gamma detecting probe and autoradiographic studies of radiolabeled antibody b72 3 in cx 1 colon xenografts  nude mice bearing cx 1 colon tumors were injected with 50 microci 125i labeled monoclonal antibody  mab  b72 3  radioactivity in tumors was studied with the gamma detecting probe  gdp  on days 1  3  7  and 10 after mab injection  on each day  two mice were sacrificed and sections were examined with autoradiography  arg   immunoperoxidase methods  imp   and routine stains  mean probe counts showed increasing tumor to background ratios and arg demonstrated a progressive increase in radionuclide in the tumors  the distribution of 125i was primarily around the vascular spaces on day 1  but by day 3 and progressively it appeared in tumor gland lumina and necrotic areas  a regional correlation was shown between radionuclide in vascular spaces and its sequestration in tumor elements  
class4	surgical wound infection and cancer among the elderly  a case control study  surgical wound infection occurs in fewer than 5  of operations  nevertheless  it represents the second most common type of hospital acquired infection and results in increased morbidity and mortality  as with all nosocomial infections  the rate of surgical wound infection increases with age  patients over 65 years of age run an approximately 15  risk of surgical wound infection  two thirds of patients with invasive cancer other than non melanotic skin cancer are aged 65 years and over  over half of them are treated surgically for their cancer  cancer and other chronic diseases have been cited as possible causes of the increased risk of nosocomial infection among the elderly  using the foothills hospital wound study data base as the sampling frame  we conducted a case control study of surgical wound infection and cancer among the elderly  cancer was found not to be a risk factor for surgical wound infection  the results are discussed in relation to the role of immunity in both disorders  
class4	long survival and prognostic factors in hepatocellular carcinoma  we studied survival and prognostic factors in all cases of hepatocellular carcinoma seen at a midwestern teaching hospital from 1947 through 1986  of the 70 cases  56 were diagnosed during life and 14 at autopsy  there were 47 males and 23 females with age at diagnosis ranging from 14 to 88  median survival for the 56 patients diagnosed during life was 106 days  only 11 patients lived longer than one year  two patients were long survivors and presumed cured  one living 27 years after diagnosis and surgical treatment and the other 19 years  cox regression model showed young age at diagnosis and low stage of disease at diagnosis to be significant predictors of long survival  white patients survived nearly twice as long as black patients but the difference was not significant  gender and year of diagnosis did not appear to be important determinants of survival  pathologic material was still available for one of the two long survivors and the histology was that of fibrolamellar carcinoma of young adults  
class4	carcinoid tumors  the authors carried out a retrospective study of 32 patients  23 m  9 f  with carcinoid tumors who were diagnosed and treated at harlem hospital center  new york  from 1967 to 1988  all the patients were black and the commonest sites were the ileum  28 1    rectosigmoid and rectum  21 9    and the appendix and lung  15 6  each   metastasis correlated with site  size  and depth of the primary tumor and occurred in 12 patients  38    most frequently to the regional lymph nodes and liver  carcinoid syndrome developed in 12 5   3 f  1 m   surgical resection for cure or palliation was the mainstay of treatment  overall 5 year survival rate was 66   and for those with metastases was 0   the poorer survival rates are probably related to the socioeconomic status of our patient population  the only observed racial difference compared to other series is the preponderance of males  and the disproportionately higher ratio of females with the carcinoid syndrome  
class4	symptomatic pericardial effusion in breast cancer patients  the role of fluid cytology  clinical and cytologic findings in 21 breast cancer patients with symptomatic pericardial effusion are presented  the etiology of the pericardial effusion was definitely malignant  by cytology histology in 13 patients  62    and suspected malignant by cytology in 2 patients  9    one patient  5   with definitely nonmalignant pericardial effusion by cytology was found to be histologically positive at autopsy  in 5 patients  24   there was no histological cytological evidence of malignancy  radiation pericarditis could be the etiology in 4 of these 5 patients  the median time from the diagnosis of breast cancer to the development of symptomatic pericardial effusion was 60 months  range  1 219 months   ten patients developed cardiac tamponade  they were treated by either pericardiocentesis or pericardiectomy  the mean survival of patients with negative cytology histology was 12 months  patients with suspicious cytology had a mean survival of 9 months  patients with malignant effusion  treated by pericardiectomy  had a mean survival of 22 3 months  while patients with malignant pericardial effusion  who were not subjected to surgery  had a mean survival of 4 7 months  only  it is concluded that the etiology of symptomatic pericardial effusion in breast cancer patients is not always malignant  which emphasizes the role of fluid cytology in establishing definite diagnosis  the survival probability is a function of the extent of extracardiac disease  among patients with malignant pericardial effusion those selected for pericardiectomy have a longer than average survival  
class4	hemicorporectomy  a collective review  hemicorporectomy or translumbar amputation has been described as the most revolutionary of all operative procedures  frederick e  kredel  who first voiced the concept of the operation in 1950  referred to it as halfectomy  demonstration of his cadaver studies established the feasibility of the operation  amputation is effected through the lower lumbar area of the body  necessary life functions are preserved in the upper torso  kredel envisioned hemicorporectomy as a curative operation for locally advanced cancer  limited to the pelvis  not encompassable by standard operative intervention  additional indications are intractable decubitus ulcers with malignant change  particularly in paraplegics  pelvic organs  and bone infection with nonhealing fistulae  and crushing trauma to the pelvis  the first hemicorporectomy operation was reported in 1960  thirty four operations have been recorded in the world literature  two heretofore unreported cases are added  raising the total to 36  review of these 36 cases confirms the conviction that hemicorporectomy is a humane and ethical alternative to the suffering encumbered by advancing  painful  malodorous malignant disease not treatable by conventional means  while cure rates are not substantial  the best results are reported in paraplegics with intractable decubitus ulcers with or without malignancy  rehabilitation is prolonged and costly  most survivors have been restored to preoperative occupations or other gainful employment  
class4	the use of interferon alpha c in patients with metastatic renal cell carcinoma arising in a congenital solitary kidney  three cases of renal cell carcinoma in a congenital solitary kidney are presented  treatment with recombinant interferon alpha c was administered in two cases  a subjective response occurred in one case  the literature is reviewed with respect to treatment options and prognostic factors  
class4	community lifestyle characteristics and risk of acute lymphoblastic leukaemia in children  high rates of leukaemia in children and young people have been associated with features of community isolation and population growth  incidence data collected by two specialist registries were used to compare incidence rates at ward level with relevant ward characteristics derived from routine census and ordnance survey data for england and wales  an excess risk of childhood acute lymphoblastic leukaemia  all  was found for wards which are farthest from large urban centres  the excess was greatest for wards of higher socioeconomic status and for children aged 1 7 years  the childhood peak   for which a two fold excess was seen  these findings in general support the hypothesis that childhood leukaemia has an infectious aetiology  
class4	matched group study of surgical resection versus cobalt 60 plaque radiotherapy for primary choroidal or ciliary body melanoma  we report the results of a nonrandomized  matched group  survival and visual preservation study of patients with a choroidal or ciliary body melanoma managed by microsurgical resection of the tumor versus cobalt 60 episcleral plaque radiotherapy  each treatment group consisted of 30 patients  all patients were matched on a case by case basis in terms of tumor size  largest linear tumor dimension   location of the anterior tumor margin relative to the ora serrata  location of the posterior tumor margin relative to the equator  and age at the time of treatment  although the estimated actuarial 5 year survival probability was slightly greater in the resection group  85 2   than in the cobalt plaque group  81 8    this difference was neither clinically impressive nor statistically significant  in contrast  there was a substantially higher rate of early posttreatment severe visual loss in the resection group  p    0008  mantel haenszel test   
class4	interleukin 2 immunotherapy in children  immunotherapy with interleukin  il  2 possesses great potential in the treatment of immune mediated diseases and cancers  however  only a few reports on a small number of children have appeared in the literature  from march 1988 to march 1989  11 children and adolescents were treated with il 2  they included 1 patient with hepatocellular carcinoma  1 with hepatoblastoma  6 with childhood atopic dermatitis  and 3 with juvenile rheumatoid arthritis  the dosages ranged from 10 000 to 50 000 u kg every 8 hours by intravenous drip  the following side effects were observed  anorexia  fever  and chillness  100    general malaise  82    irritability  64    diarrhea  100    nausea and vomiting  73    weight gain  82    edema  82    abdominal distension  73    oliguria  82    cough  91    dyspnea  27    pleural effusion  40    hypotension  82    skin eruption  82    oral ulcer  18    enlarged liver  73   liver function abnormalities  82    renal function impairment  36    electrolyte imbalance  73    anemia  91    thrombocytopenia  54    leukopenia  18    and eosinophilia  73    immunologically  numbers of natural killer cells were increased and natural killer and lymphokine activated killer cell activities were augmented after il 2 treatment  there was a tendency for serum levels of il 2 and receptor il 2 to decrease  especially in patients with atopic eczema  ten patients  91   completed one course  9 to 12 days  of therapy  and the remaining patient interrupted the treatment because of intolerable adverse effects  clinically  complete remission for 3 months was obtained in 1 juvenile rheumatoid arthritis patient  transient improvement  2 to 6 weeks  in all atopic dermatitis patients  minor response in the hepatoblastoma patient  and no response in the patient with hepatocellular carcinoma  
class4	congenital abnormalities of the lymphatic system  a new clinical classification  the numerous clinical presentations of congenital abnormalities of the lymphatic system in children and the confusing terminology used to describe their pathologic diagnoses impede the physician s understanding of the condition  the clinical classification based on the actual symptoms of the congenital problems we have presented here should help the physician identify the specific abnormality and a potential treatment  future research should concentrate on the specific causes and the treatment of these congenital abnormalities  
class4	tissue specific transformation by epidermal growth factor receptor  a single point mutation within the atp binding pocket of the erbb product increases its intrinsic kinase activity and activates its sarcomagenic potential  avian c erbb is activated to a leukemia oncogene following truncation of its amino terminal  ligand binding domain by retroviral insertion  the insertionally activated transcripts encode protein products that have constitutive tyrosine kinase activity and that can induce erythro leukemia but not sarcomas  we have found that a single point mutation within the atp binding pocket of the tyrosine kinase domain in this truncated molecule can increase the ability of this oncogene to induce anchorage independent growth of fibroblasts in vitro and fibrosarcoma formation in vivo  associated with this increased transforming potential is a corresponding increase in the kinase activity of the mutant erbb protein product  the mutation  which converts a valine to isoleucine at position 157 of the insertionally activated c erbb product  is at a residue that is highly conserved within the protein kinase family  to our knowledge  this is the first demonstration of a point mutation in the atp binding pocket that activates a tyrosine kinase  
class4	v ha ras transgene abrogates the initiation step in mouse skin tumorigenesis  effects of phorbol esters and retinoic acid  experimental carcinogenesis has led to a concept that defines two discrete stages in the development of skin tumors   i  initiation  which is accomplished by using a mutagen that presumably activates a protooncogene  and  ii  promotion  which is a reversible process brought about most commonly by repeated application of phorbol esters  we have created a transgenic mouse strain that carries the activated v ha ras oncogene fused to the promoter of the mouse embryonic alpha like  zeta globin gene  unexpectedly  these animals developed papillomas at areas of epidermal abrasion and  because abrasion can also serve as a tumor promoting event in mutagen treated mouse skin  we tested these mice for their ability to respond to phorbol ester application  within 6 weeks virtually all treated carrier mice had developed multiple papillomas  some of which went on to develop squamous cell carcinomas and  more frequently  underlying sarcomas  we conclude that the oncogene  preinitiates  carrier mice  replacing the initiation mutagenesis step and immediately sensitizing them to the action of tumor promoters  in addition  treatment of the mice with retinoic acid dramatically delays  reduces  and often completely inhibits the appearance of promoter induced papillomas  this strain has use in screening tumor promoters and for assessing antitumor and antiproliferative agents  
class4	multisurface method of pattern separation for medical diagnosis applied to breast cytology  multisurface pattern separation is a mathematical method for distinguishing between elements of two pattern sets  each element of the pattern sets is comprised of various scalar observations  in this paper  we use the diagnosis of breast cytology to demonstrate the applicability of this method to medical diagnosis and decision making  each of 11 cytological characteristics of breast fine needle aspirates reported to differ between benign and malignant samples was graded 1 to 10 at the time of sample collection  nine characteristics were found to differ significantly between benign and malignant samples  mathematically  these values for each sample were represented by a point in a nine dimensional space of real variables  benign points were separated from malignant ones by planes determined by linear programming  correct separation was accomplished in 369 of 370 samples  201 benign and 169 malignant   in the one misclassified malignant case  the fine needle aspirate cytology was so definitely benign and the cytology of the excised cancer so definitely malignant that we believe the tumor was missed on aspiration  our mathematical method is applicable to other medical diagnostic and decision making problems  
class4	embryonic stem cell virus  a recombinant murine retrovirus with expression in embryonic stem cells  the expression of moloney murine leukemia virus and vectors derived from it is restricted in undifferentiated mouse embryonal carcinoma and embryonal stem  es  cells  we have developed a retroviral vector  the murine embryonic stem cell virus  mesv   that is active in embryonal carcinoma and es cells  mesv was derived from a retroviral mutant  pcc4 cell passaged myeloproliferative sarcoma virus  pcmv   expressed in embryonal carcinoma cells but not in es cells  the enhancer region of pcmv was shown to be functional in both cell types  but sequences within the 5  untranslated region of pcmv were found to restrict viral expression in es cells  replacement of this region by related sequences obtained from the dl 587rev retrovirus results in mesv  a modified pcmv virus that confers g418 resistance to fibroblasts and es cells with similar efficiencies  expression of mesv in es cells is mediated by transcriptional regulatory elements within the 5  long terminal repeat of the viral genome  
class4	glucocorticoids locally disrupt an array of positioned nucleosomes on the rat tyrosine aminotransferase promoter in hepatoma cells  transcriptional activation by steroid hormones is often associated with the appearance of a dnase i hypersensitive site resulting from a local alteration of the nucleoprotein structure of the promoter  for the mouse mammary tumor virus long terminal repeat  a viral promoter under glucocorticoid control  a model has been proposed  the appearance of the hormonodependent dnase i hypersensitive site reflects the displacement of a single precisely positioned nucleosome associated with the glucocorticoid responsive elements  to determine if such a mechanism is of general relevance in transcriptional activation by steroid hormones  we have investigated the nucleosomal organization of the rat tyrosine aminotransferase promoter over a 1 kilobase region that contains the glucocorticoid regulatory target  this region displays a hormonodependent dnase i hypersensitive site  in the absence of hormone  micrococcal nuclease digestion of nuclei demonstrates the presence of positioned nucleosomes  with cutting sites centered around positions  3080   2900   2700   2800   2255  and  2040  treatment of the cells with dexamethasone induces a disruption of the chromatin structure over a relatively short stretch of dna  approximately positions  2400 to  2650  that overlaps two nucleosomes  these observations suggest a strong similarity in the role of chromatin structure in glucocorticoid dependent transcriptional activation of mouse mammary tumor virus and tyrosine aminotransferase promoters  
class4	mapping chromosome band 11q23 in human acute leukemia with biotinylated probes  identification of 11q23 translocation breakpoints with a yeast artificial chromosome  translocations involving chromosome 11  band q23  are frequent recurring abnormalities in human acute lymphoblastic and acute myeloid leukemia  we used 19 biotin labeled probes derived from genes and anonymous cosmids for hybridization to metaphase chromosomes from leukemia cells that contained four translocations involving band 11q23  t 4 11  q21 q23   t 6 11  q27 q23   t 9 11  p22 q23   and t 11 19  q23 p13   the location of the cosmid probes relative to the breakpoint in 11q23 was the same in all translocations  of the cosmid clones containing known genes  cd3d was proximal and pbgd  thy1  srpr  and ets1 were distal to the breakpoint on 11q23  hybridization of genomic dna from a yeast clone containing yeast artificial chromosomes  yacs   that carry 320 kilobases  kb  of human dna including cd3d and cd3g genes  showed that the yacs were split in all four translocations  these results indicate that the breakpoint at 11q23 in each of these translocations occurs within the 320 kb encompassed by these yacs  whether the breakpoint within the yacs is precisely the same in the different translocations is presently unknown  
class4	vaccination against tumor cells expressing breast cancer epithelial tumor antigen  ninety one percent of breast tumors aberrantly express an epithelial tumor antigen  eta  identified by monoclonal antibody h23  vaccinia virus recombinants expressing tumor antigens have considerable promise in the active immunotherapy of cancer  and we have evaluated the potential of vaccinia recombinants expressing the secreted  s  and cell associated  transmembrane  t  forms of h23 eta to elicit immunity to tumor cells expressing eta  tumorigenic ras transformed fischer rat fibroblast lines fr s and fr t  expressing the s or t form of h23 eta  respectively  were constructed for use in challenge experiments  expression of h23 eta in these lines was confirmed by western blotting and immunofluorescence  when challenged by subcutaneous seeding of tumor cells  97   fr s  and 91   fr t  of syngeneic fischer rats rapidly developed tumors that failed to regress  vaccination with recombinant vaccinia virus expressing eta t prior to challenge prevented tumor development in 82  of animals seeded with fr t cells but in only 61  of animals seeded with fr s  the vaccinia recombinant expressing the s form was a less effective immunogen  and vaccination protected only 29 30  of animals from developing tumors upon challenge with either fr s or  t cells  the increased immunogenicity of the recombinant expressing eta t was reflected in elevated levels of eta reactive antibody in vaccinated animals  confirming that secreted antigens expressed from vaccinia virus are less effective immunogens than their membrane associated counterparts  
class4	recognition by elam 1 of the sialyl lex determinant on myeloid and tumor cells  endothelial leukocyte adhesion molecule 1  elam 1  is an endothelial cell adhesion molecule that allows myeloid cells to attach to the walls of blood vessels adjacent to sites of inflammation  elam 1 recognizes the sialyl lewis x  sialyl lex  determinant  neuac alpha 2 3gal beta 1 4 fuc alpha 1 3 glcnac   a granulocyte carbohydrate also found on the surface of some tumor cell lines  binding of myeloid cells to soluble elam 1 is inhibited by a monoclonal antibody recognizing sialyl lex or by proteins bearing sialyl lex  some of which may participate in humoral regulation of myeloid cell adhesion  stimulated granulocytes also release an inhibitor of elam 1 binding that can be selectively adsorbed by monoclonal antibody to sialyl lex  
class4	head and neck paragangliomas  a clinicopathologic study with dna flow cytometric analysis  a total of 11 head and neck paragangliomas were the subject of pathologic study  including histologic  immunohistochemical  and dna flow cytometric analyses  we cannot absolutely predict aggressive clinical behavior using histologic parameters alone  but we can use such parameters to segregate patients into low risk and high risk groups  several trends were observed in the current study  tumors with higher s phase fractions  g2 m fractions  or aneuploid cell populations tended to behave  aggressively   the presence of sustentacular cells in the primary tumors cannot be used as an absolute indicator of tumor metastatic potential  as two metastatic paragangliomas in this study contained sustentacular cells in both the primary and metastatic lesions  dna ploidy status cannot be used as an absolute prognostic parameter as the two metastatic tumors were composed of diploid primary and metastatic lesions  the three tumors with aneuploid cell populations showed  aggressive  histologic and clinical features  but the length of the follow up period for these cases is too limited to draw any conclusions  although no absolute criteria can be used at present to gauge aggressiveness  close follow up of these patients is essential  especially if pathologic findings suggest an  aggressive  course  ie   malignant  histology  higher s phase fractions  g2 m fractions  aneuploid cell populations  or decreased sustentacular cell density   
class4	breast cancer  the military s experience at wilford hall usaf medical center  we reviewed the experience with breast cancer at wilford hall usaf medical center for the years 1978 through 1988  a total of 868 cases were identified in the wilford hall tumor registry  overall 5 year and 10 year survivals were 63  and 39   respectively  infiltrating ductal carcinoma represented the principal histologic category  the other predominant variants included invasive lobular carcinoma  lobular carcinoma in situ  and ductal carcinoma in situ  until recently  most of these patients  90   had modified radical mastectomy as their definitive surgical therapy  with chemotherapy reserved primarily for patients with advanced disease  
class4	pheochromocytoma and acute myocardial infarction  when a pheochromocytoma is manifested as an acute myocardial illness  diagnosis may be difficult to make  if the tumor is suspected early enough  a workup can be done while the complications of the myocardial illness are being controlled  as in our case   the tumor can then be expeditiously removed before any further problems develop  the case presented here underscores the importance of maintaining a high index of suspicion for a pheochromocytoma in any patient who has an unexpected myocardial event  
class4	endometriosis of the abdominal wall  endometriosis of the abdominal wall typically occurs as a painful mass in a lower abdominal incision from previous cesarean section or hysterectomy  most patients are young and in their active reproductive years  the histologic diagnosis requires a combination of either endometrial like glands  endometrial stroma  or hemosiderin pigment  the diagnosis must be considered in any woman with an abdominal wall mass and a history of transabdominal gynecologic surgery  wide excision offers the best chance to prevent recurrence  
class4	unilateral hydrocephalus in adults  the authors report 14 cases of unilateral hydrocephalus in adults  headache was the most common presenting symptom  unilateral hydrocephalus was documented in each patient with computed tomography scans  magnetic resonance imaging was also used in seven patients in the latter part of the series  unilateral hydrocephalus was caused by tumor  seven patients   venous angioma  one patient   ependymal cyst  one patient   postinflammatory gliosis  one patient   and was idiopathic in four patients  the primary surgical treatment was craniotomy with fenestration of the septum pellucidum  which relieved symptoms in eight of nine patients for whom long term follow up data were available  
class4	pedunculated giant lipoma of the esophagus  a patient with a giant lipoma of the esophagus presented with progressive dysphagia and odynophagia  fever  and recurrent melena  two years previously  when the symptoms were less pronounced  it had been misdiagnosed as achalasia  after surgical removal of the lipoma  the patient became symptom free  
class4	peritoneal mesothelioma  an unusual cause of esophageal achalasia  secondary esophageal achalasia due to malignancy is a rare condition  only 53 such cases have been reported to date  sixty two percent of the cases were due to gastric adenocarcinoma  mesothelioma of the peritoneum is an uncommon neoplasm  the usual presenting symptoms are abdominal pain  abdominal mass  or abdominal distention  the patient we are reporting had peritoneal mesothelioma which presented with dysphagia and weight loss  in addition to the radiological and manometric picture of achalasia  secondary achalasia was suspected clinically  and was confirmed by computed tomography and laparotomy  the diagnosis of peritoneal mesothelioma was made only by histopathological examination  we are not aware of any other report documenting the association of peritoneal mesothelioma and achalasia  
class4	multifocal gastric carcinoma arising from hyperplastic and adenomatous polyps  this paper is a presentation of the unusual case of a 61 yr old woman operated on for multiple gastric cancers  two of the cancers were found in the hyperplastic polyps and one in the adenoma  apart from cancers that arose from these polyps  there were four separate polypoid or flat gastric carcinomas and three other hyperplastic polyps with no signs of malignancy  in this case  the presentation is followed by a detailed discussion focusing on the possible development of carcinoma in gastric hyperplastic polyps in view of the data from the literature  
class4	synchronous diffuse well differentiated lymphocytic lymphoma and gastric adenocarcinoma presenting as splenomegaly and iron deficiency anemia  diffuse well differentiated lymphocytic lymphoma  d wdll  and chronic lymphocytic lymphoma  cll  represent closely related neoplasms which may have indolent courses  dating back more than one century  reports of associated second primary malignancies continue to intrigue clinicians  a case of synchronous d wdll and gastric adenocarcinoma  presenting as splenomegaly and iron deficiency anemia  is presented  the case and literature are reviewed  
class4	primary leiomyoma of the liver  a 30 yr old woman with right upper quadrant abdominal pain was found to have a hepatic leiomyoma  this is the youngest patient in whom this rare tumor has been found  the diagnostic approach toward gastrointestinal leiomyomata is emphasized  including the role of immunohistochemistry  
class4	liver abscess complicating intratumoral ethanol injection therapy for hcc  we report a patient who developed multiple liver abscesses and sepsis caused by lactobacilli after the percutaneous intratumoral injection of ethanol for hepatocellular carcinoma  we diagnosed the liver abscess at an early stage because of a the finding of gas on ultrasound and computed tomography  blood cultures grew gram positive rods  which were of the lactobacillus species  the patient responded to the administration of antibiotics  and his hepatic tumors have not recurred in the 7 months since treatment  this is the first report of liver abscess following percutaneous ethanol injection therapy  
class4	failure to limit quantities of benzodiazepine hypnotic drugs for outpatients  placing the elderly at risk  purpose  the long term use of benzodiazepine hypnotics by the elderly is associated with serious side effects  and prescriptions of large quantities of these agents allow such use  therefore  we determined the quantities of these agents prescribed to outpatients in our veterans administration teaching hospital  and the relationship of patient age to total number of doses prescribed per prescription  patients and methods  pharmacy and patient records related to 655 consecutive prescriptions for triazolam  halcion  and flurazepam  dalmane  were reviewed  only 266  41   of the prescriptions were for 30 or fewer doses  while 178  27   were written for 180 or more doses  results  thirty six percent of prescriptions for patients aged 65 years or older were for 180 or more doses  compared with 24  for those aged 45 to 64 years old  and 16  of the prescriptions for patients less than 45 years old  p less than 0 0001   in a multivariate analysis controlling for six other factors related to the total number of doses prescribed  patients aged 65 years or older were still more likely to receive a prescription for 180 or more doses  relative risk 1 9  95  confidence interval 1 3  2 8   conclusion  we conclude that inappropriately large quantities of benzodiazepine hypnotics were commonly prescribed  and that patients aged 65 years or older were at greatest risk for receiving such prescriptions  
class4	lack of correlation of clinical breast examination with high risk histopathology  purpose  routine breast examination frequently finds differences in palpable density and palpable nodularity  but it is not known if these differences correlate with the presence of high risk histopathology  patients and methods  to test for a relationship between clinical breast examination and histopathology  we devised separate  4 point scales of clinical density and nodularity and validated these scales by repeat examinations 4 or more months apart in 199 separate breasts  the scale was the same or within 1 point on repeat examination 87  of the time for density and 90  for nodularity   we then used these two clinical scales to compare density and nodularity to histopathology of breast tissue at the margins of segmental resections in 60 women undergoing breast conserving treatment of primary breast cancer  in cases such as these  a large sample of  normal  tissue is intentionally removed when the wide excision is done to obtain negative margins  histopathology at the margins was graded according to the consensus panel of the american college of pathology  as might be expected in women with previous cancer  some higher risk histopathology was found in 37  of cases  a relationship was sought using spearman s rank correlation coefficient  results  neither clinical breast density  rho   0 16  nor clinical breast nodularity  rho   0 01  related to the presence of high risk histopathology in the underlying tissue  interestingly  breast nodularity increased with age  rho   0 28   and clinical density and nodularity were inversely related  rho    0 28   conclusion  we conclude that neither clinical breast density nor nodularity correlates with histopathology and that it is unlikely that a larger study would find a clinically useful correlation  therefore  a clinical examination should not be used to decide that high risk histopathology is likely to be present in an individual woman s breast  
class4	role of systemic therapy in advanced non small cell lung cancer  increasing evidence supports the investigation of chemotherapy in patients with non small cell lung cancer  nsclc   randomized studies in patients with stage iv disease have shown increased survival in chemotherapy treated patients compared to best supportive care and indicate the ability of chemotherapy to alter the natural history of this disease  randomized studies involving adjuvant and neoadjuvant chemotherapy have also shown encouraging results  these studies and results of recent pilot studies utilizing neoadjuvant chemotherapy and concomitant chemoradiotherapy indicate a potential benefit from the use of chemotherapy in patients with nsclc and call for its continued intensive investigation in clinical trials  
class4	the role of attitudes  beliefs  and personal characteristics of italian physicians in the surgical treatment of early breast cancer  the influence of italian physicians  attitudes  beliefs  and personal characteristics on medical decision making is examined in the case of surgical treatment of early breast cancer  responses to a mail survey of 657 physicians from different specialties were analyzed comparing doctors recommending a radical procedure  9   to those preferring a conservative procedure for younger patients only  25    and those considering conservative surgery the treatment of choice regardless of patients  age  66    the findings suggest that the likelihood of physicians  preferring a conservative procedure is influenced by their specialty and the extent to which they feel that a patient should have a role in the treatment decision more than by differences in the beliefs of treatment outcomes  only preferences of the small group indicating radical surgery as the sole admissible treatment can be accounted for by ignorance or distrust of results of recent trials  these findings suggest that other than scientific factors guide many doctors in their decision making  they may help to explain why the diffusion of research results into clinical practice is often disappointingly slow  
class4	characteristics of duodenal wall gastrinomas  fifteen patients with duodenal wall gastrinomas  dwgs  and the zollinger ellison syndrome have been treated since 1960  in 6 of 11 patients  dwgs were recognized at operation and totally excised  in four patients  the tumor was subsequently found in the proximal duodenum of the surgical specimens  in 12 patients  dwgs were single and lymph node metastases were present in 8  in three patients  dwgs were multiple and lymph node metastases were present in two  all dwgs were submucosal and all were located in the first or second portions of the duodenum except one found in the fourth portion  tumor size ranged from 1 to 15 mm  and nine were less than 5 mm  of 12 patients with single dwgs  9 have remained eugastrinemic after resection  mean follow up  5 5 years   none of the patients with multiple dwgs became eugastrinemic after surgery  dwgs are characteristically single  small or microscopic  submucosal  located in the proximal duodenum  rarely metastasize to the liver  and are usually curable by surgical resection  
class4	glucagonoma syndrome is an underdiagnosed clinical entity  glucagonomas  considered among the rarest of the islet cell neoplasms  produce a well defined clinical syndrome characterized by necrolytic migratory erythema  diabetes mellitus  glossitis  anemia  and weight loss  this report describes seven patients with glucagonoma treated at our institution  all seven had the characteristic dermatologic manifestations  present from 1 to 6 years prior to diagnosis  five patients had extensive disease at the time of initial operation  three of whom underwent aggressive cytoreductive surgery  whereas the other two had biopsy only  the remaining two patients presented with a single nodule each  underwent distal pancreatectomy and splenectomy  and remain free of disease 2 and 6 years postoperatively  earlier recognition of the distinctive physical findings peculiar to this syndrome should increase survival  aggressive cytoreductive surgery results in prolonged remission  
class4	perioperative blood transfusion adversely affects prognosis of patients with stage i non small cell lung cancer  it has been speculated that blood transfusion might adversely affect prognosis in cancer patients by immunosuppression  to avoid the confounding affect of advanced disease  we tested this hypothesis in 117 patients with stage i non small cell lung cancer  mean and median follow up were 49 7 months and 47 months  respectively  patients who died during the postoperative period were not included  perioperative transfusion was defined as administration of whole blood or packed cells within 30 days of operation  the overall cumulative 5 year disease free survival rate was 67   in patients with transfusion  it was 53  and in patients without transfusion it was 81   p   0 0055   a multivariate analysis was performed that included patient age  race  sex  cell type  extent of operation  pneumonectomy versus lobectomy segmentectomy   operative blood loss  admission hematocrit  discharge hematocrit  and the presence or absence of perioperative transfusion  the only variable that significantly correlated with 5 year disease free survival was the presence or absence of perioperative transfusion  p   0 0278   and this effect was not related to the number of transfusions  retrospective analysis of long term results of patients surviving curative operation for stage i lung cancer shows that any perioperative transfusion significantly worsens the patient s prognosis and suggests very strongly that this association is due to an adverse effect of the transfusion rather than the transfusion serving as a marker for another risk factor  
class4	continent ileocolonic urinary reservoirs for filling and lining the post exenteration pelvis  pelvic exenteration has a high complication rate due  in large part  to the extensive raw surfaces and dead space it creates  numerous techniques have been used to control this space and line these surfaces  but none  to date  has proven to be a reliable solution  we investigated the use of continent ileocolonic urinary reservoirs as a new  flap  to fill and line the pelvis in 17 patients  and found that our historical complication rate of 44  for pelvic exenteration was reduced to 18   these reservoirs appear to be an improved method of managing the post exenteration pelvis  
class4	selective nonoperative management of patients referred with abnormal mammograms  screening mammography provides a means of detecting clinically occult breast carcinoma  but the question of whether all abnormal mammograms require biopsy remains unanswered  we retrospectively reviewed records of 214 women referred over an 8 year period for abnormal mammograms  they were selectively assigned to biopsy or mammographic follow up based on specific mammographic criteria  of 114 women initially observed mammographically  2 were later found by biopsy to have carcinoma  initial assignment to mammographic observation delayed the recommendation for biopsy 3 and 12 months  respectively  in these patients  but no effect on outcome was documented  because they have benign lesions by clinical and mammographic criteria  102 women  53   have been spared biopsy  they continue to be monitored closely  we believe these data support the use of a selective approach to biopsy based on specific mammographic criteria  
class4	when is polypectomy sufficient treatment for colorectal cancer in a polyp  eighty seven patients with a carcinoma in a polyp were reviewed over a 12 year period  ten histologic criteria were analyzed for an association with the presence of residual carcinoma  four factors were identified as having prognostic value  size greater than 1 5 cm  sessility  cancer of at least 50  of the adenoma volume  and invasive carcinoma  polypectomy alone is adequate treatment unless the carcinoma invades deeper to the muscularis mucosa and is associated with one or more of these characteristics  
class4	multimodal therapy in locally advanced breast carcinoma  among 879 patients treated for breast cancer between 1975 and 1984  advanced disease was found in 125  14    a subgroup of 34  4   presented with untreated locally advanced disease without demonstrable distant metastases at the time of diagnosis  stage iiib   t4abed  nx 2 mo   during the first 5 years  1975 through 1979   17 patients were treated primarily with sequential radiotherapy and chemotherapy  group a   from 1980 to 1984  group b   the management consisted of four courses of induction multi drug chemotherapy followed primarily by mastectomy and additional chemotherapy  the mean follow up for the most recent group  group b  is 48 months  follow up was complete  while the local disease control rate was the same for both groups  76    the survival was remarkably different  group a patients experienced a median survival of 15 months  and only one survived 5 years  in group b  the median survival was 56 months with nine patients  53   alive between 40 and 76 months  seven  41   of whom are 5 year survivors  while the overall mortality of patients with inflammatory breast cancer was greater in both groups when compared with the group with noninflammatory disease  the survival of patients in group b was better than in group a for both inflammatory and noninflammatory cancers  p less than 0 01   estrogen receptor  nodal  and menopausal status did not influence survival  these data suggest that neoadjuvant chemotherapy improves survival for patients with stage iiib breast carcinoma and delays the establishment or progression of distant metastases  mastectomy is an important component in the treatment of this disease  
class4	outpatient percutaneous central venous access in cancer patients  a 1 year experience of percutaneous subclavian catheterization in outpatients with cancer was reviewed to document reliability  safety  and cost  there were 763 catheter insertions attempted with prospective documentation of complications in 664 consecutive patients  catheter insertion was successful in 722 attempts  95    there were only 13 pneumothoraces  2    thirty catheters required repositioning  4    the average catheter duration was 191 days  range  0 to 892 days   fifty six catheters  8   were removed because of suspected infection  documented catheter sepsis occurred in 21 patients  3    catheter site infection occurred in 8 patients  1    thus  only 0 22 infections per catheter year occurred during this 382 catheter year experience  the estimated cost of catheter insertion was  562  which is one third the estimated cost for tunneled catheters   1 403  and for reservoir devices   1 738   in our experience  percutaneous subclavian catheterization is a reliable  cost effective method compared with tunneled or reservoir devices  with an equivalent incidence of catheter related infections  the cornerstone of our success with this program is a staff dedicated to catheter care and intensive patient education  in centers where a large number of patients require central venous access  percutaneous catheterization should be the technique of choice  
class4	kaposi s sarcoma of the rectum in patients with the acquired immunodeficiency syndrome  we retrospectively reviewed eight patients with biopsy proven anorectal kaposi s sarcoma  ks  treated between 1984 and 1989 at san francisco general hospital  all patients were homosexual men with the acquired immunodeficiency syndrome  aids   the average age was 34 years  three patients had primary rectal ks without metastases  five patients had disseminated ks with lesions throughout the alimentary tract  viscera  skin  or local lymph nodes  three patients were treated with radiation or chemotherapy  five patients had disseminated ks with lesions throughout the alimentary tract  viscera  skin  or local lymph nodes  three patients were treated with radiation or chemotherapy  five patients with advanced aids received no specific treatment for anorectal ks  follow up ranged from 1 month to 5 years  three of the untreated patients and the three patients treated with chemotherapy or radiotherapy were alive 1 month to 5 years after diagnosis  aggressive surgical treatment of anorectal ks is not indicated  
class4	caesarean section in a patient with haemoglobin sc disease and a phaeochromocytoma  the anaesthetic management of a patient with haemoglobin sc disease for lower segment caesarean section and excision of a phaeochromocytoma is described  the patient was given a general anaesthetic for the surgical procedure after exchange transfusion had achieved an haemoglobin a concentration of greater than 50   a live infant was delivered and a suprarenal phaeochromocytoma was excised during a 6 5 hour procedure  the patient s postoperative recovery was uneventful  
class4	tyrosine kinase and control of cell proliferation  the usefulness of phosphotyrosine antibodies for the detection of physiologically regulated or deregulated tyrosine kinases is discussed in this report  this rather rare enzymatic activity is shared by receptors for some polypeptide growth factors and by the products of class 1 oncogenes  the antibodies are able to detect proteins phosphorylated on tyrosine in fibroblasts stimulated with growth factors such as egf and pdgf  the major phosphorylated protein species are the receptors themselves  which undergo phosphorylation only after the addition of the exogenous factor and only transiently  phosphotyrosine antibodies were able to detect the products of the retroviral class 1 oncogenes  which are endowed with deregulated tyrosine kinase activity  in fact  in these cases a constitutive phosphorylation of the relevant proteins was observed  which occurred continuously and independently of the presence or lack of exogenous ligands  a tyrosine kinase constitutively activated in human gastric carcinoma cells was detected by p tyr antibodies  this molecule has been characterized at the molecular level  and the mechanisms responsible for its enzymatic activation have been investigated  the question of whether the tyrosine kinase identified is responsible for the induction and the maintenance of the transformed phenotype in gastric carcinomas remains to be answered  it is reasonable to suggest that this might be the case by analogy with other situations such as class 1 oncogenes activated by transduction by retroviruses  abnormal expression of egf receptors  or deregulated activity of c abl encoded proteins in chronic myelogenous leukemia and acute lymphoblastic leukemia  thus  the search for deregulated kinases by means of phosphotyrosine antibodies seems to be useful for identifying new activated oncogenes in clinical oncology  
class4	gene amplification in human lung cancer  the myc family genes and other proto oncogenes and growth factor genes  the development of human lung cancer may require multiple genetic deletions affecting a number of chromosomes  e g   1  3  11  13  and 17  these genetic aberrations may induce the activation of proto oncogenes  c jun  ras  c raf1  and the loss of tumor suppressor genes  p53   some of the activated proto oncogenes and tumor suppressor genes are more selectively expressed or absent in small cell lung cancer  l myc  c myb  c scr  rb gene  or non small cell lung cancer  c erbb 2  c sis  c fes   these genes may thus be of importance for selection of differentiation pathway  the c myc oncogene is frequently amplified in small cell lung cancer cell lines in a much higher frequency than in vivo  this indicates that c myc seems to be related to tumor progression and a relatively late event in the lung cancer development  the uncontrolled production of multiple growth factors has been identified in human lung cancer cell lines  these factors can promote and inhibit the proliferation via paracrine and autocrine loops via specific receptors  the products from some of the activated proto oncogenes  c sis  c erbb 2  are sequences homologous to a certain growth factor  pdgf  and a receptor  egf  identified in lung cancer  the production and action of these growth factors may be of major importance for further activation of proto oncogenes via intracellular signal transduction and specific oncogenic activation leading to further tumor progression  
class4	the ras oncogenes in human lung cancer  the three well characterized genes of the ras gene family h ras  k ras  and n ras  code for closely related 21 kd proteins that have a role in the transduction of growth signals  the ras proteins acquire transforming potential when a point mutation in the gene leads to replacement of an amino acid in one of the critical positions 12  13  or 61  overexpression of the normal protein  usually associated with gene amplification  can have similar effects  the detection of mutationally activated ras genes has been facilitated by the development of oligonucleotide hybridization assays that allow the identification of each possible mutation at the critical sites  employment of the polymerase chain reaction has greatly increased the sensitivity of these assays  studies of human lung cancer have shown that adenocarcinoma is the only subtype associated with ras mutations  these occur in about 30  of primary tumors  in almost all cases  the mutation is present in codon 12 of the k ras gene  no mutations have been observed to date in tumors of nonsmokers  suggesting that the mutation may result from exposure to carcinogenic ingredients of tobacco smoke  amplifications of ras genes were shown to be very uncommon in clinically early stages of lung cancer  analysis of the clinical data of patients who were operated on for adenocarcinoma of the lung shows that k ras mutations are not associated with particular histologic characteristics of the tumors or with specific presenting features  patients with k ras mutations  however  had significantly worse survival than did those without an activation  
class4	progression through the cell cycle  an overview  tissues in adults can be maintained at constant mass or they can increase or decrease in size because of imbalances of synthetic and degradative processes acting at the cellular and molecular levels  some size changes are caused by physiologic conditions to which the tissue must adjust  alternatively  the balance may be distorted in favor of net tissue increase in pathologic situations such as cancer  strict regulatory mechanisms are required to keep proliferation responsive to the organism s needs  these mechanisms may be defective in disease  net tissue proliferation requires repeated rounds of cell duplication in excess of that necessary to counterbalance cell death  duplication of a cell requires a net doubling of its every molecule and structure  the myriad of molecular events required for cell proliferation such as dna duplication and its partitioning at mitosis are tightly regulated in normal cells  one may conceive of two classes of molecules  those required for  housekeeping   which constitute the cell s structural and functional machinery  and those such as growth factors  their receptors  and second messengers involved in signal transduction responsible for regulating the activities of the housekeeping molecules  these molecular events and the cascade of processes that control them can be organized within the sequence of the cell cycle  in this brief overview  we illustrate these issues with a few examples taken from very recent discoveries of novel proteins that appear to have major regulatory roles  most of these results have been obtained with mammalian fibroblasts  but some have originated with discoveries made using two very different yeasts  
class4	the beta type transforming growth factor  mediators of cell regulation in the lung  an increased interest in the role of growth factors in the regulation of processes concerning normal and pathologic lung physiology has spurred a flurry of research in this area  peptide growth factors are known to control not only cell proliferation but other events such as differentiation  chemotaxis  and matrix deposition as well  the transforming growth factor beta  tgf beta  family of regulatory peptides serves as a prime example to illustrate the multiplicity of effects elicited by peptide growth factors in various lung derived cell types  at present  the tgf beta family consists of at least 17 proteins and  based on sequence analysis  they can be divided into two groups  a cluster that shows very high sequence similarity to tgf beta 1  the closely related group  and a cluster that shows weaker sequence similarity to tgf beta 1  the distantly related group  the purpose of this brief review is to summarize the salient features of tgf beta structure and regulatory abilities of the closely related group  in addition  we will outline the evidence suggesting a role for tgf beta in normal lung development and physiology  emphasis will be placed on studies with the closely related members tgf beta 1 and tgf beta 2 because  until recently  purified protein was available only for these two proteins  
class4	genetic strategies of tumor suppression  the evaluation of the cancer cell is a complex multigene process  tumor suppressor genes that are lost or inactivated  as well as genes that are overexpressed  play key roles in tumor progression  the identification of overexpressed genes has been expedited by the presence of transforming genes in some animal retroviruses  however  tumor suppressor genes have been difficult to identify and isolate because of their loss or inactivation during tumorigenesis  by a variety of methods  summarized in this review  a few tumor suppressors have been cloned and characterized  and many more have been recognized indirectly  the general finding at this time is that the same tumor suppressors  and oncogenes  are found associated with many different tumors  that several different altered genes are found typically in the same tumors  and that other oncogenes and tumor suppressor genes seem to be characteristically altered in particular tumor types as well  functions of tumor suppressor genes include the control of normal cell activities such as proliferation and differentiation as well as senescence  which is a special kind of differentiation in which cells lose their ability to divide  the genetic basis of senescence and identification of genes involved in overcoming senescence  leading to immortalization  i e   indefinite growth potential   are important areas of current investigation  our laboratory is engaged in senescence immortalization studies as a result of our discovery that normal human mammary epithelial cells can be immortalized by dna of the human papilloma virus  these new studies are summarized here  
class4	cell to cell communication and the control of growth  growth of transformed cells is inhibited by cell to cell communication with normal cells  this communication is regulated by certain oncogenes that alone or in cooperation can block the communication  
class4	src expression in small cell lung carcinoma and other neuroendocrine malignancies  the proto oncogene c src codes for two tyrosine kinases  pp60c src and pp60c srcn  the latter protein appears to be exclusively expressed in neurons and neuronally differentiated tumors  in cell lines derived from neuroblastoma and small cell lung carcinoma  src expression correlates positively with neuroendocrine differentiation  however  pp60c srcn is expressed only in highly differentiated neuroblastomas  although c src expression in neuroendocrine tumors probably reflects and is the result of the differentiation stage at which the tumors have been arrested  high c src expression and kinase activities in non neuroectodermal tumors  e g   colon carcinoma  breast carcinoma  might instead be a part of the malignant phenotype and contribute to the development of these tumors  
class4	internists  practices in health promotion and disease prevention  a survey  objective  to estimate internists  use of disease prevention and health promotion activities  and to explore demographic  professional  behavioral  psychological  cognitive  and organizational factors associated with the use of such practices  design  mail survey  setting and subjects  a sample of 2610 members and fellows of the american college of physicians  acp  participated in the study  they engaged in patient care activities more than 20 hours per week and were stratified by gender and region  they lived in four geographic areas of the united states  northeast  southeast  central  and west   comprising 21 acp regions  measurements  a questionnaire requesting background information as well as information about personal health  record keeping  use of immunizations  pneumococcal  influenza  tetanus  hepatitis b   use of screening tests and procedures for detecting cancer  breast examination  papanicolaou smear  stool occult blood test  and other diseases  electrocardiograms  cholesterol level tests  chest radiographs   and behavioral counseling to promote health  in the areas of smoking  exercise  and alcohol and seat belt use   main results  internists used effective preventive interventions less frequently and ineffective practices more frequently than experts recommend  internists  use of health promotion and disease prevention activities is associated with habit  attitude  and a lack of adequate knowledge  younger physician age  general internal medicine practice  and personal health promotion and disease prevention practices were strongly associated with more appropriate use of recommended practices  p less than 0 01   conclusions  internists  use of disease prevention and health promotion activities falls short of expert recommendations  programs to improve the delivery of preventive services might be aimed at improving physicians  personal health practices  might be directed toward patients  and might include the development of effective systems to remind physicians  
class4	cerebrospinal fluid neopterin in human immunodeficiency virus type 1 infection  we evaluated cerebrospinal fluid  csf  concentrations of neopterin  a putative marker of activated macrophages  in 97 subjects infected with human immunodeficiency virus type 1 who had a spectrum of neurological complications  the highest csf neopterin concentrations occurred in those with neurological opportunistic infections  primary central nervous systems lymphoma  and acquired immunodeficiency syndrome  aids  dementia complex  in general  the csf concentration of neopterin was independent of csf cell count and blood brain barrier disruption to albumin  in the patients with aids dementia complex  csf neopterin concentrations correlated with severity of disease and decreased in conjunction with clinical improvement following treatment with zidovudine  these results suggest that csf neopterin  although not disease specific  may be useful as a surrogate marker for the presence of aids dementia complex and its response to antiviral therapy  
class4	lymphoproliferative disorders associated with carbamazepine  carbamazepine induced lymphoproliferative disorders are relatively rare  a 32 year old woman developed cervical lymphadenopathy while taking carbamazepine  histologic evaluation of the lymph node biopsy specimen demonstrated near total effacement of the nodal architecture by a population of pleomorphic immunoblasts  the predominant cell population expressed cd3  cd2  cd5  and cd4  while results of testing for cd8 were negative  on the basis of the morphologic and immunohistologic features  a diagnosis of high grade  non hodgkin s lymphoma  t cell immunoblastic type  was made  despite the fact that aggressive behavior is usually associated with immunoblastic lymphomas  the patient has done well for 33 months after cessation of carbamazepine in the absence of chemotherapeutic treatment  the clinical features of this patient s illness  therefore  suggest that it is best regarded as a so called pseudolymphoma  
class4	image cytophotometric dna analysis of atypical hyperplasias and intraductal carcinomas of the breast  with the use of image analysis  dna content was quantified on paraffin embedded tissue sections of 25 atypical hyperplasias and 35 intraductal carcinomas of the breast by comparison of integrated gray levels of feulgen stained control and ductal cell nuclei  the mean full peak  g0 g1  control cell dna histogram coefficient of variation was 5 5   dna aneuploidy was more common in intraductal carcinomas compared with atypical hyperplasias  71  of intraductal carcinomas vs 36  of atypical hyperplasias  and correlated with a lack of cytologic  nuclear  and architectural differentiation  63  moderate vs 93  poor and 38  cribriform vs 82  solid   in addition  multiple dna stemlines were observed in 40  of intraductal carcinomas  we conclude that  1  some atypical hyperplasias demonstrate abnormal dna content consistent with neoplastic transformation   2  aggressive forms of intraductal carcinoma are more frequently associated with dna content abnormalities  and  3  frequent dna stemline heterogeneity in intraductal carcinoma supports the hypothesis that multiple genetic events occur in the development of mammary intraepithelial neoplasia  
class4	enhanced expression of c myc and h ras oncogenes in letterer siwe disease  a sequential study using colorimetric in situ hybridization  tissues from two patients with disseminated histiocytosis x  letterer siwe disease  in which histiocytosis x cells exhibited histologic and cytologic features of malignancy were evaluated by in situ hybridization with the use of biotinylated nucleic acid probes to c myc and h ras oncogenes  enhanced expression of these oncogenes was observed in mononucleated and multinucleated cells of histiocytosis x in the terminal proliferative phase but not in the early quiescent phase of letterer siwe disease in both patients  our findings indicate that deregulation of c myc and h ras in histiocytosis x are late events that likely confer a selective growth advantage to histiocytosis x cells  
class4	lack of prognostic value of nucleolar organizer region enumeration in transitional cell carcinoma of the bladder  enumeration of silver stained nucleolar organizer regions is of limited use in grading transitional cell tumors of the bladder  we attempted in this article to establish whether or not such a technique would be helpful in predicting the prognosis of such tumors within rather than between grades  in the study population of 11 high grade transitional cell carcinomas of the bladder  no correlation was found between clinical outcome and mean nucleolar organizer region count  
class4	bilateral familial carotid body paragangliomas  report of a case with dna flow cytometric and cytogenetic analyses  a case study of bilateral familial carotid body paragangliomas with dna flow cytometric and cytogenetic analyses is presented  analysis of tumor cell nuclear dna content by flow cytometry revealed aneuploid cell populations in both tumors  standard cytogenetic analysis  giemsa banding technique used  of the right carotid body paraganglioma showed no evidence of numerical or structural abnormalities  we describe parameters currently used to  predict  biological behavior in these tumors  
class4	hepatic cyst associated with peutz jeghers syndrome  a solitary hepatic cyst  associated with peutz jeghers syndrome  is described  to our knowledge  this association has not been previously reported  a developmental anomaly or hamartomatous nature of this lesion is suggested  knowledge of this association may be helpful in the clinical diagnosis of this benign entity  
class4	soft tissue tumor with abnormal amianthoid collagen fibers  electron microscopic examination of a solitary soft tissue tumor from the face demonstrated large areas with abnormal amianthoid collagen fibers in the neoplasm  the lesion was classified as a benign neoplasm of myofibroblasts and tentatively named a myofibroblastoma  the significance of the amianthoid collagen fibers is unknown  normal native collagen fibers were found in some parts of the neoplasm  
class4	extramedullary hematopoiesis in a bronchial carcinoid tumor  an unusual complication of agnogenic myeloid metaplasia  a case of bronchial carcinoid tumor with foci of extramedullary hematopoiesis is presented  the patient had a 6 year history of agnogenic myeloid metaplasia and hepatosplenomegaly  all three hematopoietic cell lines were represented in different areas of the bronchial tumor  to our knowledge  this is the first case of extramedullary hematopoiesis described in a bronchial carcinoid and only the fourth report of hematopoietic cells in a neoplasm of otherwise unrelated origin  the pathogenesis of this uncommon finding is discussed and the literature is reviewed  
class4	cholangiocarcinoma in association with multiple biliary microhamartomas  the rarity of cholangiocarcinoma occurring in von meyenburg complexes is well appreciated  we describe the case of a 35 year old man found to have cholangiocarcinoma in association with multiple biliary microhamartomas of the liver  areas of ductal proliferation and atypia within the bile duct hamartomas suggest malignant transformation to cholangiocarcinoma  
class4	acquired childhood aphasia  outcome 1 year after onset  the effects of the variables age at onset  cause  severity and bilaterality of lesion  and type of aphasia on course and outcome were investigated in a group of 28 aphasic children  analysis of spontaneous speech and tests of auditory verbal comprehension were used to determine the presence of aphasia  the severity of the cerebral lesion was assessed using a rating scale for computed tomographic scans  most of the children had not recovered completely 1 year after onset  recovery was significantly different according to etiological categories  complete recovery was seen in the majority of traumatic cases  
class4	morphine induced transactivation of hiv 1 ltr in human neuroblastoma cells  infection by human immunodeficiency virus  hiv  is followed in many cases by a clinically quiescent or latent phase that appears to continue as long as host antiviral defense is intact  this has raised the possibility that certain host susceptibility factors  i e   environmental cofactors  might influence the progression of the disease  in this study we demonstrate that morphine can function to activate hiv ltr cat fusion gene  hiv long terminal repeat chloramphenicol acetyltransferase  when transfected into undifferentiated human sh sy5y neuroblastoma cells  the stimulatory effect of morphine is amplified in sh sy5y cells that have been induced to differentiate first with phorbol 12 myristate 13 acetate  pma  and is much less in cells differentiated with retinoic acid  ra   morphine does not appreciably activate hiv ltr cat expression in human molt 3 and other t cells  morphine activation of hiv ltr cat in the sh sy5y cells is not reversible by naltrexone and appears to involve a fos jun signaling system  our results suggest that narcotics such as morphine may lead to activation of latent hiv infection  this may be particularly important in tissues  such as brain  which can host latent hiv infection and which is uniquely damaged in patients with acquired immunodeficiency syndrome  aids  as evidenced by neuronal degeneration and dementia  we also predict that these findings may have important implications for the pathogenesis of aids  particularly in opiate drug abusers  
class4	shear stress induces not only platelet aggregation but also platelet tumor cell interaction  to investigate the interaction between platelets and tumor cells under well defined flow conditions  the effect of tumor cells on platelet aggregation induced by shear stress was studied using a cone and plate viscometer adapted for measuring transmitted light intensity  aggregation was markedly enhanced by hmv 1 cells in a cell number dependent fashion under shear stress of 12 dyne cm2  enhancement was not observed at a high shear stress of 108 dyne cm2  a monoclonal antibody against gpiib iiia  7e3 completely abolished enhancement of aggregation by hmv 1  apyrase had similar inhibitory effects  scanning electronmicroscopy showed that direct contacts of platelets with hmv 1 cells could be demonstrated when platelet platelet interaction was inhibited by 7e3 or apyrase  these results may indicate that  at a shear stress of 12 dyne cm2  direct contacts of platelets and hmv 1 cells may trigger enhancement of platelet aggregation  
class4	palliative treatment of bile duct tumoral compression by an endoprosthesis  clinical results  the palliative therapy of stenoses of the biliary tract is a difficult choice  because percutaneous or endoscopic drainage methods are fraught with complications  an endoprosthesis for surgical intubation of the biliary tract has been developed  thirty patients were treated by this method  after choledochotomy  the endoprosthesis is positioned surgically above the sphincter of oddi  thereby avoiding ascending cholangitis  twenty nine patients  13 with gallbladder cancer  11 with cholangiocarcinomas  5 with metastases  presented with neoplastic compression  and one patient had an early postoperative stricture with loss of substance after right hepatectomy for hepatic metastases  the operative mortality was 3 3   one pulmonary complication   resolution of jaundice was obtained in all but two patients  and pruritus always resolved  the mean survival time for the patients with cholangiocarcinoma was 12 2 months and 6 33 months for those with gallbladder cancer  indices of satisfaction  bismuth s method  were 71   gallbladder cancer   93 5   hilar cholangiocarcinoma   and 92   metastatic compressions   this new type of surgical endoprosthesis is an alternative in the palliative treatment of neoplastic hilar compression because it is well tolerated  has a low rate of operative mortality or morbidity  and affords an acceptable quality of life for the patients  
class4	basic studies on a new material for inducing antitumor immune cells  recently  adoptive immunotherapy for cancer with lymphokine activated killer  lak  cells has been widely used experimentally  the therapy has several problems  including difficulty in handling  sterilization  and time consumption  to solve these problems  new materials able to induce antitumor immune cells were investigated  pokeweed mitogen  pwm  and pwm conjugated materials  cmc 1  could induce strong killer cells by short term stimulation of human peripheral blood lymphocytes  pbl   the induced killer cells showed a wide killing spectrum in vitro against human tumor cell lines  mkk 1  prmi4788  nbt 2  zr 7530  h 1  hela  kb  hmv 1  pc 10  c 1   human pbl stimulated for a short time by cmc 1 also showed a tumoricidal effect on tumor bearing  mkn 1  mkn 45  nude mice  these results suggest that cmc 1 may solve the problems with currently used lak therapy and may provide easily applicable extracorporeal immunotherapy for cancer  
class4	protection of the small intestine against irradiation by means of a removable prosthesis  in radiation therapy of tumors  several techniques are used to prevent injury of the intestinal loops  their purpose is to drive the intestine out of the external beam  understanding the disadvantages they present  a temporary prosthesis which effectively protects the small bowel  and is easy to remove  has been developed  the device is a 600 to 1 000 ml  silicone rubber  expandable balloon  when implanted in the pelvis or retroperitoneal cavity  and filled  this balloon displaces the intestinal loops out of the pelvic irradiation field  it may remain either filled or empty between each irradiation session  due to its particular elliptical shape  once empty  the balloon can be removed through a 3 cm incision under local or peridural anesthesia at the completion of radiotherapy  eleven patients with recurrent  8  or primary  3  cancer have been implanted  the protective effect has been evaluated on successive biologic tests  performed during treatment  no problem related to the prosthesis  no alteration of the biologic tests  nor bowel injury have been observed after several months follow up  this device is suitable for preventing intestinal complications during therapy  allowing a higher dose of radiations in some cases  
class4	large loop excision of the transformation zone  lletz  compared to carbon dioxide laser in the treatment of cin  a superior mode of treatment  a series of 199 patients with histologically confirmed cervical intraepithelial neoplasia  cin  grade ii or iii were allocated by hospital number to receive out patient treatment by carbon dioxide laser vaporization or large loop excision of the transformation zone  lletz   all patients received local anaesthesia  the women in the lletz group experienced less post operative haemorrhage  less discomfort  operative time was greatly reduced  and histological material was available for confirmation of the diagnosis  there was no significant difference in recurrence of cin after treatment between the two groups  at 6 month follow up  recurrence rates of 8 2   cin ii  and 7 5   cin iii  were observed in the laser group and 5   cin ii  and 5 3   cin iii  in the lletz group  further advantages of lletz are reduced capital expenditure and no hazard to the eyesight of the surgeon  but laser treatment is preferable in patients with widespread vaginal involvement  
class4	the relationship of  high risk  mammographic patterns to histological risk factors for development of cancer in the human breast  in the uk trial for the early detection of breast cancer in nottingham  119 women were identified as having fibrocystic change with epithelial hyperplasia or in situ carcinoma  their mammograms were classified according to wolfe s criteria and the corresponding histology for each patient was classified for degrees of epithelial hyperplasia  atypia and in situ neoplasia using page s criteria  a control population of patients presenting for breast screening was used to represent the general population  no correlation was found between the four mammographic wolfe patterns  n1  p1  p2 and dy and histological evidence of epithelial hyperplasia  atypia or in situ carcinoma  a further study was carried out to determine histological features of wolfe pattern  using radiological examination of resected breast tissue  the variation in wolfe pattern was related to the distribution of fibrous and adipose tissue in the breast interlobular stroma and appeared to have no relationship to epithelial parenchymal content  this information does not support the hypothesis that radiographic densities of p2 and dy patterns correspond to high risk epithelial proliferation  
class4	lack of late skin necrosis in man after high dose irradiation using small field sizes  experiences of grid therapy  out of a total of 437 patients with superior vena caval syndrome or advanced malignancy  given single dose grid radiotherapy  four survived to 7 years  the dose to the skin under each of the 77 holes in the grid was approximately 58 gy  the lack of skin necrosis in the total of 308 skin circles of 1 cm diameter among these survivors  compared with known necrosis rates in larger irradiated areas  implies that there is a marked field size effect for late necrosis in small areas of irradiated skin  
class4	preoperative cytology and mammography in patients with single duct nipple discharge treated by surgery  microdochectomy has been the routine management for single duct nipple discharge  our review of 176 consecutive patients surgically treated between 1975 and 1988 revealed eight patients with in situ carcinomas and seven with infiltrative carcinomas  seventeen patients had multiple papillomas  two had atypical hyperplasia and two had atypical epitheliosis  case selection for surgery has recently been advocated  in our study  nipple discharge cytology was helpful in 67 per cent of cases with underlying malignant pathology  mammography was found to be unreliable  alerting suspicion in only two of 15 cases  
class4	microdochectomy for discharge from a single lactiferous duct  microdochectomy for persistent discharge from a single lactiferous duct was performed in 162 women  invasive or in situ ductal carcinoma was diagnosed in 16 patients  10 per cent   none of whom had a palpable lump  the discharge was blood stained in 14 of these women and in two it was clear  mammography was performed in 15 of these 16 patients and was abnormal in only five  three patients had atypical ductal hyperplasia  one of whom subsequently developed an invasive ductal carcinoma  microdochectomy for persistent discharge from a single lactiferous duct is curative and gives a diagnosis of the cause  it remains the treatment of choice whether the discharge is blood stained or clear  
class4	fine needle aspiration biopsy in the diagnosis and management of fibroadenoma of the breast  cytological and histological biopsies were obtained on 75 breast lumps clinically diagnosed as fibroadenomas  of these  95 per cent of lesions were benign  in 51  68 per cent  confirmed as fibroadenomas histologically  cytology was benign in 78 per cent  but inadequate for diagnosis in 16 per cent  the remaining 24 lesions included three breast cancers and one lymph node with hodgkin s disease  in this group cytology was inadequate for diagnosis in 54 per cent  including one breast cancer  no lesion with benign cytology was subsequently shown to be malignant  the study supports the view that clinical diagnosis and cytology are accurate in the diagnosis of benign breast disease of this type  breast cancer may rarely present with the clinical features of a fibroadenoma and too few lesions have been studied to assess fully the performance of cytological biopsy in detecting these small mobile lesions  a non excisional policy should therefore include prolonged follow up and repeat biopsy  
class4	reduced psychological morbidity after breast conservation  psychological morbidity was compared in 52 patients treated by mastectomy and 67 patients treated by lumpectomy for early breast cancer  an informal counselling service was provided for all patients  morbidity was measured at 6  9 and 12 months after surgery with two self rating scales  the general health questionnaire and the leeds depression and anxiety scales  there was a significant excess of severe depression in the mastectomy group  in contrast to the findings of previous research  this result suggests that breast conservation reduces psychological morbidity  
class4	impaired polymorphonuclear leucocyte function in patients undergoing hepatectomy  adenylate energy charge and superoxide anion production in relation to hepatic mitochondrial redox state  patients undergoing hepatectomy have an increased susceptibility to infection  we therefore studied the energy metabolism of the polymorphonuclear leucocyte  pmn   focusing on energy charge and function  especially superoxide anion  o2   generation  in relation to the hepatic mitochondrial redox state  by labelling the pmn adenine nucleotide pool with radioactive adenine and by superoxide dismutase inhibitable reduction of ferricytochrome c  the energy charge and o2  production was measured in 18 patients with hepatoma  non cirrhotic  seven  cirrhotic  11  undergoing hepatectomy  their arterial ketone body ratios  kbrs   reflecting the hepatic mitochondrial redox potential  were above 0 7 before operation  after surgery  the 18 patients were divided into two groups  group a  kbr greater than 0 7  n   10  and group b  kbr less than 0 7  n   8  the energy charge and o2  release in group b decreased significantly from preoperative values  p less than 0 001 and p less than 0 01 respectively  and when compared with group a  p less than 0 05 and p less than 0 01 respectively   these results suggest that impaired hepatic energy metabolism  kbr less than 0 7  in hepatectomized patients leads to impaired energy charge and o2  production in the pmns  
class4	regional chemotherapy for colorectal liver metastases  a phase ii evaluation of targeted hepatic arterial 5 fluorouracil for colorectal liver metastases  the results of systemic chemotherapy in patients with liver metastases from colorectal cancer remain dismal  regional chemotherapy has been advocated as a method of improving the delivery of cytotoxic drugs to tumour  while minimizing systemic toxicity  the use of vasoactive agents to redistribute arterial blood flow towards tumour  and of biodegradable microspheres to slow tumour blood flow  have also been suggested as methods of further improving tumour exposure to drug  we present 21 patients who received intrahepatic arterial chemotherapy for colorectal liver metastases  combined treatment  angiotensin ii  albumin microspheres and 5 fluorouracil  was administered 4 6 weekly  and bolus 5 fluorouracil was given in the intervening weeks  toxicity was minimal  responses were seen in seven patients  fewer than half of the deaths were from liver metastases  a quarter of the patients died from non cancer related causes  survival was prolonged in the treated group compared with historical controls  these results suggest that this regimen has activity in patients with colorectal liver metastases  
class4	hepatic metastases from colorectal carcinoma  impact of surgical resection on the natural history  from 1960 to 1987  1209 patients with colorectal liver metastases were recorded  and followed until 1 january 1990  in 242 cases the diagnosis was based on external imaging  whereas 967 patients had operative confirmation and staging of their liver disease  three groups of patients were analysed  group 1 involved 921 cases  of whom 902 were deemed non resectable whereas 19 could not be unequivocally classified  only 21 patients lived for longer than 3 years  seven survived for 4 years  but there were no 5 year survivors  group 2 comprised 62 highly selected patients who at laparotomy demonstrated resectable metastatic spread confined to the liver  but this was not treated mainly because of a formerly different therapeutic approach  these patients had a significantly longer median survival time  14 2 versus 6 9 months   but also failed to achieve 5 year survival  the 226 patients forming group 3 underwent hepatic resection with intent to cure  nine of them had minimal macroscopic disease left  and 34 with all gross tumour removed had positive margins  survival of patients with these 43 eventually non radical resections followed an identical course as in group 2  median survival 13 3 months  maximum 42 months   of the 183 patients with potentially curative resection ten died after surgery  5 5 per cent   actuarial 5 and 10 year survival rates in the remaining 173 patients were 40 and 27 per cent with 25 and seven patients alive at respective periods of time  until 1 january 1990  64 patients remained free from recurrent disease for up to 24 years  in three patients the tumour status at death was unclear  the other 106 patients developed definite cancer relapse  nevertheless they demonstrated a prolongation of survival time by a median of 1 year when compared with the 43 non radically resected patients or the 62 untreated patients with resectable liver only metastases  and accomplished a maximum survival time of 8 years  radical excision of colorectal secondaries to the liver therefore offers effective palliation  and in a small number the chance of a cure  
class4	extended hepatectomy for hepatocellular carcinoma  the results of extended hepatectomy in 25 patients with hepatocellular carcinoma performed over a 16 year period have been reviewed  analysed and compared with those of 144 patients who underwent lesser liver resection  five left and 20 right extended hepatectomies were performed for tumours ranging from 3 to 20 cm in diameter  seventeen  68 per cent  of the patients had non cirrhotic livers  the major postoperative complications were  haemorrhage in five cases  major bile duct injury in three  subphrenic abscess in two  liver failure in one and wound dehiscence in one  the 30 day  operative  mortality rate was 12 per cent and the median survival duration  including operative mortality  was 9 7  range 0 2 32 1  months  the survival rate was 46 per cent at 1 year  33 per cent at 2 years and 22 per cent at 3 years  the morbidity  mortality and survival data of extended hepatectomy were comparable with the results of lesser hepatic resections for hepatocellular carcinoma  we conclude that extended hepatectomy is a worthwhile operation for large hepatocellular carcinomas and a viable alternative to liver transplantation  
class4	vastus lateralis myocutaneous flap for reconstruction of defects around the groin and pelvis  we present our experience using the vastus lateralis myocutaneous flap for the repair of defects around the groin and pelvis  it is a relatively new technique  with many advantages over other flaps used in this area  though it has limitations  the history  anatomy and surgical technique of raising the flap are described and clinical cases are discussed  the importance of patient selection is highlighted  
class4	association between extent of colonic mucosal sialomucin change and subsequent local recurrence after curative excision of primary colorectal cancer  two interrelated studies were carried out to determine whether extent of sialomucin change adjacent to a primary colorectal carcinoma predicted local tumour invasiveness and risk of local recurrence  in the first  depth of tumour penetration was correlated with the length of the sialomucin band adjacent to 72 primary colorectal cancers  there was a significant  p less than 0 05  increase in sialomucin band length adjacent to tumours invading adjacent structures compared with those which had not  mann whitney u test   although there was no overall correlation between depth of penetration  duke s classification or degree of differentiation  kruskal wallis test   a sialomucin band of greater than 3 cm was associated with a 70 per cent probability of adjacent structure  t4  invasion  these observations were then tested prospectively in a second study involving 256 patients to determine whether the presence of a greater than 3 cm sialomucin band could predict local recurrence  presence of a greater than 3 cm sialomucin band was a significant  x2   7 12  d f    1  p less than 0 001  and independent predictor of local but not distant recurrence  in addition both the interval to local recurrence and survival were significantly shorter if a greater than 3 cm sialomucin band was present  however the accuracy of greater than 3 cm sialomucin band as a predictive test for local recurrence was only 70 per cent  the extent of sialomucin adjacent to a primary colorectal cancer does provide a crude assessment of tumour invasiveness and risk of local recurrence  
class4	intraluminal pressure adjacent to left colonic anastomoses  a cumulative total of 89 h of pressure data was acquired from both sides of a left colonic anastomosis in 15 patients over a median period of 7 postoperative study days  patients had a colonic ileus lasting 3 10 days and during this proximal and distal inactivity the intraluminal pressure remained within 6 mmhg of atmospheric pressure  after recovery of activity  pressures proximal to the anastomosis in excess of 10 mmhg occurred during less than 1 per cent of the recording time  distal peak pressures were significantly elevated with respect to the proximal site  p less than 0 001   two thirds of the distal pressures recorded were between 10 and 20 mmhg and 98 per cent were less than 50 mmhg  the peak distal pressure was 90 mmhg  four patients had distal repetitive tonic contractions creating a pressure difference across the anastomosis with a mean of 20 mmhg and a peak of 45 mmhg  each contraction persisted for 15 20 min  intraluminal pressures are unlikely to play a role in anastomotic dehiscence  
class4	thallous chloride uptake and dna profile in parathyroid adenomas  thallium isotope scintigraphy is used to localize parathyroid adenomas but the mechanism underlying the technique is poorly understood  while larger adenomas are reliably localized the results are less certain for small tumours  this study explores the relationship between cellular dna profile and thallium uptake  localization accuracy  in 24 parathyroid adenomas  the dna profile was assessed using flow cytometry and standard subtraction thallium scintigraphy was performed before surgery  fifteen of the 24 adenomas demonstrated excessive mitotic activity and 13 of these glands were accurately localized  of the remaining nine glands  only five were localized accurately  p less than 0 01  chi 2 test including yates  correction   this difference in thallium uptake could not be accounted for on the basis of gland weight  thallium localization of parathyroid adenomas is related to mitotic activity  this may explain some of the limitations of this technique  
class4	the importance of calcium regulation in toxic cell injury  studies utilizing the technology of digital imaging fluorescence microscopy  the regulation of ions within the cell is of critical importance in both acute and chronic toxicology  recently  new methods have been developed for measuring such changes in living cells and correlating them with studies of structure  function  and biochemistry  a major revolution has occurred from the linkage between the computer and the light microscope  which has resulted in the use of digital imaging fluorescence microscopy and video intensification microscopy coupled with image analysis  these methods have already yielded much additional information and it is anticipated that their further application by pathologists and toxicologists will continue to uncover the important role of ion deregulation and toxic cell injury  
class4	esophageal adenocarcinoma in a patient with surgically treated achalasia  although squamous cell carcinoma of the esophagus occurs with increased incidence in primary achalasia  esophageal adenocarcinoma has been considered rare in this condition  we report a patient with long standing achalasia in whom adenocarcinoma of the esophagus occurred many years after heller esophagomyotomy  presumably related to barrett s esophagus complicating gastro esophageal reflux disease  
class4	cathepsins d and e in normal  metaplastic  dysplastic  and carcinomatous gastric tissue  an immunohistochemical study  immunohistochemical distributions of cathepsins d and e were determined in normal mucosa  metaplastic  dysplastic  and cancerous lesions of the human stomach  cathepsins d and e were localised in the foveolar epithelium and parietal cells of the normal gastric mucosa  but their intracytoplasmic distributions were different   cathepsin e distribution was even and diffuse in the cytoplasm while cathepsin d was found in coarse intracytoplasmic granules  chronic inflammation and ulcer did not influence the distribution of these enzymes  no positive staining was obtained in the incomplete type of intestinal metaplasia  dysplasia  and well differentiated adenocarcinoma  tumour cells of signet ring cell carcinoma and poorly differentiated adenocarcinoma cells  however  gave strong and diffuse stainings for cathepsins d and e in the cytoplasm  the results suggest that the distribution of cathepsins d and e is related to each specialised function of the foveolar epithelium and the parietal cells  and that their disappearance is associated with development of well differentiated adenocarcinoma from intestinal metaplasia  
class4	microspectrophotometric dna analysis in ulcerative colitis with special reference to its application in diagnosis of carcinoma and dysplasia  the deoxyribonucleic  dna  content was measured by microspectrophotometry in 100 specimens from 60 patients with ulcerative colitis  including six patients in whom the colitis was associated with carcinoma  some 23 of 30  77   specimens of dysplastic tissue showed aneuploidy or polyploidy  whereas 50 of 53  94   specimens of non dysplastic tissue showed diploidy  the difference was statistically significant  p less than 0 001   polyploidy was often observed in non dysplastic mucosa from patients who had carcinoma or dysplasia  in the non dysplastic patients all samples of inflamed tissue showed diploidy  some 10  of samples without inflammation  however  also showed polyploidy  a good correlation was found between the frequency of polyploid cells and the grade of dysplasia  microspectrophotometric measurement of dna content proved useful in the assessment and diagnosis of dysplasia in ulcerative colitis and could be considered for screening high risk patients  
class4	role of upper gastrointestinal investigations in a screening study for colorectal neoplasia  should patients with positive faecal occult blood screening tests who are free of colorectal neoplasia undergo upper gastrointestinal investigation  altogether 16 985 faecal occult blood tests were completed in a group of 18 818 asymptomatic patients  45 75 years  offered screening at two yearly intervals  a total of 447  2 6   were positive and underwent large bowel investigations  no neoplastic disease was identified in 283  63   of them  fourteen  5   also underwent gastroscopy for upper gastrointestinal symptoms  benign conditions were identified in five and a gastric carcinoma in one  no further investigations were instituted in the remaining 269 subjects who have now been followed up for a median period of 5 years  2 8 years   five have been referred for benign upper gastrointestinal conditions  but none for upper gastrointestinal malignancy  thirty one subjects have died   one from gastric cancer  a patient who had undergone a previous partial gastrectomy for a duodenal ulcer and who had persistent upper gastrointestinal symptoms   the remaining deaths were unrelated to the upper gastrointestinal tract  nineteen people who have left the trial area have been monitored for the development of malignant disease  none have presented with upper gastrointestinal malignancy  these data support the view that upper gastrointestinal investigations need not be performed routinely in this group of subjects  but may be reserved for those with relevant symptoms  
class4	role of ultrasound guided fine needle aspiration biopsy in the diagnosis of hepatocellular carcinoma  in 170 cases of hepatocellular carcinoma  ultrasound showed a high sensitivity in identifying focal liver lesions  fine needle aspiration biopsy guided by ultrasound yielded a pathological diagnosis in the majority of cases  the advantages of this technique  its high diagnostic yield and low cost  render the older technique of blind percutaneous biopsy using a coarse needle obsolete  laparoscopy retains its essential role in selected cases  complementary use of fine needle aspiration biopsy under ultrasound guidance and laparoscopy assures the highest rate of diagnostic accuracy in hepatocellular carcinoma  we confirm the poor sensitivity of alpha fetoprotein  
class4	stomal adenocarcinoma in crohn s disease  malignant change occurring at the site of a stoma in two patients with proved crohn s disease is described  patients with ulcerative colitis have an increased risk of colonic malignancy and crohn s disease is also associated with both small and large bowel carcinoma  most previous reports of stomal carcinoma have been associated with ulcerative colitis although crohn s disease seems to carry a greater risk of associated small bowel carcinomas  this is the first report of stomal carcinoma complicating crohn s disease  epithelial dysplasia is associated with gastrointestinal carcinomas in both ulcerative colitis and crohn s disease and a dysplasia carcinoma sequence has been suggested as the origin of these tumours  in both our patients with stomal adenocarcinoma  dysplasia was identified in adjacent tissues  which suggests a similar mechanism  malignant change should be suspected if epithelial dysplasia is discovered in a biopsy specimen from the mucosa of an ileostomy in crohn s disease  and this risk is increased if the dysplasia is of a high grade  
class4	squamous carcinoma in the liver  squamous carcinoma of the liver has only rarely been reported  we present a case which highlights not only the difficulties in diagnosis but also how it can closely mimic sclerosing cholangitis  
class4	function after amputation  arthrodesis  or arthroplasty for tumors about the knee  we studied the function of twenty two patients who had had a malignant skeletal tumor adjacent to the knee  an above the knee amputation was done in seven  a resection arthrodesis  in nine  and a replacement arthroplasty  in six  the patients all walked at a similar speed  sixty one to sixty six meters per minute   which is slower than normal  eighty meters per minute   they all walked with comparable efficiency at three velocities  the mean consumption of oxygen was 0 210 milliliter per kilogram of body weight per meter at free velocity  0 215 milliliter per kilogram of body weight per meter when they walked 25 per cent faster  and 0 211 to 0 240 milliliter per kilogram of body weight per meter when they walked 50 per cent faster  the three groups of patients and a normal control group consumed oxygen at similar rates  the patients who had had an amputation were very active  and they were the least worried about damaging the affected limb  but they had difficulty walking on steep  rough  or slippery surfaces  the patients who had had an arthrodesis had a more stable limb and performed the most demanding physical work and recreational activities  but they had difficulty sitting  the patients who had had an arthroplasty led sedentary lives and were the most protective of the limb  but they were the least self conscious about the limb  
class4	the van nes tibial rotationplasty  a functionally viable reconstructive procedure in children who have a tumor of the distal end of the femur  twelve patients who had a malignant tumor of the distal end of the femur were treated with a van nes tibial rotationplasty  the survival rates were comparable with those for above the knee amputees and patients who had an endoprosthetic replacement  the results of functional testing showed that these patients performed as well as those who had endoprosthetic replacement and better than those who had above the knee amputation  rotationplasty is therefore a favorable alternative to amputation or endoprosthetic replacement  either as a primary or as a salvage procedure  
class4	insulin like growth factor i expression by tumors of neuroectodermal origin with the t 11 22  chromosomal translocation  a potential autocrine growth factor  expression of insulin like growth factor i  igf i  mrna by some tumor cell lines of neuroectodermal origin has been described  to further explore the significance of igf i mrna expression in these tumors  a more extensive analysis was performed  most  9 of 10  neuroectodermal tumor cell lines with a t 11 22  translocation  primitive neuroectodermal tumor  pnet   ewing s sarcoma  esthesioneuroblastoma  expressed igf i mrna  whereas 0 of 15 cell lines without the translocation  pnet  neuroblastoma  expressed igf i  furthermore  inasmuch as all neuroblastoma  12 of 12  cell lines examined expressed igf ii rna  the pattern of igf expression could distinguish between these closely related tumors  chp 100  a pnet cell line with the t 11 22  translocation  was shown to secrete both igf i protein and an igf binding protein  igfbp 2  this cell line also expressed the type i igf receptor mrna  and blockade of this receptor by a monoclonal antibody  alpha ir3  inhibited serum free growth  these data demonstrate that igf i expression is a property of neuroectodermal tumors with a t 11 22  translocation and that interruption of an igf i autocrine loop inhibits the growth of these tumor cells  
class4	metabolic effects of cachectin tumor necrosis factor are modified by site of production  cachectin tumor necrosis factor secreting tumor in skeletal muscle induces chronic cachexia  while implantation in brain induces predominantly acute anorexia  we have developed a murine model of wasting by injecting intracerebrally cells which continuously secrete h cachectin tnf  cho tnf  to   a  determine the effects of cachectin tnf produced continuously in the central nervous system  cns   and  b  compare the metabolic effects of cachectin tnf secreting tumor in the brain to the cachexia caused by cho tnf tumor in peripheral tissue  im   intracerebral cho tnf tumors produced increased serum h cachectin tnf levels with lethal hypophagia and weight loss  mean survival time of 11 d   these changes were not observed in association with nonsecretory control brain tumors  the metabolic consequences of intracerebral cachectin tnf production were indistinguishable from acute  lethal starvation  whole body lipid content was decreased significantly but protein was conserved  although intramuscular cachectin tnf secreting tumors caused similar increases of serum h cachectin tnf levels  profound anorexia did not develop  wasting developed after a longer period of tumor burden  50 d  with classical signs of cachexia  i e   anemia and depletion of both protein and lipid   these studies provide a reproducible animal model of site specific cytokine production and suggest that  regardless of serum levels  cachectin tnf produced locally in brain influences both the rate of development of wasting and its net metabolic effects  
class4	active specific immunotherapy in patients with melanoma  a clinical trial with mouse antiidiotypic monoclonal antibodies elicited with syngeneic anti high molecular weight melanoma associated antigen monoclonal antibodies  published erratum appears in j clin invest 1991 feb 87 2  757  in two clinical trials the mouse antiidiotypic monoclonal antibody  mab  mf11 30  which bears the internal image of human high molecular weight melanoma associated antigen  hmw maa  was administered by subcutaneous route without adjuvants to patients with stage iv malignant melanoma on day 0  7  and 28  additional injections were administered if anti antiidiotypic antibodies were not found or their titer decreased  in the first phase i trial with 16 patients the initial dose was 0 5 mg per injection and escalated to 4 mg per injection  neither toxicity nor allergic reactions were observed despite the development of anti mouse ig antibodies  minor responses were observed in three patients  in a second clinical trial mab mf11 30 was administered to 21 patients at a dose of 2 mg per injection  since this dose had been shown in the initial study to be effective in inducing anti antiidiotypic antibodies  two patients were inevaluable  in the remaining 19 patients  the average duration of treatment was 34 wk  in this trial as well  neither toxicity nor allergic reactions were observed  17 of the 19 immunized patients increased the levels of anti mouse ig antibodies and 16 developed antibodies that inhibit the binding of antiidiotypic mab mf11 30 to the immunizing anti hmw maa mab 225 28  one patient increased the level of anti hmw maa antibodies  one patient achieved a complete remission with disappearance of multiple abdominal lymph nodes for a duration of 95 wk  minor responses were observed in three patients  these results suggest that mouse antiidiotypic mab that bear the internal image of hmw maa may be useful reagents to implement active specific immunotherapy in patients with melanoma  
class4	occurrence of human papillomavirus type 16 dna in cutaneous squamous and basal cell neoplasms  sixty eight cutaneous squamous cell neoplasms  in situ and invasive  and 26 basal cell carcinomas from 89 patients were analyzed for dna sequences homologous to the human papillomavirus  hpv  types found predominantly in the genital tract  thirty six  53   of the squamous cell neoplasms contained hpv dna as detected by filter or in situ hybridization analysis  the frequency of detection of hpv dna was dependent on the site of the lesion  of 40 genital squamous cell neoplasms  penile  vulvar  and perianal   27  68   had detectable hpv dna  in 25 of these  the hpv type was 16 or hpv 16 related  which was similar to the results for the squamous cell neoplasms of the finger  hpv dna in 9 of 11 tumors with hpv 16 in seven   none of 16 squamous cell neoplasms from sites other than the genital tract or the finger had detectable hpv dna  hpv dna was detected in one of the 26 basal cell carcinomas  4    we conclude that  for cutaneous epithelial malignancies  hpv 16 is restricted to squamous cell neoplasms of the genital tract and finger  these data are consistent with venereal transmission of hpv 16 to the periungual region and suggests a role for this virus in the evolution of squamous cell carcinoma at this site  
class4	spitz nevi in black children  four black children with spitz nevi are presented  the initial clinical diagnosis was pyogenic granuloma for three patients  one child had two spitz nevi  histologic examination revealed melanocytic dendritic hyperplasia in all cases  
class4	ocular melanoma in families with dysplastic nevus syndrome  five families with the dysplastic nevus syndrome  in each of which one member had ocular melanoma  are reported  these five families were examined within a 3 year period in one medical center  to date only five other families with such a combination have been reported  we suggest a causal relation between ocular melanoma and the familial dysplastic nevus syndrome  
class4	polypoid melanoma  a virulent variant of nodular melanoma  report of three cases and literature review  we report the cases of three patients with polypoid melanoma  in no case was there microscopic evidence of melanoma cell invasion below the papillary dermis  in the polypoid variant of nodular melanoma  melanoma cells accumulate in large volume above the skin s surface  this increase in tumor volume encourages dislodgment of melanoma cells that are carried to superficial lymphatic vessels without invading the reticular dermis  this feature differentiates polypoid melanoma from the nonpolypoid nodular variant  although polypoid melanoma is considered the most malignant form of melanoma  our findings  albeit limited to three cases  suggest that early diagnosis and prompt surgical excision may provide a favorable 5 year survival rate  
class4	photopheresis for the treatment of cutaneous t cell lymphoma  we investigated the use of extracorporeal chemotherapy  photopheresis  in eight patients with cutaneous t cell lymphoma  initially described by edelson et al  for the treatment of erythrodermic cutaneous t cell lymphoma  we have expanded the treatment to include patients with extensive patch plaque disease as well as tumor stage disease  four of five patients with erythrodermic stage disease had either a complete or a partial clinical remission with photopheresis alone  one patient with extensive patch plaque disease continued to have a partial clinical remission of 7 months  duration with photopheresis alone  of the two patients with tumor stage disease  one remained without evidence of clinical disease at 10 months with photopheresis alone  whereas the second patient had a partial clinical remission of 5 months with a combination of local radiation therapy followed by monthly photopheresis  the skin biopsy specimen obtained from the patient with tumor stage disease in complete clinical remission did not show cutaneous t cell lymphoma  we conclude that photopheresis is an effective modality alone or in combination with adjunctive therapy for erythroderma  extensive patch plaque disease  and some tumor stage disease  
class4	causes of death in the elderly and their changing pattern in hisayama  a japanese community  results from a long term and autopsy based study  the causes of death for the elderly were prospectively studied in hisayama  japan  a rural community  we compared 1 621 subjects  aged 40 years or over  recruited in 1961  and 2 053 subjects recruited in 1974  each cohort was studied in a follow up that lasted 10 years  they had autopsy rates of 82 1  and 86 1  during each 10 year period  respectively  the most common causes of death for those aged 70 years or over were cerebrovascular disease  malignant neoplasms  and pneumonia  deaths due to cerebrovascular disease tended to decrease in the recent cohort  but the proportion of decline was more prominent in cases aged 40 to 69 years  there was a sex difference in the changing pattern of mortality from heart diseases including ischemic heart disease  deaths by both heart diseases and ischemic heart disease increased in the more recent cohort of aged women  whereas they decreased in the aged men  pneumonia was an important cause of death for the elderly in both cohorts  deaths due to  senility  were rare  being only 1  of the deceased aged 70 or over  with prolonged lifespan  especially for women  the impact of atherosclerosis and its related disorders on the recent japanese aged population appears to have increased  
class4	leukocyte larceny  spurious hypoxemia confirmed with pulse oximetry leukemic patients with extremely high white blood counts may exhibit the phenomenon of leukocyte larceny  in which white blood cells metabolize plasma oxygen in arterial blood gas samples  abg  producing a spuriously low oxygen tension  we report the case of a leukemic patient with a white blood count in excess of 500 000 in whom multiple abgs documented hypoxemia out of proportion to his clinical picture  pulse oximetry was used to confirm higher hemoglobin oxygen saturation to establish the leukocyte larceny  
class4	blepharospasm oromandibular dystonia associated with a left cerebellopontine angle meningioma  blepharospasm oromandibular dystonia is characterized by the presence of spasms of the orbicularis oculi  blepharospasm  and of the lower facial or oromandibular muscles  a patient with this syndrome is presented in which a left cerebellopontine angle meningioma appeared to act as a triggering mechanism for the development of this disorder  on the basis of this report  we recommend that physicians search for this tumor in patients with this disorder  
class4	a randomized trial of the effect of three non steroid anti inflammatory agents in ameliorating cancer induced fever  paraneoplastic fever is well known  and is not an uncommon problem in daily practice  in an effort to ameliorate tumour induced fever we randomized 48 patients to receive three different non steroid anti inflammatory drugs  naproxen  500 mg d 1   indomethacin  75 mg d 1  or diclophenac sodium  75 mg d 1   all patients had solid tumours  and microbial infection had been excluded  all three drugs were equally effective in bringing the temperature down to normal for a period of 30 33 d  naproxen had the most rapid effect  in cases of fever relapse with the first drug  when the other two drugs were given instead  both proved equally effective  no side effects were observed  we conclude that naproxen  indomethacin and diclophenac sodium are equally effective in ameliorating paraneoplastic fever  in relapse  a second drug given subsequently can be effective as well  
class4	castanospermine vs  its 6 o butanoyl analog  a comparison of toxicity and antiviral activity in vitro and in vivo  inhibitors of glycoprotein processing  such as castanospermine  1 6 7 8 tetrahydroxyoctahydroindolizine   have been shown previously to inhibit human immunodeficiency virus type 1  hiv 1  with acceptable toxicity in cultured human cells  in prior experiments  we have tested the toxicity and antiviral efficacy of castanospermine in mice infected with the rauscher murine leukemia virus  rlv   when compared with 3  azido 3  deoxythymidine  azt  zidovudine   castanospermine was less effective and more toxic  since the 6 o butanoyl analog of castanospermine was previously found to have a more favorable activity profile than the parent compound against hiv 1 in cultured cells  we compared the antiviral efficacy of both compounds in parallel in vitro and in vivo in the rlv system  plaque formation in the xc assay was inhibited with a 50  inhibitory concentration  ic50  of 2 4 microm for the 6 o butanoyl analog of castanospermine  as compared to 9 microm for castanospermine  for both compounds  concentrations resulting in significant cytotoxicity were about ten times higher  both compounds significantly decreased hiv 1 env induced syncytium formation in a novel in vitro assay  in rlv exposed mice  the 6 o butanoyl analog showed no advantage over the parent compound  both curves for toxicity as well as antiviral efficacy were super imposable  we conclude that the 6 o butanoyl analog of castanospermine as well as castanospermine itself are active antiviral agents in mice and that prolonged oral administration is tolerable  however  in comparison to azt  their antiviral activity profiles are less favorable  
class4	incidence of polymyositis dermatomyositis  a 20 year study of hospital diagnosed cases in allegheny county  pa 1963 1982  the incidence of hospital diagnosed polymyositis dermatomyositis  pm dm  among residents of pittsburgh and allegheny county  pa was determined from 1963 to 1982  medical records of all allegheny county hospitals were searched for patients diagnosed pm dm  and each accepted case was reviewed and verified by a physician  according to specified criteria  direct age adjusted incidence rates were computed for race and sex  as new cases million population year  with the 1970 allegheny county population as the standard  one hundred seventy seven cases were identified during this 20 year survey for a total annual incidence of 5 5 million population  incidence more than tripled during 1973 1982 compared to the first decade of study  with the greatest increase occurring in black women  overall  the female to male incidence ratio was 2 2 1  but during the childbearing years  ages 15 44  this ratio increased to greater than 5 1 in both races  detection of pm dm is increasing  as shown by temporal trends  although our series has significantly more adult pm and less dm and overlap cases than other published studies  annual incidence is similar to that reported in other locales  
class4	bladder outlet obstruction due to pelvic lipoma  computerized tomography  magnetic resonance imaging and radiographic evaluation  we report an unusual case of long standing bladder outlet obstruction due to pelvic lipoma in a 31 year old white man  the mass was evaluated by plain film  computerized tomography and magnetic resonance imaging  the differential diagnosis of fat containing extraperitoneal pelvic masses is discussed  
class4	adenocarcinoma of the urachus associated with elevated levels of ca 125  adenocarcinoma of the urachus is a rare genitourinary tumor with a poor prognosis  the treatment of choice is en bloc surgical resection  although combination therapy with surgery and chemotherapy has been used with mixed results  we describe a 69 year old woman with adenocarcinoma of the urachus and elevated serum levels of ca 125 tumor marker  she was treated with resection plus 5 fluorouracil  doxorubicin and mitomycin  alternating with platinum based chemotherapy  the serum ca 125 level decreased precipitously after the operation and became normal after 2 months of chemotherapy  the patient remained free of disease 1 year postoperatively  serum ca 125 may be a useful tumor marker for urachal carcinoma and adjuvant chemotherapy may be effective in treating the disease  
class4	unresectable calcified bladder tumor  hemiacidrin irrigation as an adjunct to resection  radiographic calcification of urothelial malignancies is an uncommon finding  to our knowledge  calcification of transitional cell carcinoma of the bladder preventing transurethral resection has not been reported previously  we report a case of an initially unresectable radiopaque bladder tumor and discuss the successful  conservative management with continuous bladder irrigation with hemiacidrin followed by complete transurethral resection  
class4	rectourethral fistula caused by kaposi s sarcoma  a 35 year old man with the acquired immunodeficiency syndrome related complex was evaluated for a persistent urethral discharge  pneumaturia and watery diarrhea  radiographic and endoscopic procedures established the diagnosis of a rectourethral fistula  perineal exploration and excision of the fistula revealed the pathological diagnosis of kaposi s sarcoma  the differential diagnosis of an acquired rectourethral fistula and the significance of kaposi s sarcoma are discussed  
class4	adenocarcinoma of the prostate in a 41 year old man with xxy karyotype and chronic lymphocytic leukemia  report of a case  we report a case of adenocarcinoma of the prostate in a 41 year old man with 47xxy karyotype  klinefelter s syndrome  and chronic lymphocytic leukemia  the increased incidence of malignancy in individuals with klinefelter s syndrome has been well documented for certain neoplasms  adenocarcinoma of the prostate has not been reported previously in a patient with klinefelter s syndrome and a 47xxy karyotype  absence of mosaicism was confirmed by peripheral lymphocyte  skin fibroblast  bone marrow cell and spleen stroma fibroblast cultures  chronic lymphocyte leukemia  especially the t cell cytotoxic suppressive variant  may additionally add to an immunological deficit  since carcinoma of the prostate  klinefelter s syndrome and chronic lymphocytic leukemia are common  the lack of a previous report is interesting  etiological aspects are discussed  
class4	exaggerated venous mural hypertrophy in association with metastatic adenocarcinoma of the prostate  a 61 year old black man presented with metastases to the right groin 5 years after 125iodine treatment for a well differentiated primary prostatic adenocarcinoma  medium sized veins within and immediately adjacent to the neoplasm showed marked mural thickening due to hypertrophy and hyperplasia of the inner circular and outer longitudinal muscles  there was no histological evidence of radiation effect in the stroma or in the tumor cells  we could find no report in the literature of such changes associated with metastatic carcinoma  
class4	end stage renal disease serum contains a specific renal cell growth factor  end stage renal disease  esrd  kidneys display abnormal growth characterized by a continuum of cystic disease  adenoma and carcinoma  this study evaluates the hypothesis that serum of patients with esrd contains increased amounts of a growth factor which specifically induces proliferation of renal cells  esrd sera compared to sera from normal controls induced a two to three fold increase in the proliferative rate of renal cell carcinoma cell lines and normal kidney explants compared to cell lines from other sites  the increased proliferative activity of esrd sera on renal cells was paralleled by an increase in cytosolic free calcium  the growth factor activity was encoded by a polypeptide of between 15 and 30 kd  the activity of esrd sera on renal cells was not mimicked or inhibited by epidermal growth factor  basic fibroblast growth factor and platelet derived growth factor indicating that the renal cell specific growth factor activity in esrd is different from these factors  
class4	cytotoxic effects of high energy shock waves in different in vitro models  influence of the experimental set up  high energy shock waves  electromagnetically generated  siemens lithostar  were studied for their effects in vitro on different  tumor  cell types  cells were exposed to the shock waves as a single cell suspension or as a cell pellet on the bottom of a test tube  in both cases  a dose dependent direct cytotoxicity  established by trypan blue dye exclusion  was observed after treatment with 1000 or 2000 shock waves  also  the antiproliferative capacity as determined by clonogenic potential  double layer soft agar  and growth rate  plastic  were affected in this way  however  comparing the results after treatment in suspension or pellet  a discrepancy was evident  the cell lines showed a different susceptibility in pellet vs  suspension  also the differential sensitivity of the cell types varied in these two treatment models  furthermore the outcome depended on the cell concentration  direct cytotoxicity in a cell suspension was more pronounced at higher cell concentrations  while in a pellet this was increased by decreasing the number of cells  finally  no shock wave induced cytotoxicity could be seen after fixation of cells in gelatine or by placing the pellet on a bottom layer of gelatine  pressure measurements revealed no adequate explanation for this phenomenon  these results indicate that in vitro effects depend on the way cells are exposed to the shock waves and can be greatly influenced by changing the conditions of the microenvironment  therefore  precise descriptions of the experimental set up and careful interpretations of their outcome are obligatory  
class4	surgical management and prognosis of renal cell carcinoma invading the vena cava  a total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection  of these patients 27 had primary tumor confined within gerota s fascia  negative lymph nodes and no distant metastases  stage t3cn0m0   patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69  5 year survival rate  median 9 9 years  but patients with tumor thrombus directly invading the vena cava had a 26  5 year survival rate  median 1 2 years   which improved to 57   median 5 3 years  if the involved vena caval side wall was resected successfully  of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension  regional lymphadenopathy or distant metastases  and the 5 year survival rate was less than 18  in all groups  median survival less than 0 9 years   prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension  patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer  positive lymph nodes or distant metastases  however  when partial venacavectomy establishes negative surgical margins then survival markedly improves  
class4	progression of stage t1 bladder tumors after intravesical bacillus calmette guerin  published erratum appears in j urol 1991 apr 145 4  840  of 221 patients with superficial bladder tumors  stages ta  tis and t1  treated by transurethral resection and an initial 6 week course of intravesical bacillus calmette guerin  bcg  195 were evaluated after 3 months for local response  of these patients 17  8 7   had a stage t1 tumor  of whom 14  82   subsequently had muscle invasion  7   uncontrolled local disease  6  or metastasis  1   the median interval to progression was 8 4 months  which was significantly  p   0 0001  less than among the other 178 patients with a nonstage t1 lesion or no tumor found at 3 months  of whom 44  25   had progression  median more than 5 years   these data suggest that patients with stage t1 tumor 3 months after bcg therapy require additional therapy other than simple tumor resection and meticulous followup  
class4	results of contemporary radical cystectomy for invasive bladder cancer  a clinicopathological study with an emphasis on the inadequacy of the tumor  nodes and metastases classification  we reviewed 261 patients who underwent a radical operation at a single institution as definitive treatment of invasive bladder cancer to evaluate the survival and accuracy of the tumor  nodes and metastasis system in characterizing the prognosis  between january 1979 and june 1987 the 261 evaluable patients underwent 1 stage radical cystectomy with pelvic node dissection and urinary diversion  no chemotherapy and or radiation therapy was given before or after the operation  the postoperative mortality rate was 1 8   the over all staging error between clinical and pathological stages was as high as 44   the over all actuarial 5 year survival rate was 54 5   the 5 year survival rates were 75  for stage pt1  63  for stage pt2  31  for stage pt3 and 21  for stage pt4 disease  a significant difference in the survival  p less than 0 002  was observed in stage pt3 by dividing tumors confined within the bladder wall  pt3a  50   from those extending throughout the bladder wall  pt3b  15    a careful evaluation of transitional cell involvement of the prostate in stage pt4a cancer led to the identification of 2 different patterns  1  contiguous when a bladder tumor extended directly into the prostate through the bladder wall and 2  noncontiguous when a bladder tumor and a transitional cell carcinoma of the prostate were found simultaneously  these patterns had completely different  p less than 0 05  survival rates  6 versus 37    the patients with high grade tumors had a worse prognosis in comparison with those with grades 1 and 2 tumors  41 versus 56   p less than 0 005   the over all 5 year survival of patients with positive nodes was 4  in comparison with 60  of those without nodal involvement  p less than 0 001   despite current optimal surgical treatment  nearly 50  of all patients with invasive bladder cancer continue to die  the need for a modification of the current tumor  nodes and metastasis tumor classification to provide the clinician a more reliable staging system for planning treatment modalities is indeed mandatory  
class4	total bladder replacement using detubularized sigmoid colon  technique and results  we performed total bladder replacement with a detubularized segment of sigmoid colon in patients after cystoprostatectomy  the surgical technique and long term results in 27 patients are reported  this neobladder configuration compared favorably with other neobladder types regarding ease of construction  the surgical complications were acceptable  initial reservoir function was good but improved further with time  after 1 year the capacity averaged 600 cc  pressures during filling and at capacity were low  average 12 and 16 cm  water  and emptying was satisfactory  residual urine 4 to 80 cc   all patients were continent during the day and 67  were continent at night without excessive voiding habits  nighttime incontinence was further resolved in 2 patients by using the ams 800 artificial sphincter around the bulbous urethra  the detubularized sigmoid is an excellent neobladder configuration after cystoprostatectomy  
class5	osteoma of the middle ear  report of a case  osteomas of the middle ear are rare  we report a case of a 7 year old boy with osteoma originating from the pyramidal eminence  combined with congenital cholesteatoma  the osteoma and cholesteatoma were successfully removed by tympanomastoidectomy  the long process of the incus and the superstructure of the stapes disappeared  the body of the incus was sculpted and used as a columella  histopathologically  the osteoma was much the same as an external auditory canal osteoma  the possibility of a primary congenital origin of this neoplasm is suggested  
class5	replacement of an aortic valve cusp after neonatal endocarditis  septic arthritis developed in a neonate after an infection of her hand  despite medical and surgical treatment endocarditis of her aortic valve developed and the resultant regurgitation required emergency surgery  at operation a new valve cusp was fashioned from preserved calf pericardium  nine years later she was well and had full exercise tolerance with minimal aortic regurgitation  
class5	chondrosarcoma of bone in children  chondrosarcoma of bone rarely occurs in children  this report analyzes the clinicopathologic features in a series of 47 patients with conventional chondrosarcoma who were less than 17 years of age  of the 47 cases  14 were from the mayo clinic files  and 33 were from our consultation files  most of the lesions occurred in the trunk and upper ends of the long bones  with the humerus being the most frequent skeletal site  twelve of the 47 tumors were secondary  the radiographic findings were the same as those seen in adult chondrosarcoma  pathologically  the tumors were low grade  en bloc resection is the treatment of choice because of the high incidence of local recurrence with lesser surgical margins  prognosis in childhood chondrosarcoma is no different from that in adult chondrosarcoma  none of the patients with follow up data had metastasis  
class5	klinefelter s syndrome with anomalous origin of left main coronary artery klinefelter s syndrome is a rare entity  even rarer is an anomalous origin of the left main coronary artery  for both conditions to occur in the same patient is hence exceedingly rare  reported here is a never previously reported case of a coronary congenital anomaly in a patient with klinefelter s syndrome together with the proper angiographic approach  
class5	the importance of calcium ions for in vitro malignant hyperthermia testing  intracellular ca   levels in skeletal muscle are elevated during the in vitro contracture response of muscle from subjects with malignant hyperthermia  the role of ca   in the bathing medium and the consequences of substitution of sr   for ca   in the response to agents associated with malignant hyperthermia were examined  when ca   was omitted from the bathing medium the contractures induced in human vastus lateralis by halothane  three per cent  or succinylcholine  50 mm  were reduced by 80 and 100 per cent  respectively  while contractures induced by caffeine  8 mm  were only reduced by 50 per cent  substitution of ca   by another divalent cation  sr    completely restored contractures induced by caffeine  but only partially restored contractures induced by halothane or succinylcholine  to 50 and 30 per cent of ca     containing medium  respectively   mepacrine  10 microm  was effective in antagonizing contractures by caffeine  whereas verapamil and nifedipine  10 microm  were not  these results support an essential role for extracellular ca   not fulfilled by sr   in contracture induction by halothane and succinylcholine  but not by caffeine  
class5	intertrochanteric corrective osteotomy in slipped capital femoral epiphysis  a long term follow up study of 26 patients  the results of intertrochanteric corrective osteotomy in a series of 26 hips with moderate to severe chronic slipped capital femoral epiphysis are reported from follow up studies in 1976 and 1986  in hips with a slippage of less than 40 degrees  ten hips   arthrosis was present in one hip  in the remaining 16 cases in which slippage exceeded 40 degrees  osteoarthrosis was present in 15  even though correction was adequate  from these observations it can be concluded that intertrochanteric corrective osteotomy does not prevent degeneration in cases with the most severe slip  on the basis of the present observations on treated and untreated cases  the authors advocate treatment by fixation without realignment  accepting the deformity in moderate and severe chronic slips  rotational osteotomy may be considered in the event of hip joint contracture  
class5	five year postoperative results of cemented femoral arthroplasty in patients with systemic bone disease  to determine whether bone cellular abnormality affects the results of cemented femoral arthroplasty  21 patients had biopsies of the iliac crest and femoral cortex at the time of surgery  roentgenographic and histomorphometric studies were used to characterize fibrous membrane formation  cancellous bone  calcar resorption  and bone turnover  patients with high bone turnover and decreased femoral thickness and density before surgery were at risk of developing calcar resorption and cancellous diaphyses  conditions that weaken proximal stem support and lead to early failure  these findings suggest that noncemented stems may be indicated in this group  another group  osteoporotic patients  suffered from osteoblastic insufficiency  which may be the indication for the use of cemented stems rather than noncemented stems  which require bony ingrowth  
class5	trochanteric fractures  influence of reduction and implant position on impaction and complications  a review of roentgenograms and charts was made of 532 trochanteric fractures treated by the sliding screw technique  according to evans  modified classification  65  of the fractures were unstable  there was no breakage or bending of implants  twenty  3 8   reoperations were performed because of technical complications or nonunion  the singh index revealed more unstable fractures and technical complications in hips with grades 1 3 than in hips with grades 4 6  reoperation was more frequent if the screw tip was within 8 mm from the subchondral line in the superolateral quadrant or in the anteroproximal quadrant than if the screw ended farther from the subchondral line  fifty five  10 8   of the lag screws migrated 2 mm or more  postoperatively  the neck shaft angle decreased more in unstable fractures than in stable fractures  the decrease in neck shaft angle was less when the proximal fragment impinged medially on the shaft fragment  unstable fractures with this type of reduction also impacted less than hips with anatomic reduction or medial reduction of the shaft fragment  weight bearing did not significantly influence the degree of impaction  
class5	the influence of joint line position on knee stability after condylar knee arthroplasty  using a special knee testing device  ten knees obtained at autopsy were subjected to varus valgus  anterior posterior  and flexion rotation analysis in the intact state and after total knee arthroplasty  the ten knees showed no significant change in stability after knee replacement when the joint line was maintained in its natural position  when the femoral component was repositioned 5 mm proximally and 5 mm anteriorly  a significant increase in laxity occurred during midflexion  when the joint line was shifted 5 mm distal and 5 mm posterior to its anatomic location  significant tightening occurred in midrange of motion  coupled rotation of the tibia with knee flexion was decreased after surgery in all knees with no specific relationship to joint line position  coupled rotation with varus valgus testing  however  remained within the normal range through the first 30 degrees of flexion only when the joint line was restored to its normal anatomic position  stability in condylar knee arthroplasty is in part dependent on position of the joint line  surgical techniques that rely on restoring the flexion and extension gap without regard to joint line position may result in alteration of varus valgus or anterior posterior displacement in midrange flexion  
class5	pediatric spondyloarthropathies  seronegative spondyloarthropathies in childhood are often misdiagnosed as juvenile rheumatoid arthritis  but recognition of their distinct clinical manifestations and unique underlying pathophysiologies can aid in making a proper diagnosis  ankylosing spondylitis  reiter s syndrome  psoriatic arthritis  and the arthritis associated with inflammatory bowel disease are arthritides most often found in young adults  but they may also be present in children  extraarticular manifestations include inflammation of the eyes  skin  gastrointestinal tract  and genitourinary tract associated with inflammation of the entheses  the proper diagnosis will allow for treatment regimens that differ from those usually used for juvenile rheumatoid arthritis  early diagnosis and treatment often lead to an early recovery and a return to normal daily activities  
class5	the relationship between bone morphogenetic protein and neoplastic bone diseases  the monoclonal antibody against bovine bone morphogenetic protein was used for demonstration of bone morphogenetic protein  bmp  in neoplastic bone diseases  the avidin biotin peroxidase complex method demonstrated that bmp mainly exists in the cytoplasm of tumor cells of osteosarcoma and chondrosarcoma  immunostaining showed that a majority of osteosarcomas and all of the chondrosarcoma cells contained a large quantity of bmp  conversely  none of the fibrosarcomas showed positive staining  thus  it was possible to differentiate osteosarcomas from fibrosarcomas by immunostaining  in fibrous dysplasia of bone  bmp was abundant in the fibrocellular tissue that had osteogenic activity  in contrast  fibrous tissue of ossifying fibroma showed weak positive staining  only the osteoblasts rimming the bone showed a positive reaction  immunostaining showed that bmp was also detected in other neoplastic bone diseases such as osteoma  chondroma  and other tumors  
class5	the influence of growth hormone on the reversibility of articular cartilage degeneration in rabbits  growth hormone has chondrogenic affects on normal as well as on damaged articular cartilage  in this study  the influence of growth hormone is investigated on early degenerative changes in the articular cartilage in 72 new zealand white rabbits  cartilage lesions were created in femoral condyles using an immobilization model  cartilage damage was assessed using biochemical  histologic  and biomechanical criteria  growth hormone had no influence on prevention of immobilization abnormalities but had a significant affect on healing of established lesions  
class5	effects of corticosteroids on mechanical strength of intervertebral joints and vertebrae in dogs  dogs with hyperadrenocorticism had a higher incidence of intervertebral joint disease  i e   disc protrusion or spondylosis  in comparing cases of hyperadrenocorticism with age  and breed matched controls with hypothyroidism  the incidence was significantly greater than expected  this was not seen  however  in beagle dogs in which the incidence was already high and attributed to chondrodystrophoid tendencies in this breed  to investigate the pathogenesis of this association and its possible relationship to steroid induced osteopenia  adult dogs were given a placebo  prednisone  or prednisone plus calcium for six months  torque testing of intervertebral joints revealed a consistent trend of lower force to failure in both prednisone treated groups  but the difference was not statistically significant  in these dogs with mild to moderate hyperadrenocorticism  compression tests of intact vertebral bodies were not significantly different  but blocks of trabecular bone cut from the vertebral bodies failed at significantly lower compressive forces in both prednisone treated groups compared with controls  histomorphometric evaluation of lumbar vertebral trabecular bone revealed that the percentage of bone volume was not significantly decreased in the prednisone treated groups  nor was there any difference in the thickness or porosity of vertebral end plates  which might contribute to weakening of intervertebral ligamentous insertions  
class5	biomechanical comparison of single  and double pin fixation for acute slipped capital femoral epiphysis  biomechanics of pin fixation for acute slipped capital femoral epiphysis  scfe  was studied in an in vitro immature canine model  acute scfe were created in 24 paired femurs  the paired specimens were pinned with either one or two pins and loaded to failure  strength and stiffness of the paired limbs were expressed as percentages of the loads necessary to create the initial scfe in the intact specimen  strength and stiffness were equivalent statistically for the intact physis and the fractured physis fixed with two pins  single pinning was only 83  as strong and 78  as stiff as the intact physeal plate  double pin fixation is recommended over single pin fixation for acute scfe  these data  however  should not be extrapolated to the clinical situation of fixation for chronic scfe  
class5	results of treatment of tibial and femoral osteomyelitis in adults  from january 1  1971  to december 31  1985  425 patients with chronic osteomyelitis of the femur or tibia were seen at the authors  institution  the success rate in this recent experience was 84 4  compared with 50 9  in the authors  results published in 1970  a classification of chronic osteomyelitis is as follows   1  hematogenous osteomyelitis   2  osteomyelitis in united fractures  fracture with union    3  osteomyelitis in nonunion  fracture with nonunion   and  4  postoperative or posttraumatic osteomyelitis in which bone was not fractured  for management of the scarring of surrounding soft tissue  there has been a change to excision of the scarred tissue and reliance on muscle flap  free tissue transfer  or closure of soft tissues without irrigation with antibiotic solution  in recent years  free microvascular osseous grafts have permitted more aggressive resection of the involved osseous tissue  the predominance of gram negative organisms and penicillin resistant staphylococcus aureus and the occurrence of methicillin resistant s  aureus continue  
class5	ocular complications of rheumatic diseases of childhood  the association between inflammatory ocular and articular disease is a strong one  although the pathogenesis of this relationship is obscure  for the physician or surgeon caring for children with chronic arthritis  awareness of the risk of chronic asymptomatic anterior uveitis is essential if early diagnosis  treatment  and prevention of visual impairment are to be accomplished  this is particularly true for children with pauciarticular onset juvenile rheumatoid arthritis or psoriatic arthritis  acute symptomatic anterior uveitis is characteristic of disorders such as ankylosing spondylitis  whereas this disease is initially more unpleasant for the child  it has a good long term prognosis  
class5	combined laminoplasty and posterolateral fusion for spinal canal surgery in children and adolescents  spinal deformities  especially kyphosis and instability  after laminectomy for tumors and other diseases  are major clinical problems  since 1981  combined laminoplasty and posterolateral fusion for the prevention of postlaminectomy spinal deformities was performed on eight male and two female patients aged two to 26 years  average  13 9 years   the follow up period was from six months to seven years and three months  average  three years and five months   two patients died six and ten months postoperatively because of brain metastases  astrocytoma  and lung metastases  neuroblastoma   respectively  good alignment with no instability of the cervical or thoracic spine was obtained for all patients  including the two who died  laminoplasty combined with posterolateral fusion was found to be very effective in preventing the development of spinal deformities after spinal canal surgery for spinal cord tumors or other diseases in children and adolescents  
class5	comparison of quantitative sensory threshold measures for their association with foot ulceration in diabetic patients  we compared the accuracy of cutaneous pressure perception threshold measurements with that of other sensory threshold measurements for detecting diabetic foot ulcer patients  three hundred fourteen non insulin dependent diabetic patients were studied  of whom 91 had either a current foot ulcer or a history of foot ulceration  foot ulcer patients had much higher pressure perception thresholds at the hallux than those without foot ulcers  mean     se 4 63     0 05 vs  3 54     0 04 u  p less than 0 001   the magnitude of association was higher than that for vibration thresholds and markedly greater than those for cool and warm thresholds  pressure thresholds were highly accurate for identifying foot ulcer patients  at a threshold level of 4 21 u  the sensitivity was 0 84  with a specificity of 0 96  at similar sensitivities for vibration and thermal thresholds  specificities were lower  foot ulceration and cutaneous pressure perception threshold are strongly associated  pressure threshold measurements are extremely accurate and perform at least as well as other quantitative sensory tests in identifying foot ulcer patients  assessment of the foot pressure threshold may have promise as a simple and inexpensive method for detecting diabetic patients at risk for foot ulcers  
class5	measuring vibration sensations with graduated tuning fork  simple and reliable means to detect diabetic patients at risk of neuropathic foot ulceration  to find a simple and reliable means to measure vibration sensations  189 diabetic patients and 88 control subjects were tested at different sites with a graduated tuning fork  within test variation at big toes reached 8 4  in diabetic patients vs  2 2  in control subjects  mean contralateral variation was 7 5  in diabetic patients vs  2 5  in control subjects  tuning fork sensations were inversely correlated with duration of diabetes  whereas no correlation was found with hba1c levels or the severity of retinopathy  ninety nine  52   patients had vibratory sensation at big toes of less than 99th percentile of normal values for age  in addition  51  of the patients with clinical symptoms at extremities  n   67   70  of the patients without tendon reflexes  n   50   and 75  of the patients with abnormal nerve conduction velocities  n   60  also had low vibration sensations  all patients with lower limb injuries  n   7  had values at big toes of less than 2  altogether  the graduated tuning fork represents a simple and reliable alternative to quantitate vibration sensations  long term follow up of asymptomatic patients will indicate whether these abnormalities reflect underlying neuropathy  patients with abnormal values at screening will necessitate additional investigations and special foot care education programs  
class5	chiari pelvic osteotomy for osteoarthritis  the influence of the torn and detached acetabular labrum  we assessed the results of chiari pelvic osteotomy in 64 hips with early osteoarthritis in terms of acetabular labral detachment detected pre operatively by arthrography  at an average follow up of four years  assessment by the merle d aubigne score showed 83  excellent or good results  these satisfactory results were achieved in only half the cases with a detached labrum  but in nearly all cases with normal or torn acetabular labra  other factors such as the acetabular index  the level and angle of osteotomy  and the displacement following osteotomy did not affect the results  chiari pelvic osteotomy is a worthwhile procedure for early osteoarthritis in selected cases  but a detached acetabular labrum increases the risk of clinical failure  
class5	the incidence of deep vein thrombosis after cementless and cemented knee replacement  the incidence of deep vein thrombosis in 244 patients who had total knee replacement has been studied  in 120 the prosthesis was cemented and in 124 it was cementless  in all cases the replacement was primary and a porous coated prosthesis with a porous coated central tibial stem was used  deep vein thrombosis was diagnosed by venography  and pulmonary embolism by perfusion scanning  the incidence of deep vein thrombosis in the cementless knees  23 8   and in the cemented  25   was approximately the same  the only significant predisposing factors for deep vein thrombosis in both groups were obesity  prolonged postoperative immobilisation  previous venous disease and hyperlipidaemia  
class5	external fixation for type iii open tibial fractures  an analysis of 51 type iii open tibial fractures treated by external skeletal fixation is presented  the fractures are subdivided according to the classification of gustilo  mendoza and williams  1984  into types iiia  iiib and iiic  the different prognoses of these fracture subtypes is examined  the use of the hoffmann and hughes external fixators in the management of type iii open tibial fractures is presented and it is suggested that the prognosis is independent of the type of fixator used  
class5	mechanism of the pivot shift  the mechanism of the pivot shift was investigated by analysing movements under valgus torque in 29 fresh cadaveric knees  the movements were measured in three dimensions  using biplanar photography  when all the ligaments were intact  and then after the ligaments were sequentially divided  when only the anterior cruciate ligament was sectioned  the pivot shift occurred in seven out of 20 knees examined  in the other 13  though the pivot shift was not observed  an abnormal internal rotation occurred at between 10 degrees and 50 degrees of flexion  division of the iliotibial tract in addition to division of the anterior cruciate ligament stopped the pivot shift  as the tibia remained internally rotated throughout the range of flexion  the axis of rotation of the pivot shift was located at the medial collateral ligament  which was kept tight by the applied valgus torque  the sudden movement in the pivot shift was caused by a complex interaction between the geometry of the knee and the valgus torque applied  
class5	healing of non vascularised diaphyseal bone transplants  an experimental study  four different experiments were performed to study the healing of a large  non vascularised  diaphyseal  bone segment in adult cats  in the first experiment  a 4 cm segment of tibia with its periosteum was excised and replaced in its bed  the other experiments were similar  except that in the second  the periosteum of the segment was removed  in the third its medullary canal was blocked with a silastic rod  and in the last group the segment was isolated from its muscle bed by a silastic sheet  the reparative processes were quantified by estimating the resorption index  the cortical new bone formation index  the callus encasement index  and the osteocyte count  bone resorption and apposition occurred in the segment even when the periosteum was absent or the medullary canal was blocked  with osseous union at both ends by eight to 12 weeks  provided the segment was not isolated from its muscle bed  thus  the muscle bed played a significant role in these reparative processes  
class5	the management of the painful first metatarsophalangeal joint in the older patient  arthrodesis or keller s arthroplasty  we report a prospective randomised trial comparing keller s arthroplasty and arthrodesis of the first metatarsophalangeal joint for the management of symptomatic hallux valgus and hallux rigidus in the older patient  in 81 patients  110 feet   with a minimum of two years follow up  both procedures gave a similar degree of patient satisfaction and symptom relief  the incidence of metatarsalgia was also similar  as there were no obvious advantages to arthrodesis  and since six out of 50 arthrodesed toes required revision  we suggest that keller s arthroplasty is the better operation in these patients  
class5	neonatal osteomyelitis  thirty four neonates with osteomyelitis were reviewed  the hip  19  was the most common site involved  swelling and pseudoparalysis were the most significant local signs  radiographic abnormalities  such as metaphyseal rarefaction and or joint subluxation were found on the initial radiographs in 18 of the 19 hips involved  all patients were treated with antibiotics and all infections involving joints were drained surgically  good results were achieved in 75  of all sites and in 68  of hips  
class5	ultrasound guided aspiration for transient synovitis of the hip  we reviewed 15 children with transient synovitis of the hip who had aspiration of an effusion under local anaesthesia with ultrasound guidance  there were no significant complications  aspiration was useful for diagnosis and gave considerable symptomatic relief  we discuss the role of ultrasound in diagnosis and treatment  
class5	surgical treatment for severe slipping of the upper femoral epiphysis  we have used a modified technique of cervical osteotomy to treat a consecutive series of 23 patients with chronic slip of the upper femoral epiphysis  it has been successful in correcting both moderate and severe deformities with a low incidence of avascular necrosis  comparable to that seen after subtrochanteric osteotomies  we describe the operative details and discuss the features which make cervical osteotomy technically superior to intertrochanteric and subtrochanteric procedures  
class5	transient cyst like cortical defects following fractures in children  medullary fat within the subperiosteal haematoma  asymptomatic cyst like cortical defects appearing after fractures in children have been occasionally reported  typically  these defects appear during fracture consolidation  within the newly formed subperiosteal bone  proximal to the fracture line  do not enlarge  and progressively disappear  we have previously shown a fatty density on ct scan within the early cortical defect  we now present two additional cases in which early ct scans appeared to confirm that these transient cortical defects may consist of fat  and probably result from the inclusion of medullary fat within the subperiosteal haematoma  
class5	open transpedicular biopsy of the vertebral body  we describe a method of obtaining a biopsy from the body of a vertebra by an open transpedicular route  this minimises the danger of contamination of tissue planes and spaces  
class5	the modified schollner costoplasty  the modified schollner costoplasty is a cosmetic procedure for the correction of rib prominence deformity in scoliosis  we present the results of the procedure in 21 patients who had previously undergone spinal fusion for scoliosis  we found the procedure to be well tolerated without major complications  objective cosmetic improvement was achieved in all but one case  all but one patient considered the procedure to have been of cosmetic benefit  
class5	a surgical approach to the cervicothoracic spine  we describe a method for approaching the lower cervical and upper thoracic spine  the brachial plexus and related vessels  the method involves the elevation of the medial corner of the manubrium  the sternoclavicular joint  and the medial half of the clavicle on a pedicle of the sternomastoid muscle  we have used this exposure in 17 cases with few complications and good results  its successful performance requires high standards of anaesthesia  surgical technique and postoperative care  
class5	operative and conservative treatment of moderate spondylolisthesis in young patients  we made a retrospective study of 149 children and adolescents with moderate spondylolisthesis  slip less than or equal to 30    77 treated by fusion and 72 conservatively at an average follow up of 13 3 years  both groups were fully comparable with regard to age at diagnosis  sex distribution  46  girls   and mean slip  the patients who were treated operatively had more pain before treatment and showed more initial progression of the slip  they had better clinical results and less pain at latest review  but the total progression of the slip over the whole follow up showed no statistical differences between the two groups  patients with a pseudarthrosis after attempted fusion had had a longer period of postoperative pain  but at the latest review had no more pain than those with sound fusion  none of those treated conservatively came to fusion later and the long term results in 18 patients who had refused the advised operation were no worse than those for other conservatively treated patients  our results suggest that a moderate grade of spondylolisthesis in adolescents usually has a benign course  it seems that spontaneous segmental stabilisation occurs as a result of degeneration of the disc at the level of the slip  
class5	lumbar intervertebral disc prolapse in teenage twins  a case report and review of the literature  we report the cases of teenage twin girls presenting within months of each other with severe symptoms from lumbosacral disc prolapses  requiring laminectomy in one and chemonucleolysis in the other  ct scans showed similarities in spinal configuration  including the presence of disc bulges at the l4 5 level  this suggests a strong hereditary factor in prolapse of intervertebral discs  but a review of the literature showed little information on that aspect  
class5	radiographic appearances in lumbar disc prolapse  the pre operative lumbar spine radiographs of 200 consecutive patients who had undergone discectomy for prolapsed intervertebral disc were reviewed  prolapse was recognized as bulging or sequestration of the disc with consequent root compromise  measurement of the lumbar level of the interiliac line was shown to correlate with the level of disc prolapse and the incidence of transitional vertebrae at the lumbosacral junction was significantly higher than normal  a pathological value for the lumbosacral angle could not be identified  
class5	autoantibodies to the hla b27 sequence cross react with the hypothetical peptide from the arthritis associated shigella plasmid  we previously reported elevated serum antibody levels to a peptide representing the hla b27 polymorphic region  b27 peptide  in hla b27    ankylosing spondylitis  as  patients  a plasmid  phs 2  isolated from arthritogenic shigella flexneri strains had been shown to encode an amino acid sequence homologous to hla b27  rabbit antibody to this sequence  phs 2 peptide  strongly cross reacted with b27 peptide and  to a much lesser extent  with klebsiella nitrogenase peptide  serum antibody levels to phs 2 peptide were studied in 160 spondylarthropathy patients  12 of 115  10 4   as patients  2 of 45  4 4   patients with reiter s syndrome or reactive arthritis as well as 6 of 147  4 1   normal controls were shown to have elevated anti phs 2 peptide antibodies  antibody levels to b27 and phs 2 peptides were significantly correlated in 134 hla b27    patients  r   0 333  p less than 0 001   13 of 15 affinity purified anti b27 peptide antibodies from patients strongly cross reacted with phs 2 peptide  whereas only 3 weakly cross reacted to nitrogenase peptide  leucine appeared to be a critical residue for this cross reaction  as patients  anti b27 peptide antibodies reacted with hla b27 transfected l cells  these results may suggest that phs 2 peptide more efficiently  mimics  b27 peptide than does nitrogenase peptide  involvement of phs 2 in pathogenesis of spondylarthropathy through molecular mimicry mechanisms requires further study  
class5	scleroderma and l tryptophan  a possible explanation of the eosinophilia myalgia syndrome  scleroderma developed in six women who were taking l tryptophan  fasciitis and morphea were most common  but one patient had pleural effusion  hypertension  and signs of cardiac and kidney failure  in five patients the biopsy findings were characteristic of scleroderma  the sixth patient had crohn s disease and developed fasciitis  her biopsy specimen showed inflammatory arteritis  all patients  conditions improved after cessation of their l tryptophan intake  initiation of corticosteroid therapy  or both  these findings confirm previous data that show altered tryptophan kynurenine metabolism in some patients with scleroderma and fasciitis  particularly with tryptophan loading  
class5	dermatoses associated with sterile lytic bone lesions  in recent years several dermatoses  palmoplantar pustulosis  acne fulminans  and sweet s syndrome  have been associated with sterile lytic bone lesions  this article discusses the clinical  laboratory  and histologic findings of these disorders and postulates a common mechanism underlying the bone lesions  
class5	the restorative and surgical technique for the full maxillary subperiosteal implant  the edentulous atrophic maxilla represents one of the most challenging implant restorative opportunities  when prescribed within the appropriate diagnostic range and performed by a highly skilled and experienced practitioner  the full maxillary subperiosteal implant is a predictable solution for the patient with an edentulous atrophic maxilla  
class5	regenerating bone in clinical periodontics  bone autografts and allografts  various alloplastic materials  and guided tissue regeneration are used to reconstruct lost periodontal tissues  this paper focuses on controversies related to these therapeutic modalities as well as their role in periodontal regeneration  
class5	imidazole salicylate versus piroxicam in the treatment of arthrosis in elderly patients  a double blind clinical and endoscopic trial  the clinical efficacy and gastroduodenal tolerability of imidazole salicylate  imidazole 2 hydroxybenzoate  itf 182   a new synthetic drug with an anti inflammatory action  was evaluated endoscopically in comparison with those of piroxicam in elderly patients suffering from osteoarthrosis  of the 41 patients entering the trial  only 38 completed the protocol  6 men and 32 women  mean age  71  range  65 80 years   after upper gastrointestinal endoscopy for the purpose of excluding gastric and duodenal mucosal lesions  the patients were allocated at random  according to a double blind  double dummy protocol  to treatment either with imidazole salicylate 750 mg three times daily or with piroxicam 20 mg once daily for a period of 4 weeks  imidazole salicylate proved active in controlling a number of the pain symptoms caused by arthrosis  although its efficacy was inferior to that of piroxicam  grade 2 gastric mucosal lesions were detected in 1 of 20 patients  5   treated with imidazole salicylate  lesions corresponding to grades 2  3  and 4 were found in 6 of 18  33   of those treated with piroxicam  p    034   painful dyspepsia was reported by 15  of the patients in the imidazole salicylate group and by 28  of those in the piroxicam group  on the basis of these results and under the experimental conditions adopted in this trial  the authors concluded that imidazole salicylate is characterized by good gastric tolerability and can thus be used in the treatment of rheumatic diseases in the elderly  
class5	dermatomyositis  correlative mr imaging and p 31 mr spectroscopy for quantitative characterization of inflammatory disease magnetic resonance  mr  imaging and phosphorus 31 mr spectroscopy were used to examine four patients with dermatomyositis and five control subjects  t2 weighted images of the thigh muscles of patients showed increased signal intensity  with focal and inhomogeneous involvement predominantly in the vastus lateralis and secondarily in the vastus intermedius and vastus medialis  t1 and t2 values of the vastus lateralis in patients were significantly higher than those of the control subjects  t1 values of the rectus femoris and biceps femoris with more generalized inflammation were moderately elevated but still significantly higher than those of the control subjects  p 31 mr spectra of the quadriceps muscles were obtained during rest  during exercise at two graded levels  and in recovery  concentrations of adenosine triphosphate and phosphocreatine  pcr  in the diseased muscles were 30  below normal values  and the inorganic phosphate pcr ratios were increased in the patients  muscles at rest and throughout exercise  the t1 and t2 values as well as the p 31 metabolite data correlated with symptoms and clinical assessment  
class5	cytomegalovirus induced osteomyelitis in a patient with the acquired immunodeficiency syndrome  a 43 year old man with aids had a periodontal abscess  no fever  and normal findings on funduscopic examination  three months later  the abscess area was debrided  and histologic examination of the tissue revealed osteomyelitis of the mandible  within the area of osteomyelitis were numerous cells with inclusions typical of cytomegalovirus  cmv  infected cells  funduscopic examination at that time revealed extensive cmv retinitis  osteomyelitis should be added to the list of infections caused by cmv in patients with aids  
class5	sagittal plane analysis in idiopathic scoliosis patients treated with cotrel dubousset instrumentation  one hundred sixty patients with idiopathic scoliosis treated with cotrel dubousset instrumentation  cdi  underwent preoperative and postoperative sagittal plane analysis of the thoracic spine  thoracolumbar junction  and lumbar spine  the data suggest that mild to moderate improvements in thoracic hypokyphosis are possible  when crossing the thoracolumbar junction  reversal of rod bend and reversal of hooks on the derotation rod appear to provide the most physiologic sagittal contour  cotrel dubousset instrumentation to the mid and distal lumbar spine can preserve and  at times  enhance lumbar lordosis  
class5	long scoliosis fusion to the sacrum in adults with nonparalytic scoliosis  an improved method  the first 17 adults with nonparalytic scoliosis having long fusion to the sacrum treated with the luque galveston technique were reviewed  there were 3 men and 14 women  their average age at the time of surgery was 47 years and the mean follow up period was 42 months  there were no neurologic complications and no patient developed significant loss of lumbar lordosis  fusion occurred in 88  of patients  two patients developed pseudarthrosis  neither of whom had anterior fusion at the level of pseudarthrosis  the best results occurred in patients who had two stage procedures  with initial anterior lumbar fusion to the sacrum without instrumentation followed by posterior segmental instrumentation with the galveston technique of fixation to the pelvis  
class5	herniated intervertebral discs associated with unstable spinal injuries  to examine the occurrence of traumatic herniated intervertebral discs associated with unstable spinal injuries  the authors reviewed the records of all patients with spinal cord level unstable spine injuries managed at their institution over a 26 month period  ninety three patients were identified  all patients had roentgenographic and computed tomographic  ct  evaluation  magnetic resonance imaging was performed in 48 patients  and revealed the presence of a herniated intervertebral disc in 16  with the highest incidence being in the cervical spine  in the patients who had only plain film and ct scans  no disc pathology was identified  magnetic resonance imaging provides a noninvasive means of examining intervertebral disc damage in unstable spinal injuries that might otherwise be unidentified and result in spinal cord injury at the time of surgery  
class5	high levels of inflammatory phospholipase a2 activity in lumbar disc herniations  inflammation of neural elements is frequently mentioned clinically in association with lumbar radiculopathy  mechanical embarrassment of neural elements by definable structural abnormalities is inadequate as a sole explanation of nerve injury in this condition  the purpose of this study was to demonstrate whether an enzymatic marker for inflammation  phospholipase a2  could be identified in human disc samples removed at surgery for radiculopathy due to lumbar disc disease  samples were assayed for phospholipase a2 activity  the level of activity in the disc samples was compared with values obtained from other human tissues using the same assay  specific activity  percent hydrolysis radiolabelled substrate  ranged from 238 to 1 014 5 nmol min mg  mean activity for the human disc material was 568 7 nmol min mg  compared with 0 006 nmol min mg for human pmn  and 12 1 nmol min mg for inflammatory human synovial effusion  the ph and cation related activity were identical to those demonstrated for phospholipase a2 inflammatory conditions  human lumbar disc phospholipase a2 activity is from 20  to 100 000 fold more active than any other phospholipase a2 that has been described  as the enzyme responsible for the liberation of arachidonic acid from cell membranes  phospholipase a2 is the rate limiting step in the production of prostaglandins and leukotrienes  these data establish biochemical evidence of inflammation at the site of lumbar disc herniations  
class5	high lumbar disc degeneration  incidence and etiology  three hundred seventy nine consecutive magnetic resonance images  mris  with dual echo images of the entire lumbar spine were reviewed by the authors  all 379 patients presented with back pain and or leg pain  they were interviewed and examined  pain drawings were completed by all  there were 42 patients  11 1   with disc pathologies involving t12 l1  l1 2  and or l2 3 levels  six patients  1 6   had isolated disc degeneration and or herniations limited only to these high lumbar segments  the remaining 36 patients had degenerative changes of the higher discs with variable involvement of the lower lumbar discs  out of 12 spondylolistheses of l5 on s1  7 had high disc pathologies at one or more levels presenting as skipped lesions  more severe high disc lesions were noted in grade ii slips  isolated high disc degeneration is often associated with pre existing abnormalities such as end plate defects  scheuermann s disease  limbus vertebra  and so forth  and stressful cumulative work activities such as in construction workers  airplane mechanics  and so forth  high disc degeneration was noted above or below previous fractures  high disc involvement with diffuse changes in lower lumbar spine was more commonly found in ascending fashion in older age groups  and in patients who have had previous lower lumbar spine surgeries  prior fusions in particular  our findings suggest that altered mechanics are associated with the high lumbar disc pathologies  
class5	the natural history of lumbar intervertebral disc extrusions treated nonoperatively  the purpose of this study was to evaluate the natural history of morphologic changes within the lumbar spine in patients who sustained lumbar disc extrusions  all patients in this study were treated nonoperatively for radicular pain and neurologic loss  the following questions were addressed  1  does perithecal or perineural fibrosis result when extrusions are not removed surgically  and 2  do disc extrusions spontaneously resolve  and  if so  how rapidly  the study population consisted of 11 patients with extrusions and radiculopathy  all patients were successfully treated nonoperatively  all had a primary complaint of leg pain and all had positive straight leg raising reproducing their leg pain at less than or equal to 60 degrees  additionally  87  had muscle weakness on a neurologic basis in a root level distribution corresponding to the site of disc pathology  computed tomographic  ct  examinations were obtained on all patients at the inception of treatment  these studies were compared with follow up mri studies  the initial ct scans were evaluated for the following criteria  disc size and position  thecal sac effacement  nerve root enlargement or displacement  and evidence of central or intervertebral canal stenosis  in addition to the pathomorphology evaluated on the ct scans  follow up mri studies also evaluated disc hydration at the herniated and contiguous levels  and the presence of perithecal or perineural fibrosis  the following grading system was used to evaluate change in fragment size on the follow up studies  grade 1 0 to 50  decrease in size  grade 2 50 to 75  decrease in size  grade 3 75 to 100  decrease in size  
class5	metabolic bone disease in lumbar pseudarthrosis  pseudarthrosis occurs in many patients who undergo lumbar spine fusion and it has been suggested that abnormalities of bone metabolism contribute to it  the authors evaluated 47 patients with pseudarthrosis for metabolic bone disease  symptomatic patients with pseudarthrosis underwent metabolic bone evaluation  abnormal results of laboratory tests were found in 7 patients  14 9    3 low or borderline 1 25 dihydroxy vitamin d3  2 elevated 24 hour urine calcium  and 2 low serum testosterone  none of these abnormalities correlated with other clinical findings  bone density was low in 14 of 24 patients in whom it was measured  low values did not correlate with smoking or abnormal laboratory values  metabolic bone abnormalities do not appear to play a frequent or significant role in pseudarthrosis after attempted lumbar spine fusion  
class5	lumbar discography followed by computed tomography  refining the diagnosis of low back pain  two hundred fifty patients with low back pain who underwent lumbar discography followed by computed tomography  ct  are the subject of this prospective study  in 93  of the patients  these combined imaging techniques provided additional useful diagnostic information that affected patient management and the selection of treatment alternatives  lumbar discography followed by ct proved valuable in determining the significance of equivocal or multiple level abnormalities  determining the type of disc herniation  defining surgical options  and evaluating the previously operated spine  in 94  of patients who had surgery  ct discography correctly predicted the type of disc herniation as protruded  extruded  sequestrated  or internally disrupted  computed tomography discography may be more sensitive that magnetic resonance imaging  mri  in the early stages of disc degeneration because 18 of 177 discs with a normal t2 weighted image were discographically abnormal and the ct discogram revealed annular tears or radial fissuring  the radiographic morphology of the normal herniated and degenerative lumbar discs shown by ct discography gives unique insight into the pathogenesis of disc degeneration  the complications that followed the 750 discograms were one case of urticaria and one disc space infection  even with the availability of high resolution ct and mri  lumbar discography remains the only pain provocation challenge to the lumbar disc  
class5	a multicenter analysis of percutaneous discectomy  this study was performed to evaluate a group of patients undergoing percutaneous discectomy  all patients had a single level unilateral l4 5 or l5 s1 disc herniation documented on either computer tomographic  ct  scan  myelogram  and or magnetic resonance imaging  mri   average follow up after percutaneous discectomy was 16 8 months  range  2 46 months   the average hospitalization time was 1 7 days  range  1 5 days   only 21 patients  55   were able to return to work after the procedure  thirteen patients ultimately underwent surgical discectomy for continued symptoms after the procedure  the additional 4 patients did not undergo surgical discectomy and never returned to work  of those 25 percutaneous discectomy patients who did not undergo surgical discectomy  there was significantly more pain  residual weakness  and numbness compared with the patients undergoing surgical discectomy  the results of this study clearly indicate that percutaneous discectomy does not appear to be as predictable or successful a treatment modality as surgical discectomy  
class5	tryptophan induced eosinophilia myalgia syndrome eight patients who became ill while taking tryptophan had myalgia  fatigue  rash  fever  edema  alopecia  arthralgias  diminished joint motion  skin tightening  muscle cramping  and distal paresthesias  three had shortness of breath  and one had pulmonary hypertension  laboratory abnormalities included peripheral eosinophilia  leukocytosis  thrombocytosis  raised erythrocyte sedimentation rate  and elevated serum levels of aldolase  lactate dehydrogenase  and liver enzymes  of 4 chest radiographs  3 were abnormal  of 5 skin and muscle biopsies  4 showed sclerosis or mixed inflammatory cell infiltration of the dermis  subcutis  and fascia  eosinophils were often present  but vasculitis was absent  muscle inflammation was minimal  we conclude that the  eosinophilia myalgia syndrome  is related to the ingestion of tryptophan and that abnormalities in the secretion of lymphokines may be important in its pathogenesis  
class5	disc space infection  a case report with mri diagnosis  vertebral disc space infection is an uncommon cause of back pain  physical findings may be unimpressive and laboratory evaluation may only disclose an elevated erythrocyte sedimentation rate  magnetic resonance imaging is particularly useful  since it reveals abnormalities earlier than plain radiographs and is more precise than bone scan  
class5	factors influencing the development of metabolic bone disease in primary biliary cirrhosis  the prevalence  type  and factors that may influence the development of bone disease in primary biliary cirrhosis  have been investigated in 20 consecutive patients  who  in addition to liver function tests and mineral and vitamin d metabolism studies  were submitted to a transiliac bone biopsy after tetracycline double labeling for quantitative histomorphometric examination  intestinal calcium absorption was also assessed in 16 patients  seven patients  35   had reduced bone volume and were considered osteoporotic  three also had bone mineralization impairment  but did not have criteria for osteomalacia  bone formation was depressed in 15 patients  and bone resorption was low or normal in 19 cases  eroded surfaces were reduced in all osteoporotic patients  duration of primary biliary cirrhosis was significantly longer in patients with osteoporosis  6 3     0 6 yr  than in those without osteoporosis  2 6     0 6  p   0 004   moreover  osteoporosis was more prevalent in postmenopausal women  and in those who had intestinal calcium malabsorption  which was present in 80  of osteoporotic patients but in only 18  of nonosteoporotic patients  p   0 03   osteoporosis and mineralization bone impairment were unrelated to the severity of cholestasis  25 hydroxyvitamin d was significantly lower in those patients with intestinal calcium malabsorption  the results of this study indicate that osteodystrophy in primary biliary cirrhosis is characterized mainly by  low turnover  osteoporosis  which is related to the duration of the liver disease  postmenopausal condition  and calcium malabsorption  
class5	phenotypic heterogeneity in osteogenesis imperfecta  the mildly affected mother of a proband with a lethal variant has the same mutation substituting cysteine for alpha 1 glycine 904 in a type i procollagen gene  col1a1   a proband with a lethal variant of osteogenesis imperfecta  oi  has been shown to have  in one allele in a gene for type i procollagen  col1a1   a single base mutation that converted the codon for alpha 1 glycine 904 to a codon for cysteine  the mutation caused the synthesis of type i procollagen that was posttranslationally overmodified  secreted at a decreased rate  and had a decreased thermal stability  the results here demonstrate that the proband s mother had the same single base mutation as the proband  the mother had no fractures and no signs of oi except for short stature  slightly blue sclerae  and mild frontal bossing  as a child  however  she had the triangular facies frequently seen in many patients with oi  on repeated subculturing  the proband s fibroblasts grew more slowly than the mother s  but they continued to synthesize large amounts of the mutated procollagen in passages 7 14  in contrast  the mother s fibroblasts synthesized decreasing amounts of the mutated procollagen after passage 11  also  the relative amount of the mutated allele in the mother s fibroblasts decreased with passage number  in addition  the ratio of the mutated allele to the normal allele in leukocyte dna from the mother was half the value in fibroblast dna from the proband  the simplest interpretation of the data is that the mother was mildly affected because she was a mosaic for the mutation that produced a lethal phenotype in one of her three children  
class5	postpartum osteomyelitis caused by group b streptococcus  postpartum infections caused by group b streptococci are generally limited in scope  we report a case of vaginal colonization with group b streptococcus that progressed in the postpartum period to osteomyelitis that necessitated total hip replacement  the patient had no risk factors predisposing to streptococcal osteomyelitis  an altered immune status in pregnancy and intrapartum bacteremia may be involved in the pathogenesis of this infection  
class5	magnetic resonance imaging of radiation optic neuropathy  three patients with delayed radiation optic neuropathy after radiation therapy for parasellar neoplasms underwent magnetic resonance imaging  the affected optic nerves and chiasms showed enlargement and focal gadopentetate dimeglumine enhancement  the magnetic resonance imaging technique effectively detected and defined anterior visual pathway changes of radionecrosis and excluded the clinical possibility of visual loss because of tumor recurrence  
class5	early facial reanimation following radical parotid and temporal bone tumor resections  a retrospective study of 35 patients who underwent early facial reanimation following extirpative parotid and temporal bone surgery requiring facial nerve sacrifice was performed  regional facial reanimation performed immediately or within several days included 16 patients who underwent temporalis muscle transposition and 27 who underwent gold weight or eyespring lid reanimation with lower lid tightening  simultaneous nerve grafts or nerve crossover procedures were performed in 22 patients  the authors  favored approaches to facial reanimation are discussed  with an emphasis on the value of early reanimation using properly selected techniques  
class5	mandibular reconstruction with composite microvascular tissue transfer  microvascular free tissue transfer has provided a variety of methods of restoring vascularized bone and soft tissue to difficult defects created by tumor resection and trauma  over 7 years  26 patients have undergone 28 free flaps for mandibular reconstruction  15 for primary squamous cell carcinoma of the floor of the mouth or tongue  7 for recurrent tumor  and 6 for other reasons  lymphangioma  1   infection  1   gunshot wound  1   and osteoradionecrosis  3    primary reconstruction was performed in 19 cases and secondary in 9  all repairs were composite flaps including 12 scapula  5 radial forearm  3 fibula  2 serratus  and 6 deep circumflex iliac artery  mandibular defects included the symphysis alone  7   symphysis and body  5   symphysis body ramus condyle  2   body or ramus  13   and bilateral body  1   fourteen patients had received prior radiotherapy to adjuvant or curative doses  eight received postoperative radiotherapy  all patients had initially successful vascularized reconstruction by clinical examination  28  and positive radionuclide scan  22 of 22   bony stability was achieved in 25 of 26 patients and oral continence in 24 of 26  one complete flap loss occurred at 14 days  complications of some degree developed in 22 patients including partial skin necrosis  3   orocutaneous fistula  3   plate exposure  1   donor site infection  3   fracture of reconstruction  1   and fracture of the radius  1   microvascular transfer of bone and soft tissue allows a reliable reconstruction  despite previous radiotherapy  infection  foreign body  or surgery  in almost every situation in which mandible and soft tissue are absent  bony union  a healed wound  and reasonable function and appearance are likely despite early fistula  skin loss  or metal plate or bone exposure  
class5	reconstruction of mandibular defects in irradiated patients  in this prospective study  mandibular reconstruction using titanium plates was evaluated in 31 patients treated between july 1988 and january 1990  sixteen patients had prior surgery  13 had prior radiotherapy  in 11 patients  prior radiation and surgery had failed  sixteen patients received postoperative radiotherapy either in standard or accelerated fractions  twelve patients had complications of either intraoral  8   extraoral  5   or combined  1  plate exposure or fistula formation  2   factors significantly related to complications were poor nutrition  accelerated radiation  and recurrence  sixty one percent of all patients healed uneventfully  when patients with complications secondary to recurrence who subsequently died were excluded  the success rate was 73   only one patient had an unacceptable result that produced a cosmetic and functional deformity despite secondary repair  
class5	predicting the severity of cocaine associated rhabdomyolysis  study objectives  the syndrome of rhabdomyolysis associated with cocaine use has been recently described  but the incidence  severity  risk factors  and complications are unknown  this study sought to describe the spectrum of the syndrome and identify clinical features of patients at risk  design  retrospective case series with analysis of common clinical features  setting  medical emergency department of an urban teaching hospital serving an indigent population  types of participants  ed patients with acute cocaine intoxication and a serum creatine kinase  all mm  of more than 500 u l  8 3 ukat l  who were admitted for in hospital management  measurements and main results  twenty nine patients  representing 5  of cocaine related patient visits  were identified over 20 months  patients were divided into three groups  mild  characterized by anxiety  tachycardia  diaphoresis  dyspnea  or chest pain  moderate  characterized by delirium  agitation  fever  leukocytosis  or an elevated serum creatinine  and severe  characterized by seizure  coma  hypotension  arrhythmia  or cardiac arrest  there was a significant association between the rating system for level of intoxication and the severity of rhabdomyolysis and its complications  p less than  01   patients at highest risk for complications of rhabdomyolysis were those in the moderate or severe groups  conclusion  this classification system may be useful for the management of patients with acute cocaine intoxication  predicting those patients in whom aggressive therapy should be initiated in the ed to minimize the complications of rhabdomyolysis  
class5	treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol  a randomized controlled study objective  to study the efficacy of synthetic 1 25 dihydroxyvitamin d3  calcitriol  in the treatment of osteoporosis  design  two year  double blind  randomized clinical trial  setting  university medical center  patients  fifty postmenopausal women with vertebral fractures recruited by referral  intervention  calcium intake was adjusted to 25 mmol d  1000 mg d  at baseline  patients were then randomized to treatment with either calcitriol or placebo  during the study  calcium intake was reduced to 15 mmol d  600 mg d  and the dose of calcitriol was adjusted to maintain serum calcium less than 2 74 mmol l  less than 11 0 mg dl  or urine calcium less than 9 96 mmol d  less than 400 mg d   measurements and main results  after 2 years  the mean dose of calcitriol in the treated group was 0 62 micrograms d  bone mineral density of the spine increased 1 94  with calcitriol therapy and decreased 3 92  with placebo  p   0 001   total body calcium increased 0 21  with calcitriol therapy and decreased 1 85  with placebo  p   0 004   patients receiving placebo had significant decreases in spine density  p   0 0007  and total body calcium  p   0 0004   there were no differences in vertebral fracture rates between the groups  renal function studies were not statistically different between the groups after 2 years  conclusion  the treatment of postmenopausal osteoporotic women with synthetic calcitriol for 2 years was associated with increases in spine density and total body calcium  no adverse effects on renal function were seen after long term calcitriol therapy  
class5	an unusual cause of thoracic mass  a previously well 10 year old boy presented with scoliosis  a mass in the chest wall  and a pleural effusion  chest radiography showed the triad of chronic consolidation  pleural effusion  and rib periostitis  investigations confirmed thoracic actinomycosis  tissue spread was evaluated by computed tomography  it was successfully treated with benzylpenicillin  which was later replaced by clindamycin  
class5	eosinophilia myalgia syndrome  recognition of a distinct clinicopathologic entity the eosinophilia myalgia syndrome is a newly described disorder related to the ingestion of l tryptophan containing products  its presentation may mimic other disorders characterized by eosinophilia and muscle pain and or weakness  but can be differentiated by certain characteristic laboratory and pathologic findings  we report two such cases  describe their features  and review similar syndromes  
class5	eosinophilia myalgia syndrome associated with l tryptophan ingestion  analysis of four patients and implications for differential diagnosis and pathogenesis four patients fulfilling the case definition for eosinophilia myalgia syndrome are described  including one whose disease began in 1986  each displayed a variety of symptoms  one suffered principally from myalgia and recovered spontaneously on discontinuation of l tryptophan therapy  one exhibited progressive sclerodermiform skin changes  neuropathy  and myopathy  a third had prominent neuromuscular disease and sclerodermiform skin changes  and the fourth experienced profound weight loss  an axonal polyneuropathy  and perivascular lymphoid infiltrates simulating a lymphoma  evidence of t cell activation was present in peripheral blood and affected tissues during the clinically active progressive phase of disease  among other manifestations pleural effusion  cutaneous vasculitis  joint contractures  and bloody diarrhea were observed  a history of l tryptophan ingestion should be sought in patients with myalgia  fatigue  or the above outlined symptoms  
class5	congenital myopathy and cardiomyopathy with identical ultrastructural changes  a 7 day old girl with congenital hypotonia and unexplained episodes of bradycardia had a broad spectrum of similar skeletal muscle and myocardial degenerative ultrastructural abnormalities  ultrastructural studies showed obliteration of cross striations  myofilament disorganization  streaming  smearing  clumping  and zigzag z band deformities  a decrease in glycogen  mitochondria  and t tubular system occurred in the regions showing z band abnormalities of both skeletal muscle and myocardium  concurrent structural cardiomyopathy should be considered in patients with congenital myopathies  particularly with unexplained cardiac conduction abnormalities or contractile insufficiency  ultrastructural evaluation of skeletal and cardiac muscle may be necessary to define such disorders  
class5	unusual cause of  piriformis muscle syndrome   the piriformis muscle syndrome is a controversial  clinical  syndrome primarily characterized by signs and symptoms of sciatic nerve compression at the region of the piriformis muscle as it passes through the greater sciatic notch  the syndrome is often referred to  however  cases are rarely reported  and it is generally an uncommon diagnosis  of those cases reported  the incidence is six times more frequent in females than in males  and is typically temporally related to minor pelvic or buttock trauma  we describe a case of a 40 year old woman presenting with signs and symptoms suggestive of piriformis muscle syndrome following a gynecologic procedure performed in the dorsal lithotomy position  electromyographic findings were consistent with this clinical entity  operative exploration  however  revealed the source of neural compression to be a pseudoaneurysm of the inferior gluteal artery adjacent to the piriformis muscle  the diagnostic features of this clinical syndrome are discussed  
class5	imbalance between the mechanisms of activation and inhibition of metalloproteases in the early lesions of experimental osteoarthritis  levels of tissue inhibitor of metalloproteases  timp  and plasminogen activator  pa  plasmin were measured and the distribution of pa was studied by immunohistochemical techniques in cartilage and synovium samples from dogs subjected to sectioning of the anterior cruciate ligament of their right knees and sham operation of their left knees  controls   twenty three animals were divided into 3 groups and killed at 2  4  or 8 weeks after surgery  the levels of pa and plasmin were found to be significantly elevated in the osteoarthritic  oa  knee cartilage and synovium at all times after surgery  except for levels of pa in the oa cartilage at 2 weeks  there was a positive correlation between the levels of pa and plasmin in the synovial membrane  r   0 64  p less than 0 001   in oa knees  the presence of high levels of total and active collagenase was detected in cartilage and in synovium  the levels of these 2 forms of collagenase showed a positive correlation both in cartilage  r   0 65  p less than 0 001  and in synovium  r   0 77  p less than 0 001   the levels of timp in cartilage from oa and sham operated knees were similar  although the timp level was increased in the oa synovium  it was found only in trace amounts in cartilage  immunohistochemical studies revealed that both forms of pa  urokinase type pa and tissue type pa  and timp were present in oa tissues  in the synovium  they were found mainly in monocyte macrophages  synovial lining cells  and blood vessel cells  in oa cartilage  pa was present only at the superficial level in chondrocytes and in cartilage matrix  whereas timp was present in chondrocyte lacunae throughout the full thickness of the cartilage  timp was also detected in the superficial level of cartilage from sham operated knees  the results of this study indicate that in oa tissues  there are conditions that favor the synthesis and activation of metalloproteases  pa and plasmin are likely to play an important role in the physiologic activation of metalloproteases  although they are probably not the only system involved in this process  the lack of increased timp levels in the oa cartilage  in the presence of increased metalloprotease activity  is also a possible contributing factor in the enzymatic degradation of this tissue  
class5	cellular immune response toward human articular chondrocytes  t cell reactivities against chondrocyte and fibroblast membranes in destructive joint diseases  articular cartilage is one of the major targets in destructive joint diseases in humans  we studied cellular immune reactions against cartilage cell surface membranes  because it has recently been suggested that these represent possible antigenic structures  based upon the observation of autoantibodies with this specificity in certain joint diseases  a striking t cell reactivity toward chondrocyte membranes was found both in blood and synovial tissue from patients with rheumatoid arthritis  this reactivity was strongly dependent on the presence of monocytes and had all the characteristics of an antigen driven process  clonal analysis demonstrated high precursor frequencies in peripheral blood t cells that were reactive against chondrocyte membranes  this response to chondrocyte membranes greatly exceeded the t cell stimulation induced by membranes from other sources such as fibroblasts or epithelial cells  in contrast to patients with rheumatoid arthritis  individuals with osteoarthritis showed a strong peripheral blood and synovial fluid t cell response not only to chondrocyte membranes  but also to fibroblast membrane material  however  there was no reactivity to epithelial cell membranes  normal donors generally did not show significant responses to any membrane preparation  these data indicate that there is a strong t cell reactivity toward chondrocyte membranes in destructive joint disorders  and this may significantly contribute to the pathogenetic processes that occur in these diseases  
class5	relationship of glucocorticoid dosage to serum bone gla protein concentration in patients with rheumatologic disorders  serum bone gla protein  bgp  measurements in 50 rheumatic disease patients receiving long term prednisone therapy revealed an inverse relationship  r    0 71  p less than 0 001  between serum bgp levels and prednisone dosage  multiple regression analysis demonstrated significant relationships  r2   0 72  p less than 0 001  between serum bgp1 2 and prednisone dosage  dosage2  serum creatinine  age  and an age creatinine interaction  this model predicts the suppression of serum bgp with low dosages of steroids and 50  suppression with dosages of 20 25 mg day  
class5	specificity of antibodies to type ii collagen in rheumatoid arthritis  to reassess the role of autoantibodies to type ii collagen in the pathogenesis of diseases  we studied antibodies from patients with rheumatoid arthritis  ra  and from patients with relapsing polychondritis for species specificity and collagen type specificity  using an improved enzyme linked immunosorbent assay  antibodies were found in the sera of 15  of the ra patients and 50  of the relapsing polychondritis patients  as well as in the cartilage of 69  of the ra patients examined  reaction with both homologous and heterologous type ii collagens was common  analysis of 19 selected ra sera revealed that autoantibodies were generally associated with specific antibodies to some species of heterologous type ii collagen  in contrast  antibodies found in 4  of the non ra controls were specific for either bovine or chick type ii collagen  these findings indicate that autoantibody formation in ra and relapsing polychondritis may occur as a result of an immune response to heterologous type ii collagen  however  since ra and relapsing polychondritis patient sera differed in their reactivity with the cyanogen bromide digested peptides  it is possible that the clinical manifestation of collagen autoimmunity might be influenced by the epitope specificity of the antibodies  
class5	renal disease in chronic arthritis of childhood  a study of urinary n acetyl beta glucosaminidase and beta 2 microglobulin excretion  urinalyses of randomly obtained samples from children with various types of chronic arthritis revealed proteinuria in 2 3  of patients  hemoglobinuria in 3 5   erythrocyturia in 4 1   and leukocyturia in 5 3   these frequencies are within the range found by screening school children  however  raised urinary levels of n acetyl beta glucosaminidase and or beta 2 microglobulin  both sensitive measures of renal tubular damage  were found more frequently in children with chronic arthritis than in controls  p less than 0 0001   abnormalities of either n acetyl beta glucosaminidase or beta 2 microglobulin excretion were associated with active arthritis as measured by physician global estimate of disease activity  with a polyarticular onset of juvenile rheumatoid arthritis  and with the use of slow acting antirheumatic drugs or the concurrent use of more than 1 nonsteroidal antiinflamtory drug  abnormal renal tubular function appears to be common in chronic arthritis of childhood  the long term consequences of this abnormality remain to be elucidated  
class5	pseudotumor of the craniocervical junction during long term hemodialysis  a systematic study of the upper cervical spine was performed using magnetic resonance imaging in 25 patients  15 men and 10 women  who had been undergoing hemodialysis for more than 10 years  seven pseudotumors of the periodontoid soft tissue were disclosed  which were similar to the pannus recently described in rheumatoid arthritis  bone cystic radiolucencies were observed in association with these pseudotumors in 5 patients  the radiolucencies were located in the atlas  1 in the lateral mass and 1 in the anterior branch  and in the axis  3 in the odontoid process and 1 in the vertebral body   no horizontal or vertical atlantoaxial subluxation was demonstrated  these features were observed only in patients who had amyloid arthropathy  they could be a frequent  yet thus far little recognized  feature of beta 2 microglobulin amyloidosis  
class5	human immunodeficiency virus associated psoriasis  psoriatic arthritis  and reiter s syndrome  a disease continuum  the presence of peripheral arthritis and hla a  b  c  dr  and dq antigens was evaluated prospectively in 18 caucasian men with human immunodeficiency virus associated psoriasis  an asymmetric polyarthritis occurred in 32  of the patients and correlated with the presence of hla b27  extensive clinical overlap between psoriatic arthritis  psoriasis  and reiter s syndrome was noted  no significant excess of the hla antigens previously found to be associated with psoriasis was seen  which suggests that human immunodeficiency virus associated psoriasis per se may instead constitute another form of spondylarthropathy that is more closely related to reiter s syndrome  
class5	intravenous pulse cyclophosphamide therapy in myositis and sjogren s syndrome  we describe a patient with primary sjogren s syndrome who developed myositis  the results of muscle pathologic analysis before and after treatment with monthly pulses of cyclophosphamide  intravenously   are presented  
class5	alcohol and bone disease  alcohol is considered to be an important risk factor for various bone diseases but recent studies have shown that moderate alcohol intake can be beneficial to bone structure  alcohol decreases osteoblastic activity  leading to decreased bone formation and defective mineralization  the changes reported in calciotropic hormones  mainly vitamin d and parathyroid hormone  are observed due in part to a deficient intestinal absorption of vitamin d and an inadequate synthesis of its hepatic metabolite  although greater emphasis has been given to dietary deficiencies or lack of exposure to sun  the changes in parathyroid hormone are not consistent and since there is no greater incidence of hyperparathyroidism in alcoholic patients  it suggests that alcohol does not have a long term effect on the parathyroid glands  alcohol increases calcitonin secretion acutely  calcitonin is an inhibitor of bone resorption and may be the mechanism by which moderate alcohol intake protects bone structure  alcohol increases urinary calcium  magnesium and zinc excretion  zinc deficiency has been postulated as a cause of oesteoporisis because it causes hypogonadism  the decrease in the levels of the gonadal hormones and the increase of cortisol  observed in chronic alcoholics  may indirectly cause osteopenia and aseptic necrosis  to these actions must be added the acidosis due to alcohol and the greater tendency of the alcoholic to fall  all of which influence bone changes and increase the incidence of bone fractures  
class5	the effect of local deep microwave hyperthermia on experimental zymosan induced arthritis in rabbits  the effect of local deep microwave hyperthermia  ldmwh  on normal and zymosan induced arthritis has been evaluated in 12 rabbits  24 joints   ldmwh  four treatments to each joint  twice weekly for a period of 2 wk   was generated by an antenna operating at 915 mhz for 60 min  reaching an intraarticular temperature of 42 5     0 5 degrees c  a surface cooling system was used with the microwave apparatus  two weeks after the last treatment  all animals were sacrificed  the application of ldmwh on normal joints induced a limited proliferation of the synovial lining cells with a minimal perivascular infiltration of mononuclear and neutrophil cells  however  no histologic damage to the skin  muscles  bone  cartilage or bone marrow adjacent to the heated joints could be noted  induction of zymosan arthritis  2 wk before ldmwh  was characterized by pannus formation and granulomatous reaction accompanied by fibrinoid deposits and disseminated necrotic foci in the synovial intima  the ldmwh treatment on the examined arthritic joints brought about a reduction in the degree of granulomatous reaction concomitant with the appearance of some fibrocytes and fine collagen fibrils  these findings suggest that ldmwh can be safely applied  even repeatedly  without morphologic evidence of damage to any normal mesenchymal tissue  moreover  it reduces the inflammatory process in experimentally induced synovitis  
class5	pivoting larynx  an unusual clinical observation at laryngoscopy  rigid oesophagoscopy was planned in the investigation of a young patient with dysphagia  during laryngoscopy for tracheal intubation an unusual pivoting manoeuvre was required to see the vocal cords  although the initial diagnostic investigations were unhelpful  follow up directed at explaining the clinical observations led to an eventual diagnosis of anterior tubercles of c6  which explained the observation and accounted for the dysphagia  
class5	extradural abscess following local anaesthetic and steroid injection for chronic low back pain  a case is described of extradural abscess following extradural injection of local anaesthetic and steroid for the management of chronic low back pain  the common signs and symptoms are reviewed  possible causes discussed and the association with diabetes stressed  
class5	prediction of hip fracture in elderly women  a prospective study objective  to assess the relative importance of osteoporosis of the os calcis  cognisance  and mobility in the risk of subsequent fracture of the hip in elderly women  design  prospective study of elderly women in residential care over two years  setting  21 private or 38 local authority residential homes for the elderly and 4 geriatric hospitals in doncaster and hull  subjects  1414 ambulant women aged over 69  in private or local authority residential care or geriatric care  those who had had bilateral hip surgery were excluded  main outcome measures  broad band ultrasonic attenuation  bua  index  clifton assessment procedures for the elderly test  for cognisance   and mobility on a six point scale  and fracture of the hip in the subsequent two year period  results  73 women fractured their hip during the two years  their mean age was not significantly different from that of the women who did not have a fracture  85 3  sd 5 6  v 83 9  6 3   p   0 07   but their mean bua index  40 3  19 3  v 50 9  22 2  db mh2   and score for cognisance  median 19  interquartile range 10 5 27 0  v 24  17 30   were significantly lower  both p less than 0 001   these variables had independent associations with fracture of the hip  women with fractures had a significantly lower score for the psychomotor component of the cognisance test  4 5  1 8  v 7  2 10   p less than 0 0025 and were significantly more mobile  1 1 3  v 3  1 6   p less than 0 02   subdividing women according to high  medium  and low scores for bua index and cognisance testing disclosed a high risk group  118 women  with low bua index and cognisance score  whose incidence of fracture was 12 8   in the group at lowest risk  136 women  with high bua index and cognisance score  the incidence of fracture was only 1 5   relative risk 8 4  95  confidence interval  2 0 to 35 5   further analysis showed that those most at risk were  additionally  most mobile but that less mobile women with good cognisance had a low incidence of fractures  regardless of the bua index   1 2   high index  v 0 9   low index   conclusions  elderly women most at risk of sustaining hip fractures were those with low bua index  low cognisance test score  and high mobility  improving bone strength and cognisance in elderly women may reduce their incidence of hip fracture  
class5	the sulphated glycosaminoglycan levels in synovial fluid aspirates in patients with acute and chronic joint disease  proteoglycan levels were measured in a series of synovial fluid samples from patients with acute and chronic joint diseases using a modified chemical dye binding method  levels found in 50 miscellaneous inflammatory arthritis fluids  mean   173 2     90 9 micrograms ml  were higher than found in either 50 with rheumatoid arthritis  96 3     31 3 micrograms ml  or 50 with osteoarthritis  83 8     27 3 micrograms ml   for comparison  proteoglycan levels were measured in 15 cadaver synovial fluids  98 9     44 2 micrograms ml  and 12 synovial fluids from patients with sports injury  163 7     79 4 micrograms ml   patients were recruited into a trial where synovial fluid was aspirated as often as possible over a 6 month period during which the patients were followed using a number of well proven clinical parameters  no correlation was found between the degree of joint destruction as measured by x ray damage and the concentration or total amount of proteoglycan in the synovial fluid  in addition  there was no correlation between the level or total amount of proteoglycan and any clinical parameter of disease activity  
class5	patients with arthritis and anti u1 rnp antibodies  a 10 year follow up  five hundred and forty patients attending a rheumatology ward were screened for antinuclear antibodies  ana  by indirect immunofluorescence  ifl   seventy had a significant titre of ana  twenty three had u1 ribonucleoprotein antibodies  u1 rnp ab   the clinical findings in u1 rnp ab positive patients were consistent with mixed connective tissue disease  mctd   disease was more serious in the u1 rnp ab positive patients in terms of polyarthritis severity as well as mortality due to rheumatic disease  thus  in this arthritis patient population  u1 rnp ab positivity predicted an aggressive disease characterized by an erosive arthritis  
class5	diffuse idiopathic skeletal hyperostosis  dish  of the shoulder  a cause of shoulder pain  shoulder pain is a common complaint and shoulder hyperostosis a frequent radiological condition  however  little is known about the association between the clinical and radiological findings  to evaluate the clinical relevance of shoulder hyperostosis we performed a controlled  blind study of 99 hospitalized probands with and without thoracospinal hyperostosis on lateral chest x rays  the study included grading of the shoulder hyperostosis on the basis of three bilateral standard radiographs  assessing shoulder pain in a standardized way by an interviewer and recording extraskeletal causes of shoulder pain  the prevalence of shoulder hyperostosis was doubled in probands with thoracospinal hyperostosis compared to controls  chi 2   5 90  p less than 0 025  n   99   shoulder hyperostosis  irrespective of thoracospinal hyperostosis  predisposed to shoulder pain  40  versus 18   chi 2   4 06  p less than 0 05  n   74   shoulder hyperostosis in combination with thoracospinal hyperostosis  shoulder dish  predisposed to shoulder pain to an even greater extent  46  versus 12   chi 2   6 64  p less than 0 01  n   47   we conclude that shoulder hyperostosis is a radiological finding of potential clinical relevance  
class5	a clinical epidemiological study in low back pain  description of two clinical syndromes  in 100 patients with mainly chronic low back pain  lbp  signs and symptoms were evaluated prospectively and without preconceived expectation of particular findings  two clinical syndromes were distinguished  both characterized by  typical local tenderness  and associated with specific clinical features  these syndromes  described previously in the literature but receiving scant attention  were named the greater trochanteric pain syndrome  trochanteric bursitis  and the iliac crest pain syndrome  iliolumbar syndrome   and occurred in 35  and 43  of the patients  respectively  the recognition of these syndromes may enable us to study aetiology  prognosis  and therapy of lbp in more homogeneous groups of patients  
class5	lesions of the mid shaft of the humerus presenting as shoulder capsulitis  we describe three patients who presented with pain and restriction of movement at the shoulder suggestive of capsulitis  but proved to have lesions of the mid shaft of the humerus  it is important to be aware of the possibility of this cause of a  frozen shoulder   since radiographs of the shoulder are usually cropped at the mid humerus and lesions at this level may easily be missed  a radiograph of the entire humerus  or an isotope bone scan  may be more useful than repeated shoulder radiographs in patients whose shoulder symptoms do not respond to standard treatment  
class5	abdominal wall pain  an alternative diagnosis  the cause of abdominal pain need not necessarily reside in the viscera  the abdominal wall is another source of symptoms  some causes of abdominal wall pain are obvious  e g  hernias  but not so others such as nerve entrapment syndromes  this review is concerned with causes of abdominal wall pain which  although common  may be easily overlooked  
class5	cemented total knee arthroplasty for gonarthrosis in patients 55 years old or younger  the results of 68 cemented total knee arthroplasties  tkas  in 50 patients with gonarthrosis who were 55 years old or younger at the time of surgery were reviewed  these patients were operated on between 1979 and 1987 and were followed for an average of 6 2 years  the average age of the patients was 50 years  patients were evaluated by the hospital for special surgery knee score  the average preoperative score was 53  and the average follow up score was 90  overall  55 tkas were rated as excellent and 13 as good  using the knee rating score advocated by the knee society  the average postoperative score was 92 for pain and 84 for function  there were four successful reoperations for patellar component loosening  all in metal backed patellae  the femoral and tibial components in these patients were intact  and at the follow up period  two knees were rated as excellent and two as good  detailed roentgenographic evaluation demonstrated that 20  of tibial components had radiolucencies in at least one zone on the anteroposterior roentgenogram and in 11  on the lateral roentgenogram  femoral radiolucencies occurred in only 2  of knees  patellar radiolucencies in one or more zones occurred in 20  of knees that had not had patellar revision  no complete or progressive radiolucencies at the bone cement interface were noted for any component  and no components were considered to be roentgenographically loose  cemented tkas can achieve excellent long term results in patients younger than 55 years old with gonarthrosis of the knee  these results compare with those obtained in published reports on older age groups  
class5	total knee arthroplasty in diabetes mellitus  a retrospective study was done of 59 total knee arthroplasties  tkas  in 40 patients diagnosed with diabetes mellitus  the overall infection rate was 7   with an overall revision rate of 10  and an average follow up period of 4 3 years  wound complications were present in 12  of the tkas  the rate of deep joint infections in diabetic patients was statistically higher than the reported incidence of sepsis in nondiabetic patients  therefore  maximum precautions should be taken for diabetic patients having tka to minimize both wound complications and joint sepsis  
class5	bone loss in the distal anterior femur after total knee arthroplasty  bone loss in the distal anterior femur in asymptomatic total knee arthroplasty  tka  patients has been noted roentgenographically and during revision surgery  a retrospective roentgenographic review of 147 tka cases was carried out to document bone loss  the influence that the mode of fixation  porous coated and cemented  and the implant design have on bone loss was examined  the time of onset and the progression of bone loss were studied  bone loss occurred in the distal anterior femur in the majority of cases reviewed  68    the prevalence of bone loss was independent of the mode of fixation and the implant design  by qualitative observation  roentgenographically detectable bone loss occurred within the first postoperative year and did not progress further  previously three dimensional finite element analysis demonstrated that the replacement of the bearing surface of the femur with a stiff metallic implant reduces the stress in the distal anterior femur by at least one order of magnitude  it is therefore speculated that the observed bone loss results from stress shielding  the apparent lack of progression may reflect the development of a new remodeling equilibrium under the altered stress conditions  the bone loss in the distal anterior femur described has not been implicated as a source of failure  however  since the bone strength in the femoral region is compromised as it becomes osteopenic  bone failure may occur with longer periods of cyclic loading  furthermore  as a result of bone loss  revision arthroplasty may be more difficult  
class5	a sequential three step lateral release for correcting fixed valgus knee deformities during total knee arthroplasty  an approach to mild  moderate  and severe fixed valgus deformities of the knee is described  the sequential approach to soft tissue releases in the fixed valgus knee allows the surgeon to regain a neutral alignment in valgus deformities of up to 90 degrees  an additional benefit of the approach is spontaneous correction of fixed external tibial rotation deformities  using this approach  early and late stability allows the use of unconstrained knee implants  including those with mobile bearing elements  
class5	anterior acromioplasty for treatment of the shoulder impingement syndrome  between 1975 and 1979  anterior acromioplasty was performed in 65 patients with 66 involved shoulders  the procedure appears to be safe and reasonably effective  of the 65 patients in this study  50 had chronic tendon inflammation with fibrosis  and 16 also had a small supraspinatus tendon tear  these 16 had rotator cuff repairs  twenty six patients were also treated with distal clavicle excision  and seven had tenodesis of the long head of the biceps brachii  the average age of the patients was 50 years  range  23 75 years   all patients were followed for an average of eight years  range  three to 13 years   at final evaluation  no or slight pain was present in 77  of the shoulders  39 of 50 without tendon tearing and 12 of 16 with tendon tearing and repair  active shoulder abduction averaged 167 degrees  ninety two percent returned to employment  including 18  with some job modification  eighty six percent returned to recreational athletics  20  with some modification of activities  seven patients had additional surgical treatment  the progression of rotator cuff disease is not always prevented  but the need for subsequent shoulder treatment generally decreases  
class5	humeral head retroversion in patients with unstable humeroscapular joints  humeral head retroversion and shoulder rotation in both the frontal and scapular plane were studied in 34 patients with anterior glenohumeral instability  twenty two patients had traumatic anterior shoulder dislocations and another 12 patients had nontraumatic dislocations with generalized joint laxity  patients with traumatic recurrent dislocations had a smaller than normal retroversion angle in the unstable shoulder  the angles were 26 degrees on the dominant side and 23 degrees on the nondominant side compared with 33 degrees and 29 degrees  respectively  in normal shoulders  the stable contralateral shoulder joint was clinically and roentgenographically similar to the normal shoulder  the patients with nontraumatic dislocations had increased rotation and smaller retroversion angles  irrespective of stability in the shoulder joint  the retroversion angles were 18 degrees for unstable shoulders on the dominant side and 15 degrees on the nondominant side  the retroversion angle of the stable contralateral joint in these patients was less in five of eight shoulders  
class5	chondrosarcoma complicating total hip arthroplasty in maffucci s syndrome  a 70 year old woman who was followed for 60 years for maffucci s syndrome required a total hip arthroplasty  tha  of the right hip for degenerative arthritis  this did not relieve pain  three years later  chondrosarcoma of the femur developed around the femoral component and was fatal  the roentgenographic changes after the tha were incorrectly interpreted as being caused by infection  
class5	total hip arthroplasties in patients younger than 45 years  a nine  to ten year follow up study  eighty one cemented total hip arthroplasties in patients younger than 45 years were reviewed with an average 9 2 year follow up interval  the results were compared with the same group previously reported at an average follow up time of 4 5 years  clinically satisfactory results were 58  compared with 78  at 4 5 years  the revision rate almost tripled to 33   impending failure was present in 56  of those hips not yet revised  in the first study  technique was a primary determinant of success  in this report there was no influence of technique on the incidence of revision  age did not influence revision rates either  with 35  in patients younger than 30 years and 32  in patients aged 30 45 years  patients younger than 30 years had fewer satisfactory clinical results and a higher rate of impending failure  as in the first study  the best results were obtained in patients with inflammatory collagen disease aged from 30 to 45 years  
class5	giant cell reparative granuloma of the hand and foot bones  giant cell reparative granuloma  gcrg  is an uncommon benign reactive intraosseous lesion  it occurs in the skull  jaw  hand  foot  and facial bones and rarely in other skeletal sites  it is a solitary  lytic  expanded lesion and infrequently may extend into the surrounding soft tissue  histologically  it is composed of fibrous stroma with spindle shaped fibroblasts  multinucleated giant cells  and inflammatory mononuclear cells  areas of hemorrhage are uniformly present  it may be difficult to distinguish this entity from an aneurysmal bone cyst  giant cell tumor  or brown tumor of hyperparathyroidism because of roentgenographic and histologic similarities  accurate diagnosis is essential for appropriate treatment  serum calcium  phosphorus  and parathyroid hormone levels should be measured  curettage and bone graft are effective treatments for both primary lesions and recurrences  second recurrences are rare  
class5	primary inflammatory reaction in synovial fluid and tissue in rabbit immobilization osteoarthritis  the kinetics and composition of the primary cellular inflammatory process were studied in the synovial fluid  sf  and synovial tissue  st  compartments of a rabbit knee immobilization osteoarthritis model  immobilization induced rapid migration of neutrophils  59      26  of all cells  into sf in three days  which was accompanied by nonspecific esterase positive monocytes  71      8  of all mononuclear cells   this finding suggests that non specific inflammation mediated by phagocytic leukocytes predominates the cellular response in the sf compartment  in contrast  morphometric analysis of st proper showed an inflammatory mononuclear cell response  the intensity of which diminished over time during the study period from day 3  416     59 cells per 0 049 mm2 st tissue  through day 10  305     32 cells  to day 35  174     36 cells   a dotlike t pattern alpha naphthyl acetate esterase  anae  was found in the t cell dependent areas of secondary lymphatic tissue in the spleen  enabling immunocytologic anae marker studies  the st response in situ was predominated by tissue macrophage  though infiltrates rich in t lymphocytes were present in the immediate sublining stroma  there was a significant correlation between the intensity of the sf cell response  total recovery  and the percentage of neutrophils  but there was no correlation between the intensity of the st response and the proportion of t lymphocytes  these t cell accumulations together with the local proliferation of fibroblastlike lining cells and stromal fibroblasts suggest that the primary inflammatory cell response is not caused by either wear and tear or mechanically by cartilage fragments  
class5	comparison of patellar resurfacing versus nonresurfacing in bilateral total knee arthroplasty  twenty five patients who received bilateral total knee prostheses were studied to evaluate the advantages and disadvantages of patellar resurfacing  only patients with advanced patellofemoral disease were included in the study  in all patients  patellar resurfacing had been done in the right knee but not in the left knee  the depuy porous coated implant was used in all cases  subjective criteria were compared with objective criteria  which included range of motion  knee flexion and extension  and roentgenographic evaluation  the findings in this study suggest that patellar resurfacing can offer the patient a superior knee with regard to pain relief and strength  
class5	the inwardly pointing knee  an unrecognized problem of external rotational malalignment  twelve patients with inwardly pointing knees had chronic knee pain and disability suggestive of patellofemoral subluxation  none had responded well to conservative measures or surgical correction at the level of the soft tissues  their pattern of limb alignment was studied roentgenographically and was found to differ significantly from the control group of 49 healthy young adults  the deformities primarily related to the tibia were external tibial torsion  excess varus angulation of the tibial plateau  and varus knees  angulation of the femoral condyles was normal and femoral anteversion did not appear to contribute significantly to the deformity  surgery in seven cases  nine knees  was by derotation valgus maquet osteotomy of the tibia and lateral release realignment of the patellae  outcome assessments after a three year follow up period  five knees  were excellent  early results on the remaining cases were satisfactory  
class5	late recurrence of varus deformity after proximal tibial osteotomy  one hundred thirteen knees with medial gonarthrosis in 95 patients were treated by valgus producing proximal tibial osteotomy and followed clinically and roentgenographically for a minimum of five years  mean  6 3 years   sixty four knees  57   were pain free or had only mild discomfort when walking  the standing femorotibial angle decreased from a postoperative average of 9 3 degrees valgus to 7 8 degrees valgus at the final follow up examination  the tendency for varus recurrence greater than 5 degrees and for medial  or lateral compartment arthritic progression was evaluated using the kaplan meier survival method  varus recurred in 18   lateral compartment arthritic progression in 60   and medial compartment arthritic progression in 83  by nine years after surgery  the probability of arthritic progression is much higher than the probability of significant varus recurrence in long term roentgenographic follow up studies of patients with valgus producing proximal tibial osteotomies  
class5	two  to four year results of posterior cruciate sparing condylar total knee arthroplasty with an uncemented femoral component  one hundred fourteen hybrid press fit condylar total knee arthroplasties  tkas  were reviewed an average of 2 8 years after surgery to determine if this method of implantation provided satisfactory results compared with conventional cemented tkas  ninety three percent of the knees had good or excellent results  and 94  of the knees had at most only mild or occasional pain  one knee with a metal backed patella was revised for mechanical failure of the patellar button  roentgenographic analysis of the femoral component interface showed that 30  of knees had a radiolucent line in at least one zone  however  none of the lines was wider than 1 mm  and none was about the central stem  there were no signs of loosening about any of the components  it was concluded that hybrid tka provides a good and predictable result that is comparable to cemented tka  
class5	fetal imaging in the skeletal dysplasias  second trimester diagnosis of fetal skeletal dysplasia is becoming increasingly common  by careful examination of the fetus for skeletal mineralization  shape and size of long bones and cranium  and abnormalities of other organ systems  a definitive diagnosis can often be achieved by ultrasound  fetal radiography is very helpful in giving more information about bone shape and mineralization as well as in confirming the diagnosis  subsequent obstetric management should be dictated by the natural history of the disease  the parents  wishes  and the gestational age at diagnosis  because many of these disorders have a high recurrence risk  genetic counseling and follow up are an important part of the management of these patients  
class5	does alternate day cloprednol therapy prevent bone loss  a longitudinal double blind  controlled clinical study  osteoporosis is a serious side effect of systemic treatment with steroids  cloprednol  a synthetic glucocorticoid with an anti inflammatory potency twice that of prednisone  causes less calcium and nitrogen excretion than does prednisone in equipotent doses  therefore a double blind study was undertaken comparing the effects of alternate day cloprednol and prednisone therapy on bone mineral density in 39 patients  cloprendol  13 men and 8 women aged 48 5     2 8 years  prednisone  9 men and 9 women aged 49 7     1 7 years  with lung diseases  ten patients with asthma  9 men and 1 woman aged 37 8     3 7 years  inhaling daily beclomethasone served as control subjects  trabecular and total bone density of the distal tibia and radius was determined quarterly during 1 year with a special purpose computed tomographic system  initial mean trabecular bone density of the patients receiving cloprednol and prednisone was 17  below normal  after a treatment period of 1 year  we found a loss of radial trabecular bone density  mean     sem  of 1 33      0 49  in the cloprednol group and 2 38      0 69  in the prednisone group  in postmenopausal women  prednisone but not cloprednol therapy caused significant  p less than 0 01  trabecular bone loss  5 29      0 99  versus 0 70      0 65    the control group lost 0 91      0 79   loss of cortical bone was insignificant in all three groups  in post menopausal women  1 year of alternate day cloprednol therapy was associated with significantly less bone loss than was prednisone therapy in equipotent dosages  
class5	studies of the porcine intestinal calcitriol receptor in pseudo vitamin d deficiency rickets type i  1  calcitriol  1 25 dihydroxyvitamin d3  concentrations in plasma of humans and pigs with pseudo vitamin d deficiency rickets type i  pvdri  have been reported to be significantly lower than in normal subjects and animals  sometimes  however  calcitriol concentrations are relatively high in these subjects and animals  50 80 pmol l  and nevertheless clinical symptoms of rickets develop  we have studied whether or not the development of rachitic lesions in piglets with pvdri is due to altered binding properties of the intestinal calcitriol receptor in addition to the defective renal production of calcitriol  pvdri piglets with clinical and biochemical symptoms of rickets  hypocalcaemia  increased activity of alkaline phosphatase  and with calcitriol concentrations in plasma of 83 7     4 2 pmol l  n   7  were used  they were compared with unaffected piglets with normal calcitriol concentrations  178 0     17 7 pmol l  n   9   2  the equilibrium dissociation constant  kd  of the receptor in the pvdri piglets  0 31     0 05 nmol l  and in control piglets  0 33     0 05 nmol l  and the maximum binding capacity  bmax    674     103 and 719     122 fmol mg of protein  respectively  were not different  n   9   3  the association rate constant  kass  at 4 degrees c  0 15 x 10 7  and 0 24 x 10 7   mol l  1 min 1  and the dissociation rate constant  kdiss   0 40 x 10  3  and 0 48 x 10  3  min 1  half life of dissociation   24 1 and 28 9 h  respectively  were also not different between diseased and control piglets  
class5	kyphoscoliosis and respiratory failure  a patient treated with assisted ventilation for 27 years  a 62 year old woman had had kyphoscoliosis since age 12 years  respiratory failure developed at age 35 years following a respiratory infection  a tracheostomy was done and she required assisted ventilation using a respiratory  bird   many attempts at weaning her from the ventilator were unsuccessful  she has remained dependent on assisted ventilation for more than 27 years but has had a relatively comfortable and meaningful life  in 1983  a left pleuroscopy was done related to recurrent pneumothorax and numerous small bullae were seen on the lung surface  recent investigation using computed tomographic scanning has shown patchy areas of emphysema in both lungs  emphysema is not a feature of kyphoscoliosis and it is suggested that intermittent positive pressure applied to the lung over long duration may cause the lung destruction of emphysema  
class5	macrophage colony stimulating factor restores in vivo bone resorption in the op op osteopetrotic mouse  the op op variant of murine osteopetrosis is a recessive mutation characterized by impaired bone resorption due to lack of osteoclasts  cultured osteoblasts and fibroblasts from this mutant do not secrete m csf activity and resident macrophages are absent in bone marrow  this failure has been related to a mutation within the m csf coding region  we report now that the administration of recombinant human m csf  rhm csf  corrects in vivo the impaired bone resorption in this animal  the treatment restores the bone marrow cavity virtually absent in the op op animal and induces the appearance of resorbing osteoclasts and of resident bone marrow macrophages  this proves that the deficiency of m csf is the cause of the op op bone disorder and that this cytokine is directly or indirectly necessary for physiological osteoclastogenesis  the resulting bone resorption and for the establishment of bone marrow hemopoiesis  
class5	soft tissue rheumatism of the upper extremities  diagnosis and management  upper extremity tendinitis and bursitis are usually the result of repetitive microtrauma  probably resulting in disruption of fibers  a focus of inflammation often occurs  producing pain  spasm  and disability  with a careful history and physical exam  the diagnosis can be made  distinguishing soft tissue rheumatism from arthritis  treatment consists of rest  heat or ice  and frequently  the use of non steroidal anti inflammatory drugs or injections to control the inflammatory response  protection from repeated trauma may be beneficial in preventing recurrence  
class5	calcium absorption in bone disease associated with chronic cholestasis during childhood  fractional absorption of calcium was determined in 9 children aged 4 9 to 16 9 yr with chronic cholestatic liver disease to determine the role of calcium malabsorption in the development of metabolic bone disease  radiological evidence of rickets was absent in all patients  but bone density  measured by single beam photon absorptiometry of the distal radius  was reduced in eight of nine subjects  serum calcium and phosphorus concentrations were normal in all except one subject  serum 25 hydroxyvitamin d concentration was decreased compared with controls in only one of nine patients  but serum 1 25 dihydroxyvitamin d concentrations were diminished in seven of nine subjects  in all subjects  dietary calcium and phosphorus intakes were greater than 80  of the rda  fractional absorption of calcium  determined by oral and intravenous administration of stable calcium isotopes  was similar in cholestatic compared with control subjects  37 1      12 5  vs  34 0      16 4    in the cholestatic subjects  calcium absorption correlated with serum 1 25 dihydroxyvitamin d  r   0 871  p less than 0 002  but not 25 hydroxyvitamin d concentrations  calcium balance  assessed by the duplicate diet method  was positive in four of five subjects  anthropometric measurements were performed to examine the relationship between nutritional status and bone mineral content  heights of all subjects were less than or equal to the 10th percentile and fat stores and somatic protein stores were less than the 25th percentile in six of nine subjects  we conclude that factors other than calcium malabsorption and decreased serum 25 hydroxyvitamin d concentration contribute to diminished bone mass in children with cholestatic liver disease  
class5	results of treatment of displaced patellar fractures by partial patellectomy  the results of partial patellectomy as a treatment for displaced patellar fractures were assessed retrospectively with use of clinical  radiographic  and isokinetic strength testing criteria  forty patients who had been followed for an average of 8 4 years were studied  in the extremity that had been operated on  the mean active range of motion was 94 per cent  the circumference of the thigh was 100 per cent  and the strength of the quadriceps was 85 per cent of these measurements in the contralateral extremity  the over all result was rated as excellent in twenty patients  good in eleven  fair in six  and poor in three  there was a significant statistical correlation between the type of fracture and the outcome  the results of this study indicate that partial patellectomy can be an effective treatment for selected patellar fractures  
class5	arthrometric evaluation of knees that have a torn anterior cruciate ligament  we used the kt 1000 arthrometer to test the knees of 107 patients who had an acute tear of the anterior cruciate ligament  153 patients who had a chronic tear  and 141 control subjects  for a total of 401 individuals  the three testing parameters were the extent of anterior translation at eighty nine newtons of force and at maximum manual force  and the compliance index  the differences between the involved and the uninvolved knees were calculated  at eighty nine newtons  all but one of the control subjects had anterior translation of ten millimeters or less  compared with 58 per cent of the patients who had a chronic tear  at maximum manual force  all but two of the control subjects had translation of ten millimeters or less  compared with 20 per cent of the patients who had an acute or a chronic tear  analysis of variance showed that the clinical diagnosis correlated well with the results for all tests  p less than 0 001   however  when the uninjured knees of patients who had an acute or a chronic tear were compared with the knees of the control subjects  significant differences were noted  p less than 0 001 to 0 006   in the patients who had a chronic tear  there was no relationship between the time from injury to operation and the extent of anterior translation  the arthrometric test at maximum manual force was the strongest discriminant  it differentiated normal from abnormal knees  p less than 0 001  with high sensitivity  92 per cent   high specificity  95 per cent   and high positive predictive accuracy  the cut off point was eleven millimeters or less  
class5	measurement of anterior posterior displacement of the knee  a comparison of the results with instrumented devices and with clinical examination  thirteen subjects who had normal knees and fifteen patients who had a chronic rupture of the anterior cruciate ligament were tested in order to compare the measurements of tibiofemoral displacement as recorded by four commercial devices  the acufex knee signature system  the genucom knee analysis system  the medmetric kt 1000 arthrometer  and the stryker knee laxity tester  anterior and posterior displacement were measured at forces of eighty nine newtons  twenty pounds  and 133 newtons  thirty pounds   we found significant differences in reproducibility of measurement among the devices  the acufex  medmetric  and stryker devices had more reproducible measurements  and they could be used to identify 80 to 90 per cent of the normal subjects and anterior cruciate deficient patients  the genucom device had poorer reproducibility of measurement  and it tended to register greater differences in displacement between the right and left knees of normal subjects  
class5	evaluation of an electrogoniometric instrument for measurement of laxity of the knee  eight lower extremities from cadavera were tested for anterior posterior laxity in two positions before and after transection of the anterior cruciate ligament  at critical points in the tests  electrogoniometric and radiographic measurements of tibiofemoral translation were compared  by direct measurement  we determined the accuracy of the radiographic method to     0 4 millimeter  95 per cent  in measuring anterior posterior translations of the tibia with respect to the femur  the electrogoniometer estimated displacement of the tibia with respect to the femur during the anterior drawer test to be 3 5     8 2 millimeters at 90 degrees of flexion of the knee and 11 1     16 1 millimeters at 30 degrees of flexion  direct comparison of these measurements with those obtained by means of the radiographic technique showed that the electrogoniometer tended  on average  to overestimate the tibial translation  the amount of overestimation was 0 7 millimeter for intact knees and 1 9 millimeters after sacrifice of the anterior cruciate ligament  despite this small average error in measurement of tibial translation  the difference between individual electrogoniometric and radiographic measurements varied greatly  with a 95 per cent confidence limit of     5 5 millimeters  the error of the electrogoniometric measurements varied with the angle of flexion of the knee during testing  both the accuracy and the reliability of the electrogoniometric measurements being greatly diminished at 30 degrees of flexion  the electrogoniometric method also tended to overestimate tibial internal rotation  by an average of 10 5 degrees  and external rotation  by an average of 9 3 degrees   the reliability of these measurements was     6 9 degrees  
class5	use of a knee brace for control of tibial translation and rotation  a comparison  in cadavera  of available models  we assessed the relative restraints that are provided by fourteen currently available functional knee braces  using six limbs in cadavera  the tests were made at 30 and 60 degrees of flexion of the knee  and a mechanical loading system applied loads that caused anterior posterior translation and internal external rotation  the braces limited abnormal tibiofemoral displacements by 10 to 75 per cent in translation  there was more variation in rotation  this study demonstrated that functional knee braces provide a restraining influence that may be beneficial in the control of abnormal displacements of the knee  but that the degree of restraint varies considerably  
class5	hypertension after operative correction of club foot deformity  severe hypertension occurred as a postoperative complication after correction of a club foot deformity in four children  seven feet  who were between the ages of two and three years and had no history of hypertension  the hypertension subsided slowly after administration of antihypertensive medications or more rapidly after release of the correction that had been obtained operatively  
class5	the lateral approach for operative release of post traumatic contracture of the elbow  a lateral approach was used to release a post traumatic contracture of the elbow in seven patients  and the results were evaluated an average of thirty eight months postoperatively  extension improved from an average flexion contracture of 45 degrees preoperatively to one of 12 degrees postoperatively  and the average point of maximum flexion increased from 116 degrees preoperatively to 129 degrees postoperatively  the average arc of motion increased 46 degrees  all patients began using a continuous passive motion device immediately after the operation  there were no problems with wound healing or formation of heterotopic bone  
class5	arthrodesis of the ankle with cancellous bone screws and fibular strut graft  biomechanical analysis  the stability of an arthrodesis with two cancellous bone screws across the ankle joint was evaluated in eighteen ankles from fresh frozen cadavera  tibiotalar motion was recorded in response to the following loading modes  medial lateral moment  plantar flexion dorsiflexion moment  and internal external tibial torque  the series of loading tests was performed with two cancellous bone screws through the tibia into the talus and a lateral fibular strut graft fixed with a proximal and a distal screw  the tests were repeated after the strut graft was removed  and again after it had been reapplied  the amount of motion at the site of the arthrodesis was greatest with tibial torque and was least with medial lateral bending  this was true for specimens with or without a fibular strut graft  removal of the strut graft allowed increased tibiotalar motion for all modes of loading  increases in motion were far greater for specimens of poor bone quality  
class5	spondyloepiphyseal dysplasia of maroteaux  the cases of four patients who had an unusual clinical entity of disproportionately short stature  referred to as spondyloepiphyseal dysplasia of maroteaux  are described  in patients who have this syndrome  the abnormalities are confined to the musculoskeletal system  the patients do not have corneal opacities or increased excretion of keratosulphate  the mode of transmission appears to be autosomal dominant  platyspondylysis is present but there are no anterior tongue like deformities of the vertebral bodies  because of the presence of spondyloepiphyseal dysplasia and normal intelligence  and the lack of abnormalities at birth  this entity seems to mimic morquio syndrome  however  unlike morquio syndrome  the disorder involves no biochemical abnormalities  thus  the entity may be classified as new  
class5	the patellofemoral joint after total knee arthroplasty without patellar resurfacing  one hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years  eighty four per cent of the knees were affected by osteoarthrosis  graded according to the knee rating system of the hospital for special surgery  there were eighteen excellent  fifty three good  eighteen fair  and eleven poor results  at the most recent follow up  twenty nine knees  29 per cent   nine of which were affected by rheumatoid arthritis  were still painful in the patellofemoral area  the height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively  small patients who had osteoarthrosis were exceptionally free of pain  regardless of sex  age  or level of activity  it seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain  are more than 160 centimeters tall  weigh more than sixty kilograms  and have advanced changes in the patella at the time of the operation  
class5	thyroid abnormalities in the mccune albright syndrome  ultrasonography and hormonal studies  hyperthyroidism and goiter have been reported frequently in association with the mccune albright syndrome  mas   to assess the prevalence and extent of thyroid abnormalities in girls with mas  we studied 19 patients  mean age  6 6     1      se  yr  mean bone age  9 5     1 yr  and 18 normal control girls  mean age  10 3     0 5 yr   all patients appeared euthyroid when examined  1 was taking antithyroid medication  ultrasonography revealed thyroid abnormalities in 7 patients  including generalized inhomogeneity  small  2 4 mm  and large  greater than 10 mm  hypoechoic regions  and echogenic nodule like regions  repeat ultrasonography after intervals of 9 18 months showed enlargement of large hypoechoic regions in 2 patients  in the patients with abnormal ultrasound findings  serum tsh was uniformly low or suppressed both at baseline and after administration of 7 micrograms kg trh  the mean serum t3 level in this group was significantly higher than that in controls  2 9     0 2 vs  2 3     0 1 nmol l  p less than 0 05   whereas mean serum t4  free t4  and t4 binding globulin levels did not differ from those of controls  in the remaining 11 patients  thyroid ultrasonography was normal  and the serum levels of t3  t4  free t4  and tsh were normal  bioassay showed no detectable thyroid stimulating activity in the plasma of the mas patients with suppressed tsh levels  none of the patients became overtly thyrotoxic over 3 6 yr of observation  and their serum iodothyronine levels remained stable  we conclude that thyroid dysfunction is common in girls with mas  but that it may be clinically occult and not rapidly progressive  the thyroid dysfunction  like that of the ovaries  is associated with structural abnormalities in the gland itself  together with suppressed levels of the respective stimulating hormones  
class5	mandibular osteomyelitis in a patient with sickle cell anemia  report of case  a case is presented in which mandibular osteomyelitis and mental nerve paresthesia developed in a patient with sickle cell anemia  this infection appeared to precipitate a sickle cell crisis  the mechanisms for these patients  propensity to infection and the diagnosis and management of sickle cell osteomyelitis of the jaws are discussed  
class5	musculoskeletal impairments and physical disablement among the aged  this article summarizes the results of a longitudinal investigation of the progression of sight  hearing  and musculoskeletal impairments and their association with change in physical disability  in 10 adls among members of the massachusetts health care panel study  the findings confirm widely held clinical beliefs that specific types of musculoskeletal decrement are an important cause of physical disability among older persons  decrement in hand function is a significant musculoskeletal impairment influencing limitations in basic adl  and progression of instrumental adl dysfunction is influenced by progression of lower extremity impairments  progression of sight and hearing impairments was not associated with change in physical disability  musculoskeletal impairments  one of the most prevalent and symptomatic chronic complaints of middle and old age  deserve increased attention from epidemiologists  disability researchers  and clinicians seeking ways to prevent disablement among the aged  
class5	monosodium urate crystals stimulate phospholipase a2 enzyme activities and the synthesis of a phospholipase a2 activating protein  eicosanoids are important mediators of the inflammatory response to monosodium urate crystals  msuc  that results in gout  phospholipase enzymes cleave fatty acids from membrane phospholipids  and this is thought to be the rate limiting step in eicosanoid production  to understand better the mechanism of eicosanoid production in this disease  we stimulated human peripheral blood neutrophils and monocytes with msuc and measured phospholipase enzyme activities  msuc stimulated both intracellular and secretory phospholipase a2 enzyme activities in a time and concentration dependent manner  specificity was observed  as phospholipase c activities were not affected  pretreatment with colchicine  but not aspirin  indomethacin  allopurinol  or islet activating protein  abrogated the enhanced phospholipase a2 activities  we have recently isolated and characterized a phospholipase a2 activating protein termed plap from synovial fluid from patients with rheumatoid arthritis  and from murine and bovine cell lines  plap was detected in gouty synovial fluid by immunodot blotting and elisa assays and expressed the same characteristics as plap identified from other sources  to examine the role of plap in msuc induced phospholipase a2 stimulation  we treated cells with msuc and observed an increase in immunoreactive plap  this response also could be blunted by colchicine  but not other drugs  both phospholipase a2 and plap induced production by human monocytes of pge2 and leukotriene b4 by neutrophils  these findings suggest that phospholipase a2 activation in response to msuc requires an intact microtubule structure  and that phospholipase a2 and plap may be important modulators of at least a portion of the gouty inflammatory response  
class5	a distinctive triad of malformations of the central nervous system in the meckel gruber syndrome  a distinct triad of central nervous system  cns  malformations  prosencephalic dysgenesis  occipital exencephalocele and rhombic roof dysgenesis  was present in seven cases of the meckel gruber syndrome examined at autopsy  we compared our findings with those previously described  microcephaly  sloping forehead  posterior occipital exencephalocele  cerebellar hypoplasia  chiari malformation  hydrocephalus  polymicrogyria  arhinencephaly  holoprosencephaly and anencephaly constituted a broad spectrum of the reported cns anomalies  few reports contained a comprehensive description of the observed cns malformations  in those reports  and in our cases  features of prosencephalic dysgenesis included agenesis of olfactory bulbs and tracts  arhinencephaly   hypoplasia of optic nerves and chiasm  agenesis of corpus callosum  fused thalami or complete holoprosencephaly  the occipital encephalocele has consisted of a displacement of rhombic roof elements  including caudal third ventricle  cerebellar vermis and fourth ventricle  extruded through an enlarged posterior fontanelle rather than through an occipital cranium bifidum and is thus more precisely labeled an exencephalocele  different degrees of dysgenesis of posterior fossa structures  described by some as a variant of dandy walker cyst with features of a chiari malformation  were often associated with this occipital exencephalocele  this pattern of cns anomalies represents a triad of malformations probably associated with defective ventral induction of the developing cns by the prechordal mesoderm  
class5	limited precision of lumbar spine dual photon absorptiometry by variations in the soft tissue background  the estimation error due to variations in soft tissue baseline in lumbar bone mineral content  bmc  measured by dual photon absorptiometry  dpa  was calculated with a new method of automatic baseline subtraction  in water phantom measurements  the s d  of the soft tissue  st  baseline matched closely  r   0 98  to the random error  calculated using 44 kev and 100 kev count rates and the directly determined baseline variations  in 21 volunteers and in 70 patients with osteoporosis  the st variations were larger than the expected random error  revealing a source of error related to the inhomogeneity of soft tissue  the estimation error in bmc caused by st variations was 0 7  in healthy subjects  mean bmc 40 5 gha  and 1 5  in patients  mean bmc   26 4 gha   these results indicate that st related errors are an important limit to the precision of lumbar dpa measurements  
class5	evaluation of anterior maxillary alveolar ridge resorption when opposed by the transmandibular implant  fifteen edentulous patients with complaints regarding denture comfort and or function were treated with the transmandibular implant  all patients were restored with conventional maxillary dentures opposed by implant supported removable prostheses  two to 4 years after surgery  these patients were evaluated for vertical and horizontal maxillary bone loss with a radiographic analysis developed by the authors  with this technique  attention was focused on vertical alveolar ridge resorption in the anterior maxilla  although the sample size was small  the findings from this study indicate that vertical bone loss in the anterior maxilla does occur when a maxillary denture is opposed by an implant supported overdenture  comparison of these results with a previous study that evaluated anterior maxillary resorption when a complete maxillary denture opposed natural mandibular anterior teeth and a distal extension removable partial denture demonstrated no statistically significant difference  
class5	rhabdomyolysis and acute renal failure associated with cocaine abuse  cocaine abuse has emerged as a major public health problem among young adults  illicit use of cocaine has been associated with an increasing array of medical complications  both traumatic and nontraumatic rhabdomyolysis  often complicated by acute renal failure  has recently been described following cocaine abuse  the present report describes our experience with 15 such patients and serves to further define the spectrum of muscle injury associated with cocaine abuse ranging from the incidental finding of elevated serum levels of muscle enzymes to acute renal failure  those patients who developed renal failure experienced more severe rhabdomyolysis in association with trauma  seizures or hyperpyrexia  
class5	indirect revascularization of the lower extremity by means of microvascular free muscle flap  a preliminary report  we describe the treatment of a patient with end stage peripheral vascular disease and ischemic ulceration of the lower extremity in whom an obliteration of the distal arterial bed precluded conventional arterial reconstruction  a nonhealing dorsal foot ulcer was debrided  and soft tissue reconstruction was accomplished by the free microsurgical transfer of a muscle flap to the distal lower extremity  arterial inflow to this free flap was provided by a contralateral reversed saphenous vein graft from the proximal arterial tree of the leg  this procedure resulted in a healed wound  stable coverage  and limb salvage  the patient also noted complete relief of rest pain and improvement in his claudication symptoms  a follow up arteriogram was done 2 months after surgery  contrast injection directly into the artery of this flap showed new blood vessel growth from the muscle flap into the foot with anastomoses of these  new vessels  to the patient s native circulation  this experience suggests that limb salvage may be possible by the free microvascular transplantation of a muscle flap onto the limb in selected patients whose limbs are deemed  nonreconstructible    
class5	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  
class5	polymyositis  a case history approach to the differential diagnosis and treatment  a wide range of conditions can mimic polymyositis  thus  diagnosing this condition can be a challenge  although no single criterion is diagnostic of polymyositis  the following criteria have been proposed and widely used   1  symmetric proximal muscle weakness   2  characteristic violaceous rash on the hands  elbows  and knees   3  increased muscle enzymes in the serum   4  characteristic electromyographic findings  insertional activity  fibrillation potentials  motor unit potentials of increased frequency and decreased duration  and normal conduction velocity in nerves   and  5  muscle biopsy specimen with characteristic inflammatory and myopathic changes  although polymyositis primarily involves muscle  up to 20  of patients may have extramuscular problems  the main treatment for polymyositis is high dose corticosteroids  in corticosteroid resistant patients  methotrexate is often effective  in this report  case histories are presented to highlight the usefulness and the limitations of the common diagnostic criteria for polymyositis  
class5	electrophysiological spectrum of inclusion body myositis  we present electrodiagnostic data on 30 patients with inclusion body myositis  ibm  in order to better delineate its electrophysiological features  comprehensive electromyography  emg  and nerve conduction studies  ncs  were performed in all cases  twelve patients had single fiber electromyography  sfemg   emg showed abundant short small motor unit potentials  mup  with fibrillations and positive sharp waves in 56 6  of patients  and a mixed pattern of large and small mup in 36 7   in 6 7   only  neurogenic  features were seen  ncs were slow in 33 3   sfemg revealed a mildly abnormal jitter and a slightly increased fiber density  ibm demonstrates a heterogeneous emg profile  a pattern of large and small mup is highly suggestive of ibm but is seen in only about one third of cases  
class5	central changes in hypothyroid myopathy  a case report  a muscle biopsy from a patient with hypothyroid myopathy showed striking central changes   cores  were seen in most type 1 fibers with oxidative enzyme preparations  electron microscopy of these areas revealed z disc streaming  myofilament disruption  and absent mitochondria  the myopathy rapidly improved with thyroxine treatment  this biopsy is of interest  as numerous  cores  have not previously been reported in hypothyroid myopathy  
class5	quantitative electromyography in polymyositis  a reappraisal  manual analysis of motor unit action potentials  muaps  was performed in 33 patients with polymyositis of whom 16 were studied in the acute stage and 17 in the chronic stage  contrary to common description of  myopathic potentials  as being of low amplitude  short duration  and polyphasic shape  the quantitated study revealed no difference as to amplitude of short duration muaps in patients and normal subjects though short duration muap and short duration polyphasic potentials were 4 and 3 times  respectively  more common in patients than in controls  although the mean duration of muaps usually was significantly shorter in polymyositis than in controls  the average scatter of muaps duration was the same in the 2 groups  the average incidence of polyphasic muaps was 4 times higher in patients than in controls  as was the incidence of those of long duration  to avoid misinterpretation of emg findings due to an excess of polyphasic muaps  a greater number of individual potentials than usually recommended should be collected allowing a valid estimate of the mean duration of muaps of simple configuration  
class5	the little women of loja  growth hormone receptor deficiency in an inbred population of southern ecuador  background and methods  laron type dwarfism  which is characterized by the clinical appearance of isolated growth hormone deficiency with elevated serum levels of growth hormone and decreased serum levels of insulin like growth factor i  igf i   has been described in approximately 50 patients  this condition is caused by a deficiency of the cellular receptor for growth hormone  and it is transmitted as an autosomal recessive trait  as indicated by an equal sex distribution and a high rate of consanguinity in affected families  we studied 20 patients  19 females and 1 male  2 to 49 years of age   from an inbred spanish population in southern ecuador  who had the clinical features of laron type dwarfism  results  seventeen patients were members of two large pedigrees  among the 13 affected sibships  there were 19 affected and 24 unaffected female siblings and 1 affected and 21 unaffected male siblings  the patients  heights ranged from 10 0 to 6 7 sd below the normal mean height for age in the united states  in addition to the previously described features  15 patients had limited elbow extensibility  all had blue scleras  affected adults had relatively short extremities  and all four affected women over 30 years of age had hip degeneration  basal serum concentrations of growth hormone were elevated in all affected children  30 to 160 micrograms per liter  and normal to moderately elevated in the adults  the serum level of growth hormone binding protein ranged from 1 to 30 percent of normal  igf i concentrations were low  less than or equal to 7 micrograms per liter in the children and less than or equal to 66 micrograms per liter in the adults  normal for ecuadorean women  98 to 238   serum levels of igf ii and growth hormone dependent igf binding protein 3 were also low  conclusions  we describe an inbred population with a high incidence of growth hormone receptor deficiency resulting in a clinical picture resembling laron type dwarfism but differing principally in showing a marked predominance of affected females  this population  of mediterranean origin  may be genetically related to other reported populations with laron type dwarfism  but with the genetic defect linked to a trait resulting in the early fetal death of most affected males  
class5	characterization of a newly established malignant meningioma cell line of the human brain  iomm lee  a permanent malignant meningioma  mm  cell line of the human brain designated  iomm lee  is reported  this cell line was successfully established from the tumor of a 61 year old chinese man with repeated recurrent primary intraosseous malignant meningioma of the skull  it has been subcultured for more than 60 passages during the past 30 months  the doubling time of cultured cells is approximately 62 hours  tumorigenicity in athymic nude mice  balb c nu nu  who develop multiple pulmonary metastases was observed  the doubling time of tumor volume in vivo is approximately 5 days  karyotypic analysis revealed this cell line to be of human origin and near diploid  with a modal chromosome number of 49  the mesenchymal tumor marker vimentin and intracytoplasmic microfilaments were identified in the cytoplasm of tumor cells by indirect immunohistochemical peroxidase anti peroxidase assays and immunogold ultrastructural localization by transmission electron microscopy  respectively  scanning electron microscopy of cultured cells and xenografted tumors revealed ellipsoidal or carrot shaped tumor cells presenting a wrinkled surface with short sparse microvilli  potential proliferating activity was determined by ki 67 monoclonal antibody  the ki 67 labeling index of cultured cells and xenografted tumors was approximately 36  and 30   respectively  this newly established malignant meningioma cell line of the human brain may prove useful as a research model  
class5	intradural herniation of a thoracic disc presenting as flaccid paraplegia  case report  a case of intradural herniation of a thoracic disc in a patient with a flaccid paraplegia is described  intradural herniation of a thoracic disc is considered a rare event  a review of the relevant patient literature revealed 14 other reports involving 28 patients  no other report has described a patient with an intradural thoracic disc herniation who developed a flaccid paraplegia  
class5	a case of dyschondroplasia associated with brain stem glioma  diagnosis by stereotactic biopsy  we present a 24 year old patient with multiple chondromas of both hands  the pelvis  the left leg  and an associated brain stem glioma  there was no evidence of hemangioma or dyschromia  and the condition was diagnosed as ollier s disease  a special type of dyschondroplasia like maffucci s syndrome and kast s disease  an increased overall risk for development of malignant skeletal and nonskeletal tumors is associated with maffucci s syndrome  the risk of malignant degeneration is lower in ollier s disease  a glioma in the pons and the right lobe of the cerebellum was found in this patient  the literature describes an association with gliomas in only 12 cases of dyschondroplasia and an infratentorial localization in just one case  signs of malignancy were histologically confirmed in 7 cases without significant preponderance of any one type  our patient had a low grade brain stem astrocytoma with fibrillar and gemistocytic components  a stereotactic serial biopsy made it possible to rule out malignant degeneration  stereotactic brain tumor biopsy as a routine neurosurgical procedure is particularly valuable for deep space occupying processes and forms the basis for therapy  in the present case  irradiation was not recommended  
class5	radical osteoclastic craniectomy in sagittal synostosis we report our experience in the surgical treatment of sagittal synostosis using radical osteoclastic craniectomy in 60 consecutive patients  after surgery in children aged 6 months or younger  group i   reossification usually started 2 weeks postoperatively and was complete within 6 months  resulting in an optimal skull contour  in children aged 7 to 12 months  group ii   reossification was prolonged and lasted for 12 months or longer  the skull contour normalized in its biparietal width and improved in sagittal diameter  remaining  however  slightly abnormal  in children older than 12 months  group iii   the skull contour partly improved in the biparietal diameter but did not change in the sagittal direction  reossification was incomplete with persistent pseudosutures  enlarged frontal subarachnoid spaces were reversible or improved in all patients independent of age at the time of surgery  we encountered no complications in our series  in our opinion  radical osteoclastic craniectomy is the simplest  most efficient  and most physiologically sound method for the treatment of sagittal synostosis in patients up to 6 months of age  this procedure allows the rapidly growing brain to form its skull vault  thus providing optimal cosmetic results  in older children  osteoplastic morcellation procedures should be the treatment of choice  
class5	maffucci s syndrome with bilateral cartilaginous tumors of the cerebellopontine angle  maffucci s syndrome is characterized by the combination of multiple enchondromas  ollier s disease  and hemangiomatosis  these hemangiomas develop in the subcutaneous tissue and form red blue tumors dispersed over the whole body  intracranial involvement is rare  making a preoperative radiological diagnosis and differentiation from other tumors rather difficult  the radiological characteristics and successful removal of the intracranial part of a chondrosarcoma of the cerebellopontine angle in a case of maffucci s syndrome are reported in this paper  
class5	electron transfer flavoprotein  ubiquinone oxidoreductase  etf qo  deficiency in an adult  a 19 year old woman with mild myopathic symptoms from age 6 and fasting intolerance presented with a reye like syndrome and a myopathy  investigations disclosed a lipid storage myopathy  type ii glutaric acidemia  and carnitine deficiency in skeletal muscle  riboflavin and carnitine treatment corrected the metabolic abnormalities and she improved clinically  she later died from pulmonary complications secondary to aspiration  subsequent studies established electron transfer flavoprotein  ubiquinone oxidoreductase  etf qo  deficiency  fibroblast etf qo activity was 2 9 mu mg  normal range is 14 1     3 8 mu mg  as the cause of her illness  this is the first documented case of etf qo diagnosed in an adult  
class5	eosinophilia myalgia syndrome  l tryptophan associated neuromyopathy   histopathologic study of skeletal muscle biopsy in a patient with eosinophilia myalgia syndrome following l tryptophan use showed prominent lymphocytic perineuritis  neuritis  and perimysial fasciitis  the presence of perineuritis and neuritis provides a histopathologic basis for clinical features of neuropathy in eosinophilia myalgia syndrome and occurred in conjunction with a fasciitis or interstitial myositis that was predominantly perimysial and focally endomysial  
class5	psoriatic arthropathy of the temporomandibular joint  a case of psoriatic arthritis of both temporomandibular joints is described with a brief review of the literature and discussion on the management of this condition  to date  psoriatic arthritis has been successfully treated by conservative means  in the case reported  surgical replacement of the condyles became necessary to eliminate pain and restore function  
class5	quantitative evaluation of digital dental radiograph imaging systems  two digital imaging systems  a video camera and analog to digital converter  and a charge coupled device linear photodiode array slide scanner  were tested for their suitability in quantitative studies of periodontal disease  the information content in the original films was estimated  and digital systems were assessed according to these requirements  radiometric and geometric performance criteria for the digital systems were estimated from measurements and observations  the scanner based image acquisition  digitization  system had no detectable noise and had a modulation transfer function curve superior to that of the video based system  the scanner based system was equivalent to the video based system in recording radiographic film densities and had more geometric distortion than the video based system  the comparison demonstrated the superiority of the charge coupled device linear array system for the quantification of periodontal disease extent and activity  
class5	cross sectional radiography for implant site assessment  an accurate tomographic technique is described for acquisition of optimal cross sectional images of implant sites before implant surgery  the described technique is applicable to tomographic systems equipped with a cephalometric head positioner  this cross sectional tomographic technique was performed on a series of patients and the images of the first 20 patients subsequently evaluated  the cross sectional images allowed for the characterization of the alveolar crest and visualization of anatomic structures in a buccolingual dimension while providing an accurate estimation of available vertical space from the crest  
class5	heritability of symptoms in an experimental model of neuropathic pain  male and female rats underwent transection and ligation of the sciatic and saphenous nerves  and the development of autonomy was monitored  the deafferented animals were then interbred  always selecting males and females that expressed relatively high and  alternatively  relatively low levels of autotomy  offspring were similarly operated and interbred  by the sixth generation of selective breeding  lines were achieved in which autotomy was consistently high  ha  or consistently low  la   there was no indication of sex linkage  thermal and mechanical nocifensive responsiveness co selected with propensity to express autotomy following nerve injury  response thresholds were lower in ha than in la rats  f1 hybrids formed by crossing homozygous ha and la animals showed low levels of autotomy  similar to la stock  this indicates recessive inheritance of the autotomy trait  backcrossing f1 hybrids onto the la line yielded a low autotomy phenotype in almost all cases  backcrossing f1 hybrids onto ha stock yielded about 50  high autotomy and 50  low autotomy  these ratios are consistent with simple mendelian inheritance of a single gene  taken together  the data suggest that autotomy is inherited as a single gene autosomal recessive trait  
class5	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  
class5	thrombocytosis after pneumonia with empyema and other bacterial infections in children  thrombocytosis is seen in association with many conditions  including infectious diseases  we studied thrombocytosis after severe bacterial infections  particularly pneumonia with empyema in children  a systematic survey of the phenomenon was conducted  twenty seven children admitted for pneumonia with empyema were studied  thrombocytosis  platelet counts greater than 500 x 10 3  microliters  was present in 92 5   platelet counts reached their maximum at 15 1     3 7 days  range  7 to 25  and declined to normal after 3 weeks of illness  compared with a healthy control group  significant thrombocytosis  but of lower incidence  was also noted in children with lobar pneumonia without pleural effusion  bacterial meningitis and osteomyelitis  platelet functions were examined in seven of the children but no abnormalities were observed  bone marrow aspiration of three children with pneumonia and empyema showed megakaryocytic hyperplasia  we found no correlation between thrombocytosis  neutrophilia  fever  the clinical course  complications  prognosis or treatment  neither thromboembolic nor hemorrhagic phenomena were observed  
class5	young adults with special health care needs  prevalence  severity  and access to health services  health care needs of disabled young adults and access to care are analyzed using the 1984 national health interview survey  a nationally representative sample of 10 394 randomly selected noninstitutionalized young adults aged 19 to 24  in 1984  1 4 million young adults  almost 6   suffered from disabilities  the leading cause of disability was diseases of the musculoskeletal system and connective tissue  young adults living in poverty  in households where the family reference person had less than a high school education  and who were male were at elevated risk of disability  disabled young adults made almost three times as many physician contacts and were hospitalized for close to six times as many days as nondisabled young adults  one of every 5 disabled young adults was uninsured in 1984  forty one percent of disabled hispanic 19  to 24 year olds and 51  of disabled young adults of other races were uninsured compared with 19  of whites and blacks  research and financing policy implications are discussed  
class5	the older adult  a comparative assessment  thorough assessment of older men and women is a complex but vital part of their health care  the ability to differentiate the changes owing to normal aging from those resulting from pathologic processes is necessary if their lives are to be as productive and enjoyable as they are prolonged  each body system and function must be examined or tested with this difference in mind  because aging occurs in different individuals at differing rates  a variety of functions may all be considered healthy or normal  assessment findings must be viewed through the focus of the individual person as well as that of the population  the nurse will find opportunities to use assessment skills for older adults in many settings  ranging from independent living arrangements to institutional residential areas  in the community  social meeting places  day care facilities  meal sites  and shopping areas are but a few of the places where older adults may be found  alone or in groups  assessment opportunities can be identified or structured in any milieu  the setting itself  as well as the needs of the older adult s   will help to determine the complexity of the assessment activities  the benefit to nursing of increased and expanded ability to assess the older adult is considerable  the organized concern of science and health care with aging is a relatively recent phenomenon  the older adults of today are unique  there are more of them than ever before  and they are living longer  although their lives are not without health complications  they are  in a sense  role models for the rest of us  pathfinders in aging who can  if we observe them carefully  give us insight and direction for our own healthy aging processes and those of generations to come  nursing is uniquely poised to use our caring methodology with the older adult  the elderly are interested in their health and willingly cooperate with those whose assessments are knowledgeable and realistic  nursing is challenged to develop and implement advanced and specialized ways to identify and meet their needs  
class5	eosinophilia myalgia syndrome linked to tryptophan  eosinophilia myalgia syndrome has been linked to ingestion of tryptophan  but the exact cause of this recently recognized syndrome is unclear  as in other reported cases  the disease in the patient described here developed while she was taking tryptophan  although eosinophilia resolved following glucocorticoid therapy  the disease in this patient continues to progress  
class5	diastrophic dysplasia gene maps to the distal long arm of chromosome 5  we have used polymorphic dna markers to map the gene for a clinically well characterized form of osteochondrodysplasia  diastrophic dysplasia  dd   an autosomal recessive disorder of unknown pathogenesis  linkage was analyzed in 13 families with two or three affected sibs comprising a total of 84 individuals  positive two point logarithm of odds  lod  scores were obtained between the dd locus and three polymorphic markers on chromosome 5  the highest pairwise lod score estimate of 7 37 with zero recombination to locus d5s72 suggests very tight linkage  there was no evidence of heterogeneity  multipoint linkage analysis against the published order of the three loci gave the result centromere d5s84  dd  d5s72  d5s61 terminus with a four point lod score of 9 11  the present findings place the dd locus distal to the gene for adenomatous polyposis coli on the distal part of the long arm of chromosome 5  our results provide a basis for refining the map position of the dd locus followed by physical localization  isolation  and characterization of the gene  
class5	fructose induced aberration of metabolism in familial gout identified by 31p magnetic resonance spectroscopy  the hyperuricemia responsible for the development of gouty arthritis results from a wide range of environmental factors and underlying genetically determined aberrations of metabolism  31p magnetic resonance spectroscopy studies of children with hereditary fructose intolerance revealed a readily detectable rise in phosphomonoesters with a marked fall in inorganic phosphate in their liver in vivo and a rise in serum urate in response to very low doses of oral fructose  parents and some family members heterozygous for this enzyme deficiency showed a similar pattern when given a substantially larger dose of fructose  three of the nine heterozygotes thus identified also had clinical gout  suggesting the possibility of this defect being a fairly common cause of gout  in the present study this same noninvasive technology was used to identify the same spectral pattern in 2 of the 11 families studied with hereditary gout  in one family  the index patient s three brothers and his mother all showed the fructose induced abnormality of metabolism  in agreement with the maternal inheritance of the gout in this family group  the test dose of fructose used produced a significantly larger increment in the concentration of serum urate in the patients showing the changes in 31p magnetic resonance spectra than in the other patients with familial gout or in nonaffected members  thus suggesting a simpler method for initial screening for the defect  
class5	hypodense eosinophils and interleukin 5 activity in the blood of patients with the eosinophilia myalgia syndrome  the recent recognition of the eosinophilia myalgia syndrome  ems  associated with the ingestion of l tryptophan prompted an analysis of the peripheral blood eosinophil phenotypes and of the serum eosinophil hematopoietins in this disorder  five patients with an illness characterized by the abrupt onset of aching skeletal muscles  edema  thickening and induration of the skin  and marked blood eosinophilia associated with l tryptophan ingestion provided eosinophils  serum  or both  for evaluation  gradient sedimentation density analysis of the peripheral blood eosinophils from four of these patients revealed that 43     13   mean     sem  of the cells had converted to the abnormal  hypodense  sedimenting phenotype  when normodense eosinophils from the reference donors were cultured for 3 days in medium supplemented with increasing concentrations of serum from the patients with ems  their viability increased in a dose dependent manner to 45   which was significantly augmented over the effect of normal serum  this eosinophil viability sustaining activity was inhibited by 76     7   mean     sem  n   3  by the addition of anti interleukin 5  il 5  but not by neutralizing antibodies monospecific for either granulocyte macrophage colony stimulating factor  gm csf  or il 3  il 5  an eosinophilopoietic factor  converts normodense peripheral blood eosinophils in vitro to a hypodense sedimenting form with extended viability and augmented biologic responses to activating stimuli  thus  the presence of il 5 in the sera of patients with ems may contribute to the development and maintenance of the eosinophilia and may regulate the conversion of the peripheral blood eosinophils to the hypodense phenotype with augmented pathobiologic potential  
class5	treatment of craniomaxillofacial fibrous dysplasia  how early and how extensive  twenty eight craniomaxillofacial fibrous dysplasia patients were treated as early as the symptoms occurred  the principles of surgical treatment were based on the zones of involvement  total excision of dysplastic bone of fronto orbital  zygoma  and upper maxillary origin  zone 1  and bone reconstruction primarily  conservative excision on hair bearing skull  zone 2   central cranial base  zone 3   and tooth bearing bones  zone 4   and optic canal decompression on patients with orbital dysplasia and decreasing visual acuity  patients were followed for 1 to 11 years  average 5 3 years   no recurrence or invasion of the fibrous dysplasia into the grafted bone was seen  one patient had orthognathic maxillary osteotomy on the reconstructed maxilla 6 years after initial reconstruction  five of 19 patients with alveolar dysplasia had a recurrence and were reshaped  one patient had mandibular sagittal osteotomies to set back the prognathic  fibrous dysplasic mandible after three attempts at conservative shaving  another patient with mandibular fibrous dysplasia had recurrence with pain and a hemimandibulectomy with successful immediate free vascularized iliac bone graft reconstruction  
class5	the use of liposuction to contour cherubism  yet another application of suction lipectomy equipment is presented to remove the pathologic tissue in cherubism  owing to the variations of consistency of the material in this condition  this technique may not be successful in all patients  but it is certainly recommended when indicated  
class5	estrogen therapy during menopause and the treatment of osteoporosis  estrogen remains the single most effective agent in the treatment of menopausal symptoms and prevention of bone loss  this article focuses on the use of estrogen therapy during menopause and the pharmacotherapy of osteoporosis  risks and benefits of hormonal therapy and regimen selection for menopausal women are discussed  the second section of the article focuses on current treatment strategies for osteoporosis  
class5	tuberculous psoas muscle abscess following chemoprophylaxis with isoniazid in a patient with human immunodeficiency virus infection  a 34 year old man with human immunodeficiency virus infection and disseminated mycobacterium avium and mycobacterium intracellulare infection developed a right psoas muscle abscess due to mycobacterium tuberculosis  the abscess occurred 18 months after completion of a 12 month course of chemoprophylaxis with isoniazid that was given because of a positive reaction with purified protein derivative of tuberculin  the adjacent vertebrae did not appear to be involved  the abscess was drained with a percutaneously inserted catheter  and he received standard antituberculous chemotherapy  three weeks into therapy  a second drainage with a catheter was required  the isolation of two mycobacteria in this patient and the apparent failure of chemoprophylaxis with isoniazid are noted  
class5	a case of group b streptococcal pyomyositis the group b streptococcus is an opportunistic pathogen that causes a variety of serious infections including bacteremias  puerperal sepsis  and neonatal meningitis  group b streptococcal infections of muscle are rare  we report here an unusual case of group b streptococcal pyomyositis  pyomyositis arises predominantly from infections caused by staphylococcus aureus and  occasionally  streptococcus pyogenes  because of the rarity of pyomyositis in temperate climates  the common lack of localizing signs or symptoms  and the frequently negative blood cultures  considerable delay often precedes the diagnosis of pyomyositis  in fact  the infection has been initially misdiagnosed as muscle hematoma  cellulitis  thrombophlebitis  osteomyelitis  or neoplasm  diagnosis may be greatly aided by radiologic techniques that can demonstrate the sites of muscle enlargement and the presence of fluid collections  the response to antibiotics is usually rapid  but resolution of the infection may require aspiration of deeply situated muscle abscesses  this report describes a diabetic patient with an unusual presentation of pyomyositis that mimicked an acute abdomen  
class5	group c streptococcal arthritis  case report and review  streptococci account for approximately 15  20  of cases of nongonococcal septic arthritis  the majority of these are due to group a streptococci  but group b and group g streptococci are being isolated more frequently  we present a case of group c streptococcal arthritis and summarize nine additional cases reported in the literature  the group c streptococci include the large colony of voges proskauer negative bacteria  streptococcus equi  streptococcus equisimilis  streptococcus zooepidemicus  and streptococcus dysgalactiae  as well as as the minute colony of voges proskauer positive streptococcus anginosus   streptococcus milleri   group c organisms  any joint may become infected  but joints affected by preexisting rheumatologic abnormalities are more frequently involved  bacteremia was documented in five of the 10 patients  one patient had an associated pneumonia  and another patient had an associated acute aortic valve endocarditis  none of the infections involved a prosthetic joint or an overlying cellulitis  associations reported for group g streptococcal arthritis  surgical drainage of the infected joint was required in six of the 10 patients  we concluded that the presence of two groups of organisms sharing the same lancefield group antigen necessitates the careful identification of isolates to determine potential clinical differences  
class5	1990 volvo award in clinical sciences  lumbar spinal pathology in cadaveric material in relation to history of back pain  occupation  and physical loading  the occurrence of symmetric disc degeneration  anular ruptures  end plate defects  vertebral body osteophytosis  and facet joint osteoarthrosis was examined radiographically and osteologically in 86 male cadavers for whom occupational  physical loading  and back pain histories were obtained from the men s families  history of back pain and the parameters of spinal pathology were related to the highest and lowest degrees of physical loading  in multivariate analyses  history of back injury was related to the occurrence of symmetric disc degeneration  anular ruptures  and vertebral osteophytosis  symmetric disc degeneration was associated with sedentary work  and vertebral osteophytosis was related to heavy work  history of back pain was related to occupational physical loading after control for the effects of the other covariates  the results indicate that the least pathology stemmed from moderate or mixed physical loading  but the least back pain was associated with sedentary work  
class5	1990 volvo award in experimental studies  anulus tears and intervertebral disc degeneration  an experimental study using an animal model  an animal model was developed to test the hypothesis that discrete peripheral tears within the anulus lead to secondary degenerative changes in other disc components  in 21 adult sheep  a cut was made in the left anterolateral anulus of three randomly selected lumbar discs  the cut was parallel and adjacent to the inferior end plate  and had a controlled depth of 5 mm  this left the inner third of the anulus and the nucleus pulposus intact and closely reproduced the rim lear lesion described by schmorl  animals were randomly allocated to different groups in relation to the length of time interval between operation and death  varying from 1 to 18 months  at death  the lumbar spine was cut into individual joint units and each disc sectioned into six parasagittal slabs  after observation of the slabs under the dissecting microscope  two of the six slabs  the one containing the anulus lesion and a contralateral  were processed for histology  the results of this study suggest that  despite the great care taken at operation to ensure that the inner anulus was left intact  progressive failure of the inner anulus was seen in all sheep and occurred in the majority of discs between 4 and 12 months after the operation  although the outermost anulus showed the ability to heal  the defect induced by the cut led initially to deformation and bulging of the collagen bundles  and eventually to inner extension of the tear and complete failure  these findings suggest that discrete tears of the outer anulus may have a role in the formation of concentric clefts and in accelerating the development of radiating clefts  peripheral tears of the anulus fibrosus therefore may play an important role in the degeneration of the intervertebral joint complex  
class5	osteoporosis and back pain in the elderly  a controlled epidemiologic and radiographic study  the incidence of back pain was investigated in hip fracture patients  50 99 years of age  and in 70   75   and 81 year old controls from the same population  the prevalence of vertebral fractures were evaluated from spinal radiographs  eighty hip fracture patients and 103 controls  all between 70 and 75 years of age  were included in the radiographic study  the incidence of back pain of the controls was twice that of the hip fracture patients  45 48  compared with 23 20   respectively  for both female and male subjects  conversely  vertebral fractures were radiographically shown in 43  of the hip fracture patients and in 22  of the controls  thus  the major explanation for longstanding back pain in the elderly does not appear to be related to spinal osteoporosis  
class5	computer assisted tomography of scoliosis operated with or without harrington s rod  biomechanics aspects of the fusion  forty eight cases of posterior vertebral arthrodesis for scoliosis  performed with or without instrumentation  were examined using computed tomography  ct  scanning to study the evolving fusion mass  the authors observed that the fusion mass area is more voluminous in the cases performed without instrumentation than in the ones performed with instrumentation  and that 2 years after fusion the bone mass shows already a considerable increase  for the cases operated with harrington s technique  the increase of the fusion mass is very slow and becomes considerable 5 years after operation  in both series  the section of the fusion masses at the apex of the curve is asymmetric  with prevalence on the concave side   with an area of central resorption that shows the structure of a long bone  box section   
class5	factors influencing the result of posterior spinal fusion in the treatment of adolescent idiopathic scoliosis  sixty six consecutive patients with adolescent idiopathic scoliosis treated by posterior spinal fusion using harrington distraction compression instrumentation were followed for a minimum of 3 years  initial surgical correction was satisfactory  but during the follow up period  mean 4 4 years  3 5 years   there was a loss of correction  several factors  age  sex  the number of vertebrae in the fusions  and the use of cross wires  were important influences on correction  a method of assessing the balance of a posterior spinal fusion is described that is useful when assessing radiographs  
class5	the operative treatment of progressive early onset scoliosis  a preliminary report  thirteen patients with progressive early onset scoliosis have been managed operatively in an attempt to achieve correction without bracing and to allow the spine to grow  all had posterior segmental spinal instrumentation  ssi  without fusion and 9 of 13 had anterior apical growth arrest as a separate additional procedure  at 2 year follow up  curve correction averaged 46   patients who had anterior apical growth arrest and ssi without fusion had less curve deterioration than those who had ssi alone  new methods are described for 1  measuring growth of the instrumented segment of the spine and 2  calculating the predicted growth of the instrumented segment  eight of the 13 had more than 50  of predicted growth  three had 30 50  of predicted growth  and two had less than 30  of predicted growth  operative treatment has been successful in the short term in all but the most malignant form of infantile idiopathic scoliosis  
class5	an analysis of the effect of the zielke operation on s shaped curves in idiopathic scoliosis  a follow up study revealing some skeletal and soft tissue factors involved in curve progression  this article analyzes the fate of s shaped idiopathic spinal curves during follow up in 18 patients having the zielke vds operation  the spinal radiographs were evaluated by cobb angle  end vertebra angles  evas   vertebral rotation  and by a new method using the tilt of the surgically fused spinal block in the frontal plane  spinal growth was measured  using the conventional criterion for cobb angle progression  83  of the lower curves and 50  of the upper curves progress  the use of evas shows that progression occurs mainly in the middle  thoracolumbar  segment of the spine  curve progression occurs in the frontal plane without any significant change in vertebral rotation  the progression of the upper curve cobb angle is not related to the progression of the cobb angle of the lower curve  but it is related to 1  tilt of the spinal block  2  growth of the spine below the block and 3  overall linear spinal growth  t1 s1   progression of the upper eva of the upper curve is associated with skeletal immaturity  the key features leading to curve progression after the zielke operation appear to be spinal asymmetry in the frontal plane  linear spinal growth  and concave lumbar muscle tether  myostatic contracture   the surgical implications of the findings are outlined  
class5	effects of rib elongation on the spine  i  distortion of the vertebral alignment in the rabbit  elongation of one rib on the right side by 1 cm was achieved in two groups of adult rabbits of different age  by osteotomy and application of a metallic expander  the procedure resulted in immediate deviation of the spine in the frontal and sagittal planes  with moderate scoliosis  convex to the left  and a significant decrease in the normal cervicothoracic lordosis and thoracolumbar kyphosis  moreover  computed tomography  ct  scanning demonstrated rotation of vertebra about the longitudinal axis relative to the anterior midline of the body  and deviation of the spinous process toward the convex  left side  of the scoliotic deformity  rib hump developed on the right side  that of the elongated rib  these changes  which occurred simultaneously in the three planes  were less pronounced in the group of older animals  two weeks after the operation  the distorted configuration of the spine remained unchanged  the observed changes in the alignment of the vertebrae  changes that  except for their direction on the horizontal plane  resembled those associated with idiopathic scoliosis in man  support the earlier proposed link between the early stage of development of this condition and asymmetry of rib growth  
class5	effects of rib elongation on the spine  ii  correction of scoliosis in the rabbit  three intercostal nerves on the right side of growing rabbits were resected partially  from 1 to 3 months later  moderate left convex thoracic scoliosis with rotation of vertebrae had developed  and the sagittal curvatures of the spine had diminished  in one group of these animals  a mechanically produced increase of 1 cm in the length of one rib on the side of the convexity resulted in an immediate correction of the scoliotic deformity  an improvement that was still evident 3 weeks after the operation  in two other groups of rabbits  a further resection of three intercostal nerves  this time on the left convex side  1 and 2 months after the first operation  resulted in regression of scoliosis or halted its progression  these results further support a new concept in which the precipitating factor in the development of scoliosis is ascribed to asymmetric longitudinal growth of the ribs  they also suggest that regulation of the rib length could be a promising approach to the effective correction of progressive scoliosis at an early stage in man  
class5	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  
class5	hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements  twenty nine patients with necrotizing fasciitis were treated from 1980 to 1988  this study evaluates how the addition of hyperbaric oxygen  hbo  therapy to surgical treatment has affected mortality and the number of debridements required to achieve wound control in these patients  two groups of patients were viewed  group 1  n   12  received surgical debridement and antibiotics only  group 2  n   17  received hbo  90 minutes at 2 5 atm  average 7 4 treatments  in addition to surgery and antibiotics  both groups were similar in age  race  sex  wound bacteriology  and antimicrobial therapy  body surface area affected was similar  however  perineal involvement was more common in group 2  53   than in group 1  12    the admitting conditions of patients in group 1  non hbo  were diabetic  33   white blood cell count more than 12 000  50   and shock  8   the admitting conditions of patients in group 2  hbo  were diabetic  47   white blood cell count more than 12 000  59   and shock  29   although group 2 patients receiving hbo were more seriously ill on admission  mortality was significantly lower  23   compared to group 1  66    p less than 0 02   in addition  only 1 2 debridements per group 2 patient were required to achieve wound control versus 3 3 debridements per group 1 patient  p less than 0 03   the addition of hbo therapy to the surgical and antimicrobial treatment of necrotizing fasciitis significantly reduced mortality and wound morbidity  number of debridements  in this study  especially among nonclostridial infections  we conclude that hbo should be used routinely in the treatment of necrotizing fasciitis  
class5	estrogen prophylaxis  the u s  preventive services task force  recommendation  although routine postmenopausal estrogen replacement is not recommended  estrogen therapy should be considered for asymptomatic women who are at increased risk for osteoporosis  who lack known contraindications and who have received adequate counseling about potential benefits and risks  
class5	nutritional rickets  nutritional rickets was diagnosed in 18 infants aged eight to 24 months  clinical features included progressive leg bowing  poor linear growth  a diet deficient in vitamin d  seizures  and abnormal serum calcium  phosphate and alkaline phosphatase levels  wrist radiographs and serum alkaline phosphatase levels were the most useful confirmatory tests  breast milk may not contain enough vitamin d to protect infants  particularly dark skinned children and those living in cloudy  northern u s  cities  from rickets after six months of age  as breast feeding becomes more widely practiced  care is required to ensure that infants at high risk for rickets receive appropriate vitamin d supplementation  
class5	mother daughter pairs  spinal and femoral bone densities and dietary intakes  bone mineral density  bmd  of the lumbar spine  l1 l4  and femur  femoral neck  ward s triangle  and trochanter  was measured in 37 healthy  white mother daughter pairs by dual photon absorptiometry  mothers and daughters were aged 52     7 and 25     4 y  mean     sd   respectively  three day dietary intakes were evaluated  significant correlations between mother daughter pairs for bmd of all lumbar and femoral areas  except for l2  r   0 26  p   0 054   indicated familial resemblances in bone mineralization  total calcium intake was significantly correlated with three bmd values for the daughters  l2  femoral neck  and trochanter  but not for the mothers  when mothers were classified as pre   n   20  or postmenopausal  n   17   correlation coefficients for bmd were higher for premenopausal mothers and their daughters and lower for postmenopausal mothers and their daughters  except for the trochanter  the results suggest that the nature of inheritance of bone mass of women may have at least two components  one influencing the level of peak bone mass and one related to bone loss at menopause  
class5	temporary loss of limb function secondary to soft tissue calcification in a patient with rhabdomyolysis induced acute renal failure  a case of unusually severe soft tissue calcification with temporary loss of limb function in a patient with rhabdomyolysis induced acute renal failure  arf  is described  a large dose of intravenous  iv  calcium was administered early in the hospital course to treat hypocalcemia  and hemodialysis  when initiated  was with a 1 75 mmol l calcium dialysate  this case illustrates the danger of administering calcium supplementation and raises questions about the use of normal to high dialysate calcium concentration in the early stages of rhabdomyolysis induced oliguric arf  calcium supplementation should be reserved for patients with clear clinical signs of hypocalcemia and dialysate calcium should be adjusted to prevent excessive positive calcium balance  
class5	nucleus driven multiple large scale deletions of the human mitochondrial genome  a new autosomal dominant disease  we studied several affected and one nonaffected individuals belonging to three unrelated pedigrees  the pathological trait was an autosomal dominant mitochondrial myopathy due to large scale multiple deletions of the mitochondrial genome  clinically  symptomatic patients had progressive external ophthalmoplegia  muscle weakness and wasting  sensorineural hypoacusia  and  in some cases  vestibular areflexia and tremor  the muscle biopsies of all patients examined showed ragged red fibers  neurogenic changes  and a partially decreased histochemical reaction to cytochrome c oxidase  multiple mtdna heteroplasmy was detected in the patients by both southern blot analysis and pcr amplification  whereas the unaffected individual had the normal homoplasmic hybridization pattern  these findings confirm and add further details to the existence of a new human disease  defined clinically as a mitochondrial myopathy  genetically as a mendelian autosomal dominant trait  and molecularly by the accumulation of multiple  large scale deletions of the mitochondrial genome  that is due to impaired nuclear control during mtdna replication  
class5	a controlled trial of intravenous immunoglobulin g in chronic fatigue syndrome purpose  currently  there is no established therapy for chronic fatigue syndrome  cfs   a recently defined illness that has been associated with a variety of immunologic abnormalities  based on the hypothesis that a chronic viral infection or an immunoregulatory defect is involved in the pathogenesis of cfs  the therapeutic benefit of intravenous immunoglobulin g  iv igg  was evaluated in a group of patients with cfs  additionally  serum immunoglobulin concentrations and peripheral blood lymphocyte subset numbers were measured at the outset of the study  and the effect of iv igg therapy on igg subclass levels was determined  patients and methods  thirty patients with cfs were enrolled in a double blind  placebo controlled trial of iv igg  the treatment regimen consisted of iv igg  1 g kg  or intravenous placebo  1  albumin solution  administered every 30 days for 6 months  participants completed a self assessment form prior to each of the six treatments  which was used to measure severity of symptoms  functional status  and health perceptions  patients were also asked to report adverse experiences defined as worsening of symptoms occurring within 48 hours of each treatment  results  twenty eight patients completed the trial  at baseline  all 28 patients complained of moderate to severe fatigue  and measures of social functioning and health perceptions showed marked impairment  low levels of igg1 were found in 12  42 9    and 18  64 3   had low levels of igg3  at the end of the study  no significant therapeutic benefit could be detected in terms of symptom amelioration or improvement in functional status  despite restoration of igg1 levels to a normal range  major adverse experiences were observed in 20  of both the iv igg and placebo groups  conclusion  the results of this study indicate that iv igg is unlikely to be of clinical benefit in cfs  in addition to the ongoing need for placebo controlled trials of candidate therapies for cfs  an expanded research effort is needed to define the etiology and pathogenesis of this disorder  
class5	a double blind  placebo controlled trial of intravenous immunoglobulin therapy in patients with chronic fatigue syndrome purpose  the chronic fatigue syndrome  cfs  is characterized by profound fatigue  neuropsychiatric dysfunction  and frequent abnormalities in cell mediated immunity  no effective therapy is known  patients and methods  forty nine patients  40 with abnormal cell mediated immunity  participated in a randomized  double blind  placebo controlled trial to determine the effectiveness of high dose intravenously administered immunoglobulin g  the patients received three intravenous infusions of a placebo solution or immunoglobulin at a dose of 2 g kg month  assessment of the severity of symptoms and associated disability  both before and after treatment  was completed at detailed interviews by a physician and psychiatrist  who were unaware of the treatment status  in addition  any change in physical symptoms and functional capacity was recorded using visual analogue scales  while changes in psychologic morbidity were assessed using patient rated indices of depression  cell mediated immunity was evaluated by t cell subset analysis  delayed type hypersensitivity skin testing  and lymphocyte transformation with phytohemagglutinin  results  at the interview conducted by the physician 3 months after the final infusion  10 of 23  43   immunoglobulin recipients and three of the 26  12   placebo recipients were assessed as having responded with a substantial reduction in their symptoms and recommencement of work  leisure  and social activities  the patients designated as having responded had improvement in physical  psychologic  and immunologic measures  p less than 0 01 for each   conclusion  immunomodulatory treatment with immunoglobulin is effective in a significant number of patients with cfs  a finding that supports the concept that an immunologic disturbance may be important in the pathogenesis of this disorder  
class5	prevalence and determinants of estrogen replacement therapy in elderly women  to better understand which women use estrogen replacement therapy  we examined the prevalence and determinants of estrogen replacement therapy in 9704 nonblack women  age greater than or equal to 65 years  who participated in the multicenter prospective study of osteoporotic fractures  overall  13 7  of women reported current use of oral estrogen  10 9  took estrogen alone and 2 8  took estrogen opposed by progestin  four percent currently used parenteral estrogen compounds  current use declined sharply with age from 17  at age 65 to 4  at age greater than or equal to 85  the primary determinant of estrogen replacement therapy was the type of menopause  the odds of using estrogen replacement therapy in current users compared with never users were approximately five times higher in women with a surgical menopause  estrogen use was more common among women who had higher levels of education and were less obese  furthermore  estrogen replacement therapy users were more likely to drink alcohol and to participate in sports and recreation  a diagnosis of osteoporosis was the major determinant of continued estrogen use  but only 24  of women with a diagnosis of osteoporosis used estrogen replacement therapy  we conclude that only a small proportion of elderly women in the united states use estrogen replacement therapy  selection factors for use of estrogen are evident and may introduce bias in studies of estrogen and disease  in consideration of the distribution of these selection factors  estrogen users will tend to be at lower risk of coronary disease and possibly breast cancer but at greater risk for hip fractures  
class5	orbital intramuscular schwannoma  in an 8 year old girl with asymptomatic proptosis  computed tomographic scans showed a large medial orbital mass that contoured the globe anteriorly  bowed the optic nerve laterally  and extended posteriorly to the orbital apex  t1 weighted coronal magnetic resonance images showed the mass to be a diffusely enlarged medial rectus muscle  histopathologic examination of a medial rectus muscle biopsy specimen disclosed a multinodular  intramuscular schwannoma  separating and infiltrating normal skeletal muscle fibers  the intramuscular location and multinodular configuration of this tumor  together with its occurrence in a child  distinguish it from previous orbital schwannomas  
class5	pathogenesis of antigen induced arthritis in mice deficient in neutrophil elastase and cathepsin g  the contribution of neutrophil derived elastase and cathepsin g to joint pathology has been examined in immune arthritis in the mouse  neutrophils from beige mice are genetically deficient in lysosomal elastase and cathepsin g  but have normal levels of the acid hydrolases  beta glucuronidase  and n acetyl beta glucosaminidase  the development of antigen induced arthritis in normal mice has been compared with that in beige mice  the pattern of synovitis  both leukocyte accumulation and plasma leakage  were indistinguishable in normal and beige mice  cartilage proteoglycan depletion was quantified by measuring the decrease in safranin o staining intensity  and this  too  was unaltered in mice lacking elastase and cathepsin g  these results suggest that neutrophil elastase and cathepsin g do not contribute to these aspects of joint pathology in antigen induced arthritis in the mouse  
class5	attenuation of suxamethonium myalgias  effect of midazolam and vecuronium  we studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone  n2o  isoflurane anaesthesia  four groups of 20 patients each were pretreated with saline  group 1   tubocurarine 0 05 mg kg  group 2   vecuronium 0 006 mg kg  group 3   or midazolam 0 025 mg kg  group 4   followed by suxamethonium 1 5 mg kg  group 5 received only vecuronium 0 1 mg kg as relaxant  no suxamethonium   fasciculations were graded  and postoperative myalgias rated on the first and third postoperative days  in groups 1 5 the incidence of fasciculations was 95  15  25  95 and 0   the incidence of myalgias on the first day after operation was 70  45  65  75 and 60   and on the third day after operation 20  5  20  20  and 5   respectively  we conclude that pretreatment with vecuronium  but not midazolam  decreases the incidence of fasciculations after suxamethonium  p less than 0 05  and that in this patient population  postoperative myalgias appear to be unrelated to the use of suxamethonium  
class5	clinical presentation of suspected malignant hyperthermia during anaesthesia in 402 probands  as anaesthetists have become more aware of malignant hyperthermia the mortality rate has fallen  but concommitantly the number of dubious and aborted cases has increased  all probands who developed a suspected malignant hyperthermia reaction during anaesthesia and subsequently underwent muscle biopsy were classified according to the clinical presentation  a probability for malignant hyperthermia can be calculated  using the classification  for each type of clinical presentation  this varied from 0 96 to 0 07  certain clinical features were found to be of more value as predictors than others  these included a high creative kinase and myoglobinuria  the accuracy of prediction depends on a clear contemporaneous description of the clinical events  
class5	erythromycin failure with subsequent pasteurella multocida meningitis and septic arthritis in a cat bite victim  we report the case of a 75 year old woman who developed pasteurella multocida meningitis and septic arthritis while being treated for a cat bite wound infection with erythromycin  review of the literature revealed that erythromycin has poor in vitro activity against this bacterium and has been associated with serious clinical failures  we recommend that erythromycin not be prescribed for empiric therapy of established animal bite infections  suggestions for optimal empiric therapy of animal bite infections and the differential diagnosis of severe cat bite associated sepsis are discussed  
class5	gallium nitrate for advanced paget disease of bone  effectiveness and dose response analysis  objective  to evaluate whether a brief course of treatment with gallium nitrate can reduce biochemical parameters of accelerated bone turnover in patients with advanced paget disease  design  unblinded trial  decreasing dose schedules of gallium nitrate  setting  university hospital with primary orthopedic and metabolic bone disease specialty  patients  ten patients with advanced paget disease who had previously received conventional therapy consisting of calcitonin  etidronate  or mithramycin  interventions  five patients were entered into each of three dose schedules  2 5 mg kg body weight per day by continuous intravenous infusion for 7 days  0 5 mg kg per day for 14 days by subcutaneous injection  and 0 25 mg kg per day for 14 days by subcutaneous injection  several patients were treated with different dose schedules  patients were followed until relapse  results  fifteen courses of treatment were administered to ten patients  reductions in serum alkaline phosphatase and urinary hydroxyproline excretion were observed after treatment with each dose schedule  after treatment with high  intermediate  and low doses  the median maximum decreases in serum alkaline phosphatase activity were 49   39   and 18   respectively  the median maximum decreases in urinary hydroxyproline excretion were 50   52   and 16   respectively  the maximum decrease in urinary hydroxyproline excretion occurred within a median of 2 weeks from the start of treatment  whereas the maximum decrease in serum alkaline phosphatase activity occurred substantially later at a median of 6 weeks  all treatment schedules were well tolerated  response duration was highly variable  range  6 to 42 weeks   conclusions  short term treatment with gallium nitrate can reduce biochemical parameters of disease activity in patients with advanced paget disease of bone  larger trials using low dose intermittent treatment schedules are required to evaluate the safety and effectiveness of this therapy  
class5	arachnoid granulation cerebrospinal fluid otorrhea  a case report and review of the temporal bone  tb  collection in the department of otolaryngology at suny health science center in syracuse demonstrated the occurrence of arachnoid granulations  ags  in the posterior fossa surface of the tb and their role in cerebrospinal fluid  csf  otorrhea  a large ag responsible for csf otorrhea in a 64 year old man was excised with soft tissue repair of the dural defect  sixteen of 188 tbs  8 5   in the collection contained 24 ags ranging in size from 0 07 to 80 65 mm3  nine ags  37   were small  less than 1 mm3  and did not demonstrate enlargement  twelve  50   were of intermediate size  2 50 to 9 32 mm3   and three  13   were large  49 82 to 80 65 mm3   the intermediate and large ags were associated with bone erosion and a high incidence of communication with a pneumatized mastoid complex  serous otitis media or meningitis   these findings suggest that ags of sufficient size to produce bone erosion are the primary responsible lesions in adult onset spontaneous csf otorrhea  
class5	prediction of acute renal failure after birth asphyxia  twenty one babies of 34 41 weeks  gestational age with birth asphyxia  5 minute apgar score less than or equal to 5 or umbilical artery ph less than or equal to 7 2  were studied during the first two days of life to find out whether the urinary excretion of tubular markers of renal function is of value in the early diagnosis of acute renal failure  urinary retinol binding protein  myoglobin  and n acetyl beta d glucosaminidase  nag   expressed as a ratio with urinary creatinine  were measured and excretion profiles repeated at 3 6 days in 15 infants and at 7 14 days in 11 infants  plasma creatinine concentration  creatinine clearance  plasma myoglobin concentration  and fractional sodium excretion were measured where possible in asphyxiated infants  control data were obtained from 50 healthy infants  28 gave urine samples alone  17 urine and blood  and five blood alone  normal urinary values were derived from 17  25  and three infants  respectively  for the three time periods  the number of control samples was limited for ethical reasons  four asphyxiated infants had acute renal failure  group 1   four had tubular dysfunction without glomerular disturbance  group 2  and 13 had normal renal function  group 3   group 1 were clearly identified by greatly increased urinary retinol binding protein  greater than 27 000 micrograms mmol creatinine  and myoglobin  greater than 1500 micrograms mmol creatinine  excretion measured in the first two days of life  in control infants the range of excretion of retinol binding protein within the same time period was 3 to 967 micrograms mmol creatinine and urinary myoglobin was undetectable  excretion of nag failed to discriminate between groups 1 and 2  
class5	spontaneous resolution of bone mineral depletion in preterm infants  fifteen preterm infants and 17 born at full term whose gestational ages ranged from 25 to 34 weeks and 38 to 42 weeks  respectively  were examined initially at postconceptional ages ranging from 38 to 44 weeks and subsequently at 46 to 71 weeks  each examination included measurement of bone mineral content of the mid forearm by single photon absorptiometry  for the preterm group  the mean  sd  value of bone mineral content at the first examination was 109 0  27 6  mg cm and was significantly lower than the corresponding value of 194 4  19 6  mg cm for the whole full term group  the mean subsequent rate of mineral accretion in the preterm group was 8 70  4 60  mg cm week  the mean individual duration of observation being 9 7 weeks  rate of mineral accretion for the full term group was independent of the duration of observation and averaged 1 60  2 20  mg cm week  the difference between mean values of rate of mineral accretion in the preterm and full term groups was highly significant  our results show that there is a phase of rapid mineral accretion starting at 40 weeks  postconception in preterm infants that substantially reduces the perinatal mineralisation deficit  
class5	outcome after acute osteomyelitis in preterm infants  eight cases of skeletal infection in preterm infants were studied  all the infants were systemically unwell  with polymorpholeucocytosis  diagnosis was by blood culture  and any radiographic changes were apparent at the time of presentation  infection was often multifocal  with sites around the knee being most commonly affected  staphylococcus aureus was the pathogen isolated in six of the eight cases  in these treatment with fusidic acid was effective and well tolerated  even at doses that were less than the recommended therapeutic minimum  even with prompt diagnosis and aggressive treatment orthopaedic sequelae are common  
class5	pheochromocytoma presenting as rhabdomyolysis and acute myoglobinuric renal failure  we report the case of a previously healthy young woman who presented with the sudden onset of rhabdomyolysis and myoglobinuric renal failure  requiring hemodialysis for 3 weeks  common causes of rhabdomyolysis were ruled out  as renal function returned  severe hypertension was noted and a pheochromocytoma was diagnosed  we suggest that pheochromocytoma causes rhabdomyolysis and myoglobinuria via catecholamine mediated vasoconstriction and skeletal muscle ischemia  
class5	the american college of rheumatology criteria for the classification and reporting of osteoarthritis of the hand  clinical criteria for the classification of symptomatic idiopathic  primary  osteoarthritis  oa  of the hands were developed from data collected in a multicenter study  patients with oa were compared with a group of patients who had hand symptoms from other causes  such as rheumatoid arthritis and the spondylarthropathies  variables from the medical history  physical examination  laboratory tests  and radiographs were analyzed  all patients had pain  aching  or stiffness in the hands  patients were classified as having clinical oa if on examination there was hard tissue enlargement involving at least 2 of 10 selected joints  swelling of fewer than 3 metacarpophalangeal joints  and hard tissue enlargement of at least 2 distal interphalangeal  dip  joints  if the patient had fewer than 2 enlarged dip joints  then deformity of at least 1 of the 10 selected joints was necessary in order to classify the symptoms as being due to oa  the 10 selected joints were the second and third dip  the second and third proximal interphalangeal  and the trapeziometacarpal  base of the thumb  joints of both hands  criteria derived using the  classification tree  method were 92  sensitive and 98  specific  the  traditional format  classification method required that at least 3 of these 4 criteria be present to classify a patient as having oa of the hand  the latter sensitivity was 94  and the specificity was 87   radiography was of less value than clinical examination in the classification of symptomatic oa of the hands  
class5	type xi collagen degrading activity in human osteoarthritic cartilage  homogenates of 6 samples of human osteoarthritic cartilage were shown to degrade exogenous type xi collagen  on sodium dodecyl sulfate polyacrylamide gel electrophoresis  the cleavage products generated by each homogenate were similar  and they were identical to those obtained by cleavage of the substrate with purified gelatinase  enzyme activity  which was inhibited by edta  was greater in extracts of fibrillated osteoarthritic cartilage than in extracts of grossly normal cartilage from the same joint or in extracts of cartilage from joints with osteonecrosis  activation with apma enhanced digestion  but breakdown was apparent in extracts of fibrillated osteoarthritic cartilage even without apma  enzymatic degradation of type xi collagen could play a significant role in the turnover of articular cartilage in health and disease states  
class5	a subluxing arthropathy associated with the anti jo 1 antibody in polymyositis dermatomyositis  of 180 patients with polymyositis dermatomyositis  pm dm  seen at the university of pittsburgh and affiliated hospitals since 1975  21 of 100 tested positive for the anti jo 1 antibody  sixteen of the 21 patients were women and 18 were white  fifteen had adult pm  4 had myositis in overlap with scleroderma  and 2 had adult dm  evidence of interstitial lung disease was found in 12 of 18 anti jo 1 positive patients  67    but in only 15 of 79 anti jo 1 negative patients  19    p less than 0 0002   the 21 anti jo 1 positive patients were divided into 3 separate groups based on the observed articular findings  four patients had a deforming  predominantly nonerosive arthropathy with subluxations of the distal interphalangeal joints  especially the thumbs  eight patients had a nondeforming arthropathy primarily affecting the small joints of the hands  wrists  shoulders  and knees  those with deformities had a longer duration of arthritis compared with those with nondeforming arthropathy  mean 14 5 years versus 3 3 years   nine anti jo 1 positive patients had no joint arthropathy  three of 4 patients with deformities have required articular reconstructive surgery for subluxation  with 2 having associated subcutaneous calcinosis  
class5	igg and iga antibodies to the collagen like region of c1q in rheumatoid vasculitis  we investigated the presence of igg and iga antibodies to c1q in serum samples from 80 patients with rheumatoid arthritis  ra   31 patients with rheumatoid vasculitis  and 80 healthy controls  igg and iga antibodies to c1q  as measured by enzyme linked immunosorbent assay  were found in less than 5  of the sera from ra patients and from healthy controls  in contrast  igg and iga antibodies to c1q were found in 29  and 61   respectively  of the sera from patients with rheumatoid vasculitis  the occurrence of iga antibodies to c1q has not been previously demonstrated  these results also demonstrate that igg antibodies to c1q do not occur exclusively in systemic lupus erythematosus patients  sera of patients with rheumatoid vasculitis frequently contain igg or iga antibodies to c1q  which contribute to immune complex formation  
class5	interleukin 1 induced interleukin 6 is required for the inhibition of proteoglycan synthesis by interleukin 1 in human articular cartilage  cartilage from normal controls  patients with osteoarthritis  and patients with rheumatoid arthritis produced no interleukin 6  il 6  in culture  however  il 1 induced massive production of il 6  up to 135 ng ml  in cartilage from all 3 sources  in a dose dependent manner  in some cases  a peak value was reached   the levels of induced il 6 were similar to those found in rheumatoid arthritis synovial fluid  at il 1 concentrations that induced almost complete inhibition of proteoglycan  pg  synthesis  il 6 production could still be increased considerably  exogenous il 6 inhibited pg synthesis by up to 25   il 1 induced inhibition of pg synthesis was reversed by antibodies against recombinant human il 6  these results suggest that il 6 is required for the il 1 induced inhibition of pg synthesis  
class5	treatment of psoriatic arthritis with oral 1 25 dihydroxyvitamin d3  a pilot study  we conducted a 6 month open label trial in which 10 patients with active psoriatic arthritis received 2 micrograms of oral 1 25 dihydroxyvitamin d3 daily  statistically significant improvement was noted in the tender joint count and physician global impression  of these 10 patients  4 had substantial  greater than or equal to 50   improvement  and 3 had moderate  greater than or equal to 25   improvement in the tender joint count  two patients were unable to receive therapeutic doses because of hypercalciuria  high dose vitamin d may be a useful therapeutic agent for psoriatic arthritis  
class5	nontropical pyomyositis as a cause of subacute  multifocal myalgia in the acquired immunodeficiency syndrome  we report a case of nontropical pyomyositis in a patient with acquired immunodeficiency syndrome and disseminated mycobacterium avium infection  in which severe myalgia was the presenting symptom over several weeks  multifocal muscle lesions were identified by gallium scanning and magnetic resonance imaging techniques  the epidemiology  possible pathogenesis  clinical features  diagnostic imaging  and therapy are reviewed  early suspicion of nontropical pyomyositis in severely immunocompromised patients with  cryptic  myalgia is recommended  
class5	outbreak of spontaneous staphylococcal arthritis and osteitis in mice  staphylococcus aureus is the most common bacterial species found in association with nongonococcal bacterial arthritis in humans  we present here the first description of spontaneous bacterial arthritis and osteitis in mice  clinically  the most obvious findings were swelling and or ankylosis of hindpaws and nodose changes of the tail  the prevalence of arthritis and osteitis ranged from 0  to greater than 50  of the mice studied  depending on the mouse strain  the most prominent histopathologic feature of the arthritis was hypertrophy of the synovial tissue and destruction of cartilage and underlying bone  most of the s aureus infected mice displayed an identical phage type  which was also the only s aureus phage type found in skin isolates from clinically healthy mice  however  a few s aureus isolates were not typeable  indicating that an additional strain s  might cause bacterial arthritis in mice  
class5	quantitative gamma ray computed tomography of the radius in normal subjects and osteoporotic patients  a new design of gamma ray computed tomography  ct  scanner was used to measure bone density in 516 normal adults and in 116 female patients with osteoporotic fractures  trabecular bone density  tbd  was measured for a core of the ultradistal radius  cortical bone mass per unit length  mls  and mass per unit volume  mvs  were computed for the radius shaft  tbd  mls and mvs peaked at the age of about 40 in females and fell by 32   15  and 24   respectively  by the age of 65  in males  tbd decreased from the third decade and mls and mvs peaked in the fourth decade  the corresponding falls by 65 years were 20   6  and 7   in patients with colles  fracture tbd and mls were reduced by 13  and 10   respectively  relative to age matched normal female subjects  for patients with vertebral crush fracture the reductions relative to age matched normal females were 36   17  and 16  for tbd  mls and mvs  in fracture patients the deficit in tbd was significantly greater than that for cortical bone but tbd was no better at discriminating normal and osteoporotic individuals because of its larger normal range  we conclude that gamma ray ct may best be used for monitoring changes in bone rather than as a diagnostic screening tool  
class5	l tryptophan implicated in human eosinophilia myalgia syndrome causes fasciitis and perimyositis in the lewis rat  tryptophan associated eosinophilia myalgia syndrome  l trp ems  is a newly described syndrome which occurred in epidemic fashion in the united states in the summer and fall of 1989  epidemiologic data has linked the syndrome to intake of l tryptophan  l trp  from one specific manufacturer  but the precise etiologic compound s  must be established by replication of the syndrome in an appropriate animal model  in this study  implicated l trp  united states pharmacopeia  usp  grade l trp  or vehicle was administered by gavage in a blinded fashion for 38 d to female lewis rats at doses comparable with those ingested by patients who developed the eosinophilia myalgia syndrome  animals receiving implicated l trp  but not those receiving usp grade l trp or vehicle  developed histologic signs consistent with fasciitis and perimyositis  specific pathologic features of human l trp ems  peripheral blood eosinophilia was not observed  hypothalamic corticotropin releasing hormone mrna levels were lower and plasma corticosterone levels tended to be lower in the animals that received implicated l trp  plasma l kynurenine was higher in both l trp treated groups compared to the vehicle treated animals  the female lewis rat is known to be susceptible to a wide variety of inflammatory diseases  identification of specific inflammatory changes in this rat following exposure to implicated l trp indicates that this animal model will be important in subsequent investigations into the etiology  pathogenesis  and treatment of human l trp ems  
class5	isolated congenital stapes ankylosis  surgical results in 32 ears and a review of the literature  isolated congenital stapes ankylosis is described in 32 operated ears from 28 patients  in 27 ears  a regular stapedectomy was performed  in the remaining 5 ears  2 had stapes gushers  2 had bony stapedial tendons  and 1 had an aberrant facial nerve crossing the oval window  the average individual hearing gain was 20 db  the mean hearing gain for the 24 successful stapedectomies was 29 db  in 24 of 32 ears  75    an essential hearing gain of at least 15 db fletcher s index hearing threshold could be achieved  a fletcher s index not exceeding 30 db could be achieved in 19 of 32 ears  60    in spite of several cases with a sensorineural component in the hearing loss  a review of the literature and overview of longer series with isolated congenital stapes ankylosis is presented  
class5	repetitive strain injuries  how to deal with  the epidemic of the 1990s   occupational trends  especially the mushrooming of computer use in the united states  have brought with them a virtual epidemic of repetitive strain injury of the upper limb  what can you as a primary care physician do to stem the tide  in this article  the authors fill you in on treatment of the most common injuries as well as remark on the ramifications for business and industry  
class5	hormone replacement therapy  how to select the best preparation and regimen  hormone replacement therapy is a mainstay of preventive healthcare for the maturing female population  estrogen deficiency that comes with menopause can have serious effects and is especially important in light of the increasing life expectancy of women  various estrogen and progesterone preparations are available  and their best application requires understanding of the different potencies and metabolic effects  daily maintenance therapy without a drug free interval is becoming the standard method of the 1990s  no doubt the future will bring even better delivery regimens  
class5	calvarial sutural abnormalities  metopic synostosis and coronal deformation  an anatomic  three dimensional radiographic  and pathologic study  the purposes of this study were  1  to evaluate the histologic differences between synostotic versus deformational suture abnormalities and  2  to correlate these histologic findings with anatomic and three dimensional computed tomographic  ct  scans  we examined three infants with premature metopic synostosis  one infant also had microcephaly trisomy 13 and curious overriding of the coronal sutures  the three dimensional ct scans demonstrated obliteration of the metopic suture inferiorly  histologic sections of this suture showed complete bony stenosis  the same pattern was found in all three infants  including the two infants with trigonocephaly who did not have trisomy 13 or microcephaly  in the trisomy 13 infant  the overlapped inferior coronal suture was obliterated on ct examination  however  histologic sections in this region showed a merging of bone  there was no synostosis  in summary  three dimensional ct re formation correlated with metopic suture histology   stenotic  fusion existed in all infants with trigonocephaly  those with normal and abnormal karyotypes  with and without microcephaly  however  three dimensional ct re formation of the trisomic infant showed opacification of the coronal suture in the areas of greatest overlap  whereas histology revealed a curious bone remodeling pattern  possibly a precursor to  deformational  craniosynostosis  
class5	the effect of early fronto orbital advancement on frontal sinus development and forehead aesthetics  the frontal sinuses make an important contribution to normal forehead and glabellar contour  this study was designed to test our clinical impression that early fronto orbital   frontal bone   advancement could have an adverse effect on frontal sinus development and consequently on forehead aesthetics  a retrospective study was conducted on 11 patients who had undergone fronto orbital advancement and also had a long period of follow up at the institute of reconstructive plastic surgery at new york university  the longitudinal cephalometric data were compared with unoperated controls  with one exception  no patient who underwent bilateral fronto orbital advancement developed a frontal sinus  and all such patients had a flattened brow contour when compared with unoperated patients  of whom 82 percent developed at least one frontal sinus  of the three patients who underwent unilateral fronto orbital advancement for plagiocephaly  flattened forehead   two developed a frontal sinus but only on the unoperated side and one developed bilateral frontal sinuses  the two patients with unilateral frontal sinus development had a particularly obvious deformity resulting from normal glabellar projection on the unoperated side and a flattened contour on the operated side  fronto orbital advancement affects forehead aesthetics and should be performed only in infant patients with moderate to severe deformities  patients with plagiocephaly whose deformity is sufficiently severe to warrant surgery should preferably undergo bilateral fronto orbital advancement  by the technique described  rather than unilateral advancement in order to avoid the brow asymmetry that results from unilateral frontal sinus development  
class5	arthritis  roles of radiography and other imaging techniques in evaluation  imaging studies are performed on patients with arthritis for a variety of reasons  to determine whether an arthritic condition is present  to establish the specific diagnosis  to determine the extent of disease  to assess the activity of disease  to detect complications of disease  to evaluate progression of disease  to judge the efficacy of drug treatment  to help in selection of surgical candidates  to aid in the choice of surgical procedures  to size  design  or fabricate prostheses  and to identify complications of surgery  conventional radiography is still the mainstay of all examinations in arthritic patients  arthrography is best applied to evaluate complications of disease and of surgery  although it may be useful in disease detection and in determining the specific diagnosis  nuclear medicine studies are best used to identify complications of surgery and may also be useful to assess disease activity or extent  ultrasound is useful to detect dissecting synovial cysts and deep venous thrombosis  the most valuable role of computed tomography is in the design and fabrication of prostheses and in evaluating complex anatomy of involved joints  magnetic resonance imaging may be useful in early detection of articular cartilage damage and may assist in determination of the specific diagnosis  enhancement with contrast material may aid in assessment of disease activity  
class5	association of vertebral end plate fracture with pediatric lumbar intervertebral disk herniation  value of ct and mr imaging  a retrospective review of the radiologic findings in 31 patients less than 21 years old who underwent laminotomy for lumbar disk herniation revealed six cases of associated avulsion fracture of the vertebral end plate  a prevalence of 19   all fractures were found in the 14 17 year old subgroup  six of 19   a prevalence of 32   in four patients  plain radiographs did not reveal the fracture  computed tomographic  ct  findings were diagnostic in all six cases  magnetic resonance  mr  images  obtained in three patients  demonstrated the avulsed cortical fragment and what are assumed to be the attached sharpey fibers  on sagittal mr images  these structures had a configuration with the appearance of a  y  or  7   four of these six patients underwent bilateral laminotomies  the need for more extensive surgical resection may not be apparent at plain radiography or myelography but can be predicted with ct and mr imaging  
class5	focal fibrocartilaginous dysplasia associated with tibia vara  focal fibrocartilaginous dysplasia of the tibia at the insertion of the pes anserinus  the expanded tendinous insertion of the gracilis  sartorius  and semitendinous muscles  is a rare unilateral lesion with a characteristic deformity of the proximal tibial metadiaphysis  it is associated with unilateral tibia vara in toddlers  three cases of this entity are described  and the radiologic features are presented  recognition of this disease is important because the response to conservative therapy is excellent  
class5	rotator cuff lesions  signal patterns at mr imaging  the signal intensity patterns of rotator cuff lesions at magnetic resonance  mr  imaging were evaluated in 80 patients who had surgical correlation and in 13 asymptomatic individuals  14 shoulders   six cadaver shoulders were examined with mr  and histologic correlation was obtained in four  all studies were performed at 1 5 t with a flexible circular surface coil  the accuracy of mr imaging in detection of full thickness cuff tears  31 patients  was 0 95 and of partial thickness tears  16 patients   0 84  the most common and accurate pattern for full thickness cuff tears  22 of 31 tears  was a region of intense signal seen on t2 weighted images  less often the torn region consisted of an extremely degenerated and attenuated tendon with moderate signal intensity or was obscured by low signal intensity scar  the intense signal pattern on t2 weighted images was also accurate  although a less common finding  seven of 16 cases   in the diagnosis of partial tears  tendinitis was recognized as focal or diffuse regions of increased signal intensity or a nonhomogeneous pattern of increased signal often associated with tendinous enlargement  in some patients  manifestations of subacromial subdeltoid bursitis was present  tendon degeneration was also manifested as regions of increased signal intensity  some similarity and overlap of signal patterns of partial interstitial tears  tendinitis  and tendon degeneration are observed  
class5	cystic rheumatoid arthritis  description of a nonerosive form  in a study of patients with rheumatoid arthritis  ra   9   n   70  were found to have a cystic form  at radiologic examination of these patients with cystic ra  the first abnormality seen consisted of periarticular intraosseous cysts without erosions  the cysts were distributed symmetrically  most often located at the proximal side of the joints and predominantly around the proximal interphalangeal  metacarpophalangeal  and wrist joints of the hands and the first interphalangeal and metatarsophalangeal joints of the feet  computed tomographic scans showed the peripheral intraosseous location of the cysts  magnetic resonance images showed that the cysts may contain fluid  inflamed synovia  or both  cysts can be an important feature in the diagnosis of ra and a supplement to the criteria of the american rheumatism association  osteoporosis  joint space narrowing  and joint destruction occurred less frequently in patients with cystic ra than in patients with classic ra  of the patients with cystic ra  54  were male  and 50  were seronegative  this study is a supplement to and an enlargement on earlier descriptions of cyst predominance in ra  
class5	magnetic resonance imaging and the nonoperative treatment of spinal epidural abscess  this report describes three patients with spinal epidural abscess diagnosed by magnetic resonance imaging and treated nonoperatively  prior to treatment  one patient was neurologically intact  one patient demonstrated a moderate neurological deficit  and one patient was severely paraparetic with loss of bladder and bowel control  following identification of the pathogenic organism  antibiotic therapy was continued until the patients demonstrated clinical improvement and radiological resolution of the abscess  all patients remained stable or improved neurologically  analysis of 33 previously reported patients treated with antibiotics suggests that nonoperative treatment may be a reasonable alternative therapy under certain clinical conditions  these include  1  identification of the pathogenic organism   2  a stable neurological condition   3  access to magnetic resonance imaging or computed tomography for potentially rapid reevaluation  and  4  appropriate neurosurgical consultation and nursing care  nonoperative treatment may also be considered as a reasonable alternative for patients who have severe concurrent medical illness  
class5	flurbiprofen versus diclofenac for the treatment of osteoarthritis of the knee  seventy four patients were enrolled in this double blind  randomized single center study to evaluate the therapeutic effectiveness of 50 mg tid regimens of flurbiprofen or diclofenac sodium in patients with osteoarthritis of the knee  by chance  the flurbiprofen patients had a significantly more advanced disease status at baseline than their diclofenac treated counterparts  however  at subsequent follow up evaluations  both treatment groups experienced a significant reduction in disease severity regardless of the baseline differences  no serious safety problems were associated with either investigational therapy  the frequency of reported medical events were distributed equally between the flurbiprofen and diclofenac groups  although the imbalance in disease severity between treatment groups made a rigorous statistical interpretation of the results very difficult  the data from this clinical trial tend to support the equiefficacy of 50 mg tid regimens of flurbiprofen versus diclofenac for treating osteoarthritis of the knee  
class5	lymphoma presenting as a periorbital tumor  lymphoma is a common tumor of the periorbital region  facial radiographs may show a soft tissue mass  radiologic differential diagnosis of orbital masses is difficult  computed tomographic scanning with intravenous contrast medium is useful in diagnosing and staging neoplasms in this area  
class5	determinants of vertebral mineral density in patients receiving long term glucocorticoid therapy  this study addresses the impact of clinical and biochemical factors on the bone density of patients receiving glucocorticoid therapy  vertebral mineral density was measured by quantitative computed tomography in 35 patients aged 17 to 77 years who had received therapeutic glucocorticoid drugs for 0 1 to 22 years  the mean      sem  vertebral mineral density z score in the subjects was  1 7     0 2  z score was unrelated to underlying diagnosis  sex  or age but was significantly related to the duration of previous steroid therapy  r     38  and to the total cumulative glucocorticoid dose  r     50   the rate of change of bone density in 16 of these subjects followed up over a period of 12 months was  8 9  and was significantly greater in subjects taking more than 12 5 mg of prednisone per day  bone loss was not influenced by sex  age  duration of previous steroid treatment  or diagnosis and was not predictable from biochemical measures of calcium metabolism  
class5	muscle involvement in the scleroderma syndromes  muscle involvement was identified in 14 patients with scleroderma or a connective tissue disease overlap syndrome with predominant features of scleroderma  patients presented with symmetrical proximal weakness indistinguishable from other inflammatory myopathies  creatine kinase and electromyography were useful to demonstrate muscle involvement  muscle histopathology demonstrated primarily the vasculopathy of scleroderma or polymyositis in similar numbers of patients  scleroderma vasculopathy and polymyositis generally occur without specificity to diffuse scleroderma  the calcinosis  raynaud s phenomenon  esophageal dysmotility  sclerodactyly  telangiectasia syndrome  or an overlap syndrome with arthritis  polymyositis also occurs when the vasculopathy of scleroderma involves other organ systems  
class5	the influence of renal function on diabetic foot ulceration  we examined the effect of renal function on the formation  severity  and outcome of diabetic foot lesions  information was collected from a retrospective hospital chart survey and analyzed by univariate and multivariate linear regression analysis  creatinine clearance  peripheral neuropathy  and peripheral vascular disease were all found to be independently associated with formation of foot lesions  indicating that each of these acts by distinct biologic mechanisms  renal function had no bearing on the severity of lesions or on their eventual healing  we conclude that foot ulcers are more likely to develop in diabetic patients who also suffer from renal impairment  but they are no less likely to heal than are those in patients with normal renal function  we further conclude that attempts to preserve functional limbs in these patients are justified  
class5	the distribution of muscle weakness in upper motoneuron lesions affecting the lower limb  to determine the distribution of weakness in the lower limb after upper motoneuron lesions the strength of 8 muscle groups was measured  four groups of patients were studied  22 control subjects  16 patients with unilateral leg paresis  4 patients with severe unilateral paralysis and 5 patients with paraparesis  in the testing posture  seated   patients with cerebral upper motoneuron lesions showed no selective loss of power in flexors or extensors on the contralateral side  gravitational torques were included in the measurements  however  proximal muscles  acting at hip and knee  were significantly less severely affected than more distal muscles  acting at ankle and hallux   at any particular joint  physiological flexors and extensors were affected equally in both the hemiparetic and paraparetic subjects  as in the upper limb  colebatch and gandevia  1989   the strength of muscles on the clinically unaffected side was reduced compared with control subjects  although no muscle groups were especially affected  
class5	capacitive coupling as an adjunctive treatment for avascular necrosis  the purpose of this study was to determine the effectiveness of capacitive coupling  a noninvasive method for applying electrical stimulation to biologic tissues  when used as an adjunct to decompression and grafting in the treatment of avascular necrosis  avn  of the femoral head  it also compared the results of core decompression and grafting with nonoperative management  forty patients with stages i iii avn of the femoral head were treated with core decompression and grafting  all wore capacitive coupling units with electrodes placed over the femoral head continuously for six months  one half of these units were active and one half were inactive  patients were followed for two to four years  results were determined by preoperative and postoperative harris ratings  quantitative roentgenographic measurements  and the number of hips that required total hip arthroplasty  tha   after all evaluations were completed  patients were divided into stimulated and nonstimulated groups  patients in both groups were similar regarding gender  etiology  and roentgenographic stage of involvement  results were also compared to 55 hips previously treated symptomatically  without surgery or electrical stimulation  there were no fractures  infections  or other significant complications in any of the hips operated on  hips treated with decompression and grafting  both with and without electrical stimulation  were more satisfactory than hips treated symptomatically in regard to roentgenographic progression and the need for tha  there was  however  no indication that the addition of capacitive coupling gave better results than decompression and grafting alone  
class5	tissue changes around loose prostheses  a canine model to investigate the effects of an antiinflammatory agent  the aseptically loosened prosthesis provided a means for investigating the in vivo and in vitro activity of the cells associated with the loosening process in seven dogs  the cells were isolated and maintained in culture for sufficient periods of time so that their biologic activity could be studied as well as the effect of different agents added to the cells in vivo or in vitro  the biologic response as determined by interleukin 1 and prostaglandin e2 activity paralleled the roentgenographic appearance of loosening and the technetium images and observations made at the time of revision surgery  the correlation between clinical  roentgenographic  histologic  and biochemical loosening indicates that the canine model is suitable for investigating the mechanisms of prosthetic failure  a canine model permits the study of possible nonsurgical therapeutic interventions with the ultimate hope of stopping or slowing the loosening process  
class5	cementless total joint arthroplasty prostheses with titanium alloy articular surfaces  a human retrieval analysis  surgical implants of titanium alloy  ti 6al 4v  have been found to be susceptible to abrasive wear  resulting in the well known phenomenon of metallosis  in the presence of the acrylic debris generated by loose joint arthroplasty prostheses  this abrasive wear is greatly increased  however  the bone loss seen in these cases has generally been presumed to be due to the osteolytic effects of particulate acrylic  not the alloy debris  which has generally been assumed to be biocompatible  to examine the in vivo effects of titanium alloy wear without the added presence of acrylic debris  a comprehensive analysis was made of cementless human joint arthroplasty prostheses with ti 6al 4v alloy surfaces articulating on ultra high molecular weight polyethylene  uhmwpe   specimens  including the prostheses  synovium  pseudocapsule and additional soft tissues  and periarticular bone  were retrieved from 22 hips and two knees  specimens were examined by histologic techniques  energy dispersive x ray analysis  and electron microscopy  serial sections of the implants were evaluated for tissue ingrowth  tissues surrounding all joints implanted more than one year showed some degree of discoloration indicative of metallosis  whereas after two years the synovium was hypertrophic and villiform  histologic evaluation showed good fixation by bony ingrowth in the vast majority of cases  although location and extent of ingrowth was dependent on numerous factors  viability of ingrowth bone was established by fluorochrome labeling  however  despite good biologic fixation  cavitary osteolysis of the bone surrounding the implants was frequently identified  these lesions were filled with sheets of aggressive macrophages within a matrix of fibrous tissue and necrotic debris  under polarized light the macrophages were found to be filled with alloy and polyethylene fragments of a characteristic size  osteoblast mediated remodeling of bone was infrequently observed  instead  the bone was resorbed along a front in contact with the granulomatous tissues filling the cystic lesions  visible burnishing was observed on every articular surface  with a linear relationship between wear and time implanted  by one year the surfaces were covered with a characteristic  scratch and gouge  pattern  similar on all sizes of femoral heads as well as the total knee prostheses  this study demonstrates that the combination of ti 6al 4v alloy and uhmwpe  when used as a bearing surface combination in total joint arthroplasty prostheses  results in excessive wear of both metal and polymer  abstract truncated at 400 words   
class5	making core decompression work  meaningful assessment of a treatment modality for osteonecrosis  on  must take into account a number of factors   1  an accurate diagnosis   2  consistent staging of the disease process   3  understanding of the variability of the disease   4  consistent application of the treatment modality  or the surgical technique   and  5  a clear understanding of the goal of the treatment used  this article reviews the important steps of a diagnostic algorithm that has been used to accurately diagnose and stage the disease process of on  a consistent surgical technique with clearly defined goals is also outlined  the results of two clinical studies that were based on these diagnostic and therapeutic philosophies and that assess the role of core decompression in the treatment of on are reviewed  the first study compared core decompression to conservative management in a prospective randomized study of 55 hips  decompression provided more predictable pain relief and changed the indications for further surgical intervention more consistently than did conservative management  the second study represents a preliminary review of a ten year study of the decompression procedure  it showed that core decompression was particularly useful in stage i and stage ii on  roentgenographic stabilization was most predictable for stage i hips  core decompression can be a safe  effective  and predictable procedure in the treatment of stage i and stage ii on  
class5	the effect of stem stiffness on femoral bone resorption after canine porous coated total hip arthroplasty  bilateral noncemented total hip arthroplasty  tha  was produced in dogs to determine the effect of stem stiffness on stress related bone resorption  two porous coated femoral implants of substantially different stiffnesses were designed for direct comparison  one was manufactured from cobalt chromium  cocr  alloy  the other from titanium alloy  the titanium stem was hollowed out to a wall thickness of 1 mm to further reduce its stiffness  the cumulative stiffness differences were about 5 4 fold axially and 3 6 fold in bending and torsion  staged bilateral tha was performed on eight dogs  each dog received a stiff cocr stem on one side and a flexible titanium stem on the other  after death  the femora were removed and processed for undecalcified thin section histology  bone ingrowth and remodeling were quantified by computer aided image analysis and compared between stem designs  all femoral specimens showed bone ingrowth fixation of both stiff and flexible stems along the implant length  tetracycline labeling indicated active bone turnover in the femoral cortex and in regions of ingrowth  however  gross differences in femoral bone remodeling were observed both roentgenographically and histologically  femora with the flexible stems consistently showed much less bone resorption than those with the stiff stems  quantitative analysis of paired cross sections indicated an average of 25  35  more cortical bone area in the femora with flexible stems  severe resorption of the cortex in the midstem region occurred in three of the femora with the stiff stems but in none with the flexible stems  stem stiffness strongly influences bone remodeling  the flexible stem results in more uniform load transfer and less stress shielding  
class5	acetabular dysplasia in the adolescent and young adult  hip dysplasia is a major cause of osteoarthrosis in adults  early aggressive osteotomy has the potential of preventing the development of arthritis  but carries with it significant risks  the problem is further complicated because the surgeon has no means of quantifying the dysplastic deformity or of predicting what a particular combination of osteotomies would do to correct the deformity  this study describes methods of quantifying hip joint geometry in three dimensions based on computed tomography and magnetic resonance studies  and of simulating pelvic osteotomy to correct the deformities  the study analyzes 49 normal hip joints and 20 dysplastic hip joints  the results show that the normal acetabulum is nearly a full hemisphere  which is anteverted 20 degrees and abducted 53 degrees  the normal lateral center edge angle is 37 degrees  the dysplastic acetabulum is not anterolaterally maldirected  as has been assumed  but is globally dysplastic  analysis of the individual dysplastic hip joints showed a wide variability  some patients were deficient globally  some anterolaterally  and some posterolaterally  methods of analyzing a patient s hip joint  quantifying abnormalities  simulating surgery  and predicting results are demonstrated in a case example  
class5	chylothorax after posterior spinal instrumentation and fusion  chylothorax occurred in a 16 year old girl after posterior spinal fusion and instrumentation for idiopathic scoliosis  nonoperative management  including chest tube drainage for 26 days and total parenteral nutrition  successfully treated this unusual complication after a posterior spinal fusion  
class5	newer concepts in antimicrobial therapy  advances in the treatment of infection have continued to increase both the length and quality of life  unfortunately  many bacteria can readily adapt to their environment and develop a tolerance to the antimicrobial agents in widespread use  during the recent past  the consumption of cephalosporins has increased so dramatically as to parallel the initial acceptance of penicillin  organisms that are resistant to the cephalosporins will no doubt continue to thrive  especially within the susceptible host  it is essential for the clinician to become familiar with the newest antimicrobial agents to more effectively treat modern infections  
class5	peroneal nerve palsy after total knee arthroplasty  the prognosis for peroneal palsy after total knee arthroplasty  tka  is poorly defined  twenty six postoperative peroneal palsies occurred after 8998 tkas performed between 1972 and 1985  eighteen patients had complete and eight had incomplete peroneal palsies  twenty three had both motor and sensory deficits  and three had only motor deficits  at an average of 5 1 years  range  one to 11 years  after arthroplasty  recovery was complete for 13 palsies and partial for 12  complete recovery was more likely in those palsies that were incomplete initially  patients with palsies that were initially partial had significantly higher knee scores than those with complete palsies  and patients whose eventual recovery was complete had significantly higher knee scores than those with incomplete recovery  this new prognostic information should be useful for surgeons who encounter this unfortunate yet persistent complication of tka  
class5	risk factors for the development of osteoarthrosis of the knee  the roles of physical activity  both work and leisure time   obesity  and history of significant knee injury on the development of severe osteoarthrosis  oa  of the knee were evaluated  a case control design compared 46 cases with a history of severe oa of the knee with 46 community controls matched for age and gender  data were gathered with a self administered questionnaire  the oa cases were 3 5 times more likely than controls to have been obese at 20 years of age  two to three times more likely than controls to have performed heavy work  and almost five times more likely than controls to have had a significant knee injury  in contrast  leisure time physical activity was not significantly different in cases compared with controls  obesity  significant knee injury  and long term heavy physical activity are important risk factors for the development of oa of the knee  
class5	simplified two stage below knee amputation for unsalvageable diabetic foot infections  a simplified two stage below knee amputation for unsalvageable diabetic foot infections was done on 19 limbs with 84  good results for healing  the first stage was the standard below knee amputation with a long posterior flap in which the fascia and skin were closed in the central portion with the medial and lateral portions of the wound left open for drainage  the second stage was delayed until closure of the open wounds three to seven days after the first stage  wagner s classification of diabetic foot lesions was used to stratify these cases  grades 3 and 4 foot infections had a uniformly good prognosis for healing with this surgical technique  grade 5 foot infections had a poor prognosis for healing  especially if associated with renal failure and dialysis  even with an initial guillotine amputation  
class5	bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis  bone fragility during fluoride therapy for osteoporosis was observed in 24  37 5   of 64 patients treated with sodium fluoride  calcium  and vitamin d for 2 5 years who developed episodes of lower limb pain during treatment  eighteen  28   of these patients had clinical and roentgenographic features of 41 stress fractures and 12 new spinal fractures  there were 26 periarticular  six femoral neck  three pubic rami  three tibia and fibula  one greater trochanter  and two subtrochanteric fractures  vertebral fractures appeared first  then periarticular  then femoral neck  and lastly long bone shaft fractures  all fractures were spontaneous in onset  the peripheral fracture rate during treatment was three times that in untreated osteoporosis  roentgenograms must be repeated at intervals of three to four weeks before the pathognomonic callus becomes visible  and the diagnosis can be made  trabecular stress fractures tend to occur in the first 18 months of treatment  and cortical stress fractures occur after 30 months of therapy  
class5	bipolar versus total hip arthroplasty for avascular necrosis of the femoral head  a comparison  in a relatively small series of cases the results of bipolar prostheses in avascular necrosis were inferior to those of total hip arthroplasty  tha   femoral loosening rates were not reduced by using bipolar prostheses  tha produced more inferior results in avascular necrosis than in degenerative joint disease  early results of noncemented tha for avascular necrosis were good but also must withstand the test of time  a fixed noncemented acetabular component was preferable over a bipolar prosthesis for avascular necrosis of the femoral head  
class5	histologic  biochemical  and ion analysis of tissue and fluids retrieved during total hip arthroplasty  large amounts of metal and polyethylene debris and high ion readings are found in capsule and fibrous membranes of both loose titanium and cobalt chromium stems  prostaglandin e2  interleukin 1  and collagenase levels are elevated when compared to control values with collagenase having the highest and most consistent elevations  synovial fluid and blood ion readings were elevated in loose cemented and cementless stems made from both materials  blood ion readings were not elevated in fixed stems  fixed stems had much less particulate debris in soft tissues  the data showed that failure of most metal hip stems was initially due to a mechanical cause  with high debris and ion counts occurring secondarily in capsule and fibrous membranes  particulate debris and high ion readings are primarily a focal problem contained by the periprosthetic fibrous connective tissue encapsulation within the femoral canal and joint capsules  no systemic problems were manifest in any of the patients examined and followed in this study  
class5	perichondral grafting for cartilage lesions of the knee  twenty five patients with 30 chondral lesions of the knee were treated with an autogenous strip of costal perichondrium  the graft was fixed to the subchondral bone with tissucol  immuno  vienna   a human fibrin glue  the leg was then immobilised for two weeks followed by two weeks of continuous passive motion  weight bearing was permitted after three months  the mean knee score  ranawat  insall and shine 1976  changed from 73 before operation to 90 one year after  in 14 patients evaluated after two years there was no decrease  in 28 cases the defect was completely filled with tissue resembling articular cartilage  we conclude that in most cases perichondral arthroplasty of cartilage defects of the knee gives excellent results  
class5	osteotomy for osteoarthritis of the hip  a survivorship analysis  we have reviewed 368 osteotomies carried out for osteoarthritis of the hip at the nuffield orthopaedic centre  survivorship analysis showed that 10 years after osteotomy 47  had required no further surgery  and even after 20 years 23  had still not had a hip replacement  hips with moderate arthritic change showed significantly better results than those with more severe degeneration  osteotomies with varus angulation as well as medial displacement showed longer survival  
class5	intra osseous pressure and oxygen tension in avascular necrosis and osteoarthritis of the hip  the intra osseous pressure  po2  and pco2 were measured in 32 hips  21 patients  which were painful but showed no severe degenerative changes  pre operative scintigraphy and radiography was performed in all patients  thirteen hips showed early osteoarthritis  eight had early osteonecrosis  and 11 had no changes  core biopsies were performed and the bone was examined histologically and graded for necrosis  histologically  necrosis was present in 27 specimens  scintigraphic findings did not correlate with the histological results but were more closely related to the radiographic findings  the intra osseous pressure in hips with histological necrosis  mean 47 mmhg  was significantly higher than in hips without necrosis  mean 26 mmhg   the po2 was lower in bone with histological necrosis  mean 44 mmhg  than in bone without  mean 71 mmhg   po2 increased and intra osseous pressure decreased after decompression  the results confirm that ischaemia plays a central role in the development of necrotic changes in bone  histological necrosis was found in hips with radiographic signs of osteonecrosis and in those with osteoarthritis  radiography  and scintigraphy are shown to be insensitive methods for differentiating between those disorders  
class5	biomechanics of a double prosthetic ligament in the anterior cruciate deficient knee  we have assessed the biomechanical properties of a  double bundle  prosthetic ligament replacing the anterior cruciate in cadaver knees  we compared the results with those of single bundle  over the top  and  through the condyle  techniques  performing anterior drawer tests at 20 degrees and 90 degrees knee flexion  the over the top reconstruction gave better anteroposterior stability at 20 degrees  while the through the condyle repair was more stable at 90 degrees  the double bundle reconstruction gave practically normal anterior stability at both 20 degrees and 90 degrees  
class5	development of the hip in multiple epiphyseal dysplasia  natural history and susceptibility to premature osteoarthritis  we have determined the natural history of hip development in 42 patients with multiple epiphyseal dysplasia  med   premature osteoarthritis was a frequent outcome and was almost inevitable before the age of 30 years in those with incongruent hips  there were two types of immature hips  type i  the more severe form  had a fragmented and flattened ossific nucleus and acetabular dysplasia  was misshapen at skeletal maturity and osteoarthritic by 30 years of age  the milder type ii hip had a small  rounded  uniformly ossified nucleus and a more normal acetabulum  type ii hips were well formed at maturity and were less prone to premature osteoarthritis  considerable variations were noted in the manifestations of med between families but not within families  the prognosis of a child s hip could be predicted  in sporadic cases from the type of immature hip  and in familial cases by also taking into account the outcome of affected relatives  
class5	failed acromioplasty for impingement syndrome  we evaluated 67 shoulders in 65 patients who had pain and dysfunction for more than two years after an initial acromioplasty for impingement syndrome without a rotator cuff tear  in addition to a thorough history  physical examination  local anaesthesia injection and any other necessary investigations all patients had arthroscopic evaluation of the shoulder  in 27 shoulders there had been diagnostic errors  and in 28 operative errors  only in 12 had the diagnosis and the operative procedure both been correct  subsequent operative intervention in patients not receiving worker s compensation benefit had a 75  success rate  whereas in those receiving such benefits the success rate was only 46   
class5	bone lysis in well fixed cemented femoral components  we have reviewed 25 cases of focal femoral osteolysis in radiographically stable  cemented femoral implants  in three hips retrieved at post mortem from two patients  we have been able to make a detailed biomechanical and histological analysis  the interval between arthroplasty and the appearance of focal osteolysis on clinical radiographs ranged from 40 to 168 months  and in over 70  of the cases this did not appear until after five or more years  few had significant pain and there was no relation to age  sex or original diagnosis  the most common site for osteolysis were gruen zones 2 and 3 on the anteroposterior radiograph and zones 5 and 6 on the lateral radiograph  in 15 cases  60    the area of osteolysis corresponded to either a defect in the cement mantle or an area of very thin cement  the rate of progression of these lesions was variable  but to date only one has progressed to gross loosening of the femoral component  the back scatter scanning electron microscopic examination of serial sections and biomechanical testing of the post mortem specimens demonstrated focal cement fracture around implants that were otherwise rigidly fixed  in eight cases from which tissue was available  histology showed a histiocytic reaction with evidence of particulate polymethylmethacrylate  we consider that this local fragmentation was the stimulus for local osteolysis in an otherwise stable cemented femoral component  
class5	localised endosteal bone lysis in relation to the femoral components of cemented total hip arthroplasties  four cases are described of localised endosteal bone lysis in the femur occurring in association with cemented femoral components that were not obviously  loose  radiologically  in each  the area of lysis was shown at operation to be related directly to a region in which there was a local defect in the cement mantle surrounding the stem  via the space between the stem and cement  such defects provide a route through which the contents of the joint cavity may reach the endosteal surface of the femur  subsequently leading to localised bone lysis  and later to frank loosening  
class5	macrophages stimulate bone resorption when they phagocytose particles  we investigated in vitro a mechanism by which particulate debris may induce bone resorption and cause implant loosening  we first studied two standard particles  latex  which is considered to be inert  and zymosan  which is inflammatory  macrophages that phagocytosed either particle became activated  and stimulated 15 times as much bone resorption as did control macrophages  for activation to occur  100 times more latex than zymosan had to be phagocytosed  we also found that bone cement and polyethylene particles activated macrophages in a similar manner  and that the necessary amounts of these were intermediate between those of latex and zymosan  none of the particles were toxic  it was concluded that implant loosening may result from bone resorption stimulated by mediators released by macrophages that have phagocytosed particles of bone cement or polyethylene  
class5	tissue expanded radial forearm free flap in neck burn contracture  neck contracture after burn injury can result in severe functional as well as aesthetic deformities  contracture can recur even after wide and complete release and full thickness skin grafting  recurrence is partly due to the inherent difficulties in both early postoperative immobilization and the required long term splinting  when adjacent tissues are also burned  adequate local tissue for reconstruction may not be available  therefore  free tissue transfer may be necessary  the large surface area that is required after adequate release may be provided by tissue expansion before free tissue transfer  in the case presented the use of tissue expanded radial forearm free flap for the reconstruction of a recurrent neck contracture is described  
class5	hearing loss due to cranio metaphysial dysplasia  craniometaphysial dysplasia is a rare cause of conductive hearing loss  it is a genetic disorder of bone due to decreased osteoclastic activity in the endosteal and periosteal regions of craniofacial and long bones  the characteristic temporal bone abnormalities are attic fixation  abnormally shaped ossicles and obliterated foramina ovale  computerised tomography is helpful in predicting operative findings  surgery should be reserved for those with a severe hearing loss  
class5	magnetic and electrical stimulation of cervical motor roots  technique  site and mechanisms of excitation  cervical motor roots and the brachial plexus were excited transcutaneously with magnetic  magstim  and electrical stimulation  elstim  applied dorsally over the spine and over the supraclavicular fossa  erb s point   the compound muscle action potentials  cmaps  from the abductor digiti minimi  adm  and the biceps muscles  biceps  could be evoked with either stimulating technique in all 52 subjects tested  with magstim over the spinous process c7  greater cmaps were obtained from adm  p less than or equal to 0 0001  paired t test  and biceps  p less than or equal to 0 005  when the inducing current in the coil as viewed from behind was clockwise for the right arm and vice versa  elstim with the cathode over c7 t1 and the anode directed cranially provided greater cmaps from the adm  p less than or equal to 0 0001  and smaller cmaps from the biceps  p less than or equal to 0 01  than with the inverse polarity  magstim of the cervical roots provided cmaps which were smaller from adm  p less than or equal to 0 0001   and greater from biceps  p less than or equal to 0 0001   than elstim  cathode c7 t1   whereas latencies did not differ significantly  p less than or equal to 0 3   when comparing elstim and magstim applied over erb s point  the former yielded greater cmaps and 0 5 ms longer latencies from both the adm and biceps  p less than or equal to 0 001   from these data and additional studies in four patients  including direct intraoperative root stimulation in one of them  it is concluded that elstim and magstim over the spine excite the motor roots at a similar site  that is  within a few cm outside the intervertebral foramina  
class5	rigid spine syndrome with respiratory failure  the pathogenesis and therapy of respiratory failure in the rigid spine syndrome are discussed in two cases who improved with respiratory assistance  in both cases  the partial pressures of oxygen and carbon dioxide were reversed in arterial blood gas analysis and  vc was less than 30   remission from respiratory failure has been obtained by the use of a ventilator during the night  the cause of the respiratory failure in both cases was severe restrictive respiratory dysfunction due to extreme flattening of the chest and fixation of the thorax during respiration as a result of contracture of costovertebral joints  all the previously reported cases of the rigid spine syndrome with respiratory failure died  appropriate use of the ventilator can improve the prognosis  
class5	sexually transmitted arthritis syndromes  sexually transmitted infections may provoke a wide variety of rheumatic lesions  disseminated n  gonorrhoeae infection leads to septic arthritis  which may be rapidly destructive but which responds promptly to appropriate antibiotic therapy  in contrast  both gonococcal and nongonococcal infections may lead to aseptic  reactive  arthritis or reiter s syndrome  inheritance of hla b27 confers a relative risk of 30 to 50 times for the development of this condition  the demonstration of c  trachomatis antigen in joint material from a minority of patients suggests that direct interaction between microbial components and class i hla antigens in the joint may be central to the pathogenesis of this disease  arthralgia and arthritis occur in up to 50  of individuals in the prodrome of hepatitis b infection  joint symptoms may be accompanied by urticarial or cutaneous vasculitic lesions  especially on the legs  both features resolve with the onset of jaundice  hepatitis b infection is also a major cause of necrotizing vasculitis  which may or may not be associated with overt hepatitis  seronegative arthritis  including reiter s syndrome  psoriatic arthritis  and undifferentiated arthritis  a sjogren s like syndrome  vasculitis  and myopathies have been described in association with hiv infection  it is clear that synovitis occurs in those patients despite the fact that hiv is present in immune cells within the joint during inflammatory arthritis and that both antigen presentation and lymphocyte responsiveness within the joint are impaired  nevertheless  synovitis may occur in the presence of marked cd4 positive lymphocyte depletion  rheumatic syndromes  including arthralgia  inflammatory arthritis  and neuropathic arthritis  may occur during any stage of congenital or acquired syphilis  syphilitic synovitis responds well to antibiotic therapy  but neuropathic lesions cannot be treated effectively  septic arthritis has rarely been described as a complication of disseminated mycoplasma or urea plasma infections  and joint lesions sometimes associated with erythema nodosum have also been reported in lymphogranuloma venereum and granuloma inguinale  
class5	asymptomatic rhabdomyolysis of unknown etiology  a 7 year old boy developed rhabdomyolysis with a peak creatine phosphokinase level of 261 400 iu l after his appendectomy  these abnormalities occurred following a 2 3 day illness consisting of upper respiratory tract symptoms  fever  and abdominal pain mimicking acute appendicitis  at the time of operation  a normal appendix was removed  and mesenteric lymphadenitis was noted  the myoglobinuria and elevation of creatine phosphokinase were transient  and the patient remained asymptomatic  we review various causes of right lower quadrant pain and rhabdomyolysis and address the roles of malignant hyperthermia and infectious agents  the possible cause of the phenomena observed in this patient is discussed  
class5	epiretinal membrane contracture associated with macular prolapse  we treated two patients with annular epiretinal membranes that produced unusual macular morphologic characteristics  contracture of the membranes caused herniation of macular tissue through a hole in the center of the membrane  the membranes were removed surgically  and ultrastructural analysis disclosed cells with properties resembling myofibroblasts and apparent new vitreous collagen  contracture of the cellular components probably produced tangential traction on the retina  which caused prolapse of the retinal tissue through a central defect in the membrane  
class5	effects of 2  lignocaine on somatosensory evoked potentials recorded in the extradural space  we have studied the effects of extradural administration of 2  lignocaine at the l3 4 interspace on somatosensory evoked potentials recorded in the cervical extradural space before corrective surgery for idiopathic adolescent scoliosis  eight patients in whom the equivalent volume of 0 9  sodium chloride solution was administered into the lumbar extradural space acted as a control group  lignocaine 2  resulted in a decrease in overall amplitude  but its main effect was a significant decrease in the amplitude of the second and third peaks  suggesting an action on the dorsal columns of the spinal cord  a significant increase in latency was found in both the lignocaine and sodium chloride groups  we conclude that the use of extradural 2  lignocaine in patients undergoing scoliosis surgery may interfere with the intraoperative monitoring of somatosensory evoked potentials  
class5	the presence of autoantibody to recombinant lipocortin i in patients with psoriasis and psoriatic arthritis  corticosteroids may mediate some of their anti inflammatory effects via induction of a specific 38 kda protein  lipocortin i  anti lipocortin i antibodies  ala  were measured by enzyme linked immunosorbent assay  elisa  in 23 patients with plaque type psoriasis alone  nap   in 21 patients with psoriasis and arthritis  pa   and in 67 healthy controls  only two of 23 nap patients had elevated ala  whereas six of 21 pa patients had raised levels of ala  p   0 2   sero negative polyarthritis was the most common pattern of joint disease in those pa patients with elevated ala  4 6   ala levels did not correlate with the extent or severity of cutaneous involvement  and are unlikely to be involved in the pathogenesis of cutaneous psoriasis  
class5	aerobic work capacity in patients with chronic fatigue syndrome objective  to determine the aerobic work capacity of patients with the chronic fatigue syndrome and compare it with that of two control groups  and to assess the patients  perception of their level of activity before and during illness  design  a symptom limited exercise treadmill test with on line gas analysis and blood sampling was used  subjects were assessed by one investigator  who was blind to the group which they were in  setting  department of medicine  royal victoria hospital  belfast  subjects  13 patients  10 women  three men  who fulfilled the diagnostic criteria for chronic fatigue syndrome  two control groups of similar age  sex  and body weight  13 normal subjects  10 women  three men  and seven patients  five women  two men  with the irritable bowel syndrome  main outcome measures  aerobic work capacity as assessed by several variables such as length of time on treadmill  heart rate  and biochemical measurements  borg score  and visual analogue scores of perceived level of physical activity  results  the patients with the chronic fatigue syndrome had a reduced exercise capacity compared with that of the other subjects  spending a significantly shorter time on the treadmill  they had a significantly higher heart rate at submaximal levels of exertion and at stage iii exertion had significantly higher blood lactate concentrations  using a borg score  they showed a significantly altered perception of their degree of physical exertion with a mean score of 8 2 compared with 6 6 and 5 3 for the normal subjects and patients with the irritable bowel syndrome respectively  using a visual analogue scale they indicated that they had a greater capacity for activity before illness than had the patients with the irritable bowel syndrome  but the scores were not significantly different between the two groups  both groups of patients indicated reduced activity at the time of testing  normal controls and patients with the irritable bowel syndrome aspired to a greater level of activity than their current level  but the patients with the chronic fatigue syndrome aspired to a level similar to that which they had had before their illness  conclusions  patients with the chronic fatigue syndrome have reduced aerobic work capacity compared with normal subjects and patients with the irritable bowel syndrome  they also have an altered perception of their degree of exertion and their premorbid level of physical activity  
class5	orbital compartment syndrome  direct measurement of orbital tissue pressure  1  technique  many disorders of the orbit produce an increase in intraorbital pressure  which may result in the development of an orbital compartment syndrome and visual loss  traditionally  orbital tension is assessed clinically by indirect means based on retrodisplacement of the globe  the authors describe their experience with the  slit catheter  technique for direct tissue pressure measurement as applied to the orbit  the preliminary results indicate that normal orbital pressure ranges from 3 0 to 6 0 mm hg  in patients with graves  orbitopathy the values ranged from 7 0 to 15 0 mm hg  the results suggest that the technique may have many exciting possibilities as a clinical research tool in orbital disease  and its use will result in better understanding of orbital compartment syndromes  
class5	effects of a multidisciplinary management program on neurologically impaired patients with dysphagia  dysphagia is a major problem in patients with neurologic disorders  aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates  assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively  this prospective study was conducted to determine if a dysphagia program would improve patients  caloric intake and body weight  decrease the instances of aspiration pneumonia  or improve patients  feeding ability  patients were referred from a 26 bed neurology neurosurgery unit  a time series design was utilized  the control group consisted of 15 patients  mean age   46 1 years   managed according to the existing ward routine  subsequently  nursing staff attended a dysphagia training program  following this  the treated group of 16 patients   mean age   49 3 years  was assessed by the dysphagia team  using bedside and videofluoroscopic examinations to determine the specific swallowing disorder  an individualized treatment program was designed for each patient  the groups were compared on the basis of deviation from their baseline weight  deviation from ideal energy intake  and the incidence of aspiration pneumonia  statistical analysis revealed that the groups were comparable in age  number of days on the study  and glasgow coma scale score  and that a significant weight gain and increase in caloric intake occurred in the treated group  no incidence of aspiration pneumonia was reported in either group  we speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups  
class5	the effects of parathyroid hormone  pth  and pth related peptide on osteoclast resorption of bone slices in vitro  an analysis of pit size and the resorption focus  the mechanism whereby pth  a potent stimulator of bone resorption  may under certain circumstances exert anabolic effects on bone is not known  but it is possible that it involves reduction of the size of osteoclast resorption lacunae  we have therefore made a detailed in vitro study of the effects of pth and pth related peptide  pthrp  on resorption by neonatal rat osteoclasts paying particular attention to the plan area of resorption pits  in order to distinguish between increased resorption at a particular site and increased numbers of sites  we have used an eyepiece graticule to define a focus of resorption  namely an area occupying 1 116th of the bone slice  which may contain either one or several pits  in addition we have studied the relationship between the number of pits in a resorption focus and the total area of bone resorbed at the focus  we found that pth and pthrp  at doses between 2 x 10  10  m and 2 x 10  8  m  while exerting significant stimulatory effects on bone resorption  caused a reduction in the median plan area of pits  an increase in the number of resorption foci was the primary stimulatory effect of pth and pthrp  occurring within 6 h in the case of pth  however  the plan area of bone resorbed at a focus showed no significant increase  despite an increase in the number of pits per focus  because as more pits were formed at a focus  the pits were smaller  thus partially dissipating the stimulatory effect of pth on resorption  these results are consistent with the activation of new remodeling sites by pth in vivo  furthermore  the formation of smaller pits under the resorptive influence of pth may  together with the maintenance of coupling between formation and resorption  play a role in the preservation of cancellous bone recorded in cases of primary hyperparathyroidism and the anabolic effect of exogenous pth  
class5	squamous cell carcinomas often produce more than a single bone resorption stimulating factor  role of interleukin 1 alpha   several cultured human squamous cell carcinoma cell lines  scc 4  scc 12b2  scc 12f2  ec gi 10  and ben  and one normal keratinocyte line  epy 1  were investigated for the production of bone resorption stimulating activity  brsa   conditioned medium  cm  from each of the six cell lines stimulated bone resorption in neonatal mouse calvariae in culture  the brsa of scc 12f2 and ec gi 10 was inhibited completely by antibody to interleukin 1 alpha  il 1 alpha   whereas the brsa in cm from the ben  scc 4  scc 12b2  and epy 1 cell lines was only partially inhibited by anti il 1 alpha  addition of indomethacin to the calvarial cultures also partially inhibited the brsa from ec gi 10  scc 4  scc 12b2  and epy 1 cells  the brsa from ben and scc 12f2 cells was inhibited completely by indomethacin  camp production by calvariae was determined after a 60 min incubation with cm  cm from ec gi 10  ben  scc 4  and epy 1 stimulated camp production by bone  preincubation of cm from ben  ec gi 10  scc 4  and epy 1 cells with two antisera against pth related protein  pthrp  one specific for two pthrp  1 141   the other recognizing both pthrp  1 40  and pthrp  1 141   completely inhibited the camp stimulating activity  using specific enzyme linked immunosorbent assays for il 1 alpha and il 1 beta  il 1 alpha was measured in cm of the scc 4  scc 12b2  scc 12f2  and epy 1 cell lines  il 1 beta was undetectable  less than 0 1 ng ml  in cm from all cell lines  our findings indicate that the brsa secreted by scc 12f2 cells can be accounted for largely or entirely by il 1 alpha  while the activity produced by scc 12b2 includes il 1 alpha and another unknown factor s   the brsa produced by ec gi 10  ben  scc 4  and epy 1 cells includes both il 1 alpha and pthrp  we conclude that il 1 alpha may be a more prevalent and biologically significant component of the brsa produced by sccs than previously recognized  
class5	congenital abnormalities of the lymphatic system  a new clinical classification  the numerous clinical presentations of congenital abnormalities of the lymphatic system in children and the confusing terminology used to describe their pathologic diagnoses impede the physician s understanding of the condition  the clinical classification based on the actual symptoms of the congenital problems we have presented here should help the physician identify the specific abnormality and a potential treatment  future research should concentrate on the specific causes and the treatment of these congenital abnormalities  
class5	biomechanics of mammalian terrestrial locomotion  mammalian skeletons experience peak locomotor stresses  force per area  that are 25 to 50  of their failure strength  indicating a safety factor of between two and four  the mechanism by which animals achieve a constant safety factor varies depending on the size of the animal  over much of their size  0 1 to 300 kilograms   larger mammals maintain uniform skeletal stress primarily by having a more upright posture  which decreases mass specific muscle force by increasing muscle mechanical advantage  at greater sizes  increased skeletal allometry and decreased locomotor performance likely maintain stresses constant  at smaller sizes  skeletal stiffness may be more critical than strength  the decrease in mass specific muscle force in mammals weighing 0 1 to 300 kilogram indicates that peak muscle stresses are also constant and correlates with a decrease in mass specific energy cost of locomotion  the consistent pattern of locomotor stresses developed in long bones at different speeds and gaits within a species may have important implications for how bones adaptively remodel to changes in stress  
class5	physician documentation of diabetes care  use of a diabetes flow sheet and patient education clinic  we assessed two interventions designed to improve the care of patients with diabetes mellitus by documenting the complications of their disease  these were a flow sheet  included with outpatient medical records  and a weekly patient education clinic  in which a nurse educator provided individualized instruction to patients with diabetes  physician compliance with recommendations of the national diabetes advisory board for diabetes care was measured before  n   45  and after  n   158  these interventions  the numbers of referrals to ophthalmologists increased from 22  to 46   urinalyses increased from 58  to 77   and lower extremity examinations increased from 36  to 61   nutrition education documentation increased from 51  to 69   and diabetes education documentation increased from 31  to 61   these results suggest that a significant improvement in physicians  documentation of care of patients with diabetes can be achieved by using a flow sheet and a diabetes patient education clinic  
class5	sternoclavicular septic arthritis due to haemophilus influenzae  we have reported a case of septic sternoclavicular arthritis illustrating a rare complication of infection with a relatively common pathogen  haemophilus influenze  early identification of the infecting organism and appropriate antibiotic therapy are essential to prevent further morbidity from the complications of this unusual pyoarthritis  
class5	eosinophilic granuloma of the cervical spine  a case report and review of the literature  this is a report of a case of eosinophilic granuloma involving the second cervical vertebra in a 33 year old woman  there have been 32 case reports in the literature describing eosinophilic granuloma presenting as cervical spine disease  due to its intimate relation to the central nervous system  the opportunity for neurological sequelae and neurosurgical intervention is common in cervical eosinophilic granuloma  in this report a brief history of eosinophilic granuloma is reviewed and case histories from the literature with cervical spine involvement are summarized  the therapeutic options are described and a recommended protocol for management is outlined  
class5	avascular necrosis of bone  a common serious complication of allogeneic bone marrow transplantation  purpose  to describe the incidence  presentation  clinical course  and management of avascular necrosis of bone following bone marrow transplantation  and to identify risk factors related to its development and outcome  patients and methods  all patients developing avascular necrosis after transplantation between march 1974 and may 1988 were identified by means of the minnesota bone marrow transplant database and hospital records and included in analysis  of 902 consecutive patients undergoing bone marrow transplantation  28 developed avascular necrosis of bone  results  twenty eight of 642 allogeneic transplant recipients  10 4  by product limit estimate  developed avascular necrosis compared to zero of 260 autologous transplant recipients  symptoms developed 1 to 62 months  median 12 months  after transplantation  in the 28 patients a total of 91 joints were affected  mean 3 3 per patient  range one to eight joints   the hip joint was most often involved  64  of patients   followed by knee  61    ankle  29    shoulder  21    and elbow  7    initial standard radiographs were negative in 13 patients  while in nine patients  technetium 99 scans and or magnetic resonance imaging demonstrated changes of osteonecrosis before changes on routine radiographs  almost all patients had received steroid prophylaxis and therapy for graft versus host disease  gvhd   we observed a significant correlation between the total cumulative dose of steroids and number of joints involved  p less than 0 01   a multivariate analysis  allogeneic transplant patients only  identified acute or chronic gvhd requiring steroid therapy  p   0 003   and increasing age  p   0 002  as significant and independent risk factors  fourteen patients required surgery  including joint replacement in 11 patients  in six of six patients  hip core decompression failed to halt disease progression  and total hip arthroplasty was subsequently required  conclusion  avascular necrosis of bone is a frequent late complication of bone marrow transplantation  causing significant morbidity and often requiring surgery  diagnosis using conventional imaging techniques may be difficult and treatment remains inadequate  
class5	reconstruction of the anterior cruciate ligament using allogeneic tendon  long term followup  eighty four patients who underwent acl reconstruction with fresh frozen allogeneic tendon were reviewed and evaluated with subjective and functional rating scales  physical examinations  instrumented anterior drawer tests  isokinetic testing  and arthroscopy  the average followup was 57 months  range  36 to 90 months  and the average age at operation was 22 years  range  16 to 37 years   the subjective and functional results were rated as excellent in 48 patients  57    good in 31  37    and fair in 2  2    three patients  3   experienced a retear of the acl  physical examinations and instrumented anterior drawer tests showed that satisfactory anterior stability was restored in 88  of the patients  isokinetic evaluations demonstrated that the extension torque of the involved knee recovered to a slightly lower level than that of the controls  although the flexion torque recovered to a level equivalent to that of the controls  arthroscopic evaluations revealed that the allografts were elaborately remodeled  viable  and taut  there was no sign of immunologic rejection at any time postoperatively  additional extraarticular procedures  consisting of both pes anserinus transfer on the medial side and iliotibial band reinforcement on the lateral side  had no effect on the results  
class5	shoulder arthroscopy  its role in evaluating shoulder disorders in the athlete  we retrospectively reviewed 100 initial shoulder arthroscopies from a general sports medicine orthopaedic practice to determine if arthroscopy is helpful diagnostically and to see if specific lesions correlate well with specific diagnoses  seventy two percent of the patients in the review had glenoid labral tears  ninety two percent of patients who had a diagnosis of either recurrent anterior dislocation or recurrent anterior subluxation demonstrated a tear of the anterior inferior margin of the glenoid labrum  sixty eight percent of patients with a diagnosis of impingement demonstrated tears at the superior margin of the labrum  there was a significant difference between throwing and nonthrowing athletes  partial rotator cuff tears were noted in 18 patients  the majority occurring in throwing athletes  other abnormalities  such as degenerative joint changes and biceps tendon lesions  were also noted at the time of arthroscopy  a large number of glenoid labral tears found at the time of arthroscopy appeared to be associated with conditions other than instability  which may or may not affect the throwing athlete  there also appeared to be a high correlation between tears in the anterior inferior glenoid labrum and anterior instability  arthroscopy enabled us to identify other significant information about the status of the biceps tendon or the undersurface of the rotator cuff  these are areas in which problems might otherwise have been missed  degenerative changes of the articular surface  not apparent on plain radiographs  may also be better evaluated arthroscopically  
class5	incidence of cervical spinal stenosis in professional and rookie football players  sagittal canal vertebral body ratios were measured on cervical spine lateral radiographs of 124 professional football players and 100 rookie football players  a total of 894 levels were measured in 224 players  thirty two percent  40  of the 124 professional football players  and 34  of the 100 rookies had a ratio of less than 0 80 at one or more levels from c3 to c6  the 0 80 ratio has been considered indicative of cervical spinal stenosis  this is the first time that the incidence of spinal stenosis  as determined by torg s ratio  has been demonstrated in a population of professional and rookie football players  because one third of this population has cervical spinal stenosis as determined by the torg ratio  other factors should be considered in the evaluation of a player with a transient quadriplegic episode when making continued play decisions  
class5	peripheral neuropathy associated with eosinophilia myalgia syndrome  in 1989  the centers for disease control recognized the existence of an epidemic illness characterized by myalgia and eosinophilia in individuals taking preparations containing l tryptophan  we evaluated 3 patients with eosinophilia myalgia syndrome who presented with subacute progressive neuropathies  the neuropathies were predominantly motor and maximal in the lower extremities  two patients were confined to a wheelchair and one was ventilator dependent and bedridden  sensory loss predominantly involved small fiber modalities  electrophysiological studies showed multifocal marked conduction slowing and conduction block indicating segmental demyelination  with associated axonal degeneration that was accentuated distally  examination of sural nerve biopsy specimens demonstrated axonal degeneration in all 3 patients and perivascular infiltrates in 2  levels of quinolinic acid  a neurotoxic metabolite of l tryptophan  were elevated in the cerebrospinal fluid in the 2 patients in whom it was measured  the cause of the neuropathy is unknown but may include immune mechanisms or toxicity of eosinophils  l tryptophan  its metabolic products  or contaminants within l tryptophan preparations  
class5	human immunodeficiency virus  hiv  associated myopathy  immunocytochemical identification of an hiv antigen  gp 41  in muscle macrophages  in a patient with acquired immunodeficiency disease syndrome  aids  and muscle weakness  a muscle biopsy specimen disclosed degeneration of muscle fibers  regeneration  and focal endomysial mononuclear inflammation  a conspicuous feature was the presence of perivascular macrophages within the endomysium that showed positive immunostaining for human immunodeficiency virus  hiv   gp 41  antigen  hiv was not detected within myofibers  our findings suggest an important role for the hiv infected macrophage in the pathogenesis of this myopathy  
class5	effect of a pulsing electromagnetic field on metabolically derived osteoporosis in rats  a pilot study  the literature suggests that a pulsating electromagnetic field  pemf  is effective against bone loss in disuse osteoporosis  this study was conducted to evaluate the effects of pemf on metabolically derived osteoporosis in rats  sixteen 5 month old female sprague dawley rats were divided into three groups  g 1 2 3   g 1 was given a normal diet and no exposure to pemf  g 2 3 were oophrectomized and fed a low calcium diet for 8 months  and g 3 was also exposed for 24 hr day to pemf generated by applying a 15 hz  5 6 a peak to peak square wave to helmholtz coils  64 cm i d   200 turns coil   the rats were sacrificed at 4  6  and 8 months  skeletal changes were analyzed by measurements of acid extracted bone calcium and bone mineral content  bmc  using single photon absorptiometry  spa   although all animals started at approximately the same weight  mean of 290 0 g   g 2 showed a more progressive increase  while the mean weight after 8 months in g 1 was 350 0 g  and 352 5 g for g 3  that in g 2 was 400 0 g  the calcium content of the femur in g 2 and g 3 at 8 months was lower than that of g 1  but there were no significant differences among the three groups  
class5	prerandomization  an alternative to classic randomization  the effects on recruitment in a controlled trial of arthroscopy for osteoarthrosis of the knee  possibly the greatest threat to the success of a randomized clinical trial is the inability to recruit an adequate number of subjects  concern that the randomized clinical trial will adversely affect the physician patient relationship is the most common reason for physicians  reluctance to enroll patients in such trials  we report a modification of a prerandomized design  first described by zelen  which was implemented in a randomized clinical trial of arthroscopy for patients who had osteoarthrosis of the knee  the method was associated with a sixfold increase in the rate of accrual of patients as compared with the use of a classic randomization trial  we propose the design as a potential solution to the problem of recruitment of subjects  particularly for clinical studies  
class5	open fractures of the tibia in children  forty one children who had forty two open fractures of the tibial metaphysis or diaphysis were studied retrospectively  twelve fractures were type i  eighteen  type ii  six  type iiia  four  type iiib  and two  type iiic  according to the classification of gustilo et al  all fractures were irrigated and debrided  and antibiotics were given for a minimum of forty eight hours after the injury  twenty fractures were initially treated with external fixation and twenty two  with immobilization in a plaster cast  three patients had an early infection of the wound  one of which was associated with osteomyelitis  all were successfully treated  the average time to healing of the fracture was five months  range  two to twenty one months   the time to union was related to the severity of the soft tissue injury  the pattern of the fracture  the amount of segmental bone loss  the occurrence of infection  and the use of external fixation  there were six delayed unions  four patients had an angular malunion of more than 10 degrees  which spontaneously corrected in three  one patient who had a proximal metaphyseal diaphyseal segmental fracture had a progressive valgus deformity  four patients who had a severe fracture that was treated with external fixation had more than one centimeter of tibial over growth  there were no amputations  the incidences of compartment syndrome  vascular injury  infection  and delayed union were similar to those reported for open tibial fractures in adults  
class5	total hip arthroplasty with cement  a long term radiographic analysis in patients who are older than fifty and younger than fifty years  the long term performance of a total of 712 charnley and sth prostheses was evaluated as a function of the patient s age  older than fifty years or younger than fifty years  and of the underlying disease  osteoarthrosis  rheumatoid arthritis  or avascular necrosis   in patients who were older than fifty years  there were lower incidences of continuous cement bone radiolucency about the acetabular component  p   0 04   wear of the polyethylene acetabular cup  p   0 03   and resorption of the calcar  p   0 03   however  larger percentages of younger patients had rheumatoid arthritis or avascular necrosis  in the cohort of patients who had osteoarthrosis  the performance of the prosthesis did not differ significantly between older and younger patients  therefore we attributed the differences that were observed to the disease  that is  to rheumatoid arthritis or avascular necrosis  
class5	hazards of internal fixation in the treatment of slipped capital femoral epiphysis  we reviewed the records of 202 patients  308 hips  in whom a slipped capital femoral epiphysis had been fixed with pins or screws  a serious complication that was directly related to the use of internal fixation developed in eighty hips  26 per cent   the rate of complications in the 202 patients was 40 per cent  in thirty six  18 per cent  of the 202 patients  an additional procedure was done to correct a pin related complication  forty one hip joints had been penetrated by a pin  other complications included avascular necrosis  fourteen hips   chondrolysis  nine   fracture  one   infection  one   further slippage  one   sciatic nerve injury  one   and breakage of a screw  eight   ways of decreasing the incidence of complications of fixation were explored  
class5	osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip  published erratum appears in j bone joint surg  am  1991 feb 73 2  293  four hundred and eight siblings  parents  and grandparents of seventy eight children from the new england area who had congenital dysplasia of the hip were evaluated  by clinical examination and by measurements of the acetabulum on pelvic radiographs  for the signs and sequelae of congenital dysplasia of the hip  six siblings and four mothers  representing seven of seventy eight families  had been diagnosed with congenital dysplasia of the hip during childhood  the other ninety one siblings were asymptomatic and had no radiographic evidence of dysplasia of the hip  in the adults in these families  acetabular coverage  as measured by the center edge angle of wiberg  was no different from that in the control subjects  there was no difference between the study group and the control subjects in the prevalence of osteoarthrosis of the hip or of osteoarthrosis that could be considered secondary to congenital dysplasia of the hip  the results indicate that children born to families that have a history of congenital dysplasia of the hip have a greater prevalence of this problem compared with the general population  but also that examinations of the hip in newborns are effective in detecting congenital dysplasia of the hip in such families  the greater prevalence of congenital disease of the hip among the siblings and mothers in these families is consistent with a multifactorial inheritance  the fact that acetabular development in the family members who did not have congenital dysplasia of the hip was no different from that in the control subjects suggests that acetabular dysplasia  rather than being an inherited abnormality  is secondary to subluxation or dislocation  
class5	failure of acetabular autogenous grafts in total hip arthroplasty  increasing incidence  a follow up note  we reported previously on the application of an autogenous femoral head graft to the acetabulum during total hip arthroplasty for compensation of marked osseous deficiency in patients who had arthritis secondary to severe congenital dysplasia or dislocation of the hip  an average of seven years postoperatively  the graft seemed to have been a successful adjunct to the arthroplasty  five years later  to assess our long term results  we reviewed the findings in the same forty six hips  thirty seven patients  that we had studied previously  an average of 11 8 years after the total replacement and use of the autogenous femoral head graft  nine hips  20 per cent  needed a second operation because the acetabular fixation had failed  two had had a resection arthroplasty and seven  a complex revision  in one additional hip  a resection arthroplasty was done for infection that had developed after operative reattachment of the greater trochanter  in twelve of the remaining thirty six hips  there was definite radiographic evidence of acetabular loosening  thus  the total incidence of loosening of the acetabular component was 46 per cent  twenty one hips   the average time from the index operation to the first definite radiographic evidence that the fixation had failed was 6 4 years  range  2 9 to 12 7 years   while we recognize that application of a bulk autogenous graft to the acetabulum is useful when the acetabular bone stock is extremely deficient  we no longer recommend the use of bulk corticocancellous autogenous grafts in other situations  
class5	the molecular basis of hereditary 1 25 dihydroxyvitamin d3 resistant rickets in seven related families  hereditary 1 25 dihydroxyvitamin d3  1 25 oh 2d3  resistant rickets  hvdrr  is an autosomal recessive disease caused by target organ resistance to the action of 1 25 oh 2d3  the active form of the hormone  the defect in target cells is heterogenous and commonly appears to be a mutation in the gene encoding the vitamin d receptor  vdr   we have studied cultured skin fibroblasts and epstein barr virus transformed lymphoblasts of seven family branches of an extended kindred having eight children affected with hvdrr  we have previously shown that cells from three affected children in this group contain an  ochre  nonsense mutation coding for a premature stop codon in exon 7 within the steroid binding domain of the vdr gene  in the current studies  we found that cells from affected children failed to bind  3h 1 25 oh 2d3 and had undetectable levels of vdr as determined by immunoblots using an anti vdr monoclonal antibody  measurement of vdr mrna by hybridization to a human vdr cdna probe showed undetectable or decreased abundance of steady state vdr mrna  parents  expected to be obligate heterozygotes  showed approximately half the normal levels of  3h 1 25 oh 2d3 binding  vdr protein  and mrna  the mutation at nucleotide 970  counting from the mrna cap site  results in the conversion of gtac to gtaa  which eliminates an rsa i restriction enzyme site and facilitates identification of the mutation  we found that polymerase chain reaction  pcr  amplification of exons 7 and 8 from family members and subsequent rsa i digestion allows detection of the specific genotype of the individuals  when rsa i digests of pcr amplified dna are subjected to polyacrylamide gel electrophoresis  children with hvdrr exhibit a homozygous banding pattern with loss of an rsa i site  parents exhibit a heterozygotic dna pattern with detection of both normal and mutant alleles  in summary  our data show that the genetic abnormality is a point mutation within the steroid binding domain of the vdr in all seven related families with hvdrr  analysis of restriction fragment length polymorphism at the 970 locus of pcr amplified dna fragments can be used to diagnose this mutation in both affected children and parents carrying the disease  
class5	serum uric acid correlates in elderly men and women with special reference to body composition and dietary intake  dutch nutrition surveillance system   in 460 apparently healthy dutch elderly  aged 65 79 years  serum uric acid correlates were studied by linear regression analyses  for men and women separately  diuretic therapy  total serum cholesterol  women only  and creatinine clearance  in bivariate analysis only  were significantly associated with serum uric acid level  positive associations of serum uric acid with body weight  body mass index  body fatness  men  and lean body mass  men  were observed  with and without adjustment for diuretic therapy  creatinine clearance and age  serum uric acid levels  whether adjusted or not for these variables and for body mass index  were positively associated with alcohol intake  men  and consumption of meat and fish  women   and inversely with consumption of bread  margarine and milk products  women   these results indicate that limited medication with diuretics  weight control and restriction of alcohol use may help to prevent hyperuricemia in the elderly  
class5	examination by logistic regression modelling of the variables which increase the relative risk of elderly women falling compared to elderly men  in a community based  prospective study to determine risk factors for falls  465 women and 296 men 70 years and over were followed for 1 year and 507 falls were documented  a greater proportion of women  32 7   than men  23 0   experienced at least one fall in which there was no or minimal external contribution  using unconditional logistic regression models we investigated the effect of physical and sociological variables on the sex difference in fall rate  controlling for the variables age  use of psychotropic drugs  inability to rise from a chair without using arms  going outdoors less than daily and living alone decreased the relative risk of women falling compared to men from 2 02  95  ci  1 40 2 92  to 1 55  95  ci 1 04 2 31   some of the increased risk of falling associated with being a women was able to be explained and is potentially correctable  but even after controlling for the physical and social variables which we had assessed  women compared to men still had a significantly increased relative risk of falling  
class5	joint inflammation provoked by a local synovial allergic reaction  homocytotropic antibody was stimulated in animals by administering protein antigens in a vaccine with b  pertussis adjuvant  the titers of the allergic antibody responses were judged by passive cutaneous anaphylaxis reactions  sera or globulin fractions containing high titers of antibody activity were injected into the knee joints of experimental animals  after sufficient delay for unfixed proteins to be cleared from the knee joints  animals were challenged intravenously with the corresponding antigen  the resultant local reaction of swelling and warmth  passive synovial anaphylaxis  was judged visually and by scanning procedures  histological studies showed evidence of mast cell degranulation concurrent with synovial reaction  
class5	adherent synovial cells from nonrheumatoid arthritis do not release interleukin 1 beta and prostaglandin e2 spontaneously in longterm culture  adherent synovial cells from both 13 patients without rheumatoid arthritis  ra   gout  osteoarthritis and meniscal lesion  and 8 patients with ra consisted of dendritic cells  macrophage like cells and fibroblast like cells after cloning in a similar fashion as reported in our previous paper  all the adherent synovial cells from patients without ra did not release interleukin 1  il 1  beta and prostaglandin e2  pge2  spontaneously  while those cells released comparable amounts of il 1 beta  but not pge2 to ra cells after type ii collagen stimulation  only the synovial cells from ra  irrespective of morphology and cloning  released il 1 beta and pge2 without stimulation  nonrheumatoid synovial cells may differ functionally from ra cells  
class5	incidence of polymyositis dermatomyositis  a 20 year study of hospital diagnosed cases in allegheny county  pa 1963 1982  the incidence of hospital diagnosed polymyositis dermatomyositis  pm dm  among residents of pittsburgh and allegheny county  pa was determined from 1963 to 1982  medical records of all allegheny county hospitals were searched for patients diagnosed pm dm  and each accepted case was reviewed and verified by a physician  according to specified criteria  direct age adjusted incidence rates were computed for race and sex  as new cases million population year  with the 1970 allegheny county population as the standard  one hundred seventy seven cases were identified during this 20 year survey for a total annual incidence of 5 5 million population  incidence more than tripled during 1973 1982 compared to the first decade of study  with the greatest increase occurring in black women  overall  the female to male incidence ratio was 2 2 1  but during the childbearing years  ages 15 44  this ratio increased to greater than 5 1 in both races  detection of pm dm is increasing  as shown by temporal trends  although our series has significantly more adult pm and less dm and overlap cases than other published studies  annual incidence is similar to that reported in other locales  
class5	prevention of a false diagnosis of sexually acquired reactive arthritis by synovial lymphocyte responses  three cases are reported in which a diagnosis of sexually acquired reactive arthritis might have been made erroneously from the history  but the enteric origin of the reactive arthritis was evident from synovial lymphocyte responses  the importance of making the correct diagnosis and the avoidance of unwarranted spousal dysharmony is stressed  
class5	restricted dose and duration of corticosteroid treatment in patients with polymyalgia rheumatica and temporal arteritis  to analyze whether corticosteroids in low doses during limited time periods could be safely used in the treatment of patients with polymyalgia rheumatica  pmr  or temporal arteritis  ta  the records of 91 patients diagnosed between 1980 and 1987 were reviewed  the mean initial prednisolone dose was in patients with pmr 18 mg day and the mean duration of treatment was 17 months  in patients with ta the mean initial dose was 31 mg day and the mean duration of treatment 16 months  and in all the corticosteroid treatment was terminated within 24 months  patients with coexisting ta and pmr demanded longer treatment compared to patients with either ta or pmr and thus 18 91 patients were treated for more than 2 years  no visual or neurological complications occurred after treatment with corticosteroids had been initiated  our study indicates that most patients with pmr or ta can be treated safely with an initial prednisolone dose of 10 mg given twice daily  with few exceptions corticosteroid treatment can be terminated within 24 months  
class5	pyogenic sacroiliitis in a rural population  we describe 10 cases of pyogenic sacroiliitis occurring in a rural population  seven were male and 3 were female with a mean age of 22 4 years  none was a recent intravenous drug abuser  five patients had a history of recent pelvic trauma  99mtechnetium scintiscans revealed increased sacroiliac  si  joint uptake in 8 of 8 cases  blood cultures were positive in 60  of patients  staphylococcus aureus was isolated in 7 cases from blood and or si aspirates and hemophilus influenzae type b in one case  nine of 10 patients recovered completely  one underwent arthrodesis for recurrent si pain without evidence of relapse of infection  median followup was 18 months  
class5	synthesis and release of phospholipase a2 by unstimulated human articular chondrocytes  high activity of proinflammatory  type ii phospholipase a2  pla2  was found in synovial fluids  sf  in inflammatory arthritis  in search for the sources of this pla2  we cultured human articular chondrocytes and cartilage explants from healthy  osteoarthritic and rheumatoid joints  all cultures  unstimulated by cytokines  released pla2 extracellularly  cultures obtained from the deep layers of the cartilage released more pla2 than those obtained from the superficial layers  deep layer explants released 0 38 to 18 16 pmol min mg protein pla2 day  whereas superficial layer explants released 0 39 3 18 pmol min mg day  chondrocyte cell cultures continuously released pla2  in the first day 909 46347 pmol min  10 6 cells and after 9 26 days of culture 166 2115 pmol min 10 6  cells  pla2 released from chondrocytes was calcium dependent and had optimum activity at ph 7 5  cycloheximide markedly inhibited its release  chondrocyte cultures also released muramidase  lzm  but there was no correlation between pla2 and lzm release  it may be concluded that cytokine unstimulated human articular chondrocytes synthesize and release pla2 extracellularly which is similar to that found in the sf  thus  chondrocytes may possibly serve as one of the sources of intraarticular pla2  
class5	sternocostoclavicular hyperostosis  two cases with differing dermatologic syndromes  sternocostoclavicular hyperostosis is a rare rheumatic condition characterized by ossification and erosion of the clavicle and the first rib  that has been shown to be associated with pustular skin lesions  we present 2 cases  one of which had features of pustulosis palmaris et plantaris and the other dissecting cellulitis of the scalp  although the dermatologic manifestations differ  both cases have rheumatologic and roentgenographic features diagnostic of sternocostoclavicular hyperostosis  
class5	yersinia enterocolitica tenosynovitis  the first case  we describe a case of tenosynovitis of tibialis posterior due to yersinia enterocolitica occurring after injury by a plant thorn in a 55 year old man  the illness was chronic with 2 recurrences in spite of antibiotic treatment  full recovery was obtained only after surgical intervention  our patient s chronic course was fostered by the persistence of thorn fragments in the infected area and the exceptionally pathogenic character of the isolated colony of yersinia  
class5	septic streptococcus milleri spondylodiscitis  we describe 2 patients presenting lumbar spondylitis due to streptococcus milleri  in both cases origin was related to preexistent intestinal pathology  surgical drainage of a collection of pus was necessary in one case  longterm antibiotic therapy led to full recovery  despite confused nomenclature streptococcus milleri must be considered a serious pathogen mainly associated with purulent infection with osteoarticular affinity  
class6	evaluation of women with possible appendicitis using technetium 99m leukocyte scan  the authors evaluated the use of technetium 99m albumin colloid white blood cell  tac wbc  scan in women with possible appendicitis  one hundred and nine women underwent 110 tac wbc scans  one woman had a second scan on a separate admission and was considered two individual patients in the analysis  twenty six women had appendicitis  10 of whom had a perforated appendix at surgery  the tac wbc scan was indeterminate  abnormal but nondiagnostic for appendicitis  in 52 women  47    nine of whom had appendicitis  fifty eight scans were read as positive or negative for appendiceal pathology  there were 16 true positives  5 false positives  36 true negatives  and 1 false negative  the predictive value of a positive scan was 76   and the predictive value of a negative scan was 97   the tac wbc scan was positive in 62  of patients with appendicitis and negative in 43  of the patients without appendicitis resulting in an overall accuracy of 47  in the 109 women  the main value of tac wbc scan in women with possible appendicitis is its high negative predictive value and the main problem with the tac wbc scan is its high indeterminate rate  
class6	intermittent obstruction of an incarcerated hiatal hernia with a total thoracic stomach  a case of intermittent obstruction of a sliding hiatal hernia is presented  the obstruction occurred when the patient s stomach was totally above the diaphragm  the anatomy of sliding hiatal hernias is discussed  as well as the presenting signs and symptoms of obstruction in sliding hiatal hernias  
class6	a retrospective analysis of therapy for acute graft versus host disease  initial treatment  we have reviewed results of therapy in 740 patients with grades ii iv acute graft versus host disease  gvhd  after allogeneic marrow transplantation  at the beginning of therapy  597 patients  81   had rash  369  50   had liver dysfunction and 396  54   had gut dysfunction  initial treatment was with glucocorticoids  n   531   cyclosporine  n   170   antithymocyte globulin  atg   n   156  or monoclonal antibody  n   3  either singly  n   633  or in combination  n   107   parameters of gvhd severity in each organ were recorded weekly  and evaluation of response was made using values at the initiation of secondary treatment or  for patients without such treatment  using values on day 29 of primary treatment or the last recorded value before death  whichever occurred first  minimal criteria for improvement or progression were defined for each organ  but no attempt was made to define liver or gut outcome if another complication such as venocclusive disease or infectious enteritis was present  improvement rates were 43  for skin disease  35  for evaluable liver disease and 50  for evaluable gut disease  overall complete or partial responses were seen in 44  of patients  multivariate analyses were carried out to identify patient  disease or treatment factors associated with likelihood of overall improvement and likelihood of response in at least one organ  a similar analysis was also carried out to identify covariates associated with time to treatment failure  defined as initiation of secondary therapy or death not due to relapse of malignancy   in all three models  gvhd prophylaxis using cyclosporine combined with methotrexate was associated with favorable gvhd treatment outcome compared to prophylaxis with either agent alone  and treatment with glucocorticoids or cyclosporine was more successful than treatment with atg  other factors associated with unfavorable outcome in the model of time to treatment failure and also entered in one of the response models were recipient hla disparity with the donor  presence of a liver complication other than gvhd  and early onset of gvhd  results of this analysis indicate that glucocorticoids represent the best initial therapy available for treatment of acute gvhd  although much room for improvement remains  
class6	the management of pseudomyxoma peritonei  the management of nine patients with pseudomyxoma peritonei was reviewed  aggressive surgical resection of tumor is the standard of treatment  with many patients requiring multiple laparotomies  chemotherapy  including the use of cisplatin is not effective  long term nutritional support provides a better quality of survival for select patients  
class6	epidural morphine for analgesia after caesarean section  a report of 4880 patients this retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following caesarean section under epidural anaesthesia  the morphine was administered as a single bolus  following delivery  in doses ranging from 2 to 5 mg  the charts of 4880 caesarean sections  performed on 4500 patients  were reviewed  the duration of analgesia and the occurrence of any symptoms which might be side effects of the epidural morphine were recorded  the duration of analgesia was 22 9     10 1 hr and was not correlated with the dose of epidural morphine  eleven per cent of the patients required no supplemental analgesia during the first 48 hr  twelve patients  0 25 per cent  had respiratory rates less than 10 breaths per minute  on at least one occasion  no serious sequelae resulted from these periods of bradypnoea  pruritus occurred in 58 per cent of patients  nausea and vomiting in 39 9 per cent and dizziness in ten per cent  herpes simplex labialis was recorded in 3 5 per cent of patients  epidural morphine is thus confirmed as an effective analgesic technique post caesarean section with 3 mg being the optimal dose  even in this young healthy patient population  clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated  
class6	prospective trial comparing a combination ph probe nasogastric tube with aspirated gastric ph in intensive care unit patients  upper gi bleeding related to stress ulcer syndrome is estimated to affect as much as 15  of patients in an icu  since the occurrence of bleeding after icu admission may be associated with increased morbidity and mortality  many efforts have been directed at defining optimal therapy for stress ulcer prophylaxis  titration of intragastric ph with antacids or iv doses of h2 receptor antagonists may prevent stress ulcer bleeding in high risk icu patients  we evaluated a recently developed ph probe incorporated into an ng tube and compared it with aspiration of gastric contents using ph paper as a means to monitor ph in 22 surgical icu patients  regression analysis comparing the intragastric probe ph values with the aspirated ph values showed a good correlation between the two methods  r    71   this new technique for intragastric ph measurement appears technically simple and clinically applicable for use on patients at risk for stress ulcer bleeding  it may be more accurate than ph paper in patients receiving antacids  
class6	the exeter dysphagia assessment technique  the exeter dysphagia assessment technique  edat  uses noninvasive equipment to record  simultaneously   feeding respiratory patterns   the time drink entered the mouth  and associated swallow sounds during feeding  the easily portable equipment enabled patients  swallowing ability to be tested  at the bedside if necessary  using a small amount of fruit flavored drink  the results appear in chart form  edat findings from groups of normal subjects aged 2 90 years were compared with those from patients with dysphagia of neurologic origin and normal subjects under experimental feeding conditions  the results revealed maturation of the feeding respiratory pattern in the teenage years and remarkable consistency thereafter  differences in the recordings between the normal and abnormal subjects were sufficiently marked to allow the findings to be used in the diagnosis of other patients with dysphagia of doubtful neurologic cause  interpretation of the charts and recorded timings of the oral and pharyngeal stages of swallowing permitted a more accurate identification of sensory nerve  motor nerve  and functional involvement causing dysphagia of neurologic origin and may be used as a guide to the origin of the sensory deficit  
class6	transient mitral regurgitation due to mitral valve prolapse accompanied by systolic anterior motion of the mitral valve  a grade 4 6 systolic murmur  systolic anterior motion of the mitral valve  sam   and severe mitral regurgitation  mr  documented by two dimensional doppler echocardiography developed suddenly on the structurally normal heart of a patient with idiopathic portal hypertension  the patient did not have signs of congestive heart failure and the aforementioned phenomenon disappeared completely when the patient was in hepatic failure  this could be explained by a change in circulating blood volume either by gastrointestinal hemorrhage or hepatic failure  
class6	resolution of the adult respiratory distress syndrome following colectomy and liver transplantation  a 32 year old woman with liver failure from end stage cirrhosis and ulcerative colitis developed septicemia and severe ards  subtotal colectomy and a successful liver transplantation resulted in complete resolution of the ards  
class6	esophageal contribution to chest pain in patients with coronary artery disease  we conducted a prospective study to determine the role of the esophagus in causing chest pain in patients with established cad on optimum therapy  thirty two men with documented cad who complained of frequent and usually daily retrosternal chest pain were evaluated  following a standard esophageal manometry and acid perfusion test  simultaneous two channel ambulatory holter monitor and esophageal ph record tests were performed for 24 hours  fifty three episodes of chest pain were documented in 20 patients  11 patients were free of pain  of the 20 patients who complained of chest pains  17  85 percent  demonstrated at least one episode of ppr  defined as a drop in distal esophageal ph to less than 4 within ten minutes before or after the onset chest pain  episodes of asymptomatic ger were common  the correlation of ppr with chest pain was 70 percent  37 53 episodes  and of ischemic ecg changes with chest pain 13 percent  7 53   in the remaining  there was no correlation with either  two patients demonstrated simultaneous ppr and ischemic ecg changes  seventeen esophageal motility abnormalities were observed in 14 patients  45 percent   it is our conclusion that esophageal disorders contribute to chest pain in patients with documented cad  in this group  ger plays a greater role than in those with normal coronary arteries  in addition  esophageal motility disorders are common in these patients  esophageal testing can be undertaken safely in these patients  
class6	absorption and motility of the bypassed human ileum  the authors assessed absorption and motility of the human ileum after a prolonged period of disuse  in eight patients with ulcerative colitis  a manometric catheter assembly was placed via the ileostomy into the unused portion of distal ileum two months after ileal pouch anal anastomosis and temporary diverting loop ileostomy  the distal ileum was perfused at 5 ml min with an isosmotic solution of either sodium chloride or ileal chyme diluted with sodium chloride for three hours before and three hours after a meal on two consecutive days  absorption was measured  single and clustered pressure waves were identified and quantitated with the aid of a computer program  and a motility index was calculated  mean absorption     s e m  of both perfusates was poor on day 1   10     2 ml 25 cm x 30 min   and the meal induced no ileal motor response  by day 2  however  absorption of both perfusates was much improved   1     2 ml 25 cm x 30 min  p less than 0 05   and the number of discrete clustered contractions and the motility index now clearly increased after the meal  2 6     0 6 vs  7 2     1 0 clustered waves hr  7 5     0 5 vs  9 7     0 2 motility units 30 min  p less than 0 05   the conclusion was that absorption and motility of the human ileum were impaired after two months of disuse  but that ileal absorption and motility improved one day after the introduction of isosmotic ileal perfusates  
class6	the freckle sign  an endoscopic feature of the cecum  mucosal spots  or  freckles   surrounding the appendiceal orifice are an endoscopic feature of the cecum  these are clusters of 1 to 2 mm round or oval slightly raised spots  each with a pale center and an erythematous border  they correlate microscopically with subepithelial and submucosal lymphoid follicles  the freckling pattern  identified in about one third of colonoscopies  was seen best with the videoendoscope and was identified more commonly in patients with systemic illness  recognition of mucosal freckling around the appendiceal orifice helps identify the cecum and may be useful in the evaluation of cecal and appendiceal pathology  
class6	the starved colon  diminished mucosal nutrition  diminished absorption  and colitis  nutrition of colonic epithelial cells is mainly from short chain fatty acids  scfas  produced by bacterial fermentation in the colonic lumen  n butyrate contributes more carbon of oxidation to epithelial cells than glucose or glutamine from the vasculature  incomplete starvation of colonic epithelial cells through lack of luminal scfas leads  in the short term  to mucosal hypoplasia with either diminished absorption or diarrhea  a chronic lack of scfas or complete organ starvation in conjunction with other factors leads to nutritional colitis  either  diversion colitis  or  starvation colitis   whether predominantly diarrhea or colitis develops in mucosal malnutrition appears to depend upon the severity and duration of starvation  ulcerative colitis may be classified as a nutritional colitis in that colonic epithelial cells are unable to utilize scfas reflecting epithelial starvation despite abundant scfas  
class6	crohn s disease and pregnancy  seventy eight pregnancies in 50 patients were reviewed to evaluate the effects of crohn s disease on the outcome of pregnancy and the influence of the pregnancy on the course of crohn s disease  overall  21 pregnancies  27 percent  had abnormal outcomes including spontaneous abortions  9   infants small for gestational age  6   premature infants  5   and infants who developed respiratory distress  1   eight  50 percent  patients with active disease compared with 13  21 percent  patients with inactive disease at conception had abnormal outcomes  p less than 0 05   during pregnancy 15  55 percent  with active disease and 6  12 percent  with inactive disease had an abnormal outcome  p less than 0 001   neither medical nor surgical treatment  independent of disease activity  appeared to affect the outcome adversely  eighteen of 73  25 percent  patients with quiescent or mild disease relapsed  and seven of 16 patients with some disease activity improved  44 percent   of 34 patients on medication  nine relapsed  27 percent   and of 39 patients not on medication  nine relapsed  24 percent   p   n s    these results suggest that the outcome of pregnancy is not adversely affected by crohn s disease  however  patients with active disease at conception and or during the pregnancy have poorer outcomes independent of the use of medication or requirement of surgery  neither pregnancy nor medications taken affect the course of the disease  
class6	short term chemoprophylaxis with ceftizoxime vs  five day aminoglycoside with metronidazole in  contaminated  lower gastrointestinal surgery  in a prospective  open  randomized controlled trial  173 patients requiring surgery for potentially  contaminated  lower gastrointestinal surgery were allocated to receive either two doses of ceftizoxime  2 gm  with one dose of metronidazole  1 5 gm  or gentamicin 3 mg kg day for five days with one dose of metronidazole  1 5 gm   eighty nine patients received ceftizoxime and 84 patients received gentamicin  the groups were comparable with respect to diagnosis  procedure  type of anastomosis  and wound closure  the incidence of withdrawal due to failure to respond to the study drug  11 5 percent  was equivalent in the two groups  there was no difference in the overall incidence of postsurgical infection between the ceftizoxime and metronidazole group  22 2 percent  and the gentamicin and metronidazole group  25 7 percent   the incidence of wound infection  ceftizoxime and metronidazole  6 9 percent  gentamicin and metronidazole  10 percent  and deep sepsis  ceftizoxime and metronidazole  15 3 percent  gentamicin and metronidazole  15 7 percent  was similar  
class6	gastrointestinal tuberculosis  report of four cases  gastrointestinal tuberculosis is a rare disease in the united states  correct identification is often delayed because it is not considered early on in the differential diagnosis  four patients with gastrointestinal tuberculosis and the symptoms  diagnosis  complications  and treatment of the disease are discussed  gastrointestinal tuberculosis should be considered in asian immigrant patients who present with symptoms and signs of inflammatory bowel disease  
class6	scintigraphic measurement of oropharyngeal transit in man  scintigraphic studies of the oropharyngeal transit of a liquid bolus were performed in 15 healthy controls  12 patients with symptoms of oral pharyngeal dysphagia  and 13 patients with neuromuscular disease  who did not have dysphagia  gamma camera imaging of the head  neck  and upper thorax was undertaken  in the lateral projection  during the swallowing of the radiolabeled bolus of water  inspection of summed images permitted the selection of regions of interest  roi  to represent the mouth  pharynx  and upper esophagus  transit times between each roi were calculated and compared  significant prolongation of bolus transit time between the mouth and esophagus was present in both patients with and without dysphagia  0 59     0 38 sec and 0 33     0 7 sec  mean     sd  respectively  compared with controls  0 26     0 04 sec p less than 0 001  p less than 0 01  respectively  mann whitney u test   repeat studies in 25 individuals indicated that the transit measurements were more reproducible between swallows in normal subjects than in patients with symptoms  deglutitive scintigraphy provides a noninvasive technique for the quantitative study of swallowing and its disorders  
class6	effects of milk  prostaglandin  and antacid on experimentally induced duodenitis in the rat  use of myeloperoxidase as an index of inflammation  ulcerogenesis of the duodenal mucosa frequently involves an inflammatory reaction with infiltration of leukocytes  measurement of neutrophil myeloperoxidase activity might thus be a sensitive indicator of damage  before visible lesions occur  to test this possibility  a rat model for duodenal injury was used where fasted animals were treated with indomethacin and histamine dihcl  twenty four hours after indomethacin treatment  duodenal tissues were collected for histochemical staining and biochemical assay for myeloperoxidase activity  indomethacin  and histamine challenged rats had significantly elevated myeloperoxidase activity compared to unchallenged controls  p less than 0 05  for both histochemistry and biochemistry  there was also a significant correlation between these two parameters  r   0 68  p less than 0 001   the duodenal injury model then was used to test the effectiveness of known gastric protective agents  results indicated that milk and buttermilk did not aggravate or protect against duodenal injury  while antacid and prostaglandin did significantly protect against inflammation  p less than 0 02   we concluded that measurement of myeloperoxidase activity is a sensitive and potentially useful estimate of duodenal injury that can be valuable in assessing ulcerogenesis and healing  
class6	gastric dysrhythmias following pylorus preserving pancreaticoduodenectomy  possible mechanism for early delayed gastric emptying  transient delayed gastric emptying is reported as a frequent complication following pancreas preserving pancreaticoduodenectomy  ppw   we placed serosal electrodes on the stomach of a patient undergoing ppw  myoelectric recordings were obtained postoperatively and correlated with simultaneous radionuclide liquid gastric emptying studies  the patient developed early postoperative gastric atony  associated with frequent gastric dysrhythmias  these dysrhythmias may have been exacerbated by a perihepatic abscess  the gastric dysrhythmias correlated with alterations in liquid gastric emptying  gastric dysrhythmias may be a mechanism for gastric dysfunction in the early postoperative period  
class6	sterol dependence of gastric protective activity of unsaturated phospholipids  the major aim of this study was to investigate the gastric protective effect of unsaturated phospholipids and to determine the ability of neutral lipids to enhance this activity  we found that although a liposomal suspension of unsaturated phosphatidylcholine  pc  administered intragastrically failed to protect rats from acid induced gastric ulcer formation  addition of cholesterol to unsaturated pc induced a dose dependent protective response with the maximally effective dose  reducing lesion score greater than 70   this effect also was seen with the plant sterol  beta sitosterol  reducing lesion score by 81 6     36   but was blocked if cholesterol was esterified to fatty acids of varying chain length  addition of sterols to liposomes of saturated dipalmitoylphosphatidylcholine  in contrast  attenuated the gastric protective action of the saturated pc  it appears that the protective mechanism elicited by sterols and unsaturated pc is not mediated by alterations in gastric emptying rate or prostaglandin biosynthesis  although maintenance of surface hydrophobicity may be involved  these results suggest that the sterol may promote the packing of adjacent unsaturated phospholipid molecules of either the cell membrane or a putative extracellular hydrophobic lining of the gastric epithelium to provide the mucosa with protection against luminal acid  
class6	gastric lesions secondary to long distance running  gastrointestinal disorders have been reported during long distance running  the purpose of this study was to evaluate the effects of prolonged exercise on the upper digestive tract  seven subjects were submitted to a standard endoscopic examination of the upper digestive tract before and after long distance running  range 18 50 km   mucosal biopsy specimens were taken during all endoscopies  after running  all runners had histologically pathological features in the stomach  vascular lesions were present in the chorion in six subjects after running  with the intensity of the lesions ranging from congestion to hemorrhage  postexercise histological examination also showed a decrease in mucosal secretion  these lesions secondary to prolonged exercise indicate the presence of hemodynamic perturbations in the upper digestive tract  
class6	outpatient health care utilization of patients with inflammatory bowel disease  on the basis of the normal life expectancy of inflammatory bowel disease patients  the early onset of their disease  and the variety of symptoms  inflammatory bowel disease patients were anticipated to be frequent users of outpatients services  this study assesses  1  the characteristics   2  outpatient health care utilization  and  3  the degree of satisfaction with health care of inflammatory bowel disease patients compared to patients with other gastrointestinal disease  the study method was a secondary analysis of data collected on 395 patients attending the university of calgary gastroenterology outpatient clinic in 1988  inflammatory bowel disease patients were significantly younger  p less than 0 001  and better educated  p less than 0 05  than other patients  during the past year inflammatory bowel disease patients consulted significantly more often with their gastroenterologist  p less than 0 001  and spent more time in hospital  p less than 0 05  than other patients  inflammatory bowel disease patients also consulted more frequently with herbalists and naturopaths  lastly  inflammatory bowel disease patients were as satisfied with the health care they received as other patients  these results provide information useful for health care planners as well as for those dealing directly with inflammatory bowel disease patients  
class6	irritable bowel syndrome in women having diagnostic laparoscopy or hysterectomy  relation to gynecologic features and outcome  we identified irritable bowel syndrome  ibs  in 47 7  of 86 women having diagnostic laparoscopy for chronic pelvic pain  39 5  of 172 women having elective hysterectomy  and 32 0  of 172 controls age matched for the hysterectomy group  p   ns   constipation and pain subtype ibs were more common in hysterectomy patients than controls  p less than 0 05   in laparoscopy patients  dyspareunia was more common in those with ibs than in those without it  p less than 0 05   in the hysterectomy group  more ibs patients had chronic pelvic pain  p less than 0 005   and abnormal menses  p less than 0 01   chronic pelvic pain was more frequently the only prehysterectomy diagnosis in ibs patients  p less than 0 05   and ibs was present more often when pain was a reason for hysterectomy  p less than 0 01   one year after laparoscopy  ibs patients gave lower overall status ratings  p less than 0 01  and lower pain improvement ratings  p less than 0 05  than non ibs patients  in women who had a hysterectomy for pain  there was less pain improvement one year later in those with the pain subtype of ibs than in non ibs patients  p less than 0 05   ibs is associated with gynecologic symptoms and affects the symptomatic outcome of diagnostic laparoscopy and hysterectomy  
class6	investigation of mode of action of biofeedback in treatment of fecal incontinence  a study was carried out in 25 incontinent patients to evaluate some of the factors thought to be responsible for the success of retraining for fecal incontinence  subjects were initially allocated to one of two groups  one group was trained to perceive small rectal volumes  active retraining   the other group carried out the same maneuvers but were not given any information or instruction  active sensory retraining reduced the sensory threshold from 32     8 to 7     2 ml  p less than 0 001   corrected any sensory delay that was present  p less than 0 004   and reduced the frequency of incontinence from 5     1 to 1     1 episodes per week  p less than 0 01   sham retraining caused a modest reduction in the sensory threshold  from 29     9 to 20     8  p less than 0 05  but did not significantly reduce the frequency of incontinence  subsequent strength and coordination training did not significantly improve continence  although at the end of the study  50  of patients had no incontinent episodes at all and 76  of patients had reduced the frequency of incontinence episodes by more than 75   this improvement in continence was not associated with any change in sphincter pressures or in the continence to rectally infused saline but was associated with significant improvements in rectal sensation  the functional improvement was sustained over a period of two years in 16 of the 22 patients available for follow up  in conclusion  the results support the use of retraining in the management of fecal incontinence and suggest that retraining may work by enhancing rectal sensitivity and instilling confidence  
class6	analysis of 24 hour esophageal pressure and ph data in unselected patients with noncardiac chest pain  fourty four unselected patients with noncardiac chest pain were studied using conventional manometry with additional edrophonium provocation and 24 hour ambulatory esophageal ph and pressure recording with a system developed by our group  new  fully automated techniques of statistical analysis of the complete set of esophageal pressure and ph signals were used to examine the temporal relation between pain  esophageal motility disturbances  and gastroesophageal reflux  the analysis used the 97 5th percentile of amplitude and duration of all esophageal contractions in each patient as well as a chi 2 test of the distribution of contraction types to determine whether a pain episode was related to abnormal motility or not  the edrophonium test results were positive in 2 patients  only 25 patients  56 8   had at least one pain episode  total  111 episodes  during 24 hour recording  thirty three percent of the pain episodes were related to reflux and 23 4  to abnormal motility  and 43 2  were not related to an esophageal function disturbance  in the patient oriented analysis in this study  it was required for a positive correlation that the symptom index  percentage of related pain episodes  was higher than 75   it was found that the pain was related to reflux in 2 patients  4 6    to reflux and motor abnormalities in 4  9 2    and to motor abnormalities in 2 patients  4 6    in 36 patients  81 8    no relation with an esophageal abnormality could be established  either because the patients had no pain during the 24 hour study  or because the pain seemed unrelated to reflux or abnormal motility  
class6	phospholipids from rat  human  and canine gastric mucosa  composition and metabolism of molecular classes of phosphatidylcholine  to validate a recent proposal that a phospholipid lining with a high content of dipalmitoylphosphatidylcholine may protect gastric mucosa against luminal acid  it was decided to study composition and metabolism of phospholipids in the gastric mucosa  phospholipids were analyzed in rat  human  and dog gastric mucosal surface tissue and in a chloroform methanol lavage of rat and canine stomach  phosphatidylcholine and phosphatidylethanolamine were the main components  saturated fatty acids were almost exclusively esterified at the sn 1 position of the glycerol moiety of phosphatidylcholine  and unsaturated fatty acids mainly at the sn 2 position  the disaturated class of phosphatidylcholine comprised 2  6  of total phosphatidylcholine  precursors of phosphatidylcholine  i e    32p orthophosphate and  methyl 14c choline  were preferentially incorporated into the disaturated molecular class 0 5 6 hours after iv administration  it can be speculated that disaturated phosphatidylcholine  although quantitatively a minor component  is specifically triggered in mucosal renewal processes  
class6	multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers  a prospective  randomized trial  this study prospectively compares multipolar electrocoagulation and injection therapy in high risk patients with bleeding ulcers  patients were considered for entry if they had a bloody nasogastric aspirate  melena  or hematochezia and unstable vital signs  transfusion of greater than or equal to 2 u of blood in 12 hours  or a decrease in hematocrit of greater than or equal to 6  in 12 hours  sixty patients with endoscopic evidence of an ulcer with active bleeding  n   26  or a nonbleeding visible vessel  n   34  were randomly assigned to receive multipolar electrocoagulation or injection with absolute ethanol  hemostasis was achieved in 14 of 14 actively bleeding patients with multipolar electrocoagulation vs  10 of 12  83   treated with injection  no significant differences were observed between electrocoagulation and injection therapy in any parameter assessed during the hospitalization  incidence of further bleeding  6  vs  10    units of blood transfused after treatment  1 8     0 6 vs  1 3     0 4   incidence of surgery for bleeding  6  vs  7    length of hospital stay in days  5 8     0 9 vs  7 2     2 5   cost of hospitalization   7160      1630 vs   8520      2960   or mortality rate  3  vs  3    treatment induced bleeding in nonbleeding visible vessels in 35  of subjects in each group  but this was controlled with continued treatment in all patients  one delayed perforation occurred 9 days after multipolar electrocoagulation  multipolar electrocoagulation and injection therapy are of comparable efficacy in the treatment of patients with clinical evidence of a major upper gastrointestinal bleed and endoscopic evidence of an ulcer with active bleeding or a nonbleeding visible vessel  
class6	evolution of fundic argyrophil cell hyperplasia in nonantral atrophic gastritis  fundic argyrophil cells were studied for a mean period of 68 7 months  range  11 170  in 18 patients with fundic atrophic gastritis and achlorhydria  initially  12 patients had hyperplasia of the argyrophil cells  the severity of which was assessed using a semiquantitative classification based on the number of argyrophil clusters per square millimeter  at the end of the study  the degree of hyperplasia was unchanged in 9 patients  had decreased in 2  and had increased in 1  no significant increase in the number of argyrophil clusters  precarcinoid changes  or carcinoid tumors were observed and the high level of gastrinemia  mean  4 8  range  1 9 8 1  times the upper limit for normal  did not change significantly  of the 6 patients with no hyperplasia at the outset of the study  4 continued without hyperplasia and 2 presented a low grade hyperplasia at the 20th and 130th month  gastrinemia increased significantly in the last patient and stayed normal in the other 5  this study argues in favor of the stable appearance of fundic argyrophil cells in patients with atrophic gastritis and stable gastrinemia  
class6	a small animal model of human helicobacter pylori active chronic gastritis  isolation of a spiral shaped bacterium closely related to helicobacter pylori from the cat stomach made it possible to investigate new small animal models of gastric infection  pure cultures of this bacterium  provisionally named  helicobacter felis   were fed to germ free mice  the organism colonized the stomach in large numbers in mucus and deep in the gastric pits and showed the same gastric trophism found with h  pylori  significant histopathology was seen in all h  felis infected mice  at 2 weeks postinfection  an acute inflammatory response was seen composed primarily of eosinophils and neutrophils  at 3 weeks  the polymorphonuclear response was more pronounced with large numbers of neutrophils in some areas forming small microabscesses  lymphocytes also increased in number  by 8 weeks  several relatively large lymphoid nodules were present in the submucosa  multiple small microabscesses were still present in the pyloric mucosa  this is the first animal model of bacterial gastritis to be described that shows progression from acute inflammation to persistent acute on chronic inflammation  active chronic  as is seen in human infection with h  pylori  
class6	a comparison in vitro of human and rabbit distal colonic muscle responses to inflammatory mediators  the present study compared in vitro the motor responses of human and rabbit distal colonic longitudinal and circular muscle to acetylcholine  histamine  leukotrienes b4 and d4  and prostaglandins e2 and f2 alpha  the active and passive mechanical properties of these muscles were also evaluated  all muscle types were contracted by acetylcholine and histamine  longitudinal muscle from both species was contracted by prostaglandin e2 and prostaglandin f2 alpha  although rabbit muscle was more sensitive  prostaglandin e2 relaxed the majority of both human and rabbit circular muscle preparations that were studied  prostaglandin f2 alpha first relaxed and then contracted circular muscle from both species  leukotriene b4 had no effect on any tissue studied  leukotriene d4 caused transient relaxations in a proportion of all muscle types  but the relaxations were not concentration related  contractile responses did not differ under isotonic recording conditions  but relaxations were much more clearly defined  based on experiments using atropine  phentolamine and propranolol  and pyrilamine or tetrodotoxin  it was concluded that the responses of both human and rabbit distal colonic muscles to these inflammatory mediators have a similar pharmacological basis  all muscle types exhibited low passive tension and developed active tension in the range 0 8 1 2 lo  these data strongly support the belief that after the onset of an induced colitis  the rabbit colon has value as a predictive model for the study of inflammatory mediator induced colonic motility changes in humans  
class6	long term 6 mercaptopurine treatment in adolescents with crohn s disease although 6 mercaptopurine is often used to treat adolescents with intractable crohn s disease  its long term efficacy has not yet been studied in this population  this study shows data derived from 36 adolescents  mean age     sd  16 5     3 3 years  27 males  9 females  treated at least 6 months with 6 mercaptopurine  1 5 mg kg 1 day 1  maximum of 75 mg day   sites of crohn s disease at the start of 6 mercaptopurine therapy included 17 ileocolic  9 pancolic  7 small bowel  and 3 partial colon  all had received corticosteroids  sulfasalazine  antibiotics  and nutritional support for 5 0     3 0 years before administering 6 mercaptopurine  but intractable symptoms persisted  disease activity lessened during the first year of 6 mercaptopurine  reflected by a higher lloyd still disease activity score  pre  64     9 vs  6 mercaptopurine  72     11  p less than 0 0001   general activity  physical examination  nutrition  and laboratory subscores all improved  p less than 0 004   lessened disease activity occurred despite concomitant decrease in duration of prednisone use  pre  9 5     4 2 vs  6 mercaptopurine  6 6     4 9 months year  p less than 0 001  and cumulative annual prednisone exposure  pre  3672     2106 vs  6 mercaptopurine  1964     1460 mg  p less than 0 0007   the frequency of perianal fistulae and abscesses also decreased  p less than 0 01  during treatment  annual rates of hospitalization decreased in 44  of subjects during 6 mercaptopurine treatment  while increasing in only 22   follow up beyond 1 year of 6 mercaptopurine treatment showed continued remission in 23 of 30 subjects  no serious complications were seen  6 mercaptopurine is an effective long term therapy for adolescents with intractable crohn s disease  while inducing remission  it also has a significant steroid sparing effect which may be of particular benefit to this population  
class6	anorectal function in incontinent patients with cerebrospinal disease  anorectal manometry and the electrical activity of the external anal sphincter were measured in 20 patients with well defined  incomplete spinal lesions who were referred because of fecal incontinence and in 30 normal subjects  six patients had a high spinal lesion  11 had a low spinal lesion  and 3 had mixed high and low spinal lesions  patients with high spinal lesions had normal basal pressures but abnormally low squeeze pressures and impaired rectal sensation  unlike normal subjects  there was no relationship between the depth of sphincter relaxation and the distention volumes  the external sphincter responses to rectal distention and increases in intraabdominal pressure were enhanced  and leakage of perfusion fluid was uncommon  patients with low spinal lesions had abnormally low basal and squeeze pressures  blunted rectal sensation  and showed impaired external anal sphincter responses to rectal distention or increases in intraabdominal pressures  most of these patients leaked the infused fluid during these maneuvers  sphincter function in patients with mixed lesions was more severely impaired than in patients with low and high spinal lesions  patients with mixed lesions showed abnormally low basal and squeeze pressures  impaired rectal sensation  and no external anal sphincter responses to either rectal distention or increases in intraabdominal pressure  leakage occurred during these maneuvers in all patients with mixed lesions  
class6	alpha 1 antitrypsin excretion in stool in normal subjects and in patients with gastrointestinal disorders  fecal clearance of plasma alpha 1 antitrypsin is used as a measure of protein leakage into the intestinal tract  in this study  the alpha 1 antitrypsin concentration in stool and the plasma clearance of alpha 1 antitrypsin in normal subjects and in a consecutive series of patients with chronic diarrhea  malabsorption  or unexplained hypoalbuminemia was determined  the normal subjects were studied in their usual state and also when they had diarrhea secondary to ingestion of lactulose  sorbitol  sodium sulfate  or phenolphthalein  the study first concluded that induced diarrhea can cause an increase in alpha 1 antitrypsin clearance  if this is not considered in establishing normal values  there may be an overdiagnosis of excess protein leakage in patients with diarrhea  second  there is a highly significant statistical correlation  p less than 0 001  between alpha 1 antitrypsin clearance and serum albumin concentration  on average  the serum albumin falls below 3 0 g dl  30 g l  when the alpha 1 antitrypsin clearance exceeds 180 ml day  a value that is about threefold higher than the upper limit of normal  third  three of nine patients with microscopic collagenous colitis had elevated clearance of alpha 1 antitrypsin  by contrast  abnormal alpha 1 antitrypsin clearance was not found in 23 patients with idiopathic secretory diarrhea  fourth  fecal alpha 1 antitrypsin concentration is not a reliable index of abnormal alpha 1 antitrypsin clearance  
class6	randomized  double blind  placebo controlled trial of somatostatin for variceal bleeding  emergency control and prevention of early variceal rebleeding  a randomized  double blind  placebo controlled trial of somatostatin was conducted among 120 patients admitted for bleeding esophageal varices  59 placebo  61 somatostatin   an initial 250 micrograms bolus of somatostatin followed by a 5 day continuous infusion of 250 micrograms h and an identical administration of placebo were evaluated for both the control of bleeding and prevention of early rebleeding from varices  failure to control bleeding occurred in 22  36   somatostatin patients vs  35  59   placebo patients  with time to failure occurring earlier with placebo  p   0 036   blood and plasma transfused per hour during drug infusion of trial drug was reduced in the somatostatin group  median 0 033 vs  0 105 unit h  p   0 025   use of balloon tamponade was halved in somatostatin treated patients  the average effect of somatostatin was a 41  reduction in the hazard of failure  95  confidence interval   1  to 65   p   0 0545  after adjustment for the severity of liver disease  which was the only other variable having a significant influence on time to failure  there was no difference in 30 day mortality per admission  7 placebo  9 somatostatin  or complications  it is concluded that somatostatin is safe and more effective than placebo for the control of variceal bleeding  
class6	hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage  in a double blind randomized trial  the hemodynamic events following the administration of propranolol  n   51  or a placebo  n   51  were prospectively studied in cirrhotic patients with esophageal varices  the hepatic venous pressure gradient  heart rate  and variceal size were determined at the baseline and 3  12  and 24 months after the beginning of therapy  baseline values were similar in both groups  at 3 months  the hepatic venous pressure gradient decreased significantly in propranolol treated patients  from 18 1     4 2 to 15 7     3 4 mm hg  p less than 0 05  but not in patients receiving the placebo  19 6     6 8 to 17 5     5 3 mm hg  ns   at subsequent time intervals this gradient decreased significantly from the baseline value in both groups  heart rate decreased significantly in the propranolol treated group at all times  p less than 0 001   variceal hemorrhage occurred in 13 patients  11 placebo   2 propranolol treated  p less than 0 01   all of whom had a hepatic venous pressure gradient greater than 12 mm hg  in 21 patients  14 propranolol   7 placebo treated  the hepatic venous pressure gradient decreased to less than or equal to 12 mm hg  none of them bled from esophageal varices  and their mortality rate also decreased  because most of the bleeding events occurred during the first year  10 placebo   1 propranolol treated  p less than 0 01   propranolol seems to have its protective effect during the period associated with the largest reduction in the hepatic venous pressure gradient  because a reduction in the hepatic venous pressure gradient to less than 12 mm hg protects from variceal bleeding and increases the rate of survival  this should be the aim of the pharmacological therapy of portal hypertension  
class6	effect of weight reduction on hepatic abnormalities in overweight patients  the effects of weight reduction on hepatic test results and physical findings related to the liver were retrospectively evaluated in 39 overweight patients screened to exclude other factors affecting the liver  an additional 11 overweight patients with primary liver disease were retrospectively evaluated to compare the effect of weight reduction in patients with liver disease with its effect in those without primary liver disease  this study showed that in overweight adults without primary liver disease  a weight reduction of greater than or equal to 10  corrected abnormal hepatic test results  decreased hepatosplenomegaly  and resolved some stigmata of liver disease  in similarly studied overweight patients with primary liver disease  some findings improved  but the changes did not correlate with a greater than or equal to 10  weight loss  increased alanine aminotransferase activity was the most frequent hepatic enzyme abnormality in this population  for every 1  reduction in body weight  alanine aminotransferase activity improved by 8 1   after other causes of liver disease are eliminated by clinical and biochemical parameters  weight reduction should be tried for overweight patients with abnormal hepatic test results in the absence of obvious primary liver disease as judged by clinical and biochemical parameters before extensive and expensive studies are undertaken  
class6	immunochemical characterization and quantitative distribution of pancreatic stone protein in sera and pancreatic secretions in pancreatic disorders  a fluorometric immunoassay has been established to quantitate pancreatic stone protein providing a sensitivity for concentrations from 0 015 to 0 5 micrograms ml  when concentrations of pancreatic stone protein were determined from pancreatic secretions obtained either from patients suffering from chronic pancreatitis  n   31   including the calcifying forms  n   10    pancreatic cancer  n   22   or nonpancreatic diseases  n   17   no significant differences were found  in contrast  increased concentrations were found in serum samples from patients with chronic  39 66  and acute pancreatitis  16 20  compared with control patients  the differences between these diagnostic groups and controls were highly significant  p less than 0 0001  and independent of pancreatic enzyme activity  immunochemical analyses of serum pancreatic stone protein showed an isoelectric point  ph 9  similar to that reported for the pancreatic thread protein  with respect to recent communications  these data do not support the etiopathogenic role postulated for pancreatic stone protein in chronic pancreatitis and chronic calcifying pancreatitis by other investigators  
class6	piezoelectric lithotripsy  stone disintegration and follow up results in patients with symptomatic gallbladder stones  one hundred symptomatic patients with radiolucent gallbladder stones were treated with a new piezoelectric lithotripter and oral chemolitholytic agents  stone disintegration was achieved in 99 of these patients  99   with a mean      sd  maximum fragment size of 5 1     4 1 mm  significant differences were found when the mean      sd  fragment sizes of single stones less than or equal to 20 mm  4 2     2 5 mm  were compared with those of single stones greater than 20 mm  5 8     3 4 mm  p less than 0 05  and multiple stones  6 2     3 8 mm  p less than 0 05   respectively  none of the patients required anesthesia  analgesics  or sedatives before or during the treatment  the stone free rates for all patients followed up for up to 4 12 months  mean     sd  10 7     2 9 months  were 18   1 month   25   2 months   38   4 months   52   8 months   and 67   12 months   partly significant differences were obtained in stone free rates for single stones  less than or equal to 20 mm  compared with larger stones  greater than 20 mm  and multiple stones  p less than 0 05   respectively  serious adverse reactions  i e   cholestasis and pancreatitis  were observed in only 3 patients  3    these conditions were induced by fragment impaction in the common bile duct  in 2 of these patients  endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy was required  it is concluded that piezoelectrically generated shock waves are suitable for the effective and safe disintegration of gallbladder stones in humans  the anesthesia free and analgesia free shock wave application opens up the possibility to perform biliary lithotripsy as an outpatient procedure  the stone free rate achieved in combination with oral bile acids is most promising for single stones  less than or equal to 20 mm   
class6	the effects of synthetic human secretin on calcium carbonate solubility in human bile this study sought to determine the effects of synthetic human secretin on ionized calcium and carbonate concentrations in human hepatic bile  five patients with a nasobiliary drain in the right hepatic duct were studied  three basal samples of bile were collected  each over a 15 minute period  synthetic human secretin was then infused iv at 0 05 micrograms kg 1 h 1 for 45 minutes followed by 0 5 micrograms kg 1 h 1 for 45 minutes  bile was sampled over 15 minute periods  to document return to baseline conditions  two further samples of bile were obtained over 15 minute periods 2 hours after the infusion was terminated  bile acid concentration was determined by an enzymatic method  ph and pco2 were measured with an automated analyzer  total calcium was determined by inductively coupled plasma emission spectrometry and ionized calcium by an ion specific electrode  bicarbonate and carbonate concentrations were calculated using henry s law and the henderson hasselbalch equation  the fraction of bile sampled by the catheter was determined by indocyanin green recovery at the end of the experiment  secretin caused an increase in bile flow and bicarbonate output  bicarbonate concentrations increased from 26     3 mmol l to 41     3 mmol l  p less than 0 05   and chloride concentrations decreased  mean bile acid concentrations declined significantly from 14 6     2 mmol l to 4 7     1 mmol l  p less than 0 05   ionized calcium concentrations decreased from 0 7     0 005 mmol l to 0 5     0 02 mmol l  p less than 0 05  while ph increased significantly from 7 44     0 06 to 7 6     0 04  p less than 0 05   carbonate concentrations increased significantly from 0 15     0 02 mmol l to 0 26     0 03 mmol l  and the ion product for calcium carbonate increased significantly from 0 099     0 002  mmol l 2 to 0 135     0 015  mmol l 2  p less than 0 05   synthetic human secretin augments the ion product of calcium and carbonate in human hepatic bile  increasing the tendency for calcium carbonate precipitation  
class6	in vivo assessment of shock wave pressures  implication for biliary lithotripsy  during extracorporeal shock wave lithotripsy  the pressure profile  which is generated by the lithotriptor  determines the risk of tissue damage  in the present study  the pressure distribution of a lithotriptor  lithostar  siemens a g   erlangen  federal republic of germany  was investigated in 10 pigs  five of which had gallstones surgically implanted into the gallbladder  the in vivo values were compared with in vitro data  measurements were carried out along the shock wave transmission path at the focus within the gallbladder  the adjacent liver  the diaphragmatic surface of the right lung  and the shock wave exit site from the skin  interposition of ribs did not cause a significant decrease in focal positive pressure  however  a gallstone positioned in the focus caused a 30  65  reduction in pressure  recorded immediately behind the stone  pressures obtained in vivo were always 15  25  lower than those measured in vitro  the spatial distributions of the positive pressure in vivo and in vitro were almost identical  there was a high correlation between the pressures in vitro and in vivo  r   0 88  p less than or equal to 0 01   this justifies assessment of shock wave energies generated during biliary lithotripsy by extrapolation of in vitro data  it is concluded that it is possible to characterize different lithotriptors by in vitro pressure profile measurements  
class6	endoscopic retrograde brush cytology  a new technique  endoscopic retrograde cholangiopancreatography has been shown to be a very valuable adjunct in the diagnosis of malignancy involving the biliary and or pancreatic ductal system  however  characteristic endoscopic retrograde cholangiopancreatography radiographic findings associated with malignant strictures are frequently not specific and cytological confirmation becomes essential for the diagnosis  unfortunately  the current overall diagnostic yield of positive cytology in such circumstances ranges from 18  56  depending on the technique  a new brush device has been designed which is uniquely adapted to pancreaticobiliary strictures of varying anatomical configurations  this study shows results using this new cytology brush in a series of 53 patients with pancreaticobiliary malignancy  a significant improvement in the cytological yield of tumor confirmation was obtained with a diagnostic sensitivity of 70  and specificity of 100  using the new brush technique  
class6	bile duct emptying in response to fat  a validation study  fatty meal sonography has been suggested to assess patients with biliary pain after cholecystectomy  but the effects of gallbladder removal on biliary dynamics has not been studied prospectively  before elective cholecystectomy  25 patients had their common hepatic ducts  diameter measured by ultrasonography before and after a fat stimulus  in 23  tests were repeated 1 month  1 year  and 5 years after surgery  in preoperative studies  5 patients showed dilatation after fat and 2 of these had stones in the common bile duct  however  another 4 patients with stones or sludge in the duct did not show dilatation  so that the response to fat was a poor indicator of patients requiring common bile duct exploration  no patient had major symptoms after surgery  at 1 month and 12 months  the response to fat was variable with more than half of those tested showing no decrease in duct size  a more consistent pattern emerged at 5 years  when 14 of 18 patients tested showed a decrease in common hepatic duct after fat  3 were unchanged and 1 increased by 1 mm  the response to fat was less consistent and more difficult to measure in the common bile duct  even 5 years after operation  it was concluded that not all patients with indications for exploration of the common bile duct on operative cholangiography show a dilatation response to fat on preoperative testing  also  fatty meal sonography should be used with caution because the response to fat in asymptomatic patients soon after operation is unpredictable  with occasional patients showing dilation without apparent obstruction  measurement of common hepatic duct is preferred to common bile duct and increases in diameter of 1 mm are probably not significant  
class6	pemoline associated hepatic injury  among 100 cases of hepatic injury attributed to the administration of pemoline  43 had sufficient accompanying information to permit analysis  all but two patients were less than 20 years old  and 80  were less than 12 years old  males predominated the study  injury appeared as early as 1 week or as late as greater than 1 year of taking the drug  the injury was uniformly hepatocellular as judged by the high values for aminotransferases and by death in massive necrosis in one patient  mechanism was judged to be idiosyncratic  and the idiosyncrasy was probably metabolic rather than immunologic  
class6	endosonography of peri anal and peri colorectal fistula and or abscess in crohn s disease  transcolorectal endosonography  es  was performed in 36 patients with crohn s disease suspected clinically to have a fistula or abscess  a hypoechoic or anechoic duct like lesion immediately adjacent to the anorectal lumen compatible with a fistula was found in 32 patients  a communication between the fistulous tract and adjacent structures such as the skin  anal canal  or vagina was detected in all 32 patients  an anechoic cavity adjacent to or communicating with the fistula was visualized in 29 of the 36 patients  a fistula was visualized in the remaining seven patients with no evidence of an abscess  this anechoic cavity compatible with an abscess was surgically confirmed in 14 of 17 patients  we judged the extent and configuration of the abnormalities to be more clearly visualized by es when results were compared with fistulography in five patients  there were no es complications  and we conclude that es is the preferred diagnostic procedure in patients with peri rectal pathology because of the low risk of bacterial dissemination and low incidence of patient discomfort  utilizing es after non surgical treatment was successful in 19 patients for documentation of the response to therapy  
class6	mechanical lithotripsy of common duct stones  over the past 8 years we have utilized various types of mechanical lithotriptors to crush common bile duct stones  the procedure was performed in 93 patients with an overall success rate of 94   however  because many accessories were in a developmental stage  entrapment of stones was not always possible on the first attempt  and the procedure was repeated in some patients a second or third time  during the interim  while awaiting another attempt at lithotripsy  cholangitis was prevented by leaving a prosthesis in place  a variety of lithotriptor models from different manufacturers have proven effective  we recommend that endoscopists use these devices to rid the bile duct of retained stones  
class6	endoscopic palliative intubation of the esophagus invaded by lung cancer  thirty two patients with esophageal involvement by lung cancer were managed by endoscopic intubation  in 22 patients with extrinsic esophageal strictures  the success rate of intubation was 91   and 82  were discharged with their dysphagia relieved and esophageal patency restored  the mean survival rate was 4 4 months  in 10 patients with esophago bronchial fistulas  3 had the fistulous tract obliterated and lived a mean of 5 months  this low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor associated stenosis  the overall morbidity rate was 28 1   18 8  perforation  6 3  hemorrhage  and 3 1  tracheal obstruction   the overall mortality rate was 18 8   although complications were more frequent than in primary esophageal tumors  endoscopic intubation was the only way to palliate this desperate condition and provided 66 6  of patients with relief of symptoms  nutritional improvement  and a mean survival time of 4 5 months  
class6	endoscopic cholangiopancreatography in hepatic clonorchiasis  a follow up study  cholangiographic changes of the biliary system in 16 patients with proven hepatic clonorchiasis  diagnosed by positive stool or bile ova isolates  were studied  all patients presented with epigastric pain  other symptoms included jaundice in 31   5 of 16  and fever in 12 5   2 of 16   praziquantel given at 25 mg kg for three doses in 1 day were administered  three consecutive stool tests were performed 3 months after treatment and were negative in 87 5   14 of 16   ercp studies were repeated at a mean interval of 31 6 months  range  8 to 69 months   measurements of the bile ducts on retrograde cholangiograms before and after treatment were compared using the paired student s t test  filling defects and blunting of the terminal bile ducts seen on the initial cholangiogram  interpreted as the presence of adult worms  disappeared after treatment  however  there was no significant change between pre  and post treatment measurement of bile duct caliber  bile duct dilation  irregularities  and ductal proliferation persisted despite eradication of the parasite  
class6	the role of ercp in children and adolescents  the diagnostic and therapeutic role of ercp in 42 patients ranging from 1 to 19 years of age is discussed  ercp provided useful additional information in 15 patients with biliary tract disease  15 patients with pancreatic disease  and 9 patients with abdominal pain  the appropriate duct was cannulated in 95  of cases  mild pancreatitis occurred in two patients after ercp  endoscopic papillotomy was successful in five patients  ercp plays an important part in the investigation of unexplained biliary tract and pancreatic disease  it rarely demonstrates abnormal pathology in patients with otherwise unexplained abdominal pain  
class6	can clinicians accurately assess esophageal dilation without fluoroscopy  this study questioned whether clinicians could determine the success of esophageal dilation accurately without the aid of fluoroscopy  twenty patients were enrolled with the diagnosis of distal esophageal stenosis  including benign peptic stricture  17   schatski s ring  2   and squamous cell carcinoma of the esophagus  1   dilation attempts using only maloney dilators were monitored fluoroscopically by the principle investigator  the physician and patient being unaware of the findings  physicians then predicted whether or not their dilations were successful  and they examined various features to determine their usefulness in predicting successful dilation  they were able to predict successful dilation accurately in 97  of the cases studied  however  their predictions of unsuccessful dilation were correct only 60  of the time  features helpful in predicting passage included easy passage of the dilator  98   and the patient feeling the dilator in the stomach  95    excessive resistance suggesting unsuccessful passage was an unreliable feature and was often due to the dilator curling in the stomach  when maloney dilators are used to dilate simple distal strictures  if the physician predicts successful passage  he is reliably accurate without the use of fluoroscopy  however  if unsuccessful passage is suspected  fluoroscopy must be used for confirmation  
class6	endoscopic appearance and significance of functional lymphangiectasia of the duodenal mucosa  intestinal lymphangiectasia is found in a wide variety of pathologic conditions  functional lymphangiectasia has not been well characterized  we report 20 patients followed for 9 to 55 months  mean 30 months  after incidental detection at endoscopy of lymphangiectasia  our study indicates that functional lymphangiectasia is not pathologic and does not warrant repeat endoscopy in the absence of other clinical indications  
class6	circulating antibodies against human colonic extract enriched with a 40 kda protein in patients with ulcerative colitis  we have previously described a 40 kda colonic protein s  which is specifically recognised by tissue bound immunoglobulin g obtained from the colon of patients with ulcerative colitis  we now report the presence of circulating antibodies against this antigen using an enzyme linked immunosorbent assay with a highly enriched preparation of the 40 kda protein from normal colon extracts  serum was collected from 79 patients with ulcerative colitis  36 with crohn s disease  16 with specific diarrhoeal syndromes  and from 19 normal subjects  twenty nine of 79 patients with ulcerative colitis  21 of 36 with crohn s disease  and all patients with diarrhoea were symptomatic during the collection of sera  the difference in optical density values between patients with symptomatic ulcerative colitis and each of the other groups  including patients with ulcerative colitis in remission  was highly significant  p less than 0 01   seventy nine per cent of patients with symptomatic ulcerative colitis had optical density values above the means for all other groups  fifty five per cent of sera from patients with symptomatic ulcerative colitis had optical densities beyond two sds of the values for all other groups and only two of 71 sera from non ulcerative colitis patients  one crohn s disease and one normal subject  had values in this range  these results show the presence of anti colon antibodies against the 40 kda protein s  in the sera of many patients with symptomatic ulcerative colitis  
class6	effect of ulcerative colitis and smoking on rectal blood flow  rectal blood flow was measured by laser doppler flowmetry over 60 minutes in eight patients with colitis in remission and eight healthy male non smokers  ten smokers were also examined on two occasions  one of which included smoking a cigarette  plasma nicotine concentrations were measured in smokers  all subjects showed a pronounced fall in rectal blood flow in the first 30 minutes and patients with colitis had significantly higher values compared with smokers  p less than 0 002  p less than 0 04  and non smokers  p less than 0 007  p less than 0 002  during the first and second 30 minutes respectively  values in smokers and non smokers were similar  but smoking a cigarette was associated with a significant fall in blood flow  p less than 0 04  and this change was inversely related to the rise in plasma nicotine concentration  r    0 63  p less than 0 05   the findings may be relevant to the association between colitis and the smoking history  
class6	daytime reduction of gastro oesophageal reflux after healing of oesophagitis and its value as an indicator of favourable response to maintenance treatment  in order to investigate the response of gastro oesophageal reflux after medically induced healing of oesophagitis and its relation to the occurrence of relapse during prophylactic treatment  20 patients with erosive ulcerative oesophagitis underwent 24 hour oesophageal ph monitoring before and after healing achieved with 12 to 24 week treatment with ranitidine 150 or 300 mg twice daily  compared with pretreatment values  after macroscopic healing  a significant reduction in daytime median percentage of reflux time  10 0 v 6 5  p less than 0 05  and median number of reflux episodes lasting more than 5 minutes  5 5 v 1 0  p less than 0 05  were observed  whereas during night time reflux frequency and severity did not change  during maintenance treatment with ranitidine 150 or 300 mg nocte  five of the six patients  who had shown no improvement in gastro oesophageal reflux after acute healing  relapsed  these results suggest that  in contrast with previous work  a decrease in gastro oesophageal reflux in patients with reflux oesophagitis can be achieved after macroscopic healing  and that the occurrence of such a reduction after acute healing is predictive of a good response to longterm treatment  
class6	inhibition of cell mediated cytotoxicity by sulphasalazine  effect of in vivo treatment with 5 aminosalicylic acid and sulphasalazine on in vitro natural killer cell activity  decreased cell mediated cytotoxicity occurs frequently in inflammatory bowel disease  particularly in patients with active disease  it is not clear  however  whether this decrease is caused by the disease or is a consequence of the medical treatment  in this study we evaluated the effect of in vivo treatment with 5 aminosalicylic acid and sulphasalazine on the in vitro natural killer cell activity in five patients with inflammatory bowel disease in remission and in four healthy control subjects in a double blind randomised crossover trial preceded and separated by four weeks of treatment with placebo  the natural killer cell activity was significantly impaired in 67   six of nine subjects  after four weeks  sulphasalazine treatment and tended to be related to subjects with a slow acetylator phenotype  in contrast  5 aminosalicylic acid treatment caused only a marginal reaction in the natural killer cell activity in 22   two of nine subjects   the inhibitory effects were found to be reversible since the decreased natural killer cell activity was completely restored after placebo treatment in all subjects  in conclusion  in vivo treatment with sulphasalazine inhibits the in vitro natural killer cell activity and this seems to be mediated by the sulphapyridine moiety  this phenomenon may contribute to the low natural killer cell activity found in patients with active inflammatory bowel disease  
class6	soluble interleukin 2 receptor in crohn s disease  relation of serum concentrations to disease activity  serum concentrations of soluble interleukin 2 receptor  sil 2r  were measured as a marker of immune activation in a group of 30 patients with crohn s disease  sil 2r concentrations were determined by enzyme linked immunosorbent assay during periods of active and inactive disease and correlated with standard parameters of disease activity  serum concentrations of sil 2r were significantly raised in patients with active crohn s disease compared with patients with inactive disease  p less than 0 001  and control subjects  there was a significant correlation between serum sil 2r concentrations and disease activity as assessed by the harvey bradshaw index  r   0 42  p less than 0 01   platelet numbers  r   0 49  p less than 0 01   and orosomucoid  r   0 47  p less than 0 01   alpha 1 antitrypsin  r   0 44  p less than 0 01   and c reactive protein concentrations  r   0 48  p less than 0 001  but not with the erythrocyte sedimentation rate  measurement of serum sil 2r concentration is a simple and useful laboratory means of assessing disease activity  raised concentrations in patients with active crohn s disease is further evidence for in vivo immune activation occurring in this disease  
class6	occupational distribution of inflammatory bowel disease among german employees  previous reports have shown that both crohn s disease and ulcerative colitis affect people in white collar occupations associated with higher income and higher social class more frequently than other groups in the population  this study sought to carry these analyses one step further and investigate the distribution of inflammatory bowel disease by individual occupations  the german social security statistics for  rehabilitation  were used to assess the occupational distribution of crohn s disease and ulcerative colitis  from 1982 to 1988  a total of 12 014 people were granted rehabilitation as a result of inflammatory bowel disease  low male prevalence of inflammatory bowel disease was found among bricklayers  road construction workers  unskilled workers in brick and stone  unskilled labourers  and security personnel  low rates were found among women employed in cleaning and maintenance  and in those without occupation  in contrast  a high male prevalence was found among instrument makers  electricians  bakers  and technical assistants  among female employees  inflammatory bowel disease was significantly associated with sales representatives  office workers  health occupations  and hairdressers  these associations were found in the complete data for 1982 8 as well as in the separate data for the two half periods 1982 5 and 1986 8  highly significant correlations between the occupational distribution of crohn s disease and ulcerative colitis were found among both male and female employees  it seems that occupations involving work in the open air and physical exercise are protective  while being exposed to air conditioned artificial working conditions or extended and irregular shift working confer a risk of contracting inflammatory bowel disease  
class6	low diacylglycerol values in colonic adenomas and colorectal cancer  the biochemical events that make colonic epithelial cells proceed along the adenoma carcinoma sequence are not well understood  the phosphoinositol signal transduction pathway is involved in the regulation of cell growth and differentiation  to determine its role in colonic neoplasias we performed mass measurements of its second messenger sn 1 2 diacylglycerol in biopsy specimens from normal mucosa and neoplasias of the colon  normal colonic mucosa was also investigated in patients without colonic abnormalities  n   10   compared with pooled diacylglycerol values from five colonic sites  100    values in patients with a normal colon were highest in the ascending colon  120  5    p less than 0 05  and lowest in the rectum  81  5    p less than 0 01   absolute diacylglycerol values in patients with normal colons  2 62  0 16  nmol mg protein  were not significantly different from those found in the normal mucosa of patients with colorectal neoplasias  2 45  0 17  nmol mg protein   both colonic adenomas  n   15  and colorectal carcinomas  n   14  showed significantly decreased diacylglycerol values compared with the adjacent normal mucosa of each patient  72  4    p less than 0 001  and 71  4    p less than 0 001 respectively   the appreciable decrease in mass diacylglycerol values clearly distinguishes adenomas and carcinomas of the colon from the surrounding normal mucosa  this finding suggests that profound metabolic changes of the phosphoinositol signal transduction pathway occur early in the adenoma carcinoma sequence and may be important in colonic carcinogenesis  
class6	use of the pudendo anal reflex in the treatment of neurogenic faecal incontinence  an electrical stimulator has been devised to treat neurogenic faecal incontinence caused by pudendal nerve neuropathy and works on the basis of repeated stimulation of the pudendo anal reflex arc  although conduction in the pudendo anal reflex arc may be prolonged  and is so in neurogenic faecal incontinence  it must be shown to be present before the method can be used  this stimulation results in an immediate rise in the pressure in the anal canal and a significant increase in the electromyographic activity of the external anal sphincter  maintenance of the stimulus over a two month period raised the mean resting pressure significantly in the anal canal and increased the reflex and voluntary responses of the external anal sphincter to coughing and squeezing actions respectively  the length of the sphincter was not affected  there was widening of the mean motor unit potential duration  though this was not significant  the resting electromyogram was enhanced after the course of treatment  indicating greater spontaneous activity in the external sphincter  the changes led to seven of the eight patients studied becoming continent at the end of the treatment  
class6	relation between rectal sensation and anal function in normal subjects and patients with faecal incontinence  the relation between sensory perception of rapid balloon distension of the rectum and the motor responses of the rectum and external and internal anal sphincters in 27 normal subjects and 16 patients with faecal incontinence who had impaired rectal sensation but normal sphincter pressures was studied  in both patients and normal subjects  the onset and duration of rectal sensation correlated closely with the external anal sphincter electrical activity  r   0 8  p less than 0 0001  and with rectal contraction  r   0 51  p less than 0 001   but not with internal sphincter relaxation  all normal subjects perceived a rectal sensation within one second of rapid inflation of a rectal balloon with volumes of 20 ml or less air  six patients did not perceive any rectal sensation until 60 ml had been introduced  while in the remaining nine patients the sensation was delayed by at least two seconds  internal sphincter relaxation occurred before the sensation was perceived in three of 27 normal subjects and 11 of 16 patients  p less than 0 001   and could be associated with anal leakage  which stopped as soon as sensation was perceived  the lowest rectal volumes required to induce anal relaxation  to cause sustained relaxation  or to elicit sensations of a desire to defecate or pain were similar in patients and normal subjects  in conclusion  these results show the close association between rectal sensation and external anal sphincter contraction  and show that faecal incontinence may occur as a result of delayed or absent external anal sphincter contraction when the internal anal sphincter is relaxed  
class6	inter  and intraindividual variation in pressure volume relations of the rectum in normal subjects and patients with the irritable bowel syndrome  the relation between intrarectal volume and pressure during increasing rectal distension by a latex balloon were studied on repeated occasions in 10 healthy adult volunteers to define variations within and between individuals  a wide intersubject variation in the maximum tolerable volume  58 908 ml  and pressure  12 2 108 8 cm h2o  at this end point was seen  and these two values were correlated  r   0 78   intrasubject variation in maximum tolerable volume also occurred which was related to study order and progressively reduced with repeated study  in 26 unselected patients with pain predominant irritable bowel syndrome similar intersubject variation was noted and virtually all patients data fell within the calculated 95  confidence limits of the normal individuals  differentiation between patients and normal subjects was not possible from knowledge of rectal responses  these noticeable inter  and intrasubject variations in rectal responses to distension need to be considered whenever similar techniques are proposed for use in the study of rectal disease or of rectal response to treatment  
class6	referral of patients with primary biliary cirrhosis for liver transplantation  all patients with primary biliary cirrhosis referred to this unit for consideration for transplantation between april 1981 and january 1989 were analysed retrospectively to assess whether disease stage at referral affects the outcome after grafting and whether greater awareness of the benefits of the procedure means that patients are now being referred at an earlier stage  seventy of the 107 patients have been grafted  with an overall one year actuarial survival of 62   a better prognosis at the time of referral  as assessed by both serum bilirubin concentration and a mathematically derived prognostic index  was associated with a greater probability of survival after grafting  patients in the tertile with the best prognosis  median serum bilirubin concentration at referral 84 mumol l and estimated survival in the absence of transplantation of more than nine months  had a 78  one year actuarial survival after transplantation  whereas those in the tertile with the worst prognosis  median serum bilirubin concentration 467 mumol l and estimated survival of less than four months  had a one year actuarial survival of only 50   no trend towards earlier referral of patients  however  was shown using either of these two markers  this retrospective analysis suggests that many patients are being referred too late for an optimal outcome  we recommend that patients with primary biliary cirrhosis who are potential candidates for liver grafting should be referred to a transplant centre before the serum bilirubin concentration approaches 150 mumol l  
class6	pancreatic duct abnormalities in gall stone disease  an endoscopic retrograde cholangiopancreatographic study  this study was carried out to assess pancreatic duct abnormalities in gall stone disease  endoscopic retrograde cholangiopancreatograms of 50 patients with gall stone disease were analysed and the results compared with those obtained in 33 patients investigated for cholestatic jaundice who were found to have a normal biliary tree  control group   abnormal pancreatograms were obtained in 24  48   patients with gall stone disease and in only two  6   in the control group  the differences were statistically significant  chi 2   14 3  p less than 0 001   the patients in the control group showed mild abnormalities as did those in the gall stone group  the frequency of various abnormalities were  mild 16  32    moderate five  10    and severe three  6    pancreatic duct abnormalities were more severe and occurred more frequently in patients with gall stones who had stones in the biliary tree than in patients with a normal biliary tree  postcholecystectomy patients  55  v 25   but the difference between the two groups just failed to be significant  chi 2   3 34   in conclusion  nearly half of all patients with gall stone disease have pancreatic duct abnormalities and in 16  these were severe enough to be labelled as chronic pancreatitis  
class6	pancreatic function in crohn s disease  we investigated exocrine pancreatic function in a population of patients with crohn s disease in order to correlate the pancreatic function with clinical and laboratory variables  a total of 143 patients affected by crohn s disease and 115 control subjects were studied  all had a lundh meal test  as a group patients with crohn s disease had significantly decreased activity of both amylase  p less than 0 02  and lipase  p less than 0 001  in duodenal aspirates  in patients with crohn s disease enzyme activities were not correlated to duration of disease or to extent or localisation of previous bowel resection  the lowest enzyme values were found in patients with the most extensive bowel involvement  and they were significantly lower  p less than 0 05  than in patients with disease confined to the terminal ileum  the differences between enzyme values in other subgroups of patients were not significant  for the patient group as a whole no correlation was found between disease activity and enzyme values  but for the most uniform group of patients  those with terminal ileitis  pancreatic function was significantly lower  p less than 0 05  in patients with moderate and severe disease compared with patients with mild disease  thus at least two factors seem to be responsible for impaired pancreatic function in crohn s disease  firstly disease activity and secondly localisation or extent of disease  
class6	loss of duodenal folds allows diagnosis of unsuspected coeliac disease  we report three patients with coeliac disease who presented without the classic features of malabsorption and who underwent biopsy and were diagnosed only because of the endoscopic finding of the disappearance of kerckring s folds in the descending duodenum  this sign constitutes a new and valid aid for the identification of patients with otherwise unsuspected coeliac disease  
class6	adult hepatic fibropolycystic disease presenting as obstructive jaundice  obstructive jaundice caused by compression of the common hepatic duct by a simple hepatic cyst in a 31 year old europid man is reported  the jaundice and duct compression resolved after percutaneous aspiration of the cyst under ultrasound direction and the patient has been well for 12 months  
class6	evaluation of the magnitude of gastro oesophageal reflux in barrett s oesophagus  a manometric study to determine the role of gastro oesophageal reflux in barrett s oesophagus was performed on 20 patients with barrett s oesophagus and 53 patients with reflux oesophagitis without barrett s oesophagus  25 with mild oesophagitis and 28 with severe oesophagitis   for the same reason  the 20 patients with barrett s oesophagus also underwent 24 hour continuous oesophageal ph monitoring  and the results obtained were compared with those of 20 oesophagitis patients without barrett s oesophagus  10 with mild oesophagitis and 10 with severe oesophagitis   the manometric results show that the motor changes found in the barrett s group are specific but similar to the motor dysfunction associated with reflux oesophagitis  motor anomalies are probably related more to the inflammatory process in the oesophageal wall than to the metaplastic changes themselves  the ph monitoring results show that while reflux in the barrett s oesophagus patients was greater overall than in the oesophagitis group without barrett s oesophagus  the changes are similar when the results are compared with the severe oesophagitis group  in conclusion there are other factors besides gastro oesophageal reflux involved in the pathogenesis of barrett s oesophagus  
class6	comparison of omeprazole and cimetidine in reflux oesophagitis  symptomatic  endoscopic  and histological evaluations  symptomatic patients with endoscopically verified reflux oesophagitis were randomised to a double blind trial in which they received either omeprazole  20 mg once daily  or cimetidine  400 mg four times daily  for four  and if necessary  eight weeks  in an  intention to treat  analysis  oesophagitis was found to have healed after four weeks in 77 of 137  56   in the omeprazole group and in 34 of 133  26   in the cimetidine group  p less than 0 001   by eight weeks these values were 71  and 35  respectively  p less than 0 001  histological assessments were available for 73  of the patients  at entry  63   66 of 104  in the omeprazole group and 60   56 of 94  in the cimetidine group  ns  had abnormal histology  after the study  the proportions of patients who initially had had abnormal histology but who then progressed to normal were 67   44 of 66  omeprazole  and 48   27 of 56  cimetidine  respectively  p less than 0 001   all patients had reflux symptoms at entry  after four weeks  46  in the omeprazole group and 22   p less than 0 001  in the cimetidine group were asymptomatic  diary cards completed for the first two weeks showed that patients treated with omeprazole experienced fewer reflux symptoms by day and night and used fewer antacids  omeprazole  20 mg once a day for four to eight weeks  healed a greater proportion of patients with reflux oesophagitis than cimetidine  1 6 g per day  assessed endoscopically and histologically  and relieved more patients  symptoms  
class6	reduction of gastric ulcer recurrence after suppression of helicobacter pylori by cefixime  the effect on the recurrence of gastric ulcers after suppression of helicobacter pylori by combined treatment with cimetidine and the antimicrobial drug cefixime was investigated  twenty one of 43 patients with endoscopically proved gastric ulcer and h pylori infection were randomly assigned to receive cimetidine 800 mg daily for 12 weeks  the remaining 22 patients received cimetidine 800 mg daily for 12 weeks plus cefixime 100 mg daily for the last two weeks  after treatment  88  of 17 patients on cimetidine only remained h pylori positive  whereas combined administration of cimetidine and cefixime had suppressed h pylori in 78  of 18 patients  p less than 0 05   seventeen patients in the former group whose ulcers healed but who remained h pylori positive and 18 patients in the latter group whose ulcers healed and who were no longer infected with h pylori continued to be followed after treatment  these patients underwent endoscopy to detect ulcer recurrence if symptomatic  or at 12 and 24 weeks if asymptomatic  at 12 weeks  recurrence was observed in seven of 15  47   patients in whom h pylori persisted  but in only one of 14  7   patients in whom h pylori had been suppressed  p less than 0 05   at 24 weeks  however  recurrence rates were similar between the two groups  these findings indicate that h pylori infection may be closely related to early ulcer recurrence  
class6	high grade dysplasia of the gastric mucosa  a marker for gastric carcinoma  the natural history of gastric epithelial dysplasia and its relation to gastric cancer are ill defined  a consecutive series of 40 patients with an initial diagnosis of gastric epithelial dysplasia based on examination of endoscopic biopsies has been reviewed to determine the clinical outcome and to evaluate a two tier histological grading system as a predictor of the risk of cancer  on review  only 20 of the 40 patients were considered to have true dysplasia  seven patients had low grade dysplasia and 13 had high grade dysplasia  of the 13 patients with high grade dysplasia  11  85   were found to have gastric cancer within 15 months  of the 10 patients with high grade dysplasia who underwent gastrectomy  six were found to have early gastric cancer  three had cancer invading into the muscularis propria  and none had lymph node metastases  high grade dysplasia is thus a marker of gastric cancer  moreover  the cancers associated with high grade dysplasia are usually pathologically favourable and curable  the finding  by an experienced pathologist  of high grade dysplasia in two separate sets of endoscopic biopsies is therefore an indication for radical surgical treatment  provided that the patient s age and general condition permit such an approach  
class6	towards a true prevalence of peptic ulcer  the sorreisa gastrointestinal disorder study  this study  designed to overcome methodological problems inherent in earlier prevalence studies of peptic ulcer  was carried out in a municipality in northern norway  it included the total population of 2027  aged 20 69 years  and comprised a questionnaire and search for previously diagnosed peptic ulcers in the local medical records for all subjects  and additional endoscopy of all subjects with dyspepsia and their matched healthy controls  n   619   the overall prevalence was 10 5  in men and 9 5  in women  a sex ratio close to one and a higher duodenal gastric ratio than previously reported from this region  a substantial 1  prevalence of asymptomatic ulcers was also observed  
class6	duodenal ulcer and refined carbohydrate intake  a case control study assessing dietary fibre and refined sugar intake an association between duodenal ulceration and a low fibre intake and a high refined carbohydrate diet has been reported  we therefore compared the current diet  smoking habits  social class  and possible other risk factors of 78 patients with duodenal ulcer and a community control group matched for age and sex  logistic regression for matched sets was used to calculate the relative risks for successive quintiles of dietary fibre and sugar intake before and after adjustment for total calorie intake and for the possible confounding effect of other known risk factors  relative risks did not differ materially or consistently for total dietary fibre or for the cereal moiety whether adjusted or not for calorie intake  by contrast  relative risks tended to be reduced with high vegetable fibre intake and with low refined sugar intake  after controlling for smoking and social class  both of which were associated with ulcer disease  and for relative weight  quetelet s index   the relation between ulcer disease and low refined sugar intake persisted  while that with high vegetable fibre intake was reduced  the results of this study indicate that a lack of cereal or total fibre intake plays no part in duodenal ulcer development but that a low refined sugar intake may be a protective factor  
class6	duodenal ulcer is associated with low dietary linoleic acid intake  it has been suggested that the falling incidence and virulence of duodenal ulcer is related to increased dietary polyunsaturated essential fatty acid intake  the adipose fatty acid profile  which closely reflects dietary intake  was measured in 35 men with chronic duodenal ulcer and 35 matched control men  the mean percentage of linoleic acid in adipose tissue was significantly lower in the ulcer group  10 0  0 7  v 12 3  0 7    p less than 0 01  and this difference was found in both smokers and non smokers  this finding suggests that the diets of duodenal ulcer patients are deficient in linoleic acid and this could be of aetiological importance  
class6	adjuvant antibiotic therapy in duodenal ulcers treated with colloidal bismuth subcitrate  persistence of helicobacter pylori after duodenal ulcer healing is associated with high rates of ulcer relapse  we compared colloidal bismuth subcitrate alone with cbs combined with one of four antibiotic regimens in the treatment of duodenal ulcers  endoscopy and antral biopsies were performed before treatment and four weeks afterwards  biopsy specimens were examined for histological evidence of gastritis and by gram stain and culture for h pylori infection  altogether 141 patients were allocated to one of five treatment groups  giving cbs and metronidazole  400 mg tid for 7 days  with and without amoxycillin  500 mg tid  achieved higher clearance rates of h pylori than treatment with cbs alone  p less than 0 01   these two combinations also achieved higher rates of antral gastritis healing than cbs alone  p less than 0 01 and p less than 0 05 respectively   susceptibility to metronidazole was tested in 29 isolates before and in seven isolates after treatment with metronidazole by disc diffusion test and minimum inhibitory concentration assay  twenty seven  93   of the isolates were sensitive before treatment while six of seven  86   were resistant afterwards  four of the six resistant strains had acquired resistance during treatment and one of these had acquired metronidazole resistance despite concomitant treatment with amoxycillin  to which it remained sensitive  cbs with adjuvant metronidazole at a dose of 400 mg tid for seven days significantly improves the eradication of h pylori compared with cbs alone  acquired metronidazole resistance  however  seems to be an important cause of failure to eradicate h pylori  
class6	biliary cholesterol transport and precipitation  introduction and overview of conference  cholesterol is secreted into bile as cholesterol phospholipid vesicles  the cholesterol and phospholipid are subsequently exposed to the bile salts contained in the bile  which leads to the process of micellation  two situations may arise depending on whether there is enough bile salt in proportion to cholesterol to complete this  maturation  process  if the cholesterol saturation is low  at equilibrium the bile salts will have completely micellized the vesicles  on the other hand  if bile is saturated with cholesterol  the micellation process is incomplete and vesicles and micelles will be present at equilibrium  the residual vesicle in this latter situation may have a higher cholesterol phospholipid ratio because of the greater propensity of phospholipid to be micellized  this situation may result in cholesterol nucleation  the mechanism of nucleation from vesicles and the possible role of nucleating and antinucleating proteins in this process have been discussed  
class6	bile sampling  processing and analysis in clinical studies  obtaining a proper bile sample for investigative purposes is of utmost importance to obtain valid results  bile can be collected by direct aspiration of the gallbladder  by duodenal intubation or by t tube drainage  the optimal method of collection depends on the investigative question  as well as on the resources available to the investigator  the procedures for obtaining  processing and analyzing human bile  gallbladder and hepatic  are summarized  pointing out the disadvantages and pitfalls that may occur  
class6	gallbladder mucin as a pronucleating agent for cholesterol monohydrate crystals in bile  mucin is a densely glycosylated macromolecule secreted by the gallbladder epithelium as the principal constituent of gallbladder mucus  hypersecretion of gallbladder mucus occurs in response to a lithogenic diet in experimental animals  and mucus accumulates as a viscous gel within the gallbladder lumen before gallstone formation  in both animals and man  the initial stage of cholesterol gallstone formation  the nucleation of cholesterol monohydrate crystals  occurs within the mucus gel  inhibition of mucus secretion with aspirin prevents gallstone formation in the cholesterol fed prairie dog  indicating the importance of mucus in gallstone formation  mucin contains domains that bind cholesterol and lecithin transported as vesicles in supersaturated bile  furthermore  mucin accelerates the nucleation of cholesterol crystals in both supersaturated model and native biles  binding of cholesterol enriched vesicles to hydrophobic domains on the mucin protein core appears to be critical for the acceleration of cholesterol crystal nucleation by mucin  further study of the structure and function of gallbladder mucin should help to elucidate the pathogenesis of cholesterol cholelithiasis  
class6	nonmucous glycoproteins as pronucleating agents  cholesterol crystallization promoting factors probably play an important role in the pathogenesis of gallstone disease  we have isolated one of the factors involved by using lectin affinity chromatography  a potent promoting activity binds to concanavalin a sepharose  the activity is heat labile and sensitive to digestion by glycosidase but remarkably insensitive to proteases  the concanavalin a binding pronucleator affects cholesterol solubilization in model bile in two ways  it induces a shift of cholesterol and phospholipid from the micellar to the vesicular phase but also interacts directly with cholesterol phospholipid vesicles  the concanavalin a binding protein fraction contains at least two different promoting factors with gel permeation molecular weights of about 150 kd and 5 kd  respectively  the higher molecular weight activity could be assigned to a protein with an apparent molecular weight of 130 kd  concanavalin a binding promoting activity was present in bile from both patients with and without stones  indicating that it is a normal constituent of bile  however  the activity was strongly increased in bile from patients with multiple cholesterol gallstones  suggesting that it could play a key role in gallstone formation in these patients  
class6	pathogenesis of biliary sludge  the increasing application of ultrasonography in biliary tract disease had led to more frequent recognition of an old disorder   biliary sludge   sludge is detected on ultrasound as low amplitude echoes without acoustic shadowing  it layers in the most dependent part of the gallbladder and shifts with positioning  particulate matter in bile  such as cholesterol monohydrate crystals  has been shown to be echogenic  agglomeration of these crystals in biles with high mucus content accounts for the layering and the characteristic appearance of the movement of sludge with alteration in patient position  within the gallbladder  the stability of the vesicular form of cholesterol and protein lipid interactions are important determinants of cholesterol precipitation  in mixed and pigment gallstones  the equilibrium between ionized and unionized calcium and the hydrolysis of conjugated bilirubin are also important factors  although the risk factors contributing to the formation of gallbladder sludge have not been critically examined  it is now known that in some instances sludge can produce biliary pain and can be associated with acalculous cholecystitis  recurrent pancreatitis and  ultimately  the formation of gallstones  a better appreciation of the pathogenesis of sludge formation can help in the understanding of the genesis of gallstones and also perhaps in understanding other documented but poorly understood biliary and pancreatic disorders  
class6	biliary calcium and gallstone formation  the purpose of this paper is to present a brief overview of the current status of the field of biliary calcium and the role of calcium in the formation and maturation of gallstones  the study of free ca     ions in bile by electrochemical potentiometric measurements using ca     selective ion exchange electrodes is a relatively new field  but much progress has been made in the past few years  using this powerful analytical tool  new concepts and findings have arisen in almost every aspect of biliary calcium  although the current symposium is targeted primarily toward cholesterol gallstones  there are several areas in which understanding of biliary calcium may significantly contribute to a better understanding of the pathogenesis of cholesterol  as well as  pigment   calcium salt   gallstones  five broad areas are considered in relation to biliary calcium   a  physiology  calcium entry into bile    b  biophysics  the regulation of biliary free  ca      as related to gibbs donnan equilibria   c  physical chemistry  the physicochemical state of calcium in bile   d  thermodynamics  calcium solubility in bile   and  e  kinetics  pronucleating and antinucleating factors and metastable states   with more specific reference to cholesterol stones  consideration is also made of  a  the calcium salt  seed  hypothesis in cholesterol stone pathogenesis   b  the interactions of ca     with phospholipid cholesterol vesicles  with consideration of possible structural requirements and  c  thermodynamic and kinetic factors as related to peripheral or  eggshell  calcification of existing cholesterol stones  
class6	unconjugated bilirubin and cholesterol gallstone formation  cholesterol gallstones usually have small amounts of pigment at their centers and often have diffuse pigmentation or pigmented layers alternating with cholesterol layers and or pigmented rims associated with calcium carbonate  eggshell calcification   the pigments are primarily monomeric calcium salts of unconjugated bilirubin anions and or an insoluble  black  network polymer of tetrapyrroles  bilirubin presumably can precipitate only if bile is supersaturated with calcium bilirubinates  among various in vitro model systems  the aqueous solubilities and pk a values for unconjugated bilirubin differ greatly  it is therefore not known whether normal bile is saturated with unconjugated bilirubin  however  all systems indicate that unconjugated bilirubin is solubilized by binding to bile salt monomers and oligomers  as well as micelles  marked metastable supersaturation of unconjugated bilirubin can occur in the presence of bile salt micelles  and both pk a values of unconjugated bilirubin are greater than 6 0  probably because of internal hydrogen bonding of the  cooh groups  lecithin decreases equilibrium solubilization of unconjugated bilirubin crystals but enhances metastable supersaturation of unconjugated bilirubin  calcium ions form insoluble salts with unconjugated bilirubin monoanions and dianions but soluble complexes with bilirubin conjugates  the solubility products of the calcium bilirubinate salts suggest that normal hepatic bile is not saturated with cab or ca hb 2 but that gallbladder bile may be supersaturated with ca hb 2  
class6	current concepts of cholesterol transport and crystal formation in human bile  the presence of vesicles in human bile probably accounts almost entirely for the frequently observed  but hitherto unexplained  phenomenon of metastable cholesterol supersaturation  this  in turn  largely explains the prolonged stability of cholesterol solubilized in supersaturated human bile  under certain overall compositional conditions for a supersaturated native bile  the vesicular phase in its contribution to total cholesterol transport also becomes supersaturated in cholesterol  because of this  the vesicles also become unstable  leading to formation of cholesterol crystals  a simple but common example of one factor affecting composition in this way is concentration of total solutes  especially the biliary lipids  conversely  dilution of bile  e g   hepatic bile  markedly reduces the cholesterol saturation level in biliary vesicles  the result is that such vesicles become much more stable  under these conditions  cholesterol crystal formation becomes unlikely and rarely  if ever  occurs  
class6	fluorescence assays to monitor membrane fusion  potential application in biliary lipid secretion and vesicle interactions  membrane fusion constitutes an essential  intermediate step in numerous cell biological processes  occurring for example during endocytosis  membrane recycling and exocytosis  also less desirable events such as the infection of cells by animal viruses are mediated by membrane fusion during which the viral envelope merges with a cellular membrane  causing the expulsion of the viral nucleocapsid into the cytoplasm of the cell as an initial step in virus replication  much of our current knowledge concerning the mechanism of membrane fusion has been derived from studies using simple artificial membranes  such as liposomes or phospholipid vesicles  as model systems  a most essential feature of these studies has been the development of membrane fusion assays that register in a sensitive and continuous fashion the mixing of membranes or the aqueous volumes initially enclosed by these membranes  not only do these assays allow one to readily detect and quantify fusion  but they also provide the possibility to relate the kinetics of fusion to the rate by which certain molecular changes in membranes take place  obviously  this insight is of relevance for understanding the mechanism of membrane fusion  the principles and applications of some representative assays that rely on the use of fluorescence spectroscopy will be discussed  assays that monitor membrane mixing are commonly based on the detection of changes in resonance energy transfer efficiency or the relief of fluorescence self quenching of appropriate fluorescent lipid analogs  contents mixing assays rely on either the formation of a  aqueous soluble  fluorescent complex or quenching of a fluorophore  encapsulated in one vesicle population  by a suitable quencher  entrapped in a second population  
class6	hbv dna detection by gene amplification in acute hepatitis b  serum samples from 62 women  inadvertently infected with hepatitis b virus in an in vitro fertilization program  were tested for the presence of hepatitis b virus dna using the polymerase chain reaction  under conditions of a strict spatial separation of dna extraction  amplification and product analysis  we succeeded in detection of as few as 360 hepatitis b virus particles per milliliter  hepatitis b virus dna was detected with a high frequency during hbsag and hbeag antigenemia  98 5   but also in the convalescent phase after appearance of antibody to hbsag  18 2    however  all patients with hepatitis b virus dna in convalescent sera were hepatitis b virus dna negative 3 to 6 mo later  all patients with hbeag positive samples showed hepatitis b virus dna positivity by polymerase chain reaction  for acute hepatitis  gene amplification restores the relationship between hbeag and hepatitis b virus dna observed in serum from chronic hepatitis b patients and calls attention to the prolonged presence of hepatitis b virus dna in serum after generally accepted criteria for resolution of the infection have been reached  
class6	changes of serum hepatitis b virus dna and aminotransferase levels during the course of chronic hepatitis b virus infection in children  during a follow up period of 3 2     1 6  1 to 8 6  yr  1 087 serum specimens from 230 hbsag carrier children were tested for hepatitis b virus markers  dividing the serum specimens into four groups according to the status of hbeag and hepatitis b virus dna  the frequency of abnormally elevated alt levels in serum was in the following order  hbeag    hepatitis b virus dna    serum  60    hbeag    hepatitis b virus dna    serum  53    hbeag    hepatitis b virus dna    serum  41    hbeag    hepatitis b virus dna    serum  11    analysis of the data before hbeag clearance showed that both a high serum alt level and a low serum hepatitis b virus dna level correlated with an imminent clearance of hbeag  approximately two thirds of children with serum alt levels higher than 100 iu l cleared hbeag within the following year  clearance of hbeag occurred within the following year in 65   13 of 20  of cases with serum hepatitis b virus dna level less than or equal to 1 000 pg ml  in contrast to 19   30 of 157  of those with serum hepatitis b virus dna level greater than 1 000 pg ml  among 53 children who lost hbeag and hepatitis b virus dna during follow up  only nine cases did not have an identified period of abnormal serum alt levels  for the remaining 44 children  abnormal serum alt levels fell to normal with clearance of both hbeag and hepatitis b virus dna in 33 children but remained elevated in the remaining 11 cases after seroconversion  
class6	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  
class6	the auditory p300 event related potential  an objective marker of the encephalopathy of chronic liver disease  recently many variants of electroencephalogram evoked responses have been studied as potential diagnostic aids in the detection and evaluation of hepatic encephalopathy  this study assesses the value of the auditory p300 event related potential  a slow component of the auditory evoked response  as a tool in this field  twenty one nonencephalopathic and 12 encephalopathic  grade 1 2  cirrhotic patients and 26 controls were assessed clinically and psychometrically  electroencephalogram spectral analysis and visual evoked response recordings were also conducted  an auditory p300 wave was elicited using the standard two tone discrimination paradigm  the latency and amplitude of this wave were measured  the latency of the p300 was found to be significantly increased in the encephalopathic patients compared with both nonencephalopathic cirrhotic and control groups  p less than 0 05   amplitude of the wave was decreased in both nonencephalopathic and encephalopathic patients  but this was not statistically significant  this study suggests that the latency of the p300 is a good marker of grades 1 and 2 clinical hepatic encephalopathy  the delays in the p300 latency may indicate that encephalopathic patients have a deterioration of their stimulus evaluation abilities  
class6	monomicrobial nonneutrocytic bacterascites  a variant of spontaneous bacterial peritonitis  spontaneous bacterial peritonitis is diagnosed when  a  the ascitic fluid culture is positive   b  the ascitic fluid neutrophil count is greater than or equal to 250 cells mm3 and  c  there is no evident intraabdominal surgically treatable source for infection  few details are available regarding the variant of ascitic fluid infection in which the culture grows bacteria  pure growth of a single type of organism   but the neutrophil count is less than 250 cells mm3  in this prospective study of 138 episodes of culture positive spontaneously infected ascites detected in 105 patients  44  31 9   were episodes of  monomicrobial nonneutrocytic bacterascites  compared with 94  68 1   episodes of spontaneous bacterial peritonitis  seventeen patients had both types of infection  the infection related mortality and hospitalization mortality were similar between the two groups  patients with bacterascites appeared to have less severe liver disease  in 62  of bacterascites episodes in which a second paracentesis was performed before any treatment the fluid spontaneously became sterile without development of ascitic fluid neutrocytosis  thirty eight percent of patients with bacterascites  who underwent a second paracentesis before treatment was started  progressed to spontaneous bacterial peritonitis  sometimes within a few hours  the concentration of the chemoattractant c5a was not decreased in the ascitic fluid of the bacterascites patients  this excludes ascitic fluid c5a deficiency as the explanation of the lack of neutrocytosis  monomicrobial nonneutrocytic bacterascites is a common variant of ascitic fluid infection that may resolve without treatment or may progress to spontaneous bacterial peritonitis  
class6	norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis  results of a double blind  placebo controlled trial  eighty cirrhotic patients who had recovered from an episode of spontaneous bacterial peritonitis were included in a multicenter  double blind trial aimed at comparing long term norfloxacin administration  400 mg day  40 patients  vs  placebo  40 patients  in the prevention of spontaneous bacterial peritonitis recurrence  at entry  both groups were similar with respect to clinical and laboratory data  ascitic fluid protein and polymorphonuclear concentrations  number of previous episodes of spontaneous bacterial peritonitis and causative organisms of the index spontaneous bacterial peritonitis  norfloxacin administration produced a selective intestinal decontamination  elimination of aerobic gram negative bacilli from the fecal flora without significant changes in other microorganisms  throughout the study in six patients in whom the effect of norfloxacin on the fecal flora was periodically assessed  fourteen patients from the placebo group  35   and five from the norfloxacin group  12   developed spontaneous bacterial peritonitis recurrence during follow up  chi 2   5 97  p   0 014   mean follow up period   6 4     0 6 mo  range   1 to 19 mo   ten of the 14 spontaneous bacterial peritonitis recurrences in the placebo group and only one of the five spontaneous bacterial peritonitis recurrences in the norfloxacin group were caused by aerobic gram negative bacilli  chi 2   8 87  p   0 0029   the overall probability of spontaneous bacterial peritonitis recurrence at 1 yr of follow up was 20  in the norfloxacin group and 68  in the placebo group  p   0 0063  and the probability of spontaneous bacterial peritonitis recurrence caused by aerobic gram negative bacilli at 1 yr of follow up was 3  and 60   respectively  p   0 0013   
class6	relative frequencies of portosystemic pathways and renal shunt formation through the  posterior  gastric vein  portographic study in 460 patients  percutaneous transhepatic portography was carried out in 460 patients with portal hypertension to study various collateral routes  besides the left gastric vein  which was the most frequent collateral route and feeder of esophageal varices  a distinct vein located between the left gastric vein and the short gastric vein constituted a major collateral route in 191 patients  42    in terms of frequency  this vein was more significant than the short gastric  34   and the paraumbilical vein  24   as a collateral route  we propose that this previously anonymous vein be called the  posterior gastric  vein because it runs posterior to the stomach  this vein also formed a renal shunt  a common cause of encephalopathy  in 43  23   of the 191 patients  the relative frequency of renal shunt formation by this vein was significantly greater than that by the left gastric vein  12   and the short gastric vein  18    
class6	albumin absorption and protein secretion by the gallbladder in man and in the pig  to study albumin absorption by the gallbladder in man  an in vitro model was first established in the pig and compared with in vivo function in the same species  water and electrolyte transport and 125i albumin absorption and protein secretion in vivo and in vitro were compared  then similar in vitro studies were performed on human gallbladders obtained at surgery  the in vivo study in the pig was performed without disturbing the gallbladder except to tie a cannula in the cystic duct end  the in vitro model was identical in the pig and human gallbladders  gallbladders were excised using a technique causing minimal injury and anoxia  they were oxygenated on both mucosal and serosal surfaces in a temperature controlled environment  luminal and external bath test solutions consisted of modified ringers bicarbonate with added glucose  luminal solutions also contained 125i albumin from different species  depending on the study  active absorption of sodium and water occurred in both types of studies in the pig but in vivo absorption rates were considerably greater than in vitro rates  albumin absorption in vivo was substantial  although present in vitro  the absorption of albumin was diminished relatively more than electrolyte transport rates  protein secretion rates into the gallbladder were similar in vitro and in vivo  the results of studies in the human gallbladders in vitro were similar to the pig  except albumin absorption was greater  some human gallbladders were obtained from control patients and some from patients with cholesterol gallstones  there were no significant differences between the two groups for any of the variables studied  however  the numbers were small and some control gallbladders were not normal gallbladders  
class6	diagnostic value of brush cytology in the diagnosis of bile duct carcinoma  a study in 65 patients with bile duct strictures  malignant strictures of the extrahepatic bile ducts are difficult to distinguish from benign strictures  particularly in patients with primary sclerosing cholangitis  because attempts at diagnosing small cancers with fine needle aspiration biopsy are not possible in the absence of an associated mass lesion and because the sensitivity of exfoliative biliary cytology is controversial  brush cytology has been used as a potential means of establishing a specific diagnosis of bile duct carcinoma  herein we report our experience with this technique when performed on 65 patients over a 5 yr period  each had at least one brushing  thirty seven were found to have bile duct carcinoma and 28 were found to have benign strictures  of these 37  the first brushing was positive for malignancy in 15  40    whereas four  11   had cells suspected but not diagnostic of malignancy  thirteen patients with bile duct carcinoma whose initial brushings were negative for malignancy had second brushings  of these  five  38   had malignant cells  whereas three  24   yielded suspicious cells  three of the eight whose first two brushings were negative for malignancy were found to have malignant cells on the third brushing  in contrast  of the 28 patients with benign strictures  malignant cells were never found  however  in two patients  suspicious cells were reported with the first but not the second brushing  a single negative or suspicious cytological finding decreased the probability of bile duct carcinoma to 43   two and three sequential negative tests reduced the probability to 32  and 0   respectively  
class6	immunohistochemical detection of abnormal cell proliferation in colonic mucosa of subjects with polyps  previous studies have shown the presence of increased proliferation in the large bowel epithelium of those at high risk of developing colon cancer  an in vitro technique for labelling large bowel mucosa with the thymidine analogue bromodeoxyuridine  brdu  was therefore developed and its ability to distinguish differences in mucosal proliferation between subjects with colorectal adenomas and normal controls was assessed  sigmoid biopsy specimens from 15 subjects with polyps and 15 age and sex matched controls were labelled and the incorporated brdu visualised with an immunohistochemical technique  mean labelling index  li  was significantly higher in those with polyps than in controls  differences in the pattern of labelling in colonic crypts were compared by the generation of cumulative labelling distributions  analysis showed a significant expansion of the proliferative compartment in the colon crypts of those with polyps  it is concluded that in vitro labelling with brdu provides a useful method for the assessment of mucosal proliferation in subjects at high risk of developing colon cancer  
class6	serum pepsinogen i and gastrin concentrations in children positive for helicobacter pylori  serum pepsinogen i  serum gastrin concentration  and inflammatory scores were measured in a population of 71 children undergoing upper gastrointestinal endoscopy for investigation of upper abdominal pain  forty four were initially colonised with helicobacter pylori  the indices were measured before treatment  in 71 children   one month  in 41 children   and six months  in 21 children  after stopping treatment  before treatment there was a significant correlation between serum pepsinogen concentration  total inflammatory score  and h pylori state  but no correlation between serum gastrin concentrations and h pylori state  similarly  the total inflammatory score and serum pepsinogen concentrations were significantly correlated  there was no such correlation in children negative for h pylori  after treatment the inflammatory score improved in those patients in whom h pylori had been eradicated  there was also a significant fall in serum pepsinogen i and serum gastrin concentration in those patients in whom h pylori had been eradicated  these results were similar to those found six months after treatment had been stopped  these findings suggest that the serum pepsinogen i concentration could be considered a useful marker for gastritis and can be used as an index of severity of gastritis in h pylori positive subjects  the measurement of serum gastrin concentrations does not give useful information  
class6	photochemotherapy improves chronic cutaneous graft versus host disease  we have used oral psoralen photochemotherapy  puva  to treat four patients with chronic graft versus host disease of the skin  oral mucosa  and liver  who had responded only partially to long term immunosuppressive therapy  prednisolone  cyclosporine  azathioprine   puva therapy was delivered to the entire skin but not to the oral mucosa  and immunosuppressive therapy was continued in all patients  two patients  skin lesions improved considerably  the oral lesions healed and did not recur in one  immunosuppressive therapy could be reduced in these two patients  one patient with sicca signs did not improve  one patient had to interrupt puva therapy because of side effects attributed to 8 methoxypsoralen  nausea and vomiting   no flare of acute cutaneous graft versus host disease was noted during puva therapy  chronic graft versus host disease of the liver did not improve in any patient  
class6	imidazole salicylate versus piroxicam in the treatment of arthrosis in elderly patients  a double blind clinical and endoscopic trial  the clinical efficacy and gastroduodenal tolerability of imidazole salicylate  imidazole 2 hydroxybenzoate  itf 182   a new synthetic drug with an anti inflammatory action  was evaluated endoscopically in comparison with those of piroxicam in elderly patients suffering from osteoarthrosis  of the 41 patients entering the trial  only 38 completed the protocol  6 men and 32 women  mean age  71  range  65 80 years   after upper gastrointestinal endoscopy for the purpose of excluding gastric and duodenal mucosal lesions  the patients were allocated at random  according to a double blind  double dummy protocol  to treatment either with imidazole salicylate 750 mg three times daily or with piroxicam 20 mg once daily for a period of 4 weeks  imidazole salicylate proved active in controlling a number of the pain symptoms caused by arthrosis  although its efficacy was inferior to that of piroxicam  grade 2 gastric mucosal lesions were detected in 1 of 20 patients  5   treated with imidazole salicylate  lesions corresponding to grades 2  3  and 4 were found in 6 of 18  33   of those treated with piroxicam  p    034   painful dyspepsia was reported by 15  of the patients in the imidazole salicylate group and by 28  of those in the piroxicam group  on the basis of these results and under the experimental conditions adopted in this trial  the authors concluded that imidazole salicylate is characterized by good gastric tolerability and can thus be used in the treatment of rheumatic diseases in the elderly  
class6	alternation of gastric mucosal glycoprotein  lectin binding pattern  in gastric mucosa in stress  a light and electron microscopic study  gastric mucosal cells of the rat glandular stomach were studied by light and electron microscopic procedures by use of lectins in the development of acute gastric mucosal lesions  effects of the h2 receptor antagonist sofalcone  2 carboxymethoxy 4 4  bis 3 methyl 2  and truncal vagotomy with pyloroplasty on lectin binding sites and distribution were also investigated  biotinylated lectins in combination with abc  avidin biotinyl peroxidase complex  method were used for light and horseradish peroxidase  hrp  labeled lectins for electron microscopic studies  gastric mucosal cells showed the specific binding pattern for each lectin by light microscopy  especially  binding sites and distribution of peanut agglutinin  pna  were characteristic after induction of stress  truncal vagotomy  and administration of each drug  staining and distribution increased in the gastric mucosa upward and downward after that  in electron microscopic studies  pna strongly stained the membranes of the intracellular secretory canaliculi of a parietal cell  these results suggested that alternation of binding sites and distribution was regulated by change of gastric mucosal blood flow and of acidity in the parietal cells  therefore  increase of glycoconjugate distribution is supposed to be a possibility of cytoprotective effect for a change of environment in the parietal cells  
class6	generation of ammonia and mucosal lesion formation following hydrolysis of urea by urease in the rat stomach  we examined the morphological changes in gastric mucosa and the generation of ammonia after exposure of the rat stomach to urea in the presence of urease  in attempts to investigate a pathophysiological role of urea  urease  and ammonia system in gastric ulcer diseases  exposure of the stomach for 20 min to 2 ml urea  0 025 0 2   together with urease  100 iu  induced histological damages in a concentration related manner  either urea or urease alone did not induce any histological change in the mucosa  instillation of urea into the stomach generated ammonia in the presence of urease  the amount of ammonia was increased depending on the concentration of urea  and was closely associated with the severity of histological damage  the exposure of the stomach to ammonia  nh4oh  0 01 0 1   also produced histological damages in the gastric mucosa in a concentration related manner  the characteristics of injury induced by 0 5 1 0  ammonia were stasis of microcirculation  disruption of the surface epithelial cells  and necrosis of the mucosa  these results demonstrated that ammonia generated from the hydrolysis of urea by urease in the stomach causes damages in the gastric mucosa  
class6	possible role of leukotrienes in gastritis associated with campylobacter pylori  this study was done to evaluate the role of leukotrienes  lts  in gastritis associated with campylobacter pylori  biopsy specimens of gastric mucosa were obtained endoscopically from 18 patients with nonulcer dyspepsia for bacteriological and histological examination and extraction of lts  there was correlation between the ltb4 level in the mucosa and the degree of gastritis evaluated histologically  the level was higher when infiltration of neutrophils in the gastric mucosa was more extensive  the ltb4 level in mucosa infected with c  pylori was higher than that in noninfected mucosa  these findings suggest that endogenous lts may be related to the pathogenesis of gastritis associated with c  pylori  
class6	 healed  experimental gastric ulcers remain histologically and ultrastructurally abnormal  the present study was designed to assess histologic and ultrastructural features of gastric mucosa in the areas of grossly healed ulcers  acetic acid induced gastric ulcers  in rats  the specific question we studied was whether the structure and cellular composition of the gastric mucosa in an area of grossly healed ulcer were fully restored  eighty sprague dawley rats underwent laparotomy  100  acetic acid was applied to the lower gastric corpus serosa for 30 s and the abdomen was closed  the stomachs were reopened after 2 weeks or after 2  3  or 4 months  standardized gastric wall specimens from the area of grossly healed ulcers were obtained  processed  and evaluated by light microscopy and by transmission electron microscopy  the gastric mucosa of grossly healed ulcers demonstrated re epithelialization at each study time but the mucosa beneath the surface epithelium displayed prominent histologic and ultrastructural abnormalities  two different patterns of scar could be distinguished   a  the mucosa in the area of healed ulcer was thinner  25 45  reduction vs  normal   with increased connective tissue and poor differentiation and or degenerative changes in the glandular cells  or  b  the mucosa displayed ballooning dilatation of gastric glands  reduction in the microvascular network  and poor differentiation of glandular cells  we conclude that  i  the subepithelial mucosa of grossly healed gastric ulcer displays disorganized restoration of glandular and vascular structures and remains histologically and ultrastructurally abnormal   ii  these abnormalities may interfere with oxygenation  nutrient supply  and with mucosal resistance and defense  and therefore could be the basis for ulcer recurrence  
class6	vascular and microvascular changes  key factors in the development of acetic acid induced gastric ulcers in rats  the present study examined the time sequence and histologic and ultrastructural features of the formation and evolution of experimental  acetic acid induced gastric ulcerations in rats  one hundred percent acetic acid was applied to the gastric serosa of 140 fasted male sprague dawley rats through a polyethylene tube for 30 s  gastric mucosal changes were evaluated at 1  5  15  and 30 min  1 and 3 h  and 1  2  3  5  8  and 11 days after acetic acid application by visual inspection  by quantitative and qualitative light microscopy  and by transmission electron microscopy  following exposure to acetic acid  the earliest morphologic changes occurred at 1 min and consisted of dilatation of large submucosal veins and arteries and mucosal collecting venules  five to 15 minutes after injury  thrombi developed in submucosal veins and collecting venules  leading to microvascular stasis and mucosal necrosis  by 3 h  necrotic masses started to detach  by 24 48 h  necrotic changes penetrated the submucosa  by 72 h  most ulcers underwent transition into a  chronic  stage characterized histologically by the presence of granulation tissue at the bottom  and the appearance of a transitional healing zone at the margins  by 5 days  an increased amount of granulation tissue was observed and the gastric glands in transitional zones at the ulcer margin displayed cystic dilatation  based on this study  we conclude that a key feature of acetic acid induced ulcer formation is the early vascular and microvascular injury  which precedes glandular cell necrosis  
class6	further study of mucosal repair by sofalcone in experimental gastritis  the effect of sofalcone on the glandular structure and cell proliferation in the gastric mucosa of rats with gastritis induced by the administration of sodium taurocholate  tca  for 6 months was examined by histoquantitative analysis and  3h thymidine autoradiography  morphometric observation revealed that  with tca treatment  mucosal thickness  parietal cell mass  and the ratios of the length of the glandular portion total length of the gastric gland were decreased in both the fundic and pyloric glands  inflammatory cell infiltration and collagenous fiber proliferation were present in the gastric mucosa following tca and indicated the presence of atrophic gastritis  these atrophic changes and inflammatory cell infiltration were reversed by a 3 week administration of sofalcone  cellular proliferative activity assessed by the labeling indices of the gastric mucosa increased in tca induced gastritis in rats  the administration of sofalcone to rats with tca induced gastritis significantly increased labeling indices  particularly in the pyloric glands  from these results  it appears that sofalcone stimulates the compensatory increase in proliferative activity of generative cells  which then may become available to heal the gastritis  
class6	effect of epidermal growth factor in combination with sucralfate or omeprazole on the healing of chronic gastric ulcers in the rat  epidermal growth factor  egf  has been shown to enhance healing of experimental gastric ulcers when given subcutaneously or orally in the drinking water  this effect of egf occurs without reducing gastric acid secretion  on the other hand  egf reportedly is excreted rapidly from gastric lumen when administered by intragastric bolus  this suggests that further stimulation of ulcer healing may be expected if egf is given with an acid suppressive agent or with an agent allowing egf to remain in rat gastric lumen at high concentrations  in the present study  egf administered by gastric intubation at a dose of 10 micrograms kg  which is three times smaller than reported in previous studies  was evaluated for its effect on acetic acid induced rat gastric ulcers in combination with sucralfate or omeprazole  sucralfate is well known selectively to bind proteins covering the ulcer base  and omeprazole is a potent acid suppressive agent  prior to the study of combined egf and sucralfate  oral sucralfate was confirmed to allow endogenous gastric egf and mouse egf given exogenously to remain at high concentrations in gastric contents and tissues  egf and sucralfate  2 g kg day  given alone failed to stimulate ulcer healing in submandibularectomized rats  smr rat  whose endogenous gastric egf was depleted  however  the combination of both drugs administered at the same doses significantly accelerated ulcer healing in the smr rat  omeprazole  200 mg kg day  significantly enhanced ulcer healing regardless of removal of the submandibular glands  the combination of egf and omeprazole further stimulated ulcer healing in the smr rat  
class6	fibronectin related substance located in the chief cells of human and rat gastric mucosa  a novel substance located in the chief cells of human and rat gastric mucosa  which was detected immunologically by either polyclonal or monoclonal antihuman fibronectin  fn  antibodies  is reported  all three polyclonal antihuman fn antibodies used in this study reacted immunohistologically exclusively with the chief cells  monoclonal antibody against c terminal peptide or cell binding peptide reacted clearly with the human chief cells  but monoclonal antibodies against fn n terminal and midmolecule failed to react with the cells  western blot analysis of the rat gastric mucosal extract with polyclonal antihuman fn antibody showed that this substance has a molecular weight of about 70 000 da  therefore  this substance appears to be a fragment containing the c terminal peptide of whole molecule fn and thus in the present study is named fn related substance  fnrs   in a further study with ethanol induced ulcer model of the rat  the physiological significance of fnrs was examined  the fnrs decreased remarkably  in a dose dependent manner  in the fundic mucosa of the rats that ingested ethanol  the fnrs appeared to be associated with development of mucosal damage and repair  subsequently playing  in part  an important role in the gastric mucosal protection mechanism  
class6	evidence for gastric mucosal cell invasion by c  pylori  an ultrastructural study  it is now generally accepted that campylobacter pylori is closely associated with peptic ulcer disease and chronic type b gastritis  whether c  pylori is the direct etiologic cause of either or both of these illnesses remains unclear  possible pathophysiologic effects of c  pylori are still a matter of debate and conjecture  utilizing a small group of patients with gastric ulcers and chronic gastritis  we examined the ultrastructural relationship between c  pylori and gastric cells  forty eight percent of our gastric ulcer patients and 57  of our chronic gastritis patients had c  pylori in their lower corpus mucosa  examination with the transmission electron microscope indicated a very close proximation by c  pylori to the surface epithelial cells strongly suggesting adherence  we also describe for the first time the invasion of gastric cells by c  pylori  although an uncommon occurrence  we had repeated observations of c  pylori invading surface epithelial cells  parietal cells  and chief cells  most of the intracellular c  pylori were intact but other forms appearing to be degenerating organisms were also seen  we suggest that cell invasion may be one mechanism by which c  pylori causes pathologic changes in the gastric mucosa  these observations may also explain why c  pylori chronically infects gastric cells and frequently recurs after treatment  
class6	pelvic pain  lessons from anatomy and physiology  pelvic pain is often a difficult differential diagnosis in the emergency department  for physiologic reasons  pain in the pelvis is difficult to localize to a specific organ  and pelvic peritonitis is hard to recognize  on the other hand  differences in types of pain can be very useful in arriving at a correct diagnosis  the clinician must learn to recognize superficial and deep somatic pain  and differentiate between various types of visceral pain which originate from inflammation  ischemia  or colic  a review of the anatomy and physiology of pelvic pain helps identify some of the problems as well as potential aids in approaching the patient with pelvic pain  
class6	biliary lithotripsy  in vitro analysis of gallstone fragmentation for equivalent stone volumes  the relationship between gallstone fragmentation during extracorporeal shock wave lithotripsy  eswl  and gallstone volume is poorly understood  clinical results of eswl show that the highest stone free rate at 6 months occurs with radiolucent single gallstones 20 mm or less in diameter  in an in vitro study  individual gallstones from cholecystectomy specimens were divided by size and composition into nine single  and nine multiple stone groups  the stones were then paired on the basis of similar volume  eswl was performed in a phantom and the size of the largest fragment was measured at 500  1 000  and 1 500 shock waves  at 1 500 shock waves  sandlike particles were present in six of nine single stones versus two of nine multiple stone groups  the mean size of the largest fragment at 1 500 shock waves was 2 1 mm  single  and 4 4 mm  multiple  in diameter  when corrected for volume  the authors  data suggest that single stones are more easily broken into fragments smaller than 5 mm in diameter than multiple gallstones  the implication  especially when spark gap technology is used  is that more shock wave energy  ie  an increased number of shock waves at a higher kilovoltage  will be necessary to achieve the same results when treating patients with multiple stones versus a single gallstone with a similar stone volume  
class6	segmented turboflash  method for breath hold mr imaging of the liver with flexible contrast  a method called segmented turboflash imaging allows high resolution  multisection  short inversion time  ti  inversion recovery  stir   t1  or t2 weighted magnetic resonance  mr  studies of the liver to be completed within a breath hold interval  the method was applied in a phantom and in 19 patients with hepatic lesions  sequence comparisons were performed among segmented turboflash  single shot turboflash  t1 weighted gradient echo with ultrashort echo time  and t2 weighted spin echo  se  techniques  signal from fat and liver could be nulled with the segmented turboflash method  with tis of 10 and 300 msec  respectively  signal from these tissues could not be eliminated with the single shot approach  signal difference to noise ratios and contrast for the best segmented sequences were comparable with those of the best t2 weighted se and t1 weighted gradient echo techniques  it is concluded that it is feasible to obtain breath hold images with arbitrary tissue contrast by means of segmented turboflash imaging  the method may prove helpful for the detection and characterization of hepatic lesions and will likely have applications to other anatomic regions such as the chest and pelvis  
class6	intra abdominal palpation of a nasogastric tube in the stomach does not assure appropriate placement  improperly placed nasogastric  ng  tubes have been associated with considerable morbidity  the only reliable indicator of correct ng tube placement appears to be the aspiration of gastric contents  we have reported a case of major morbidity from an improperly placed ng tube that perforated the cervical esophagus  dissected the mediastinum  and terminated in the omental bursa  no gastric aspirate was obtained by suctioning of the tube  but correct placement was presumed based upon the surgeon s direct intraoperative palpation of the tip of the tube  failure to aspirate gastric contents should alert the practitioner to the possibility of improper ng tube placement  
class6	broad spectrum penicillin as an adequate therapy for acute cholangitis  in a previous study of patients with acute cholecystitis  we demonstrated equal efficacy with a broad spectrum penicillin  piperacillin  and a penicillin plus amino glycoside combination  whether a single agent broad spectrum penicillin is adequate treatment for more severe infections  such as acute cholangitis  however  is still unclear  we  therefore  conducted a three center  prospective  randomized trial to determine whether or not a broad spectrum penicillin alone is adequate therapy for patients with acute cholangitis  during a 36 month period  96 patients with sepsis and biliary obstruction were randomly assigned to receive either piperacillin  n   49  or ampicillin plus tobramycin  n   47   the two groups receiving antibiotics were similar with respect to all clinical and laboratory parameters  the incidence of blood cultures with positive results  20 versus 21 per cent  and underlying malignant lesions  51 versus 62 per cent  was also similar between the two groups  the percentage of patients with a clinical cure or significant improvement was the same in the two groups  69 versus 70 per cent   however  there was a significant difference in the cure rate between patients with benign and malignant biliary obstructions  83 versus 59 per cent  p less than 0 01   no significant differences were noted between the two antibiotic groups with respect to drug toxicity  but patients with malignant conditions were more prone to antibiotic related toxicities  2 versus 19 per cent  p less than 0 05   these data suggest that outcome of treatment in patients with acute cholangitis is similar with either a broad spectrum penicillin or a penicillin plus aminoglycoside combination and is dependent upon the nature of the biliary obstruction  
class6	synchronous carcinoma of the colon and rectum  reports on the incidence of synchronous carcinoma of the colon and rectum have varied from 2 to 11 per cent  the variability is a result of a lack of uniformity in criteria of diagnosis  differences in the population studied and differences in time period used  in this study  we evaluated the incidence and distribution of synchronous lesions during a recent time period before the use of colonoscopy became widespread  we reviewed the records of all patients with newly diagnosed adenocarcinoma of the colon and rectum who were operated upon at our institution between 1976 and 1981  in a total group of 1 000 patients of which 52 per cent were men  there were 54 patients or 5 4 per cent who had synchronous carcinomas  the group of patients with synchronous carcinomas were older than the group with nonsynchronous carcinomas  72 4 versus 68 8 years   there was also a higher incidence of associated benign polyps in the group with synchronous carcinomas  70 versus 30 per cent for a nonsynchronous carcinomas   the anatomic distribution of carcinomas of the colon and rectum in the group with synchronous lesions  111 in total  revealed a higher percentage of carcinomas located on the right side  29 7 versus 22 5 per cent   although the difference did not reach statistical significance  synchronous carcinomas were located in nonadjacent segments of the colon in 37 per cent  there was no difference in stage between the groups with and without synchronous carcinomas  the preoperative identification of synchronous lesions by either colonoscopy or barium enema is important for the proper treatment of patients with carcinoma of the colon and rectum  failure to locate these tumors may lead to the demise of the patient  
class6	congenital dilatation of the bile duct in 100 instances and its relationship with anomalous junction  published erratum appears in surg gynecol obstet 1991 mar 172 3  246  congenital dilatation of the bile duct  cdbd  or choledochal cyst has been demonstrated to be associated with an anomalous junction of the pancreaticobiliary ductal system  multifarious clinical signs and symptoms of cdbd have been shown to be closely related with the presence of this anomalous junction  in the present study  100 instances of cdbd treated surgically at our institutions during a 30 year period were classified into two types according to the morphologic features of dilatation of the bile duct  there were 77 instances of the cystic type and 23 of the cylindric type  morphologic features of the lesion  clinical signs and symptoms and laboratory findings in these 100 instances were clinically analyzed  in almost all of the patients who were less than one year of age  the disease was of the cystic type and patients presented with either a palpable mass or jaundice as the main symptom  in patients more than one year of age  the disease was of either the cystic or cylindric type  a history of episodes of characteristic abdominal pain accompanied by elevated levels of serum amylase was present in 70 of the patients with the cystic type of disease and in all of the patients with the cylindric type  histologic sections from the patients showed glandular formation with chronic inflammation  possibly a result of refluxed activated pancreatic juice  in contrast  histologic sections from the remaining patients of all ages showed only thickening of the fibrous layer  thus  such variable morphologic features and clinical signs and symptoms in cdbd are highly dependent on two factors  the age at onset and the reflux of pancreatic juice into the bile duct through the common channel  
class6	a multifactorial analysis of mortality and morbidity in perforated peptic ulcer disease  perforated peptic ulcer disease remains a source of considerable morbidity and mortality  and the suggested methods of surgical therapy are diverse  we reviewed the course of 113 patients who were treated surgically and identified 14 factors that influenced the morbidity or mortality rates  or both  multiple regression analysis showed that the number of coexisting medical conditions  a lower mean blood pressure level and the duration of acute perforation were independent risk factors for death  while age  use of a bronchodilator  a lower mean blood pressure level and the number of coexisting medical conditions correlated positively with all complications  a duodenal site was independently favorable with respect to all complications  the type of operation performed either simple closure  vagotomy and drainage or resection  did not influence morbidity or mortality  the most severely ill patients also did not benefit from any particular type of operation in the short term  long term results were improved with definitive operation  as measured by the visick classification and the need for reoperations  definitive operations are recommended for virtually all patients with perforated peptic ulcer  
class6	surgical management of islet cell dysmaturation syndrome in young children  islet cell dysmaturation syndrome  icds  encompasses the causes of infantile hyperinsulinemic hypoglycemia histologically described as islet cell hyperplasia  pancreatic adenomatosis and nesidioblastosis  eleven infants underwent 14 pancreatic resections for icds from 1965 to 1990 at the university of california at los angeles medical center for severe hypoglycemia unresponsive to medical therapy  seizures were the presenting symptoms of hypoglycemia in eight infants  six patients had nesidioblastosis  four had islet cell hyperplasia and one patient had an adenoma with histologically normal pancreatic islet cells  four neonates underwent 80 per cent pancreatic resection  three with nesidioblastosis required reoperation  90 to 95 per cent resection   four older infants underwent 80 per cent pancreatic resection but required diazoxide for less than six months postoperatively  three infants underwent 90 to 95 per cent pancreatic resection  none have required reoperation or postoperative medications  all infants are normoglycemic without pancreatic exocrine insufficiency and none had postoperative complications  five infants had preoperative neurologic impairment  with three having severe retardation  all showed some improvement postoperatively  but only one infant now has normal findings on neurologic examination  early diagnosis and aggressive surgical resection should minimize neurologic complications of the icds  
class6	ascending cholangitis  surgery versus endoscopic or percutaneous drainage  a retrospective review of 61 patients with calculous cholangitis was carried out  there were 31 men and 30 women and their mean age was 75 8 years  all patients had abdominal pain  87  had chills and fever  65  had clinical jaundice  23  were in shock  and 54  had positive blood cultures  because intravenous hydration and antibiotics did not help  33 patients underwent surgery  25 patients underwent endoscopic papillotomy  ep   and three patients underwent percutaneous transhepatic drainage of the common bile duct  ptd   morbidity in the surgery group included two wound infections  one respiratory failure  and one renal failure  morbidity in the ep ptd group was one case of arterial bleeding requiring surgery and one of pancreatitis treated conservatively  two patients  6   died in the surgery group  one of sepsis and the other of cardiorespiratory arrest  in the ep ptd group nine patients  32   died of sepsis and multisystem organ failure  these patients were considered too ill to undergo surgery and thus repeat ep ptd was carried out  cholangitis persisted  and retained common bile duct stones with sepsis was the cause of death  thus when initial ep or ptd is unsuccessful  surgical exploration of the common bile duct should be carried out to control sepsis  
class6	are cystgastrostomy and cystjejunostomy equivalent operations for pancreatic pseudocysts  to compare the effectiveness of cystgastrostomy and cystjejunostomy for treatment of pancreatic pseudocysts  39 patients with cystgastrostomy were compared to 59 patients with cystjejunostomy  the groups were comparable in age  sex  cause of pancreatitis  pseudocyst location  symptoms  and preoperative serum amylase level  cysts treated with cystgastrostomy were larger  mean diameter  11 1     0 9 cm  than cysts treated by cystjejunostomy  mean diameter  6 7     0 7 cm   p less than 0 05   mean duration of surgery was 148     11 minutes for cystgastrostomy versus 265     15 minutes for cystjejunostomy  p less than 0 05   mean blood loss was 397     82 ml for cystgastrostomy versus 703     80 ml for cystjejunostomy  p less than 0 05  mean intraoperative fluid requirements were 2640     313 ml for cystgastrostomy and 4403     362 ml for cystjejunostomy  p less than 0 05   cyst recurrence was 10  for cystgastrostomy versus 7  for cystgastrostomy  postoperative gastrointestinal bleeding occurred in 8  of patients with cystgastrostomy and in 2  of patients with cystjejunostomy  infection problems with cystjejunostomy included two wound infections and one case of septicemia  infection problems with cystjejunostomy included five intraabdominal abscesses  two wound infections  and one case of pneumonia  two patients died with cystgastrostomy  both from gastrointestinal bleeding   two patients died with cystjejunostomy  one from intraabdominal sepsis and one from pulmonary embolus   cystgastrostomy was used for significantly larger pseudocysts and was associated with significantly less blood loss and operating time than cystjejunostomy  p less than 0 05   morbidity and mortality from cystgastrostomy and cystjejunostomy were comparable  although gastrointestinal bleeding was more common with cystgastrostomy and intraabdominal abscess was more common with cystjejunostomy  since cystgastrostomy can usually be performed more quickly and with less blood loss  it should be considered whenever anatomically feasible  
class6	early results of combined electrohydraulic shock wave lithotripsy and oral litholytic therapy of gallbladder stones at the university of iowa  one hundred thirty three patients were entered into a randomized  double blind  placebo controlled trial of extracorporeal shock wave lithotripsy for symptomatic gallstones versus extracorporeal shock wave lithotripsy plus adjuvant litholytic therapy with ursodeoxycholic acid  udca   six months after lithotripsy  patients receiving placebo were crossed over to udca therapy without unblinding the study  one hundred sixteen patients have completed 6 months of follow up  five patients were dropped from the study  nine percent have required cholecystectomy  11 patients with biliary colic and 1 with acute cholecystitis   ninety one patients had a solitary stone  64 patients had stones less than or equal to 20 mm and 27 patients had stones greater than 20 mm in diameter   and 25 patients had two to three stones  fifty percent were retreated  cumulative stone free rates at 6  12  and 18 months were 26   39   and 41   respectively  at 6 months there was a significant advantage for patients treated with udca versus placebo  36  vs 17  were stone free  that had disappeared by 12 months  placebo treated patients had received 6 months of udca   patients with solitary stones equal to or less than 20 mm in diameter treated with udca had stone free rates at 6  12  and 18 months of 58   58   and 62   respectively  versus 27   56   and 50   the difference was significant only at the 6  month follow up  stone free rates for patients with large solitary stones and multiple stones were very low  extracorporeal shock wave lithotripsy is both safe and effective therapy for treatment of symptomatic gallstones in patients with a solitary stone equal to or less than 20 mm in diameter  udca markedly improves the efficiency of the procedure and results in a stone free gallbladder sooner  
class6	the diagnosis and definition of hepatic malignancies by use of arterial enhanced computerized tomographic scanning  axial computerized tomography is a useful tool in the evaluation of either primary or metastatic hepatic neoplasms  an adjunct to this technique is visceral arterial enhanced computerized tomography  aect   to determine the effectiveness of this modality  bolus intravenous enhanced computerized tomography scans and aect were compared and correlated to operative findings  fifty four consecutive patients were evaluated by aect and bolus intravenous enhanced computerized tomography over a 30 month period  may 1986 to august 1989  for suspected primary or metastatic hepatic malignancies  forty four patients  81   had hepatic lesions  fifty two percent  23 of 44 patients  of the metastatic tumors were from colonic or rectal primary lesions  and 20  were hepatocellular primary lesions  the remainder of the lesions were metastases from a variety of primary lesions  when studies were compared  34  of the patients  15 of 44 patients  differed in either the location or total number of lesions noted  the lesions of three of the 15 patients  20   were determined unresectable on the basis of aect  of the remaining patients  planned resections were revised in seven patients to either lesser or greater procedures  the number of lesions found at laparotomy equaled the number found by aect in all but two cases  aect caused no complications  aect improved our ability to identify and localize primary and metastatic lesions of the liver  this technique offers the advantage of preoperative definition of the hepatic arterial and portal venous anatomy  
class6	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  
class6	long term follow up of the ileoanal anastomosis in children and young adults  the purpose of this study was to carry out a long term study of the ileoanal anastomosis  iaa  in children and young adults  comparing the straight iaa to the j pouch  one hundred twenty one young people who had undergone iaa were studied  with 114 available for long term follow up  one hundred one were 18 years and under  forty nine patients had a straight iaa and 72 had a j pouch reservoir  there were no deaths  after surgery  three children had intraabdominal sepsis and one had pelvic sepsis  but it did not lead to excision of the iaa  the mean stool frequency in all 114 patients was 5 0     2 5 per day and 1 2     1 1 at night  the mean number of stools for the straight iaa was 6 per day and 2 1 at night  the mean number of stools for the straight iaa with balloon dilations was 5 8 per day and 1 2 at night  and for the j pouch it was 4 per day and 1 at night  patients with both the j pouch and straight iaa had good to excellent sensation  with patients with the j pouch always able to distinguish flatus from stool in 87  of patients and almost always in 13   daytime continence was very good in both groups  moderate nighttime loss of stool occurred in 10 patients  6 with a straight iaa and 4 with a j pouch  ninety five percent of the 114 patients were satisfied or very satisfied  with most children with a j pouch very satisfied  the j pouch remains the procedure of choice in young people  
class6	circadian esophageal motor function in patients with gastroesophageal reflux disease  effective esophageal peristalsis is a major determinant of esophageal clearance function and may contribute to the development of complications in gastroesophageal reflux disease  using 24 hour ambulatory esophageal manometry  we compared the circadian esophageal motor activity of normal volunteers to that of patients with increased esophageal exposure to gastric juice and various grades of mucosal injury  no mucosal injury  esophagitis  stricture  or barrett s esophagus   the prevalence of a mechanically defective lower esophageal sphincter  esophageal acid exposure time  and the frequency of nonperistaltic esophageal contractions during the supine  upright  and meal periods increased with increasing severity of mucosal injury  the median amplitude of esophageal contractions was compromised only in patients with a mechanically defective sphincter  this was particularly so in patients with stricture or barrett s esophagus and was associated with an increased frequency of ineffective contractions  less than 30 mm hg   these data show that esophageal motor function deteriorates with increasing severity of mucosal injury  this appears to be caused by persistent reflux of gastric juice across a mechanically defective lower esophageal sphincter  the need for surgical correction of a mechanically defective sphincter before the loss of esophageal body function is implicated  
class6	abnormal membrane physical properties of red cells in mcleod syndrome  mcleod red cells  rbcs  lack kx antigens and have weak expression of the kell antigens  individuals who carry the mcleod phenotype have acanthocytic rbcs and a compensated hemolytic state  to elucidate the role of the protein on which the kx antigens reside in maintaining membrane deformability  the rheologic properties of mcleod rbcs were determined by ektacytometry  rbcs were obtained from normal individuals and from four patients with mcleod syndrome  osmotic gradient deformability profiles of mcleod rbcs showed decreased whole cell deformability  resealed ghosts from mcleod rbcs also showed decreased deformability  partly because of the decreased cell surface area and partly because of an intrinsic membrane stiffness in this syndrome  for the measurement of membrane mechanical stability  resealed ghosts were subjected to constant high shear stress in the ektacytomer  and deformability was recorded continuously as the deformable ghosts fragmented into rigid spherical vesicles  membranes from mcleod rbcs showed a noticeable increase in mechanical stability  acquired causes of acanthocytosis  such as liver disease  did not cause the rheologic abnormalities observed in mcleod cells  other abnormalities noted in mcleod rbcs were decreased rbc potassium content and an increased number of dense rbcs  as determined by centrifugation on a discontinuous density gradient  the data indicate that mcleod rbcs are rigid and have decreased surface area and that their membranes are intrinsically rigid with increased mechanical stability  these abnormalities may account for the reduced rbc survival observed in mcleod syndrome  the protein that carries the kx surface antigen seems to be required for the maintenance of the normal physical function of rbc skeletal proteins  
class6	from leningrad to the day care center  the ubiquitous giardia lamblia  giardiasis is recognized as a worldwide public health problem  seroprevalence data from both the developing and developed world show high rates of carriage in populations at risk for fecal oral transmission  such as children in day care centers  outbreak investigation has expanded our understanding of reservoirs for giardia lamblia and of the routes of transmission  various host factors have been associated with infection  the pathogenesis of giardial infections is being elucidated  in particular the role of lectin activation in producing disease  three standard chemotherapeutic agents are available in the united states  the institution of community wide prevention measures is equally important  current areas of investigation including antigenic composition and enzymatic variants should result in effective forms of immunotherapy  while more effective forms of chemoprophylaxis could assist in eradicating the pathogen from institutional settings  
class6	pleuropulmonary manifestations of hepatic amebiasis pleuropulmonary manifestations of hepatic amebiasis occurred in 30 patients  18  60   presented with at least 1 pulmonary complaint and 10  33   had multiple pulmonary symptoms  in 14 patients  47    abnormalities were found on examination of the chest  in 16 chest roentgenograms  53    there was at least 1 abnormality  right sided pleural effusion  9 patients  and elevated right hemidiaphragm  8 patients  were the most common  all patients were treated with metronidazole  flagyl  and had resolution of the amebic liver abscess and pulmonary disease  pleuropulmonary disease is a common complication of amebic liver abscess  the clinical presentation and chest roentgenograms are virtually diagnostic and obviate the need for invasive procedures to confirm the diagnosis  pleuropulmonary disease resolves with amebicidal treatment of the hepatic abscess  
class6	does paramedic base hospital contact result in beneficial deviations from standard prehospital protocols  we reviewed written and audio records of paramedic base hospital radio contact to determine whether care differed from that suggested in standard prehospital care protocols  records of all 659 contacts for seizure  syncope  abdominal pain  or altered mental state during 1987  28 4  of all contacts  were scored for the use of standard therapies  such as intravenous access  oxygen  naloxone hydrochloride  and unanticipated therapies  intubation  nitroglycerin   cases that involved unanticipated treatments were reviewed to determine whether they could have been prospectively identified by simple clinical findings  standard therapies were used in the majority of patients  unanticipated therapies were administered to 13 patients  all of whom had abnormal vital signs  diaphoresis  respiratory distress  or a second prominent symptom  data suggest that protocols could replace radio contact for most patients and that the few who might benefit from radio contact can be easily identified  a 90  reduction in radio contacts in los angeles county could save  3 million each year  
class6	sudden death due to delayed rupture of hepatic subcapsular hematoma following blunt abdominal trauma  blunt abdominal trauma can cause sudden  unexpected death due to injuries to internal organs  rupture of a hepatic subcapsular hematoma is a relatively rare cause of sudden death following minor blunt abdominal trauma  death may be delayed several days to weeks  the autopsy is an invaluable diagnostic tool that can be utilized to uncover sudden deaths due to abdominal trauma  the case of an alcoholic who died of a ruptured hepatic subcapsular hematoma is presented  the death investigation revealed that the victim had sustained blunt abdominal trauma during a fall a few days prior to death  
class6	prospective randomized comparison of brown mchardy and microvasive balloon dilators in treatment of achalasia  we report the results of a randomized prospective study comparing a standard bougie rubber balloon dilator  brown mchardy  bmh   and a newer polyethylene dilator passed over a guide wire  microvasive rigiflex  mvr    twenty achalasia patients  15m  5f  mean age 45 4 yr  considered candidates for either dilator were randomized  symptom assessment  body weight  and upright radionuclide solid esophageal emptying study were measured before and 6 months after pneumatic dilatation  all dilatations were performed by one of three experienced gastroenterologists under fluoroscopic guidance  overall success occurred with 10 10 bmh and 7 10 mvr  one patient not improved with mvr had myotomy  the other two were successfully treated by bmh  no complications occurred with either dilator  
class6	features distinguishing secondary achalasia from primary achalasia  eighteen patients with cancer induced or secondary achalasia  sa  were compared to 421 patients with idiopathic or primary achalasia  pa   the aim of the study was to detect any differences in clinical presentation between the two groups  mean age of patients with sa was 57 1  range 15 78  and 47 1  range 1 90  in patients with pa  p   0 02   three patients with sa were 15  24  and 36 yr old  respectively  symptom frequency was comparable in sa versus pa  mean duration of symptoms in sa was 4 5 months  with 15 of the 18 patients experiencing symptoms for six months or less  weight loss occurred in 88 2  of patients with sa and 57 3  of patients with pa  p less than 0 05   cancer was at the gastroesophageal junction in 16 patients  duodenum in one  and breast in one  endoscopy showed tumor in 12  67    the esophagram was suspicious for tumor in only 25   we conclude that patients with sa are older  more likely to lose weight  and have a short duration of symptoms  however  sa may occur in younger patients  and endoscopy with biopsy is necessary in any newly diagnosed case of achalasia  
class6	healing or amelioration of esophagitis does not result in increased lower esophageal sphincter or esophageal contractile pressure  published erratum appears in am j gastroenterol 1991 feb 86 2  253  there is conflicting evidence regarding whether lower esophageal sphincter and esophageal contractile pressures are affected by changes in the severity of gastroesophageal reflux disease  we compared the manometric and endoscopic findings from 30 patients before and after treatment for esophagitis  before treatment  the grade of esophagitis  i iii  was significantly correlated  r    0 37  p less than 0 05  with lower esophageal sphincter pressure  but not with esophageal contractile pressure  after treatment  the grade of esophagitis did not change or became worse in 15 patients  and became better in 15 patients  of these  seven healed  the group that showed no endoscopic improvement demonstrated no change in lower esophageal sphincter or esophageal contractile pressures  the group that did show endoscopic improvement also demonstrated no increase in lower esophageal sphincter or esophageal contractile pressures  and this was particularly evident in those whose esophagitis healed  these data suggest that healing of esophagitis does not result in improvement of esophageal motor function  
class6	sucralfate used as adjunctive therapy in patients with severe erosive peptic esophagitis resulting from gastroesophageal reflux  a total of 36 patients with grade 2 or greater erosive esophagitis and an abnormal 24 h ph monitor study  were treated in a randomized  double blind fashion to assess the efficacy of sucralfate suspension as adjunctive therapy to cimetidine for severe esophagitis secondary to gastroesophageal reflux  treatment consisted of cimetidine  300 mg qid and either sucralfate suspension  1 g 10 ml  or an identical placebo suspension  10 ml after meals and 20 ml hs  patients were treated for 12 wk unless endoscopic healing occurred earlier  initial evaluation and monthly follow up consisted of symptom monitoring  endoscopic evaluation and pre  and post therapy esophageal manometry  bernstein test  and 24 h ph monitoring  the combination of cimetidine and sucralfate suspension was superior to cimetidine alone in improving daytime heartburn symptoms  p less than 0 05  but not nighttime heartburn  dysphagia  or regurgitation  sucralfate plus cimetidine improved the overall endoscopic outcome of esophagitis more than cimetidine alone  p less than 0 05   more patients exhibited endoscopic healing in the adjunctive sucralfate group than in the cimetidine only group  endoscopic healing  however  was not statistically different between groups  we conclude that sucralfate used as adjunctive therapy to cimetidine resulted in improvement of some of the symptoms of reflux  and probably increases the likelihood of complete healing of esophagitis  compared with cimetidine alone  
class6	comparison of coffee intake and coffee induced symptoms in patients with duodenal ulcer  nonulcer dyspepsia  and normal controls  coffee and decaffeinated coffee stimulate acid secretion  in addition  many patients experience dyspepsia after coffee ingestion  therefore  coffee is often prohibited by physicians in patients with peptic diseases  however  the association between peptic disease and symptoms remains unclear  this study compares coffee intake and the induction of symptoms by coffee in patients with duodenal ulcer disease  nonulcer dyspepsia  and normal controls  we have studied the coffee drinking habits of 58 duodenal ulcer patients  55 nonulcer dyspepsia patients  and 55 normal controls  the use of coffee on a daily basis was not significantly different between duodenal ulcer patients  64   and controls  56    or between nonulcer dyspepsia patients  55   and controls  there was also no difference between the three groups in the use of decaffeinated coffee  the number of cups per day  the method of preparation  the length of time of coffee use  or any change in coffee intake in the previous year  the intake of tea  caffeinated carbonated beverages  and aspirin or nonsteroidal anti inflammatory drugs was also similar in the three groups  the duodenal ulcer patients were more likely to be cigarette smokers  45   than either the controls  16   or the nonulcer dyspepsia patients  24    daily alcohol intake was not significantly different in the three groups  the prevalence of coffee induction of dyspeptic symptoms was similar in duodenal ulcer patients  29   and controls  22    but was much more common in nonulcer dyspepsia patients  53   than in controls  22    p   0 0036  in conclusion  there was no difference in coffee intake between patients with duodenal ulcer  nonulcer dyspepsia  or normal controls  however  patients with nonulcer dyspepsia  but not duodenal ulcer  were more likely to experience dyspeptic symptoms after coffee ingestion  
class6	duodenal ulcer hemorrhage with and without dyspepsia  to clarify the clinical significance of dyspepsia in patients with bleeding duodenal ulcer  we studied 298 patients prospectively  ages of patients ranged from 16 to 81 yr  mean 45 9   there were 244  82   dyspeptic and 54  18   nondyspeptic patients  in the dyspeptic group  significantly more patients were taking nonsteroidal anti inflammatory drugs  in the nondyspeptic group  there was a higher percentage of patients with duodenal bulb deformity  p less than 0 005   which deformity was related to previous peptic ulcer disease  the age  sex  past history of dyspepsia or bleeding  consumption of alcohol and cigarettes  and the hospital course of the two groups of patients did not differ significantly  our results show that the clinical course of duodenal ulcer hemorrhage is not significantly different in patients with or without dyspepsia  and indicate that bleeding and dyspepsia probably are two independent presentations in the natural course of the disease  the significance of the correlation between dyspepsia and duodenal bulb deformity is discussed  
class6	the value of push type jejunal endoscopy in familial adenomatosis coli gardner s syndrome  push type jejunal endoscopy using a long forward viewing duodenofiberscope was performed in 10 patients with familial adenomatosis coli gardner s syndrome  jejunal polypoid lesions were detected in nine of the 10 patients  90    the lesions appeared sessile  whitish  and measured 3 mm or less in diameter  histologic findings of the biopsy specimens from these polypoid lesions revealed tubular adenoma in all nine patients  in addition  this method led to the detection of duodenal adenomas in one patient  in whom duodenofiberscopy with the side viewing instrument revealed no polypoid lesions in the bulb and second portion of the duodenum  in view of these results  we recommend that push type jejunal endoscopy  as well as side viewing duodenofiberscopy  should be added to the usual preoperative examinations done in patients with this disease  
class6	liver pathology in morbidly obese patients with and without diabetes  the contribution of obesity and or diabetes to liver pathology in the morbidly obese patient is controversial  we studied the liver biopsies of 100 consecutive patients undergoing gastric bypass surgery for morbid obesity  multiple morphologic parameters were analyzed and graded independently  without knowledge of the clinical history  liver function tests  and oral glucose tolerance results of the patients  six percent of the entire group demonstrated no fat  42  mild fat  20  moderate fat  and 24  severe fatty metamorphosis of the liver  twenty three percent of the patients had central vein fibrosis  23  sinusoidal fibrosis  19  bridging fibrosis  and 4  cirrhosis  thirty six percent of the patients had some degree of steatohepatitis  66  possessed so called glycogen nuclei of hepatocytes  6  had pas positive thickening of blood vessels in the portal tracts  and 1  had lipogranulomas  the degree of fatty metamorphosis and fibrosis was analyzed in three separate groups  categorized by the glycemic status of the patient  46 patients with normal glucose tolerance  ngt   23 patients with impaired glucose tolerance  igt   and 31 patients with non insulin dependent diabetes mellitus  niddm   increasing severity of fatty metamorphosis from the normoglycemic obese to the diabetic obese patients was found  which was statistically significant by chi 2 analysis  four of the six patients showing no fatty metamorphosis were normoglycemic  glycogen nuclei and pas positive blood vessels were significantly more prevalent in the diabetic obese than in the normal obese  in conclusion  the distribution of significant liver histopathology in the morbidly obese patient correlates in severity with the degree of impaired glycemic status  
class6	factors influencing the development of metabolic bone disease in primary biliary cirrhosis  the prevalence  type  and factors that may influence the development of bone disease in primary biliary cirrhosis  have been investigated in 20 consecutive patients  who  in addition to liver function tests and mineral and vitamin d metabolism studies  were submitted to a transiliac bone biopsy after tetracycline double labeling for quantitative histomorphometric examination  intestinal calcium absorption was also assessed in 16 patients  seven patients  35   had reduced bone volume and were considered osteoporotic  three also had bone mineralization impairment  but did not have criteria for osteomalacia  bone formation was depressed in 15 patients  and bone resorption was low or normal in 19 cases  eroded surfaces were reduced in all osteoporotic patients  duration of primary biliary cirrhosis was significantly longer in patients with osteoporosis  6 3     0 6 yr  than in those without osteoporosis  2 6     0 6  p   0 004   moreover  osteoporosis was more prevalent in postmenopausal women  and in those who had intestinal calcium malabsorption  which was present in 80  of osteoporotic patients but in only 18  of nonosteoporotic patients  p   0 03   osteoporosis and mineralization bone impairment were unrelated to the severity of cholestasis  25 hydroxyvitamin d was significantly lower in those patients with intestinal calcium malabsorption  the results of this study indicate that osteodystrophy in primary biliary cirrhosis is characterized mainly by  low turnover  osteoporosis  which is related to the duration of the liver disease  postmenopausal condition  and calcium malabsorption  
class6	percutaneous transhepatic cholecystostomy for acute complicated cholecystitis in elderly patients  we report our experience with percutaneous transhepatic cholecystostomy in 10 elderly patients with acute cholecystitis  complicated by empyema formation  most of these patients has severe underlying disease  rendering them at high risk for surgical intervention  in all patients  the percutaneous procedure was followed by a rapid regression of clinical symptoms and of radiologic abnormalities  six were considered inoperable  three of these remain free of biliary symptoms  respectively 22  10  and 7 months after percutaneous cholecystostomy  three others died of nonbiliary disease 1 4 months after cholecystostomy  three patients underwent successful elective cholecystostomy 1 5 wk after percutaneous cholecystostomy  in one patient  cholecystectomy had to be performed because of recurrence of hydrops  1 wk after catheter removal  in our opinion  percutaneous transhepatic cholecystostomy is a safe and effective procedure in the treatment of elderly patients with acute complicated cholecystitis  it can be followed by elective cholecystectomy in good surgical candidates  or by an expectant conservative management in high surgical risk patients  
class6	comparative studies of du pan 2  carcinoembryonic antigen  and ca19 9 in the serum and bile of patients with pancreatic and biliary tract diseases  evaluation of the influence of obstructive jaundice  the levels of du pan 2 antigen  carcinoembryonic antigen  and ca19 9 in serum and bile of patients with pancreatic and biliary tract diseases were measured  the sensitivities  true positive  of du pan 2 in serum to pancreatic carcinoma  64   and to biliary tract carcinoma  62   were similar to those of ca19 9 in serum  69  and 72   respectively   nine of 18  50   patients with ca19 9 negative pancreatic carcinoma tested positive for du pan 2  the sensitivities of cea to pancreatic carcinoma  56   and to biliary tract carcinoma  52   were lowest  the measurement of these antigens in bile seemed to be of little diagnostic value in differentiating between malignant and benign diseases  false positives of these three assays occurred frequently in patients with benign pancreatic or biliary tract disease coupled with obstructive jaundice  after percutaneous transhepatic biliary drainage  serum du pan 2 and ca19 9 levels returned to normal ranges in patients with benign diseases  but not in patients with carcinoma of the pancreas or of the biliary tract  serum ca19 9 and du pan 2 antigens are useful tumor markers for pancreatic and biliary tract carcinomas  longitudinal assays of these antigens may be useful for the differential diagnosis of patients with obstructive jaundice  
class6	serum amylase in patients with renal insufficiency and renal failure  results vary with regard to the upper limits of serum amylase seen in patients with renal failure  and very little has been reported with patients with renal insufficiency not yet requiring dialysis  to determine the level of serum amylase elevation in renal insufficiency and renal failure  we determined serum amylase values in 128 subjects with creatinine clearances less than 90 ml min  serum amylase remained in the normal range when creatinine clearance was greater than 50 ml min  and did not become elevated until creatinine clearance was less than 50 ml min  the highest serum amylase recorded in the absence of acute pancreatitis was 503 iu l  normal  less than 128 iu l   serum lipase and trypsin values paralleled those for serum amylase  values remained normal when creatinine clearance was greater than 50 ml min  and were normal or elevated when creatinine clearance was less than 50 ml min  these results indicate that elevations of serum amylase  i e   amylase greater than 128 but less than 500 iu l  in asymptomatic patients with impaired renal function are not evident until creatinine clearances fall below 50 ml min  and probably do not represent acute pancreatitis  
class6	comparison of a new immunoassay for determining serum pancreatic isoamylase with two standard techniques  a method has recently been developed for measuring serum pancreatic  p  isoamylase  using two monoclonal antibodies specific for salivary isoamylase  we performed this test on 67 healthy controls and 133 patients  15 with acute pancreatitis  53 with chronic pancreatitis  20 during painful relapse and 33 in clinical remission   18 with pancreatic cancer  41 with nonpancreatic disease with abdominal pain  five with macroamylasemia  and one with total pancreatectomy  results were compared with those of a wheat germ inhibition method and with electrophoresis on cellulose acetate  a close correlation was found between the results of immunoinhibition assay and those of the other two tests  all patients with acute pancreatitis had abnormally high values in all three tests  in the group with chronic pancreatitis studied during painful relapse  16 had an increase in p isoamylase  as determined with the immunoinhibition assay  13 with the wheat germ inhibition test  and 15 with electrophoresis  in the group with chronic pancreatitis in clinical remission  we found low values in one patient  by immunoinhibition assay  but found low values in 17 and 19 patients by wheat germ inhibition and electrophoresis  respectively  low p isoamylase values corresponded to a severe exocrine pancreatic insufficiency  in the group with pancreatic cancer  the three tests showed similar results  and the majority of the patients had normal values  in the patients with nonpancreatic diseases  abnormally high levels were found in five  by immunoassay  in four by electrophoresis  and in three by the wheat germ inhibition method  in the five cases with macroamylasemia  both inhibition assays erroneously demonstrated an abnormal p isoamylase elevation  the results show that the three tests are equally useful for the diagnosis of acute pancreatitis  or chronic pancreatitis during an acute relapse  in these diseases  the immunoinhibition test would be the preferred assay because it is simple and rapidly performed  
class6	in vivo evaluation of monopolar versus bipolar electrosurgical polypectomy snares  the energy required and tissue damage in bipolar and monopolar polypectomy snares were compared in a canine model  the bipolar snare required an average of 34 joules of energy  whereas the monopolar snare required 228 joules to cut the same diameter of gastric mucosa tended into a polypoid structure  p   0 0005   the reduced energy delivered to the tissue from the bipolar procedure resulted in only 32  average depth of damage to the underlying gastric wall  whereas the monopolar procedure caused an average 69   p   0 001   surgically created polyps required 247 joules and 69 joules for corresponding monopolar and bipolar polypectomy  p   0 001   the decreased energy required and the correspondingly reduced damage caused to the underlying bowel wall by the bipolar snare should reduce the incidence of perforation and post polypectomy syndrome  the bipolar snare completes a local circuit about the snare  eliminating the return electrode and  consequently  the possibility of any return electrode burns  the bipolar snare thus provides an added safety margin during polypectomy  
class6	hyperplastic gastric polyps associated with persistent helicobacter pylori infection and active gastritis  we report two cases of patients with 3 yr histories of upper gastrointestinal symptoms  hyperplastic gastric polyps  and active chronic gastritis  biopsies retrospectively stained with giemsa revealed the persistent presence of helicobacter pylori  hp  in gastric biopsies of both patients throughout the 3 yr  after treatment with amoxicillin and bismuth subsalicylate  both became asymptomatic  one demonstrating disappearance and recurrence of the gastric polyps in conjunction with the hp  these cases demonstrate 3 yr of hyperplastic gastric polyps associated with hp and active gastritis  
class6	protein losing enteropathy in systemic lupus erythematosus associated with intestinal lymphangiectasia  this case report concerns a young woman with systemic lupus erythematosus who presented with a protein losing enteropathy  intestinal biopsy revealed lymphangiectasia  mesenteric lymph nodes showed paracortical lymphoid depletion and multiple small sinusoids  elevated cholesterol levels and normal lymphocyte counts characterized the peripheral blood samples  lymph nodes  though enlarged  showed no evidence of obstructive pathology  no secondary cause of lymphangiectasia could be identified  the patient exhibited antinuclear antibodies and antibodies to dsdna at the onset  and then  5 yr later  the classic features of systemic lupus erythematosus  sle   the lymphocytopenia and hypolipidemia that characterizes lymphangiectasia is not a feature of the sle cases reported to date  furthermore  the mechanism for the dilated lymphatics and villous edema is more likely immunological than mechanical disruption of lymphatics  
class6	gallbladder carcinoma producing human chorionic gonadotropin  a primary carcinoma of the gallbladder producing human chorionic gonadotropin  hcg  was encountered in an 83 yr old japanese woman  with elevation of hcg beta hcg in urine and serum  remarkable elevation of serum estradiol was an associated finding  with increased hcg  at autopsy  we found that the primary carcinoma of the gallbladder extensively involved the liver  histologically  the tumor revealed adenosquamous cell carcinoma in the primary site  and moderately to poorly differentiated adenocarcinoma in metastatic foci  immunohistochemical staining for beta hcg showed a positive reaction in adenocarcinoma components  this is an extremely rare case of an hcg producing gallbladder carcinoma  which leads us to speculate that hcg positive tumor cells may occur due to dedifferentiation  
class6	isolated ventral pancreatitis in a patient with pancreas divisum  a previously healthy 22 yr old woman was found to have chronic pancreatitis restricted to the ventral pancreas in association with pancreas divisum  when conservative treatment failed  sphincteroplasty of both papillae was performed with good results  this well documented case represents a clear exception to the commonly held concept that obstruction of the dorsal duct is the essential pathogenic factor in the development of pancreatitis associated with pancreas divisum  the importance of visualizing both the dorsal and ventral pancreatic ducts to direct therapy for patients with idiopathic pancreatitis is discussed  theories of the pathogenesis of concomitant pancreatitis and pancreas divisum are reviewed  
class6	exacerbation of chronic active hepatitis type b after short term corticosteroid therapy resulting in fatal liver failure  the case of a 36 yr old male with chronic active type b hepatitis in whom 4 wk prednisone therapy resulted in prolonged and fatal exacerbation of liver disease is described  thus  short term corticosteroid therapy may in some patients have disastrous effects on the course of chronic active hepatitis b  
class6	toxoplasmic chorioretinitis and hepatic granulomas  a 71 yr old male presented with a 2 month history of fever  malaise  and weight loss  physical exam revealed chorioretinitis  laboratory studies were notable for elevated levels of alkaline phosphatase  gamma glutamyl transpeptidase  aspartate transaminase  and alanine transaminase  immunoglobulin g antibody to toxoplasma gondii was positive to a dilution of 1 4096  whereas serologic studies for hepatitis a virus  hepatitis b virus  cytomegalovirus  epstein barr virus  human immunodeficiency virus  brucella  and tularemia were negative  a percutaneous biopsy of the liver revealed hepatic granulomas  culture of the biopsy specimen was negative for growth of mycobacteria or fungi  spontaneous improvement in clinical and laboratory parameters occurred over a 4 month period  
class6	disseminated  nonmeningeal gastrointestinal cryptococcal infection in an hiv negative patient  gastrointestinal cryptococcosis is extremely rare  especially in patients with no involvement of the central nervous system  we describe a 63 yr old man undergoing prednisone therapy for chronic hepatitis and cirrhosis who presented with peritonitis  colitis  and skin lesions  pathological studies revealed necrosis and numerous cryptococcal organisms in the colon  omentum  and skin  and cultures yielded cryptococcus neoformans  the patient died of multisystem organ failure following emergency exploratory surgery performed when he had onset of symptoms of a bowel perforation after an endoscopic biopsy  clinicians should be aware that gastrointestinal cryptococcosis can occur in the absence of infection of the central nervous system or lungs  and that it may affect relatively healthy patients who are immunocompromised because of splenectomy  chronic liver disease  or steroid therapy  
class6	peritoneal dialysis in the geriatric patient  elderly patients on chronic peritoneal dialysis  cpd  from two large chronic peritoneal dialysis programs were compared with younger patients in regard to peritonitis rates  catheter problems  hospital days  transfers to other forms of therapy  and mortality  peritonitis rates and organisms were similar in younger and older patients  catheter replacements were less common in the elderly  differences in hospital days were attributable to hospitalization for vascular disease  the elderly were more likely to have the first episode of peritonitis  to die and to change dialysis modalities at all times after the first year of continuous ambulatory peritoneal dialysis  capd  treatment  although other than increased mortality  differences between the two groups were small  cpd appears to be an acceptable form of renal replacement therapy in the elderly  
class6	treatment of wegener s granulomatosis with intermittent high dose intravenous cyclophosphamide purpose  concerns regarding the long term toxicity of daily cyclophosphamide  cp  therapy for the systemic vasculitides have led us to evaluate alternative approaches to treatment in an attempt to achieve comparable efficacy with less toxicity  this study sought to determine the efficacy  toxicity  and immunologic effects of glucocorticoids  gc  and intermittent high dose intravenous cp   pulse  cp  in the treatment of 14 patients with wegener s granulomatosis  wg   patients and methods  the diagnosis of active wg was supported by a typical clinical presentation and histopathologic findings of vasculitis  granulomatous inflammation  and tissue necrosis  gc treatment was initially provided on a daily basis and later tapered to an alternate day schedule if vasculitis remained inactive  pulse cp treatment was initially administered once a month for 6 months  if after 6 months remission had been attained and gc therapy had been discontinued  then pulse cp treatment was given at less frequent intervals thereafter  treatment and evaluation were provided for participants as inpatients in a clinical research center  national institutes of health   results  thirteen of 14 patients  93   initially experienced unequivocal improvement with pulse cp therapy  and seven of 14  50   achieved remission within 4 months  however  treatment was associated with significant toxicity in two patients and later relapses in nine patients  so that a total of 79  either failed to achieve sustained remission or were unable to continue therapy  three of 14  21   patients have achieved sustained remissions with the pulse cp protocol and one additional patient  who had a limited exacerbation of wg  continues to receive that therapy after 14 to 22 months  mean 17 months   conclusions  the use of pulse cp and gc therapy in 14 patients with wg was associated with a high initial response rate  however  failure to respond initially to treatment  to sustain improvement  or to tolerate continued treatment was noted in 79  of patients within a period of 1 to 22 months  these observations indicate that this particular pulse cp protocol does not achieve a high degree of lasting efficacy  
class6	association of helicobacter pylori infection with dyspeptic symptoms in patients undergoing gastroduodenoscopy  purpose  to determine the prevalence of helicobacter pylori in patients with non ulcer dyspepsia and ulcer disease as well as in a control population undergoing endoscopic retrograde cholangiopancreatography  ercp  for suspected pancreatic or biliary disease  patients and methods  forty six eligible patients undergoing upper endoscopy at massachusetts general hospital were studied over a period of 18 months  as well as 24 patients undergoing ercp for presumed pancreatic or biliary disease  two biopsy specimens from the fundus and two from the antrum were taken for microbiologic and histopathologic analysis  sera were examined by enzyme linked immunoabsorbent assay  all specimens were processed in a blind fashion  chi square test with yates  correction was used for statistical analysis  results  h  pylori was found in 31 of 46  67   study patients and in six of 24  25   control patients  by microbiologic or histologic techniques   p less than 0 01   h  pylori was found in all patients with peptic ulcer disease and in 60  of patients without ulcers  no association between h  pylori and any specific gastrointestinal symptom was observed  h  pylori was identified in the fundus as often as in the antrum  although in the antrum the organism was more often associated with histologic gastritis  compared with histology  serologic assays for igg and iga antibodies to h  pylori had sensitivities of 100  and 94   and specificities of 86  and 76   respectively  reexamination of selected specimens without knowledge of their identity revealed that the specificity of serology exceeded 94  while the sensitivity of histologic and microbiologic studies may have been closer to 80   conclusions  h  pylori was more common in dyspeptic patients than in our control subjects undergoing ercp  multiple biopsy sites from fundus and antrum are required to exclude infection  serologies of igg and iga were sensitive and specific for h  pylori  suggesting a possible role for non endoscopic diagnosis of this infection  the frequent association of h  pylori with active inflammation rather than with quiescent gastritis is consistent with a pathologic role of this organism  
class6	cardiorespiratory effects of endoscopic esophageal variceal sclerotherapy  endoscopic variceal sclerotherapy  evs  is an effective means of controlling variceal hemorrhage  which develops as a consequence of portal hypertension  while esophageal perforation  ulceration  strictures  and mediastinitis are potential complications associated with this procedure  it is not clear whether isolated pleuropulmonary events such as pleuritis  pneumonitis  and adult respiratory distress syndrome are causally related to the evs  endoscopy and sedation with the attendant risk of aspiration  particularly in the background of hepatic encephalopathy  may account for some of these events  recent controlled studies of respiratory function demonstrate that evs as such results in minor changes in gas exchange  lung volumes  and pulmonary and systemic hemodynamics  most pulmonary complications have been reported with the use of sodium morrhuate sclerosant  comparative studies among different sclerosants are necessary to evaluate relative safety  finally  there have been rare reports of myocardial ischemia and pericarditis reported in association with evs  but these are of a transient nature  chest symptoms  roentgenographic pleuropulmonary changes  pulmonary hemodynamics  and cardiac perturbations are transient and should not preclude offering evs to patients with variceal hemorrhage  
class6	pregnancy induced hypertension and acute fatty liver of pregnancy  atypical presentations  severe pregnancy induced hypertension and markedly elevated levels of serum alkaline phosphatase developed in a 29 year old woman in whom one pregnancy resulted in intrauterine death  acute fatty liver of pregnancy developed with good fetal outcome in the next pregnancy  this case suggests that pregnancy induced hypertension and acute fatty liver of pregnancy are part of a clinical spectrum  moreover  classic abnormalities of liver function tests need not be present in acute fatty liver of pregnancy  
class6	antenatal spontaneous perforation of the extrahepatic biliary tree  spontaneous perforation of the biliary system is an unusual neonatal phenomenon that is rarely recognized at birth  to date  it has not been reported antenatally  a 16 year old pregnant adolescent had an ultrasonogram at 25 weeks of pregnancy that revealed ascites in the fetus  after the infant was delivered at 32 weeks  a hepato iminodiacetic acid scan showed a spontaneous rupture of the common bile duct  the infant was treated with external drainage of the biliary tree and recovered well  this case demonstrates that spontaneous perforations of the bile ducts can occur much earlier than the usually described 2 to 12 weeks after birth  can be diagnosed antenatally  and should be added to the list of causes of fetal ascites  
class6	intrapartum uterine rupture and inflammatory bowel disease  the incidence of uterine rupture in pregnant women ranges from 0  to 1 1  in large series  this case report describes a woman with a history of obstetric complications  uterine rupture  and active inflammatory bowel disease that was treated with high dose prednisone  
class6	crohn s disease and retinal vascular disease  patients with crohn s disease may manifest extraintestinal findings including ocular involvement  we treated two patients with crohn s disease who manifested retinal vascular disease that may have been related to the immune nature of the underlying disease or possibly to changes in the vasculature or coagulation system  one patient had a central retinal vein occlusion and the other had retinal vasculitis involving retinal arteries and veins with an apparent branch retinal artery occlusion  both patients were in excellent health except for crohn s disease  which was confirmed by a biopsy specimen  in one patient  the diagnosis of retinal vasculitis preceded the clinical diagnosis of crohn s disease  whereas for the second patient the symptomatology of the intestinal disease preceded the ocular manifestations  we suggest that inflammatory bowel disease should be considered in the differential diagnosis of retinal vascular occlusive disease  especially in a young patient  
class6	update on the epidemiology of anorexia nervosa in a defined region of switzerland  in this follow up investigation  the authors studied all swiss women in the canton of zurich who developed anorexia nervosa between ages 12 and 25 years and who were hospitalized for the first time with this diagnosis between 1983 and 1985  data were compared with those from an earlier study  which focused on the periods 1956 1958  1963 1965  and 1973 1975  the incidence of anorexia nervosa did not increase significantly during 1983 1985 compared to 1973 1975  in contrast to the constant increase found between 1956 and 1975  however  the more frequent use of vomiting and abuse of laxatives in 1983 1985 may indicate an increase in cases with mixed features of anorexia nervosa and bulimia  
class6	endemic cryptosporidium and giardia lamblia infections in a thai orphanage  we conducted a point prevalence survey for enteric protozoa in 205 institutionalized orphans 1 61 months of age in bangkok  thailand  cryptosporidium was identified in 17 children  8    giardia lamblia in 42  20    and 3 children  1   had both parasites  at the time of diagnosis  diarrheal symptoms were present in a minority of subjects  36  of children with cryptosporidium alone  10  with g  lamblia alone  and in 20  of those with neither parasite  although chronic nutritional status  height age  was similar in all groups  acute nutritional status  weight height  was lower only in children with cryptosporidium  z score    1 39     0 13  compared with children with g  lamblia  mean z score     sem    0 56     0 26  or neither parasite  z score    0 78     0 13  p   0 05   detectable levels of cryptosporidium specific igg antibodies by elisa were identified in 15 of 16 thai children with cryptosporidium and in 17 of 19 thai children without cryptosporidium  mean od     sem   1 27     0 18 vs  1 06     0 13  respectively   but in only 1 of 18 sera from toddlers in day care centers in denver  co  od   0 128     0 03   although neither infection with cryptosporidium nor g  lamblia was consistently associated with acute diarrheal symptoms  cryptosporidium was more often associated with depressed acute nutritional status than g  lamblia  the high prevalence of specific antibodies to cryptosporidium in thai orphans suggests an association between high rates of exposure with asymptomatic excretion of the parasites  
class6	brain and liver dolichol in chronic alcoholism  a necropsy study  cerebral gray and white matter and liver dolichol levels were measured in postmortem samples from chronic alcoholics and nonalcoholic controls following recent suggestions that dolichol levels may be used as a marker for alcoholism  no significant differences in brain dolichol were found between the control and alcoholic groups  a significant reduction in the liver dolichol was observed in the alcoholic group  this was most marked in those alcoholics with liver disease  
class6	esophageal motor disorder in alcoholics  result of alcoholism or withdrawal  both acute and chronic ethanol consumption may cause esophageal dysmotility  in order to systematically evaluate the effect of ethanol on esophageal motility  we studied esophageal motility in 13 healthy subjects before and following acute intravenous administration of 0 8 g kg ethanol and in chronic alcoholics within 6 hr of their last drink  n   6  and following 24 to 48 hr of abstinence when signs of withdrawal were present  n   13   withdrawing alcoholics were also restudied after intravenous administration of 0 8 g kg ethanol  ethanol transiently decreased lower esophageal sphincter pressure  lesp  and inhibited les relaxation in all control subjects  this inhibitory effect of ethanol on lesp in alcoholics was significantly less  indicating the development of tolerance  ethanol moderately decreased esophageal contraction amplitude  eca  in 10 of 13 controls and prolonged duration of contractions in all but had no effect on velocity of esophageal contractions  in contrast  eca was significantly elevated in both groups of alcoholics  but this was significantly more marked in withdrawing alcoholics  ethanol infusion returned eca toward normal values in withdrawing alcoholics  abnormal motility was noted in three intoxicated alcoholics and 10  77   withdrawing alcoholics  this included nutcracker esophagus in five and hypertensive les in two  these data indicated that  1  esophageal motor dysfunction is common in alcoholics   2  acute ethanol administration decreases lesp and esophageal contraction amplitude  whereas chronic ethanol consumption and withdrawal from ethanol increases eca  this suggests development of a compensatory mechanism in chronic alcoholics leading to high pressure esophageal contractions during withdrawal  
class6	a hepatocellular carcinoma of massive arterioportal shunts without tumor stain treated with cddp two route chemotherapy  a case report  massive arterioportal shunts without tumor vessels or tumor stain are sometimes encountered in advanced cases of liver cirrhosis  massive arterioportal shunts without tumor stain that responded well to intensive chemotherapy with cis diamminedichloroplatinum ii are reported  
class6	methylene iodide poisoning  a 20 month old girl ingested a maximum of 25 ml of pure methylene iodide  within two hours  the patient exhibited lethargy and incoordination and vomited  an abdominal radiograph demonstrated the radiopaque material in the gut  in vivo conversion to carbon monoxide was documented with a peak carboxyhemoglobin level of 14 2  reached at 11 hours after ingestion  two days after ingestion  evidence of hepatotoxicity was apparent  and fulminant hepatic failure quickly ensued  despite aggressive supportive care and transfer to a liver transplant center  the patient died nine days after ingestion  methylene iodide ingestion has not been previously reported in human beings  this case verifies that this substance is a potent hepatotoxin  is metabolized to carbon monoxide in vivo  is radiopaque  and may cause bone marrow suppression  
class6	castor bean intoxication  we report the cases of a child who ingested two or more castor beans and two adults who each ingested four beans  all three patients developed severe gastroenteritis and recovered without sequelae after receiving iv fluids  the literature contains reports of 424 cases of castor bean intoxication  symptoms of intoxication include acute gastroenteritis  fluid and electrolyte depletion  gastrointestinal bleeding  hemolysis  and hypoglycemia  delayed cytotoxicity has not been reported  of the 424 patients  14 died  mortality rates  8 1  of untreated and 0 4  of treated   deaths were due to hypovolemic shock  recommended treatment for asymptomatic patients who have chewed one or more raw beans is emergency department evaluation  gastric decontamination  administration of activated charcoal  observation until four to six hours after ingestion  and discharge instructions to return if symptoms develop  after decontamination and activated charcoal  symptomatic patients require hospitalization for treatment with iv fluids  supportive care  and monitoring for hypoglycemia  hemolysis  and complications of hypovolemia  monitoring for delayed cytotoxicity is unnecessary  castor beans and their dust are highly allergenic and may cause anaphylaxis  
class6	management of the acute abdomen complicating oral anticoagulation therapy  acute abdominal pain in the patient receiving oral anticoagulants poses a difficult diagnostic and therapeutic challenge  we describe two cases of peritonitis requiring laparotomy in anticoagulated patients  and review 49 similar case reports from the world literature  these patients were usually explored for signs of bowel obstruction  at operation  the intestine often appeared infarcted  but pathologic examination commonly revealed intramural hematomata  in contrast  we present microscopic evidence of hemorrhagic cecal infarction complicating oral anticoagulation therapy in one patient  intramural intestinal hemorrhage is the most common cause of acute abdominal pain in the anticoagulated patient who undergoes laparotomy  in addition to intramural hemorrhage  14 per cent of patients had coexistent volvulus  appendicitis  intestinal wall disruption or intestinal infarction  we conclude that anticoagulated patients with suspected intramural intestinal hemorrhage may have severe intraabdominal pathology requiring operation  therefore  operation is mandatory for patients who fail to improve after a short course of expectant management  
class6	nonoperative management of small bowel obstruction with endoscopic long intestinal tube placement  intestinal obstruction remains a major cause of morbidity and mortality in surgical patients  we reviewed the records of 77 patients with mechanical small bowel obstruction who were treated with endoscopically and fluoroscopically placed leonard long intestinal tube decompression  most patients  59   had failed a trial of nasogastric tube or miller abbott tube decompression  overall  29 per cent of patients were able to resolve their obstruction with leonard tube decompression alone  subdivision of patients on the basis of the etiology of their obstruction demonstrated a much higher rate of success for tube decompression in adhesive obstruction  37   versus malignant obstruction  12   or inflammatory obstruction  no successes   patients with radiographic and clinical evidence of complete intestinal obstruction were significantly less likely to respond to long intestinal tube treatment  13    the long intestinal tube was easily passed in all patients  there were no complications of the intubation procedure in our series  and the incidence of tube related complications was four per cent  we conclude that an initial period of long intestinal tube decompression allows a significant percentage of patients with mechanical small bowel obstruction to be treated nonoperatively  particularly if a partial obstruction from postoperative adhesions is present  patients who have failed a trial of nasogastric tube decompression and are poor operative risks should also be considered for long intestinal tube placement  
class6	the influence of sclerotherapy on gastric mucosal blood flow distribution  hemodynamic events and structural vascular changes of the gastric mucosa in cirrhotics have caught the attention of investigators in the recent past  but as yet it is not known whether therapeutic interruption of variceal blood flow at gastroesophageal level alters such portal hypertensive mucosal features  the newly developed endoscopic laser doppler technique was used to assess whether variceal eradication by means of endoscopic sclerotherapy influences the gastric mucosal congestion in portal hypertension patients  gastric mucosal blood flow was determined at ten defined sites of the stomach  before the first session of sclerotherapy and after complete variceal eradication had been achieved in 15 patients  a statistically significant decrease  p less than 0 01 to 0 05  in microcirculation was found at the gastric antrum and corpus  an increase at the pylorus  p less than 0 05   but no change in the fundic area  an important question following these findings is  what are the consequences of such aggravation of gastric congestion on the integrity of the gastric mucosa   
class6	a five year u s  army experience with 36 250 abdominal hernia repairs  thirty six thousand two hundred fifty abdominal hernia repairs were performed in u s  army medical treatment facilities during a five year period  this study presents data about the type of hernia  incidence of complications by obstruction or strangulation  age  sex  and mortality  hernias occurring with intestinal obstruction or gangrene  strangulation  are referred to as complicated hernias  inguinal hernias in children less than two years of age  femoral hernias  and unusual  such as internal or obturator  hernias were found to have an increased incidence of complications  surgical repair of ventral  umbilical  and femoral hernias was done with a low surgical risk and the presence of complications did not significantly increase this risk  an increased risk of mortality is associated with the repair of complicated unusual hernias and complicated inguinal hernias in patients more than 60 years of age  
class6	comparison of ulcer surgery at a veterans administration and university hospital  we compared the patient populations and outcome of surgery for peptic ulcer disease in 81 patients at a veterans administration hospital  ovah  and 97 patients at an affiliated university hospital  unh   the surgeons and choice of operation were comparable at both facilities  patients were similar with respect to severity of ulcer disease  percentage of elderly patients and distribution of comorbid conditions  there were significantly more female patients  45  vs 2   p less than 0 05   patients less than 40 years old  22  vs 6   p less than 0 05   and patients with gastric ulcers  27  vs 12   p less than 0 05  at unh  alcoholism was more prevalent at ovah  57  vs 22   p less than 0 05   postoperative morbidity and mortality rates were 27 per cent and 14 per cent at ovah and 25 per cent and 16 per cent at unh  these data suggest that quality of care for surgical therapy of ulcer disease at a va hospital is comparable to its tertiary care affiliate with a similar patient population  
class6	toxic shock syndrome after inguinal hernia repair  report of a case with patient survival  a 40 year old man developed fulminant multisystem failure several days after elective repair of an inguinal hernia  toxic shock syndrome  tss  was diagnosed  there was  however  no evidence of wound infection at the time of multisystem failure  only later in his hospital course did the wound drain  staphylococcus aureus was cultured from the wound and was the presumed etiologic agent in the patient s life threatening illness  the patient recovered fully with supportive care  antibiotics  and surgical debridement of the inguinal hernia site  this case is discussed in the context of existing literature on the toxic shock syndrome  the site of infection is typically nonsuppurative  but the systemic manifestations are typically life threatening  the responsible organism is commonly believed to be a strain of s  aureus that expresses a toxin  tss toxin 1  that effects multisystem failure  but which also diminishes the local inflammatory response and explains the benign appearance of the wound  although this is a rare clinical entity  elective surgical procedures complicated by fatal tss have been reported  surgeons should understand this disease and the management necessary to avert mortality  
class6	ct diagnosis of acquired small bowel volvulus  small bowel volvulus is an uncommon but important cause of small bowel obstruction and often results in ischemia or infarction  clinical examination and plain film radiography may be nondiagnostic  leading to delay in surgical intervention with subsequent increase in morbidity and mortality  we present two patients in whom the diagnosis of strangulating small bowel volvulus was made by computed tomography  ct   allowing rapid surgical correction of this potentially life threatening condition  
class6	acute gastroenteritis in infants under 6 months old  sixty two babies under the age of 6 months who were admitted with gastroenteritis completed a study of gradual refeeding compared with abrupt refeeding after a period of rehydration  there was no difference in the incidence of recurrence of diarrhoea due to lactose intolerance  effect on weight  or duration of hospital stay  twenty six babies  42   had recurrence of diarrhoea after refeeding  all of whom settled with the introduction of a lactose free soya based formula  well nourished babies under 6 months of age with mild to moderately severe gastroenteritis can be fed immediately with full strength milk feeds after rehydration  the introduction of a lactose free soya based preparation may provide an alternative to repeated attempts at regrading with cows  milk feeds in those patients with lactose intolerance  
class6	management of gastroenteritis  childhood gastroenteritis remains a common reason for admission to british paediatric units  although the severity of the disease appears to be diminishing in recent years  we studied 215 infants and children with gastroenteritis admitted consecutively to four paediatric units in south wales in order to determine the severity of the disease  the organisms isolated  the frequency of complications  and the adequacy of management before admission  stool pathogens were isolated in 125  58   patients  viruses in 65  bacteria in 30  and protozoa in 19  with multiple infection found in 11   there was a low incidence of morbidity and complications  but prolonged diarrhoea  postenteritis syndrome  was present in 24  11   cases and 77  36   had received inappropriate treatment before admission  contemporary gastroenteritis is thus a relatively mild disease in the acute phase  but management before admission to hospital is often inadequate  and prolonged diarrhoea may be a feature in a considerable number of cases  
class6	perforated duodenal ulcer  an unusual complication of gastroenteritis  a 7 year old boy was admitted to hospital with gastroenteritis  which was complicated by an acute perforated duodenal ulcer  after oversewing of the perforation he made an uncomplicated recovery  peptic ulceration is under diagnosed in childhood and this leads to delay in diagnosis and appropriate management  ulceration is associated with severe illness and viral infections  but perforation is rare  
class6	congenital diaphragmatic hernia  impact of prostanoids in the perioperative period  a prospective study of 10 neonates with congenital diaphragmatic hernia and five controls to determine the importance of prostanoid concentrations perioperatively and the relation with persistent pulmonary hypertension  pph  is reported  in neonates with congenital diaphragmatic hernia postoperative concentrations of the vasoconstrictor thromboxane b2 rose significantly and were higher during episodes of pph  this rise may provoke pph and subsequent right to left shunting  
class6	cystic tumors of the pancreas  new clinical  radiologic  and pathologic observations in 67 patients  within a 12 year period we treated 67 patients  49 women  18 men  mean age  61 years  with cystic neoplasms of the pancreas  including 18 serous cystic adenomas  15 benign mucinous cystic neoplasms  27 mucinous cystadenocarcinomas  3 papillary cystic tumors  2 cystic islet cell tumors  and 2 cases of mucinous ductal ectasia  mean tumor size was 6 cm  2 to 16 cm   in 39  the patients had no symptoms  and in 37  the lesions had been misdiagnosed as a pseudocyst  computed tomography was useful for detection  for distinguishing the microcystic subgroup of serous cystadenoma  and for showing rim calcification  all 7 cases were malignant  but was not reliable for distinguishing neoplasm from pseudocyst  serous from mucinous tumors  or benign from malignant  arteriography showed hypervascularity in 4 of 10 serous adenomas  3 of 11 mucinous carcinomas  and 1 of 1 papillary cystic tumors  endoscopic pancreatography showed no communication with the cyst cavity in 37 of 37 cases of cystic neoplasms but opacified the ectatic ducts in 2 of 2 cases of mucinous ductal ectasia  stenosis or obstruction of the pancreatic duct indicated cancer  the tumor was resected by distal pancreatectomy in 25 patients  by proximal resection in 29  and by total pancreatectomy in one  with no operative deaths  forty four per cent of the tumors were malignant  in 10 cases the tumor was unresectable because of local extension or distant metastases  and those patients died at a mean of 4 months  seventy five per cent of those resected for cure are alive without evident recurrence  because the epithelial lining of the tumor was partially  5  to 98   absent in 40  to 72  of cases of the major tumor types  and the mucinous component comprised only about 65  of mucinous cystadenoma lining  misdiagnoses on frozen and even permanent sections were made  mitoses and histologic solid growth correlated with malignancy  neuroendocrine elements were seen in 87  of benign and 47  of malignant mucinous tumors  it is recommended that the terms macrocystic and microcystic be abandoned in favor of the histologic designations serous and mucinous  incomplete examination of the cyst wall can be misleading  however  it is suggested that mucinous ductal ectasia be recognized separately from cystic tumors and that all of these lesions be resected  with the possible exception of asymptomatic confirmed serous cystadenomas  
class6	ileal pouch anal anastomosis  reoperation for pouch related complications  the aim was to assess the value of reoperative surgery for pouch related complications after ileal pouch anal anastomosis  ipaa  for chronic ulcerative colitis and familial adenomatous polyposis  between january 1981 and august 1989  114 of 982 ipaa patients  12   seen at the mayo clinic had complications directly related to ipaa that required reoperation  among the 114 patients  the complications prevented initial ileostomy closure in 33 patients  25    occurred after ileostomy closure in 68 patients  60    and delayed ileostomy closure in the remaining patients  the salvage procedures performed included anal dilatation under anesthesia for anastomotic strictures  placement of setons and or fistulotomy for perianal fistulae  unroofing of anastomotic sinuses  simple drainage and antibiotics for perianal abscesses  abdominal exploration with drainage of intra abdominal abscesses with or without establishment of ileostomy  and complete or partial reconstruction of the reservoir for patients with inadequate emptying  none of the reoperated patients died  reoperation led to restoration of pouch function in two thirds of patients and  of these  70  had an excellent clinical outcome  however approximately 20  of the 114 pouches required excision  excision was common  especially among patients who had pelvic sepsis  salvage procedures for pouch specific complications can be done safely and will restore pouch function in two thirds of patients  complications after reoperation  however  may ultimately lead to loss of the reservoir in one in five patients  
class6	the role of prostanoids in the production of acute acalculous cholecystitis by platelet activating factor  gallbladder tissue from patients with acute acalculous cholecystitis contains increased amounts of prostanoids when compared to normal gallbladder tissue  platelet activating factor  paf  is a potent stimulus of eicosanoid formation  it has been implicated as a mediator of acute inflammatory processes and systemic responses to shock  in this study the role of paf in acute acalculous cholecystitis was evaluated  anesthetized cats underwent gallbladder perfusion with a physiologic buffer solution containing  14c polyethylene glycol as a nonabsorbable tracer to quantitate mucosal water absorption  platelet activating factor was infused into the hepatic artery for 2 hours  control experiments were performed when vehicle alone was infused  experiments also were performed when indomethacin was administered intravenously and when indomethacin and paf were administered  gallbladder mucosal absorption secretion and perfusate and tissue prostaglandin e  pge  and 6 keto prostaglandin f1 alpha  6 keto pgf1 alpha  levels were evaluated  gallbladder inflammation was evaluated by beta glucuronidase and myeloperoxidase tissue concentrations and by a histologic scoring system  platelet activating factor eliminated gallbladder absorption and produced net fluid secretion associated with dose related increases in perfusate pge concentrations and gallbladder tissue pge and 6 keto pgf1 alpha levels when compared to control values  platelet activating factor produced significant inflammation in the gallbladder with increases in the histologic score of inflammation and tissue lysosomal enzyme activities  indomethacin significantly decreased the fluid secretion  prostanoid levels  and inflammation produced by paf  the results suggest that paf may induce acute gallbladder inflammation associated with systemic stress through a prostanoid mediated mechanism  
class6	surgical aspects of sclerosing cholangitis  results in 178 patients  of 178 patients with sclerosing cholangitis treated since 1950  88 patients had associated inflammatory bowel disease  72 had no such history  and 18 had iatrogenic injury or stone disease  a total of 233 biliary operations were performed  with a 75  rate of temporary improvement after initial operation  subsequent operations resulted in a lower success rate and a higher mortality rate  radiologic findings included predominant extrahepatic  intrahepatic  and diffuse disease in 29   28   and 43  of patients  respectively  no survival differences were noted  seventy five of one hundred three deaths  73   were related to liver failure  bleeding  or sepsis  of 14 patients undergoing portosystemic shunt  13 died of surgical complications or related disease  orthotopic liver transplantation was performed in 16 patients and resulted in eight deaths  mainly in patients who had previously undergone extensive surgical treatment  no survival differences were seen between the patients with inflammatory bowel disease  those without the condition  or those who had colectomy  surgical treatment in patients with sclerosing cholangitis should be minimized  orthotopic liver transplantation should be offered as the treatment of choice for patients with portal hypertension  refractory cholangitis  advanced cirrhosis  or progressive liver failure  
class6	relief of tracheal compression by aortopexy  we have performed aortopexy in 12 children with tracheal compression  six infants had compression secondary to a vascular anomaly  group 1   and the other 6 had previous repair of esophageal atresia  group 2   eleven of the 12 children are alive after a mean follow up of 36 months  in group 1  1 patient died and 3 patients  50   experienced recurrent respiratory distress  five infants sustained a major postoperative complication  and the average postoperative hospital stay was 25 days  in group 2  however  aortopexy was uniformly successful  there were no deaths  no postoperative complications  and no cases of postoperative respiratory distress  and the mean postoperative hospital stay was only 10 days  for children with reflex apnea after repair of esophageal atresia  aortopexy is lifesaving and can be performed with minimal morbidity and mortality  great caution is indicated in children with tracheal compression from other causes  
class6	pharyngoesophageal perforation after blunt neck trauma  pharyngoesophageal perforation secondary to blunt neck trauma is an uncommon injury that can cause serious morbidity and mortality if not recognized and treated  pharyngeal perforation secondary to blunt trauma sustained while boxing is reported  review of the world literature found 10 cases of pharyngoesophageal perforation secondary to blunt neck trauma  analysis of these cases indicates that perforations less than 2 cm and limited to the pharynx may be treated medically with close observation  large perforations and those perforations that extend to the esophageal inlet or involve the esophagus exclusively are best treated surgically  
class6	risk of gastric cancer after gastric surgery for benign disorders  the objective of this review was to evaluate published evidence for the association between gastric resection for benign disorders and subsequent cancer of the gastric remnant  we searched the literature through medline  1970 to 1988  and through the references of relevant articles  fifty eight studies consisting of case series  uncontrolled surveys  and case control or cohort analyses were identified and critically assessed using defined methodological criteria  there were no consistent differences between the expected and observed number of cancers occurring within 15 years after gastric resection  however  all case control studies and seven of the eight cohort analyses  in which the prevalence of cancer was stratified by time since gastric resection  indicated a twofold to fourfold increase in the risk of gastric cancer in patients who survived 15 or more years after gastric surgery  we conclude that most studies of the association of gastric surgery with subsequent gastric cancer have relatively weak designs  still  the repetitive demonstration of this association by different investigators using different research designs supports the hypothesis that gastric resection increases the risk of cancer in the gastric remnant  
class6	the prevalence of helicobacter pylori in nonulcer dyspepsia  importance of stratification according to age helicobacter pylori  formerly campylobacter pylori  is causally related to active antral gastritis and is highly associated with duodenal and gastric ulcers  however  the relationship of h pylori to nonulcer dyspepsia is less clear  we determined the presence of h pylori in unselected patients who were undergoing upper gastrointestinal tract endoscopy  and we found a prevalence of 37  in 110 patients with nonulcer dyspepsia that was similar to previous data  patients with nonulcer dyspepsia who had h pylori were found to be significantly older than patients with nonulcer dyspepsia who did not have h pylori  in addition  when stratified according to age  we detected an increased prevalence of h pylori in patients with nonulcer dyspepsia with increasing age  similar to that reported for asymptomatic control populations  this finding casts doubt as to the causal role of h pylori for most patients with nonulcer dyspepsia and stresses the importance of considering epidemiologic factors  such as age  when evaluating the role of h pylori in specific disease states  
class6	study of preneoplastic changes of liver cells by immunohistochemical and molecular hybridization techniques  the status of hepatitis b virus dna was investigated by in situ hybridization in multifocal areas of a noncancerous hepatitis b virus associated cirrhosis  this liver exhibited a marked degree of dysplasia and adenomatous hyperplasia  the results of these studies were correlated with the histopathology and immunohistochemical stains for hepatitis b core and surface antigens  there was clear evidence of a marked reduction to absence of hepatitis b viral dna by in situ hybridization and absence of hbc and hbsag in the foci of liver cell dysplasia and adenomatous hyperplasia  these results support the hypothesis that liver cell dysplasia and adenomatous hyperplasia are preneoplastic in nature  
class6	acalculus lymphoeosinophilic cholecystitis associated with interleukin 2 and lymphokine activated killer cell therapy  a case of unusual cholecystitis that developed on completion of interleukin 2 and lymphokine activated killer cell therapy is described  a 62 year old man was treated with interleukin 2 and lymphokine activated killer cells for disseminated renal cell carcinoma  during the course of the immunotherapy  his serum alkaline phosphatase level increased  as did the peripheral eosinophil count  0 31   subsequently  clinical and radiologic evidence of acute cholecystitis was noted  the removed gallbladder showed acalculus cholecystitis with extensive diffuse infiltrates of numerous eosinophils and t lymphocytes  but sparse polymorphonuclear leukocytes  the authors name this unusual cholecystitis acalculus lymphoeosinophilic cholecystitis and believe it to be associated with interleukin 2 and lymphokine activated killer cell therapy  the pathogenic relationship is discussed  
class6	comprehensive management of acute necrotizing pancreatitis and pancreatic abscess  achieving reduced mortality rates in patients with necrotizing pancreatitis and pancreatic abscess is possible by employing a comprehensive management plan  components of the plan include  1  rapid evaluation and assessment of the degree of physiologic and anatomic derangement  the latter by the prompt use of vascular enhanced computed tomographic scan   2  adequate fluid resuscitation determined by early institution of advanced hemodynamic monitoring   3  attempts to identify and document septic foci via computed tomography guided percutaneous aspiration  and  4  aggressive surgical debridement  close adherence to these policies allowed us to keep mortality in this seriously ill group of patients to 14   most deaths occurred in patients who were referred to this service late in the course of their disease  the acute physiology and chronic health enquiry  apache  ii severity of illness index applied at the time of admission proved an accurate predictor of mortality  a score of 25 or greater was highly predictive of death  and a lesser score  of survival  
class6	blunt intestinal injury  keys to diagnosis and management  fifty six patients with blunt intestinal injury seen during 39 months were reviewed for keys to diagnosis and treatment  motor vehicle accidents were involved in 80  of the cases and seat lap belts were in use 69  of the time  blunt intestinal injury was the only abdominal injury in 70  of the cases  there were 42 perforations and 20 devascularizations  multiple injuries were common  27    abdominal tenderness was present on admission in 43 of 44 patients in whom a reliable examination was possible  peritoneal lavage was positive in 13  93   of 14 patients  computed tomography was falsely negative in three of four instances in which it was used  perforations were most common in the upper and lower ends of the small bowel and in the sigmoid colon  devascularizations were most common in the distal ileum and sigmoid colon  resection anastomosis was performed in 38  of small bowel perforations and in all small bowel devascularizations  resection diversion was required in most colonic perforations  five of six patients  and devascularizations  four of six patients   there were five deaths  9    none due to intestinal injury  there were seven complications related to intestinal injury  diagnostic delay occurred in two patients  both had resultant morbidity  blunt intestinal injury is associated with physical findings in conscious patients  peritoneal lavage should be used when tenderness cannot be evaluated  timely operative intervention minimizes morbidity and hospital stay  
class6	the recalcitrant perineal wound after rectal extirpation  applications of muscle flap closure  perineal wounds developing after abdominoperineal resection result in chronic purulent drainage and intermittent episodes of sepsis and are generally unresponsive to conservative medical and surgical treatment  thirteen consecutive patients  aged 27 to 74 years  mean  48 years  who underwent debridement and immediate muscle flap closure of these wounds were analyzed to identify risk factors for delayed healing and to evaluate the effectiveness of muscle flap coverage  three risk factors were identified  preoperative or postoperative radiation therapy  resection for recurrent carcinoma  and inflammatory bowel disease  a total of 19 muscle flaps  11 gracilis  five gluteal thigh  two gluteus maximus  and one rectus abdominis  were used to close these wounds  during an average 3 5 year follow up  four  31   minor complications and one  8   recurrence were noted to occur  muscle flaps provide safe  effective  single stage procedures for the closure of chronic perineal wounds  
class6	fibrin glue inhibits intra abdominal adhesion formation  to determine the effect of fibrin glue on intra abdominal adhesion formation  45 rats were randomized to three groups  each animal received two adhesion models  group 1 received no further treatment  groups 2 and 3 had the adhesion models covered with fibrinogen from fresh frozen plasma  1 77 g l  and cryoprecipitate  23 6 g l   respectively  in group 1  13 of 15 rats had high grade adhesions in both models  in group 2  high grade adhesions were noted in nine of 15 rats in model 1 and in 12 of 15 rats in model 2  in group 3  however  high grade adhesions were seen in only three of 15 rats in model 1  with 11 rats having no adhesions  and in only two of 15 rats in model 2  histologic analysis suggested accelerated healing in group 3  we conclude that  1  fibrin glue inhibits intra abdominal adhesion formation in rats   2  the inhibitory action is dependent on the fibrinogen concentration of the fibrin glue  and  3  adhesions are reduced by fibrin glue regardless of whether the peritoneal defect is closed  
class6	reoperative surgery for the morbidly obese  a university experience  patients who undergo surgery for morbid obesity are often subjected to reoperation for a wide array of indications  to evaluate outcome following revisional procedures  we reviewed the records of 32 such patients treated at ucla between april 1986 and may 1989  twenty five women  78   and 7 men  22   with a mean age of 44 years underwent 76 reoperations  2 4 per patient  for complications of prior obesity surgery  indications for initial surgical revision consisted primarily of metabolic derangements  12 patients  and weight related problems  11 patients   in contrast  indications for the patients  final surgical procedure were commonly for bowel obstruction  41    intra abdominal sepsis  12    and gastrointestinal bleeding  6    following initial revision  23 patients  71 8   required further surgery for major complications and four patients died  12 5    while initial revisions are frequently indicated for metabolic problems  final reoperations are more frequently undertaken for urgent  life threatening complications  revisional procedures for morbid obesity should be carefully considered  and the potential for major complications and or death should be weighted heavily against proposed benefits  
class6	endocrine consequences of alcohol abuse  the recognized endocrine consequences of alcohol abuse are reviewed on an organ by organ basis  the organ systems for which the most information is available  liver  heart  brain  are presented first followed by those where the information base is less  
class6	t cell subsets  tc  th  ts  tsi  and il2 receptor bearing cells in peripheral blood of patients in the acute phase of alcoholic hepatitis  the present study was designed to evaluate the proportion of t cell subsets and il2 receptor positive cells in the peripheral blood of patients with acute alcoholic hepatitis  aah  using monoclonal antibodies to t cell antigens and tac in a double immunofluorescent technique  the results indicate that the percentage of the total t cells and the intensity of all the t cell antigens are significantly reduced and the percentage of t helper cells and the ratio between th ts cells are significantly increased in aah when compared to healthy controls  but  significant differences in values observed in this study were not found for the absolute number of these cells  these altered values returned to normal levels during convalescence  
class6	pharmacokinetics of propofol infusions in patients with cirrhosis  we have compared the pharmacokinetics of propofol as an infusion in 10 control and 10 patients with cirrhosis  anaesthesia was induced within 3 4 min during administration of an infusion of propofol 21 mg kg 1 h 1  after 5 min  the infusion was decreased in a stepwise manner to 12 mg kg 1 h 1 and subsequently 6 mg kg 1 h 1  the mean recovery time after discontinuation of the infusion was significantly longer in the cirrhotic group  however  when patients opened their eyes  blood concentrations of propofol were similar in both groups  1 micrograms ml 1   pharmacokinetic analysis was performed from the beginning of infusion to 8 h after termination  total body clearance was not reduced significantly in cirrhotic  1 56  sd 0 48  litre min 1  compared with control  1 75  0 32  litre min 1  patients  the volume of distribution at steady state was significantly greater in patients with cirrhosis than in control patients  202  82  litre vs 121  49  litre   however  this difference did not change terminal elimination half life  the pharmacokinetics of propofol given by infusion to maintain general anaesthesia were not affected markedly by moderate cirrhosis  
class6	pivoting larynx  an unusual clinical observation at laryngoscopy  rigid oesophagoscopy was planned in the investigation of a young patient with dysphagia  during laryngoscopy for tracheal intubation an unusual pivoting manoeuvre was required to see the vocal cords  although the initial diagnostic investigations were unhelpful  follow up directed at explaining the clinical observations led to an eventual diagnosis of anterior tubercles of c6  which explained the observation and accounted for the dysphagia  
class6	postoperative analgesic requirements in patients exposed to positive intraoperative suggestions  objective  to establish whether positive suggestions given to a patient under general anaesthesia reduce postoperative pain and analgesic requirements  design  prospective double blind randomised study  setting  operating theatre and gynaecology ward of a teaching hospital  patients  63 woman undergoing elective abdominal hysterectomy were randomised to be played either a tape of positive suggestions or a blank tape during the operation through a personal stereo system  interventions  three women were withdrawn from the study  anaesthesia was standardised for all of the women  postoperative analgesia was provided through a patient controlled analgesia system for the first 24 hours  pain scores were recorded every six hours  main outcome measures  morphine consumption over the first 24 hours after the operation  pain scores  results  mean morphine requirements were 51 0 mg  95  confidence interval 42 1 to 60 0 mg in the women played positive suggestions  and 65 7 mg  55 6 to 75 7 mg  in those played a blank tape  the point estimate  95  confidence interval  for the difference of means was 14 6 mg  22 4    1 9  2 9   to 27 3 mg  41 6    p   0 028   pain scores were similar in the two groups  conclusion  positive intraoperative suggestions seem to have a significant effect in reducing patients  morphine requirements in the early postoperative period  
class6	bile acids and the increased risk of colorectal tumours after truncal vagotomy  an association between colorectal cancer and previous peptic ulcer surgery is reported  in a prospective screening study  100 asymptomatic patients  80 men and 20 women  who had undergone truncal vagotomy at least 10 years previously were investigated by barium enema  colonoscopy and gallbladder ultrasonography  control data were obtained from forensic autopsy subjects  the incidence of neoplasms greater than or equal to 1 0 cm in the vagotomized group was 14 per cent  11 adenomas  3 carcinomas  and 3 per cent in controls  p   0 01   duodenal bile obtained at endoscopy from 21 vagotomized patients with normal gallbladders and from 21 control patients undergoing endoscopy was analysed by high performance liquid chromatography  the mean percentage of cholic  ca   chenodeoxycholic  cdca   deoxycholic  dca  and lithocholic  lca  acids in the bile of vagotomized patients was 32 3  45 6  20 7 and 1 4 per cent respectively compared with 45 3  36 2  17 9 and 0 7 per cent respectively in controls  the increased proportions of cdca and lca and decreased proportions of ca in the duodenal bile of vagotomized patients were significant  p less than 0 001  p   0 02  p   0 007   abnormalities in bile acid metabolism may help to explain the increased risk of colorectal neoplasia 10 years after truncal vagotomy  
class6	urinary tissue factor activity in colorectal disease  procoagulant activity  pca  in normal urine has been recognized for over 50 years  although tissue factor  tf  is produced by certain tumours  and is increased in both tumour associated macrophages and blood monocytes  the possibility that it might also be increased in urine has not been studied in patients with cancer  we have measured urinary pca in hospital controls without inflammatory or neoplastic disease  n   79   in patients with rheumatoid arthritis  n   8   inflammatory bowel disease  n   19   colorectal cancer  n   70  and in patients undergoing colonoscopy  n   50   urinary pca was higher  p less than 0 001  in patients with colorectal cancer and inflammatory bowel disease than controls or patients with rheumatoid arthritis  fourteen  88 per cent  out of 16 colonoscopy patients subsequently found to have carcinoma or inflammatory bowel disease had levels above the control upper quartile  compared with 8  24 per cent  out of 34 with normal colonoscopy  p less than 0 001   tf inhibitors confirmed the nature of the pca and western blotting studies indicated a urinary tf molecular weight of approximately 38 000  these studies provide further evidence of abnormal haemostasis in malignancy and suggest that determination of urinary tf may provide a useful screening test in patients undergoing colonoscopy  
class6	malignant left sided large bowel obstruction managed by subtotal total colectomy  of 60 patients presenting with acute obstructing carcinoma of the left colon  49 underwent immediate resection either by radical subtotal total colectomy  31 patients  group i  or by radical segmental resection  18 patients  group ii  of whom three had immediate anastomosis after on table bowel irrigation and 15 had a planned staged procedure  the operative mortality rate was 3 per cent in group i and 11 per cent in group ii  not a statistically significant difference   however  substantial differences were found for major morbidity  6 versus 44 per cent in groups i and ii respectively  p less than 0 01  and mean length of hospital stay  17 days in group i versus 35 days in group ii  p less than 0 05   all three patients who had on table lavage developed anastomotic leaks which necessitated a second operation to form a stoma  six patients  19 per cent  in group i required antidiarrhoeal medication in the immediate postoperative period  however  subsequent improvement in stool frequency was noted in all patients  it is concluded that subtotal total colectomy is an acceptable means of managing patients with obstructing carcinoma of the left colon in that it is associated with a low morbidity and mortality rate and good functional results  
class6	blood transfusion and recurrence of colorectal cancer  the role of platelet derived growth factors  efforts to explain the possible effects of blood transfusion on the recurrence of colorectal cancer have been based entirely on the immunosuppressive effects of blood transfusion  however  the relationship between solid tumour development and the immune system is inconclusive  we have investigated an alternative mechanism involving the potential role of growth factors in this phenomenon  using a human fibroblast   125i deoxyuridine uptake mitogenesis assay  the relative amounts of growth factor in the plasma of stored blood were measured  there was a progressive increase in mitogenesis from day 0  n   6  to day 28  n   6  p less than 0 001  mann whitney u test   the effect of growth factors on the development of liver and intraperitoneal metastases was studied in hooded lister rats  following an intraportal injection of 10 5  mc28 tumour cells  the experimental group  n   25  received 2 ml of syngeneic serum intravenously for 4 days  likewise  colonic anastomoses were performed on omentectomized rats and the peritoneal cavity seeded with 10 3  cells  the experimental groups  n   20  received either 2 ml serum intravenously repeatedly or 3 ml serum intraperitoneally  n   19   there was no significant increase in liver metastases or peritoneal disease following intravenous infusion of serum but serum delivered intraperitoneally resulted in a significant increase in tumour from 22 per cent in the controls to 89 per cent in the study group  p less than 0 01   growth factors released from platelets following blood loss into the peritoneal cavity may be important in enhancing local recurrence of colorectal cancer  
class6	experimental study of starch induced intraperitoneal adhesions the effects of starch on the development of postoperative adhesions were examined in 144 sprague dawley rats  groups of rats were injected intraperitoneally with suspensions of washings from starched gloves  starch free gloves and starch poor washed gloves  and after operative manipulation of the bowel  the incidence of adhesions was greatest  78 per cent  after laparotomy and injections of starch rich washings and least when starch poor  33 per cent  or starch free glove suspensions  37 per cent  were used  confirming an advantage for washing gloves or switching to starch free products  
class6	on table pancreatography  importance in planning operative strategy  we describe our experience with 124 on table pancreatograms performed during 117 operative procedures on 112 patients in a wide variety of clinical settings  endoscopic retrograde cholangiopancreatography  ercp  was performed on 84 occasions with a 73 per cent success rate for visualization of the main pancreatic duct  on table pancreatography  otp  was performed by one of five different techniques  retrograde  prograde or ambigrade ductography  cystography and ascending loopography after pancreaticojejunostomy  otp provided important information about the main pancreatic duct when endoscopic visualization was unsuccessful  n   23   incomplete  n   17  or not performed  n   33   there was a failure rate of 4 per cent  in 35 patients either the additional information or discrepancies between ercp and otp findings resulted in a change of operative plan  19 extra procedures  16 altered procedures   complete ductography was especially helpful in the 63 patients with chronic pancreatitis  otp is technically simple  free from complications and invaluable for planning operative strategy  
class6	laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia  forty patients with widely disseminated or locally advanced malignant obstruction of the middle or lower third of the oesophagus underwent endoscopic treatment by either ndyag laser recanalization or intubation  groups were matched on the basis of tumour location and swallowing was graded clinically before and after treatment  technical success was achieved in 17 of 20 laser treated and 18 of 20 intubated patients  pretreatment swallowing ability  histology  tumour location and overall length were unrelated to functional outcome in both groups  however  circumferential tumour length identified endoscopically strongly influenced the quality of swallowing after laser recanalization  patients with excellent swallowing quality  n   7  had significantly shorter circumferential tumour lengths  3 1 1 0  cm  than those with poorer quality swallowing  n   10   6 3 1 6 cm   p less than 0 001   both methods of treatment had low complication rates and there was one death in the series in the laser treated group  laser recanalization provides a better functional result than intubation for short  less than 4 cm  circumferential tumour  intubation at a single session seems more appropriate than repeated laser therapy when tumour length exceeds 4 cm  
class6	aetiology of pancreatic cancer curative surgery is possible in only a small minority of patients with pancreatic cancer and  to date  responses to chemotherapy and radiotherapy have been disappointing  to make any impact on the incidence of the disease a clearer understanding of its aetiology is required  this review explores present knowledge of the aetiology and epidemiology of pancreatic cancer  
class6	abdominal wall pain  an alternative diagnosis  the cause of abdominal pain need not necessarily reside in the viscera  the abdominal wall is another source of symptoms  some causes of abdominal wall pain are obvious  e g  hernias  but not so others such as nerve entrapment syndromes  this review is concerned with causes of abdominal wall pain which  although common  may be easily overlooked  
class6	toxicity of high dose cytosine arabinoside in the treatment of advanced childhood tumors resistant to conventional therapy  a pediatric oncology group study  experience with high dose cytosine arabinoside  hdac  in pediatric solid tumors is limited  sixteen children with solid tumors resistant to conventional therapies were registered in a pilot pediatric oncology group  pog  study that required the administration of hdac at 3 g m2 every 12 hours for four doses  there were four cases of rhabdomyosarcoma  two cases of fibrosarcoma  four cases of neuroblastoma  and one case each of germ cell tumor  wilm s tumor  retinoblastoma  hepatocellular carcinoma  ewing s sarcoma  and burkitt s lymphoma  all eligible patients had advanced diseases and had previously received extensive chemotherapy  thirteen patients received one course of hdac and three patients received two courses of hdac  due to prior treatments  patients had less than normal marrow reserves  short term toxicity included nausea  vomiting  suppression of hemopoiesis  drug fever  and increased blood urea nitrogen  bun   creatinine  and liver enzymes  all evaluable patients recovered from their toxicities  there were no drug related deaths  none of the patients had neurologic problems  including the only patient with prior irradiation to the skull  with the above schedule  hdac appears to have manageable toxicity  
class6	effectiveness of periodic checkup by ultrasonography for the early diagnosis of hepatocellular carcinoma  periodic checkup by ultrasonography was conducted on patients with chronic liver diseases for early detection of hepatocellular carcinoma  in 19 months  a total of 2004 examinations were performed on a total of 660 cases  179 cases with liver cirrhosis in the compensatory stage  younger than 70 years  481 cases with chronic hepatitis  aged 40 to 70 years for men and 50 to 70 years for women   of the 660 cases  22 hcc cases  3 3   were detected and finally diagnosed by angiography and or histologic examination  four of those cases  18   had a single nodule smaller than 1 cm in diameter  and 11 cases  50   had a single nodule smaller than 2 cm  surgical resection was performed on 12 cases  55    in comparison with the control group  83 hcc cases not receiving any periodic checkup   the frequency of small liver cancer and the surgical resection rate in the study group were significantly higher  this examination system by periodic ultrasonography checkup of patients with chronic hepatic diseases was effective for early detection and permitted aggressive therapy of hepatocellular carcinoma  
class6	parathyroid hormone like peptide in normal and neoplastic mesothelial cells  mesothelioma has not been commonly reported as a cause of hypercalcemia of malignancy  we have studied a patient with malignant mesothelioma and hypercalcemia in association with elevated plasma concentrations of parathyroid hormone like peptide  plp   immunohistochemical analysis of the tumor and seven of eight other mesotheliomas that were not associated with hypercalcemia revealed the presence of plp cytoplasmic immunopositivity  plp immunopositivity was also detected in normal and reactive mesothelial cells  the results of these studies suggest that plp immunoreactivity is common in normal and neoplastic mesothelial cells and raises the possibility that plp production may play a role in the pathogenesis of hypercalcemia associated with mesothelioma  
class6	glomerular iga deposits in patients with celiac disease  glomerular immunopathology was studied in 25 patients with newly diagnosed celiac disease  none had clinical signs of renal disease  glomeruli were obtained by fine needle aspiration biopsy  the specimens were processed and studied by indirect immunofluorescence for immunoglobulins and complement  mesangial iga was found in 8 of the patients  it occurred occasionally together with slight igg or igm  but c3 was not seen in these patients  iga class circulating immune complexes  cic   antireticulin antibodies  ara   antigliadin antibodies  aga   and rheumatoid factor  rf  occurred significantly more often in the patients with mesangial iga than in the 17 patients having no mesangial iga  the patients with mesangial iga also had significantly higher mean levels of serum iga  iga ara and iga aga than those without  the results suggest that glomerular mesangial deposits of iga occur frequently in untreated celiac disease and that they are in some way associated with circulating iga class antibodies and immune complexes  in this situation iga seems to be deposited without being able to induce clinically overt glomerulonephritis  a circumstance that may be related to the lack of complement in the deposits  
class6	acute deterioration of renal function associated with enteric hyperoxaluria  enteric hyperoxaluria due to malabsorption syndromes has been well documented to cause renal calculi and chronic tubulointerstitial renal damage  rarely  in the setting of intestinal bypass operations for morbid obesity  enteric hyperoxaluria has produced acute renal failure  we report two patients who suffered acute deterioration of renal function associated with increased intestinal absorption and renal excretion of oxalate associated with steatorrhea  one patient had a large portion of his small bowel resected many years prior to the onset of the renal failure and the second patient had chronic pancreatitis causing steatorrhea  both patients had renal biopsy documentation of the acute nature of the tubular damage produced by oxalate deposition  the mechanisms of their deterioration of renal function may relate to sudden increases in steatorrhea in association with episodes of volume depletion  enteric hyperoxaluria may be an easily overlooked and potentially preventable etiology of acute renal dysfunction  
class6	computed tomography in patients with esophageal perforation  contrast esophagram is the diagnostic procedure of choice in patients with clinically suspected perforation of the esophagus  in patients in whom the usual clinical signs or symptoms are unrecognized and in whom the diagnosis is obscure  the diagnosis of a perforated esophagus may be suggested by the finding of mediastinal fluid and air on ct  three patients are reviewed  the perforations included one spontaneous  one from erosion of an esophageal carcinoma  and one iatrogenic  in two of the three patients  the diagnosis of perforated esophagus had not been made initially and in one patient the initial esophagram was interpreted as normal  computed tomography of the chest in each patient led to the suspected diagnosis of perforated esophagus  prompt appropriate surgical intervention followed  the findings of mediastinal fluid and more importantly mediastinal air on ct of the chest are strongly suggestive of esophageal perforation  
class6	systemic hemodynamic and cardiac function changes in patients undergoing orthotopic liver transplantation  the objective of this study was to determine the changes in systemic hemodynamics  systemic vascular resistance  svr   cardiac output  co   systemic blood pressure  sbp   and cardiac function  pulmonary artery pressure  pap  and pulmonary wedge pressure  pwp   during the 96 hours following orthotopic liver transplantation  olt  and correlate these with changes in hepatic and renal function and patient outcome  the study took place in a 12 bed medical respiratory intensive care unit in a large teaching hospital  twenty one patients had olt performed over a 21 5 month period  january 1988 to october 15  1989  for end stage liver disease  esld  from a variety of causes  a flow directed right heart catheter and an indwelling arterial cannula were inserted for hemodynamic monitoring over a 96 hour postoperative period  liver and renal function studies  total serum calcium  serum albumin  and fluid balance were determined daily  the svr increased significantly to 12 8     0 6 u at 48 hours compared with immediate  less than 8 hours  postoperative levels  p less than 0 05  and remained elevated for 96 hours  the co fell progressively and was significantly lower than baseline values from 64 to 96 hours  there was significant inverse correlation between the increase in svr and the fall in co  r    85  p less than 0 01   the sbp was stable except for a small  but significant fall at 16 and 24 hours postoperatively  the pwp increased significantly from a baseline value of 12 5     0 9 mm hg to 15     0 9 mm hg at 32 hours and remained elevated through 96 hours  p less than 0 05   the serum bilirubin level fell progressively postoperatively and the prothrombin time and partial thromboplastin time  ptt  shortened significantly  bile flow increased progressively from 107     120 ml 24 hours at the end of the first 24 hours to 188     125 ml 24 hours by 96 hours postoperatively  five patients died from nine to 43 days postoperatively  these patients  hemodynamic parameters were not significantly different from the patients who survived  successful olt is associated with a rapid increase in svr and a fall in co without changes in sbp  these findings tend to parallel the improvement found in results of liver function tests  however  there is no correlation between the improvement in the hemodynamic state and long term survival  
class6	colonoscopic screening of asymptomatic patients with a family history of colon cancer  the records of 201 asymptomatic patients who underwent colonoscopy based solely on a family history of colon cancer were reviewed  eighty five patients  42 percent  had a total of 166 lesions  fifty four  27 percent  patients of the screened population had neoplastic lesions  while 31  15 percent  patients had nonneoplastic polyps  four carcinomas were found  twenty five of the patients with polyps  29 percent  had no polyps distal to the splenic flexure  these proximal polyps  and two carcinomas  would have been missed on screening with fiberoptic sigmoidoscopy  nineteen of these 25 patients had polyps smaller than 0 5 cm  which likely would have been missed with contrast enemas  almost one half  47 percent  of all polyps discovered at screening colonoscopy were proximal to the descending colon  only one patient younger than 40 years old had adenomas  the yield of polyps and cancer in patients with familial risk indicates screening colonoscopy should be considered after age 40  
class6	perirectal abscess in crohn s disease  drainage and outcome  the role of surgical intervention in the treatment of patients with anorectal crohn s disease is controversial  to clarify the success of aggressive drainage and the subsequent clinical course of patients with crohn s disease and perirectal abscesses  the authors reviewed the records of 38 patients who presented with this condition during an eight year period  twenty two male and 16 female patients  median age  32 years  range  17 to 61 years  with clinically or pathologically confirmed crohn s disease of the bowel underwent operation for perirectal abscesses  thirty two percent of patients had no previous history of anorectal crohn s disease  thirty simple abscesses and 8 complex horseshoe abscesses were treated  at operation  53 percent of patients underwent incision and drainage whereas 26 percent received loop indwelling drains and 21 percent had mushroom catheters placed  after resolution of the index abscess  recurrent abscesses occurred in 45 percent of the patients who underwent catheter drainage and 56 percent of the patients who underwent incision and drainage  more importantly  44 percent of the incision and drainage group and only 31 percent of the catheter drainage group required subsequent proctectomy to control perineal sepsis  the healing time of the perineal wound was longer than six months in 83 percent of patients requiring rectal excision  we concluded that long term catheter drainage may offer substantial benefit in the overall outcome of the treatment of patients with crohn s disease and perirectal abscess  
class6	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  
class6	accumulation and pepsin solubility of collagens in the bowel of patients with crohn s disease  the collagen content of resected strictured intestine  with and without fistulas  from patients with crohn s disease has been compared with that in macroscopically normal intestine removed from the same patients and from others without inflammatory bowel disease  collagen content per unit wet or dry weight of tissue was significantly increased in all grossly diseased tissue whether fistulated or not  although there was a significant increase in collagen types i  iii  and v in diseased tissue  the relative proportions of major collagen types extracted by limited pepsin digestion were similar for both crohn s and non crohn s intestine  type i  65 to 70 percent  type iii  25 to 30 percent  type iv  2 to 3 percent  and type v  2 5 to 3 percent   cnbr digestion of pepsin insoluble material showed a similar relative abundance of types i and iii  indicating no major change in collagen type distribution between older  insoluble  and more newly synthesized collagen  there was no evidence of the presence of type i trimer collagen  type vi collagen  although not quantitated  was observed in 70 percent of intestinal specimens  the proportion of total collagen solubilized by pepsin treatment was significantly greater in both grossly diseased and macroscopically normal crohn s bowel compared with non inflammatory bowel disease bowel  these findings suggest that there are disturbances of collagen metabolism in crohn s intestine  which account for the stricturing process and which may predate gross pathologic changes  
class6	endometrioma  an intra abdominal troublemaker  a ten year review of intestinal and abdominal wall endometriomas is reported  seven cases of intestinal and two cases of abdominal wall endometriomas are presented  symptoms were varied but a majority had some gynecologic complaint  in this select group of patients  preoperative investigations did not assist in establishing the diagnosis  all patients underwent surgery and coexisting inflammatory bowel disease was present in two patients  this review suggests that endometrioma of the intestine requires a high index of suspicion for diagnosis and that danazol does not appear to be effective treatment for these patients  
class6	enteroglucagon and peptide y y response after construction of a pelvic reservoir in humans  the results of an investigation of plasma levels of gastrointestinal hormones in patients after the construction of a pelvic reservoir are reported  enteroglucagon  eg  and peptide tyrosine tyrosine  pyy   two hormones believed to play a relevant role in the adaptive response to bowel resection  were investigated using a specific radioimmunoassay in basal conditions and after a standard meal  pouch patients showed a statistically significant increase in basal levels of both enteroglucagon and pyy compared with control subjects  p less than 0 02 and p less than 0 001  respectively   the response of enteroglucagon to food ingestion  evaluated by means of the total integrated response  was similar in patients and controls  conversely  the response of pyy was significantly increased in pouch patients compared with control cases  p less than 0 02   results of this investigation suggest that gut hormones may be involved in mediating the adaptive response of the intestine to pouch construction  changes of gut peptides may explain  at least in part  the functional results observed after pouch construction  
class6	malignant potential of juvenile polyposis coli  report of a case and review of the literature  juvenile polyps of the colon and rectum traditionally have been viewed as being benign inflammatory or harmartomatous lesions without potential for malignant change  the authors report a case of adenocarcinoma developing in a patient with sporadic juvenile polyposis  juvenile polyposis was diagnosed in the patient at age 4 years  he underwent subtotal colectomy at age 6 years  at age 12  he underwent a proctectomy and a swenson pull through because of adenomatous changes in the rectal stump  at age 19 surveillance endoscopy revealed invasive cancer in a juvenile polyp  
class6	yersinia enterocolitica abscess of the transverse colon  report of a case  yersinia enterocolitica abscess of the bowel is a rare entity  only five cases have previously been reported  none in the surgical literature  a unique presentation for yersinia infection  abscess of the transverse colon  is described  and the literature of y  enterocolitica intestinal perforation and abscess is reviewed  
class6	ileocolic nipple valve anastomosis for preventing recurrence of surgically treated crohn s disease  long term follow up of six patients  to prevent coloileal reflux after ileocecal resection  an ileocolic nipple valve anastomosis was constructed in six patients with crohn s disease  the patients were observed for more than 7 years and were compared with 21 crohn patients in whom conventional end to end ileocolic anastomosis was performed during the same period  the outcome was more favorable in the group with nipple valve anastomosis  i e   longer interval between surgery and symptomatic relapse  and tendency to less frequent recurrence and re resection  an association was found between radiologically preserved nipple valve and remission  and two patients with intact valve at long term follow up remained symptom free  the observations implied that protection of the terminal ileum from coloileal reflux after ileocecal resection for crohn s disease may favorably influence the prognosis  
class6	plasma neurotransmitters and cortisol in duodenal ulcer patients  role of stress  levels of noradrenaline  adrenaline  dopamine  free serotonin  platelet serotonin  and cortisol were measured in the plasma of duodenal ulcer patients and controls  all subjects received antacids  and these substances were also measured  during relapse  all patients showed raised noradrenaline  adrenaline  dopamine  free serotonin  and cortisol values  in contrast  platelet serotonin showed very low values  which correlated negatively with all the former  except free serotonin  no correlations were found in parameters of the controls  after healing  significant reductions of noradrenaline  adrenaline  dopamine  free serotonin  and cortisol and significant increases of platelet serotonin values were observed  however  only dopamine  free serotonin  and cortisol reached normal values  noradrenaline and adrenaline remained higher and platelet serotonin lower  both significantly more so than normals  these still altered parameters showed similar correlations to those found during relapses  the present results demonstrate that some baseline autonomic system imbalance exists in patients  amplified and accentuated during relapse  we discuss the possibility that stress plays some role in triggering duodenal ulcer relapse  
class6	putative mechanisms of cytoprotective effect of certain antacids and sucralfate  an investigation of cytoprotective activity of certain antacids and inert particles was carried out by treating ethanol induced gastric mucosal damage in rats in order to clarify possible mechanisms by which aluminum containing antacids act  al oh 3 inhibited gastric mucosal damage in a dose related and time dependent manner  neither aluminum ions themselves nor the particle size of the al oh 3 complex were responsible for the observed cytoprotection  since neither alcl3  chemically inert al2o3 c  nor sea sand showed protective effects  hyperosmolality in the gastric lumen was not a deciding factor in inducing cytoprotection  silicic acid and titanium dioxide  with superficial charge similar to al oh 3 proved to be effective in inhibiting gastric hemorrhagic lesions and releasing pge2  suggesting that the surface charge of al oh 3 may be important in its cytoprotective properties  the same may also be valid for sucralfate  since antacid induced cytoprotection was only partly reduced by pretreatment with indomethacin  it is likely that additional mechanisms and mediators other than prostaglandins  such as nonprotein sulfhydryls  also are involved in gastric cytoprotection arising from aluminum containing antacids  
class6	gastric contents retained in rat stomach following mild irritant exposure contribute to adaptive cytoprotection  fluid retained in the gastric lumen immediately preceding the administration of a damaging product will dilute that product and decrease its injurious capacity  in an attempt to explain the phenomenon of adaptive cytoprotection  we studied the effect of mild irritant exposure on the volume of fluid retained in the gastric lumen  rats treated with 0 2 n 0 4 n hcl had a larger volume of gastric fluid retained as compared to animals treated with 0 4 n nacl  additionally  a mixture of gastric juice derived from rats exposed to 0 4 n hcl with 2 ml ethanol was significantly less damaging to the gastric mucosa than a similar mixture containing an equal volume of gastric juice derived from 0 4 n nacl exposed rats  we conclude from our observations that in mild irritant exposed stomachs  the gastric juice is a main contributor to the protection against ethanol injury  
class6	modulatory action of adenosine on gastric function and ethanol induced mucosal damage in rats  this study examines the gastric effects of adenosine and its antagonist  theophylline  on secretory function  mucosal blood flow  and on ethanol induced glandular mucosal damage in rats that were fasted for 24 hr before experimentation  the animals were anesthetized with sodium pentobarbitone  50 mg kg intraperitoneal  and their tracheae cannulated  an ex vivo stomach chamber then was prepared  the luminal bathing solution was collected every 15 min and the concentrations of h  and na  were determined by a ph autotitrator and an ionmeter  respectively  the glandular mucosal blood flow was measured by a laser doppler flowmeter and the severity of lesions was determined by measuring the hemorrhagic areas  adenosine administration  2 5 or 7 5 mg kg  subcutaneous  markedly lowered the h  and na  output but increased the secretory volume and mucosal blood flow in a dose dependent manner  the same doses of the nucleoside also prevented ethanol induced mucosal damage  these effects were prevented by pretreatment with theophylline  30 or 60 mg kg  subcutaneous   ethanol given alone significantly depressed the h  and na  secretion  both effects were not modified by adenosine treatment  however  the depressive action of ethanol on mucosal blood flow was prevented by adenosine  these findings indicate that adenosine modulates the physiological function of the stomach  it also directly activates the defensive mechanism of the stomach  which is partially mediated by the improvement of the gastric mucosal blood flow and an increase in the nonacid component of gastric secretion  
class6	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  
class6	improved scintigraphic assessment of severe cholestasis with the hepatic extraction fraction  in previous studies  we found that biliary scintigraphy with technetium 99m labeled iminodiacetic acid   99mtc ida  provided excellent discrimination between intrahepatic and extrahepatic cholestasis  except in patients with profound cholestasis who had poor visualization of the biliary tree  in this study  we have used deconvolution analysis to determine the hepatic extraction fraction  hef  of a hypothetical single circulatory pass of  99mtc ida  our hypothesis was that extraction of radionuclide from the blood would be normal in patients with extrahepatic obstruction alone  but would be impaired in patients with intrahepatic disease  ihd   the purpose of this study was to compare the hef in patients with profound cholestasis  bilirubin greater than or equal to 3 0 mg dl  due to either ihd or common bile duct obstruction  cbdo   normal subjects  n   13  had an hef of 100   patients with cbdo  n   13  had slightly reduced hef values  92 8     3 2   despite profound hyperbilirubinemia  6 1     1 0 mg dl   patients with ihd  n   23  had a markedly reduced hef  43 1     4 1   which was significantly lower than patients with cbdo and normal subjects  p less than 0 001   we conclude that the determination of the hef during biliary scintigraphy is helpful in distinguishing between intrahepatic and extrahepatic disease in patients with hyperbilirubinemia  bilirubin greater than or equal to 3 0 mg dl   
class6	effect of race upon organ donation and recipient survival in liver transplantation  the effect of the race of the donor on organ donation and on the outcome of clinical liver transplantation has not been addressed previously  the aims of this study were to determine   1  the number of organs donated by each of the major racial groups of the united states   2  the outcome of transplantation of these organs across racial groups  and  3  the pattern of liver disease that required transplantation in each of these racial groups  a significantly higher proportion of organs were donated by white non hispanic americans than either black or hispanic americans  there was no significant difference in survival when an organ was transplanted between black and white americans and vice versa  postnecrotic cirrhosis from a variety of causes was the most common indicator affecting black and white recipients  while primary biliary cirrhosis and primary sclerosing cholangitis were uncommon in the black population  while the number of organs donated by blacks was low  it was  however  proportional to the number of black recipients in this study  reasons for the low rate of donation by the black and white hispanic population are discussed  it is concluded that race is not a criteria to be used in selection of donors for liver transplantation  educational programs addressing issues of organ donation and transplantation directed towards the black and hispanic populations are recommended  
class6	cirrhosis of the liver  a risk factor for development of cholelithiasis in males  an ultrasonographic study about the prevalence of cholelithiasis was performed in 410 cirrhotic patients and in 414 controls matched for age and sex  gallstone disease was found more often in cirrhotic patients  31 9   than in controls  20 7    p less than 0 001   the female to male ratio of gallstones prevalence in cirrhotic patients approached to 1 1  gallstone disease in cirrhotic patients vs controls was significantly higher  30 2  vs 16 5    p less than 0 001  in males only  no difference was found  for gallstone disease prevalence in cirrhosis of different etiology  the prevalence of cholelithiasis increased from child s a to child s c with a significant trend  p less than 0 001   this difference was significant in males  12 3  vs 40 5    p less than 0 001  but not in females  this study shows that cirrhosis represents a risk factor for the development of cholelithiasis in males  we suggest that high levels of estrogens could play a role in these patients  by an impairment of gallbladder emptying similar to that observed in pregnant women  
class6	corticosteroid treatment reduces mast cell numbers in inflammatory bowel disease  mast cell degranulation in the gut causes mucus secretion  mucosal edema  and increased gut permeability and may be responsible for some of the symptoms and signs of inflammatory bowel disease  we have used a novel monoclonal antibody  aai  against tryptase expressed exclusively in the granules of mast cells to enumerate mast cells in rectal biopsies in order to study the effect of inflammatory bowel disease and drug treatment upon rectal mast cell numbers  rectal mast cell numbers are significantly reduced in inflammatory bowel disease patients taking corticosteroids  mean 4 95 cells mm2  when compared with control patients  10 1  p less than 0 001  and inflammatory bowel disease patients not taking corticosteroids  9 7  p less than 0 001 wilcoxon rank sum test   the reduction in mast cell counts was independent of the degree of inflammation or architectural distortion  there was a negative correlation between the dose of corticosteroids and mast cell count  r   0 53  p less than 0 05 spearman rank correlation   and the mast cell count was reduced within a few days of treatment and remained low throughout steroid therapy  mucosal mast cell depletion may be an important mechanism of action of corticosteroids in inflammatory bowel disease  
class6	small bowel phytobezoar mimicking presentation of crohn s disease  a case of small bowel phytobezoar formed from unusual ingested vegetation is described  the patient presented with recurrent subacute obstruction and a right iliac fossa mass mimicking the presentation of crohn s disease  none of the usual gastrointestinal disorders that predispose to bezoar formation were present  the phytobezoar passed spontaneously following small bowel enema and colonoscopy  it is possible that relaxation of the gut secondary to the antispasmodics administered at investigation or the physical disturbance during these procedures enabled migration through the ileocecal valve  antispasmodics may be of use in the conservative management of bezoars obstructing otherwise normal bowel  
class6	pancreatitis  pancreatitis is a common but rather poorly understood entity most often associated with alcohol abuse or biliary tract disease  despite the availability of a variety of diagnostic tests and imaging techniques  the diagnosis of pancreatitis continues to be primarily a clinical one  of major concern to the emergency physician is distinguishing pancreatitis from other  potentially lethal  causes of abdominal pain  and identifying those patients with severe pancreatitis who are at risk for a complicated course secondary to the remote systemic effects of the disease  
class6	alcoholic liver disease  alcoholic liver disease presents a wide spectrum of clinical manifestations ranging from mild asymptomatic fatty liver to alcoholic hepatitis and severe life threatening liver failure with ascites  hemorrhaging esophageal varices  and encephalopathy  although still poorly understood  the mechanism of this injury is probably the result of numerous direct toxic and metabolic effects of alcohol on the hepatocyte  therapy consists primarily of abstinence and supportive care  however  several newer treatments are actively being studied  these include prednisolone  anabolic steroids  glucagon and insulin  propylthiouracil  and cyanidanol  colchicine is promising as an agent to inhibit fibrosis  complications of cirrhosis  including ascites and variceal hemorrhage  are the result of end stage disease  a return to old techniques of ascitic fluid management suggests that therapeutic large volume paracentesis with albumin infusion is a safe and effective form of therapy  variceal hemorrhage is best treated with sclerotherapy  vasoconstrictors  and balloon tamponade  little has been done to alter the ultimately dismal prognosis and long term survival of alcoholic liver disease  
class6	natural history of congestive gastropathy in cirrhosis  the liver study group of v  cervello hospital  in a prospective study of the natural history of congestive gastropathy  212 consecutive cirrhotic patients  75 treated with sclerotherapy  were included  mean follow up was 46 months  mild gastropathy  mosaiclike pattern  was found in 110 patients and severe gastropathy  granular mucosa with cherry spots  was found in 20  prevalence of helicobacter pylori  formerly campylobacter pylori  was 50  in patients without  43  in those with mild  and 28  in those with severe gastropathy  congestive gastropathy was significantly more frequent in patients treated with sclerotherapy  83  vs  50   p less than 10  5    sixty month actuarial proportions of patients free of anemia  in the absence of hematemesis or melena   were 17  with severe  62  with mild  and 93  without gastropathy  p less than 10  8   corresponding figures for overt bleeding were 25   73   and 87   p less than 10  7   whereas those for survival were 46   72   and 85   p   0 0005   respectively  a multivariate regression analysis supported the following conclusions   a  sclerotherapy and the presence of large esophageal varices significantly increase the risk of congestive gastropathy  which  b  is a significant risk indicator of both chronic and overt bleeding but does not independently affect survival  
class6	24 hour intragastric acidity and plasma gastrin after omeprazole treatment and after proximal gastric vagotomy in duodenal ulcer patients the relationship between suppressed gastric acidity and the increase in plasma gastrin levels after pharmacological and surgical treatment of peptic ulcer disease were compared in this study  eight patients with chronic duodenal ulcer and referred for proximal gastric vagotomy were studied  24 hour intragastric acidity and plasma gastrin levels were investigated in the same patients on three consecutive occasions  preentry without any treatment  after 4 weeks of administration of 20 mg of omeprazole daily  and 4 6 months after proximal gastric vagotomy  intragastric acidity was slightly more reduced by omeprazole  94   than after proximal gastric vagotomy  78    with no difference found during the day or night with either  plasma gastrin levels increased slightly more after proximal gastric vagotomy  284   median  2120 pmol h l  range  733 2831 pmol h l   than after omeprazole administration  186   median  1586 pmol h l  range  495 2573 pmol h l    there is strong evidence that the increased plasma gastrin concentration following omeprazole treatment is caused by the reduced intragastric acidity  the slight increase in plasma gastrin concentration following proximal gastric vagotomy despite a lesser reduction in intragastric acidity may be the result of additional effects on gastrin release by the vagotomy  both treatments resulted in a modest increase in plasma levels of gastrin that were far below the gastrin levels observed in achlorhydric patients  e g   patients with pernicious anemia  
class6	role of epidermal growth factor  prostaglandin  and sulfhydryls in stress induced gastric lesions  epidermal growth factor promotes the growth of and protects gastric mucosa against various ulcerogens  including stress  but little is known about its role in the pathogenesis of stress ulcerations  in this study  wistar rats with intact and resected salivary glands were exposed to water immersion and restraint stress  during 2 14 hours of water immersion restraint stress  the formation of gastric ulcerations increased progressively and the duration of stress was accompanied by a decrease in dna synthesis in the gastric mucosa  following sialoadenectomy  a significant increase in the number of stress ulcerations and further reduction in dna synthesis were observed  exogenous epidermal growth factor and dimethyl prostaglandin e2 significantly reduced the ulcerations in the stressed rats with intact salivary glands  but this reduction was significantly less pronounced after sialoadenectomy  water immersion restraint stress also resulted in about 50  reduction in mucosal prostaglandin e2 generation  and the pretreatment with indomethacin  which suppressed prostaglandin e2 by about 90   almost doubled the number of stress ulcerations and abolished the gastro protective effect of exogenous epidermal growth factor  but not dimethyl prostaglandin e2  against the stress lesions  an inhibition of ornithine decarboxylase activity by difluoromethyl ornithine also augmented stress induced ulcerogenesis and abolished the protective action of epidermal growth factor while the administration of spermine almost completely prevented stress ulcerations in rats both without and with pretreatment with difluoromethylornithine  water immersion restraint stress also significantly reduced mucosal content of glutathione  cysteamine increased tissue glutathione and reduced stress ulcerations but n ethylmaleimide  an sulfhydryl blocker  decreased mucosal content of glutathione without affecting the stress ulcerations  this study indicates that the stress ulcers are accompanied by the reduction in mucosal synthesis of dna  prostaglandin  and glutathione and that the presence of salivary glands attenuates the stress ulcerogenesis probably by releasing epidermal growth factor which acts  in part  by enhancing ornithine decarboxylase activity  mucosal growth  and prostaglandin and glutathione formation  
class6	acute and chronic stress in duodenal ulcer disease  acute and chronic life event stressors were objectively assessed in a sample of duodenal ulcer patients and community controls  stress was assessed on two dimensions   personal threat  and  goal frustration   chronic stressors  those of 6 months  duration or more  involving high goal frustration were significantly and independently associated with the onset and relapse of duodenal ulcers  as were acute events of high immediate but transient personal threat  
class6	role of visceral afferent mechanisms in functional bowel disorders  this report analyzes the clinical and physiological evidence supporting a role for altered visceral afferent mechanisms in the pathogenesis of two functional bowel syndromes  noncardiac chest pain and the irritable bowel syndrome  considerable recent evidence indicates that increased contractility is present only in a minority of patients and that hypercontractile episodes are not temporally related to abdominal pain  in contrast  altered sensation and motor reflexes in response to physiological stimuli  such as mechanical distention or acid  is common when appropriately investigated  the vagal and spinal afferent innervation mediates visceral sensation and is involved in multiple reflex loops regulating gastrointestinal effector function  such as motility and secretion  sensory input can be modulated peripherally at the afferent nerve terminal  at the level of prevertebral ganglia  the spinal cord  and the brainstem  an up regulation of afferent mechanisms would result both in altered conscious perception of physiological stimuli and in altered motor reflexes  current evidence is consistent with an alteration in the peripheral functioning of visceral afferents and or in the central processing of afferent information in the etiology of altered somatovisceral sensation and motor function observed in patients with functional bowel disease  
class6	glucose disposal  beta cell secretion  and hepatic insulin extraction in cirrhosis  a minimal model assessment  factors controlling glucose metabolism after iv load were studied in nine patients with compensated cirrhosis and in six age matched controls  the time courses of glucose  insulin  and c peptide were analyzed by means of the minimal model technique  in cirrhosis  insulin sensitivity was reduced by approximately 70  and glucose dependent glucose uptake  glucose effectiveness  by 45   decreased glucose effectiveness explained 65  of the variance of glucose disappearance and correlated with the ratio of urinary creatinine to height  an independent measure of muscle mass  r   0 839   beta cell responsiveness to glucose  measured on c peptide kinetics  was variable and increased on average by 170  and 107   first phase and second phase  respectively   the total amount of insulin secreted by beta cells in the course of the study was nearly doubled  whereas the basal insulin secretion rate was in the normal range  the time courses of hepatic extraction of insulin did not differ between groups  and basal extraction was on average 58  in controls and 56  in patients with cirrhosis  it was reduced to 30  in a single patient who had severe hepatocellular failure and large spontaneous portosystemic shunting  we conclude that the alterations in glucose metabolism of cirrhosis include a decreased insulin sensitivity  a reduced glucose effectiveness  and an increased pancreatic responsiveness to glucose  leading to hyperinsulinemia  the hepatic extraction of insulin is reduced only in the very advanced stages of the disease  possibly because of a large reserve capacity of the hepatic parenchyma  
class6	host response to mycobacterial infection in the alcoholic rat  animals  chronically treated with alcohol  were inoculated with mycobacteria  bacillus calmette guerin  10 2 x 10 6  organisms  into the spleen to produce a granulomatous hepatitis  before infection  chronic alcohol ingestion was associated with a depressed skin test response to phytohemagglutinin  71 7  of baseline  p   0 009   mycobacterial  bacillus calmette guerin  infection stimulated phytohemagglutinin skin test response to 417  of baseline in controls and 299  in alcoholics  p less than 0 001   the hepatic granuloma response was altered with smaller but more numerous granulomas  mean     sem  81 2     1 5 microns2 of area with a frequency of 1 8 granulomas per field in alcoholics vs  129 8     5 71 microns2 and 1 2 granulomas per field in controls  p less than 0 001   these changes were associated with a 10 fold increase in colony forming units per gram of liver  54 5     18 2 in alcoholics vs  5 6     1 83 in controls  p   0 0006   this model offers precise parameters for host response to infection and indicates that alcohol significantly impairs the clearing capacity for mycobacteria from the liver  
class6	pathogenesis of ceftriaxone associated biliary sludge  in vitro studies of calcium ceftriaxone binding and solubility  ceftriaxone  a semisynthetic third generation cephalosporin  has recently been associated with biliary sludge formation  analysis of the biliary concretions induced by this agent shows a calcium salt of ceftriaxone  the present in vitro studies were undertaken to provide insight into the pathogenesis of ceftriaxone associated biliary sludge formation by evaluating possible interactions that may exist between calcium  bile salts  and ceftriaxone  ceftriaxone possessed high calcium binding affinity  the formation constant for the calcium ceftriaxone salt at 37 degrees c was about 157 3 l mol  stoichiometry of the salt was 1 1  i e   calcium ceftriaxone  the calcium binding property of ceftriaxone was observed to be additive to that of taurocholate in mixed taurocholate ceftriaxone solutions  although the solubility product constant for calcium ceftriaxone was only 1 62 x 10  6  mol l2  marked metastability was observed  neither visible nor microscopic precipitates developed until the  ca2   x  ceftriaxone  ion product exceeded the solubility product constant by a factor of 10 4  metastability of the calcium ceftriaxone salt was also observed in human gallbladder bile in vitro  estimates of human biliary calcium ceftriaxone solubility in vivo were than calculated from previously reported values for biliary  ca2     ceftriaxone   and from the solubility product constant as defined in this study  calculated saturation indices for calcium ceftriaxone in human bile generally increased  corresponding to a decrease in solubility  with increasing ceftriaxone dose  at doses less than or equal to 1 g  saturation index was well within the metastable range of this calcium salt  however  at doses greater than or equal to 2 g  the saturation index surpassed the metastable limit  under these conditions  precipitation of ceftriaxone could occur  it was concluded that the development of ceftriaxone induced biliary sludge is a solubility problem that occurs in patients receiving high dose treatment  greater than or equal to 2 g   this study proposes that the risk of developing ceftriaxone associated biliary  pseudolithiasis  increases with increasing ceftriaxone dose and in patients with impaired gallbladder emptying  
class6	gallbladder motility in cholesterol gallstone disease  effect of ursodeoxycholic acid administration and gallstone dissolution gallbladder motility was evaluated by ultrasonography in 75 cholesterol gallstone patients and in 77 matched control subjects  all 75 gallstone patients were candidates for oral bile acid therapy  radiolucent gallstones  less than 2 cm in diameter  in well opacified gallbladder   and 38 of them were also studied during ursodeoxycholic acid administration  an additional 20 gallstone patients were studied 1 year after confirmed gallstone dissolution with oral bile acids  gallstone patients showed significantly greater fasting and residual volumes  a decreased percent of gallbladder emptying  but a similar absolute emptying and emptying rate compared with the control subjects  greater fasting volumes and reduced percents of gallbladder emptying were also found in gallstone free patients who achieved complete dissolution with oral bile acids  after ursodeoxycholic acid administration  fasting gallbladder volumes were greater  and percents of gallbladder emptying were further decreased than in untreated gallstone patients  in conclusion  greater fasting volumes  and not reduced gallbladder contractility  account for the defective gallbladder function in radiolucent  cholesterol rich  gallstone patients  this condition is likely to precede  and possibly to promote  gallstone formation because it persists after gallstone dissolution  ursodeoxycholic acid administration worsens the defect observed in gallstone patients  this finding also suggests  although indirectly  that the expected normalization of cholesterol saturation during oral bile acid administration is not paralleled by an improvement in gallbladder function  
class6	primary biliary cirrhosis  quantitation of autoantibodies to purified mitochondrial enzymes and correlation with disease progression  primary biliary cirrhosis is characterized by the presence of antimitochondrial antibodies  recently  six of the autoantigens have been identified as components of the 2 oxo acid dehydrogenase multienzyme complexes located within mammalian mitochondria  immunoblotting studies have shown that two of these components  namely e2 and protein x of pyruvate dehydrogenase complex  are the major antigenic polypeptides recognized by autoantibodies  this study shows the development of an enzyme linked immunosorbent assay to detect and quantitate antibodies to these two purified antigens  coded serum samples from 166 patients with primary biliary cirrhosis  140 patients with other liver and or autoimmune disease  and 52 normal women were analyzed for reactivity using this immunoassay  these results indicate that this rapid  simple method has a 93  sensitivity and 96  specificity in the diagnosis of primary biliary cirrhosis  the titer of immunoglobulin g autoantibodies correlated not only with antimitochondrial antibody titer measured by indirect immunofluorescence  p less than 0 0001  but also with histological stage of disease  p less than 0 04  and prognostic biochemical variables such as higher serum bilirubin and lower serum albumin levels  p   0 038 and 0 028  respectively   there was no significant correlation between titer of autoantibodies and serum globulin or immunoglobulin g levels  indicating that the positive correlation with disease progression was not secondary to hypergammaglobulinemia  
class6	long term outcome after surgery for biliary atresia  study of 40 patients surviving for more than 10 years  to define long term prognosis of children who underwent surgery for biliary atresia  a retrospective study was undertaken in 122 children who underwent one of the kasai procedures between 1968 and 1977  forty of the 122 children  32 7   were alive after 10 years  firm hepatomegaly was present in 31 and splenomegaly in 29 children  serum bilirubin or all liver function tests were normal in 21 and 11 children  respectively  survival rate decreased with the age at operation  but no significant difference was observed in the rate of children surviving with normal serum bilirubin whether they underwent surgery before age 2 months or between 2 and 3 months  twenty four had esophageal varices and 15 experienced gastrointestinal bleeding  normal liver function tests and absence of portal hypertension were observed in 11 of 122 children  these results indicate that kasai s procedures were helpful in a significant proportion of children with biliary atresia who underwent surgery during this period  however  80  of children who initially underwent surgery with kasai s procedures should eventually undergo liver transplantation  
class6	microprocessor assisted solvent transfer system for gallstone dissolution  in vitro and in vivo validation  to improve the efficacy  safety  and convenience of contact dissolution of gallbladder stones  a microprocessor assisted solvent transfer system was developed  the system s two pumps simultaneously infuse and aspirate solvent into and from the gallbladder at a high flow rate through a multilumen catheter  the microprocessor controls the pumps using a closed feedback loop control algorithm to regulate intragallbladder pressure to prevent solvent escape into the duodenum  turbulent solvent flow at the catheter end in the gallbladder is designed to induce rapid stone dissolution and to suspend insoluble residue  thus promoting its aspiration  the system s response and gallbladder emptying capacity was 160 fold faster than the natural gallbladder emptying rate  the rate at which gallstones were dissolved by methyl tert butyl ether using the system was compared with that achieved with a syringe pump  for 6 of 11 pairs of stones that totally dissolved  the mean dissolution time with the system was 10     6 minutes compared with 112     81 minutes for the syringe pump  in the 5 of 11 stone pairs which dissolved incompletely  insoluble residue was completely eliminated by the system in 21     9 minutes but not by the syringe pump even at 360 minutes  when the system was used in gallstone patients  solvent recovery was 99      1   and the concentration of a nonabsorbable marker did not change  confirming the lack of appreciable absorption of methyl tert butyl ether  these studies suggest that the microprocessor assisted solvent transfer system is a device capable of safe  complete  and fully automatic contact dissolution of cholesterol gallbladder stones using methyl tert butyl ether or similar solvents  
class6	esophageal obstruction after ingestion of a fiber containing diet pill  foreign bodies of the esophagus in adults may be the result of a food bolus that becomes lodged proximal to a structural abnormality of the distal esophagus  a case of peptic stricture of the esophagus in a patient who presented with acute dysphagia after ingesting an over the counter diet pill composed of guar gum is discussed  it is recommended that anorectics composed of dietary fiber should not be used in patients with a history of esophageal stricture  
class6	idiopathic biliary ductopenia in adults  a report of five cases  the clinical and pathological findings of five adult cases of idiopathic nonsyndromatic paucity of interlobular bile ducts are reported  patients were 18 32 years old at the onset of the disease  four presented with pruritus and or jaundice and one with bleeding of the esophageal varices  two patients were siblings  serum alkaline phosphatase counts ranged from 1 to 16 times the upper normal value  and total bilirubin counts ranged from 0 6 to 8 8 mg dl  10 to 150 mumol l   initial liver biopsy showed portal and periportal fibrosis with cholangiolar proliferation and reduction in the number of interlobular bile ducts  antimitochondrial antibodies were absent  and bile ducts were normal after opacification  the patients were observed for 3 11 years  repeated liver biopsies in the five patients showed progression of the lesions  with development of biliary type cirrhosis in four  two of the four patients with cirrhosis died of hepatic failure 3 and 11 years after onset of the disease  in the two other cases  liver transplantation was performed successfully  these cases suggest that chronic cholestasis with marked ductopenia resembling the nonsyndromatic paucity described in infancy and childhood may reveal itself at an adult age  this disorder  possibly familial  may rapidly progress to severe and even fatal liver disease and could be a new indication for liver transplantation  
class6	omeprazole in the management of intractable esophageal ulceration following injection sclerotherapy  transient esophageal ulceration is a common finding after sclerotherapy of varices  a small proportion of these ulcers become chronic and resistant to conventional therapy  such chronic ulcers have been associated with pain  stricture formation  and recurrent hemorrhage  the use of omeprazole  a proton pump inhibitor  was examined in the current study in the treatment of 10 patients  6 women  4 men  age range  27 86 years  with cirrhosis  pbc  4  sclerosing cholangitis  2  chronic active liver disease  2  alcohol  1  and cryptogenic  1  who developed an esophageal ulcer after a mean of 13  range  8 21  sessions of sclerotherapy  the ulcers had been present for 3 54 months despite prolonged treatment with high dose h2 receptor antagonists and sucralfate  in each case one or more complications had occurred  severe pain in 3  stricture formation in 4  and recurrent hemorrhage in 7 cases  after an 8 week course of omeprazole  40 mg daily  endoscopy confirmed complete healing of the ulceration in all 10 cases with symptom resolution  in 2 cases the ulcer recurred  with associated bleeding within 6 weeks of discontinuing the treatment in 1 patient  both cases responded to repeat therapy  these results confirm the efficacy of omeprazole for postsclerotherapy ulceration and imply that acid pepsin has a role in perpetuating such ulcers  
class6	heterotopic liver transplantation for fulminant wilson s disease  wilson s disease may present with severe acute hepatocellular failure  the only effective treatment for fulminant wilson s disease is liver transplantation  which may lead to reversal of the underlying disease  some patients with cirrhosis who are too ill to undergo orthotopic liver transplantation have been treated with heterotopic liver transplantation  however  use of heterotopic liver transplantation for fulminant hepatocellular failure has not been successful  this case study involves a patient in whom a heterotopic liver transplant was successfully used for treatment of wilson s disease presenting with fulminant hepatocellular failure  
class6	caseating hepatic granulomas in hodgkin s lymphoma  a 68 year old man presented with recurrent hodgkin s lymphoma after a 9 year disease free interval induced by chemotherapy  in addition to histological evidence of recurrent hodgkin s disease  the liver biopsy specimen showed extensive caseating granulomas  cultures of bone marrow and liver tissue tested negative for mycobacterium tuberculosis  no antituberculous treatment was administered  and the patient had an excellent clinical response to additional chemotherapy for lymphoma  hodgkin s lymphoma should be added to the list of disease entities associated with caseating granulomas in the liver  
class6	colonic lipomas  outcome of endoscopic removal  colonic lipomas are benign adipose tumors which are usually submucosal  with the increase in the number of endoscopic procedures being performed  these tumors are often detected incidentally at colonoscopy  although the risks of removing these tumors have been recognized  numerous reports have documented safe removal by snare electrocautery  we have reviewed the clinical outcome and the endoscopic and histopathologic features of seven lipomas that were endoscopically removed over a 5 year period  four patients recovered uneventfully  while three patients  42 8   developed colonic perforation after the polypectomy  in the latter group  the lipomas were significantly larger than they were in the patients who did not develop colonic perforation  1 9     0 4 and 4 2     0 7 cm  respectively  p   0 048   furthermore  the polypectomy specimens from those patients who developed perforation all contained significant muscularis propria  lipomatous polyps that are identified at endoscopy to be greater than or equal to 2 cm in diameter and to have a limited pedicle are at the greatest risk for endoscopic perforation  
class6	a laser induced scar at the cardia increases the yield pressure of the lower esophageal sphincter low yield pressure of the lower esophageal sphincter is associated with esophageal reflux  and fundoplication must increase yield pressure if it is to prevent reflux  we attempted to increase yield pressure endoscopically in the dog by using the nd yag laser to produce a fibrous scar at the cardia in the approximate line of the gastric sling fibers  ten beagle dogs were studied  in a pilot study with two dogs  15 watts for 4 2 sec were found to produce a scar deep into the muscle coat of the stomach  three configurations of scar were used  one produced significant rises in yield pressure in all four of the dogs treated  the second produced a significant rise in one of the two dogs treated  and the third caused a significant drop in yield pressure in the one dog treated  one dog died of gastric perforation 10 days after lasering  but no other animal experienced any ill effects  these findings may have therapeutic implications for the management of esophageal reflux  
class6	endoscopic retrograde cannulation of the gallbladder  direct dissolution of gallstones  percutaneous transhepatic catheterization of the gallbladder for dissolution of cholesterol stones by instillation of methyl tert butyl ether  mtbe  is an invasive therapeutic procedure  the only non invasive alternative available to now  endoscopic retrograde cannulation of the cystic duct  was difficult because of the cystic duct s tortuosity and spiral valves  we therefore developed a catheter system which  using conventional duodenoscopes during a routine endoscopic retrograde cholangiography  erc  procedure  permits reliable and safe catheterization of the gallbladder without the need for endoscopic sphincterotomy  in 18 of 22 patients  82   we were able to place a cysto nasal catheter  and in 14 patients mtbe dissolution therapy was then performed  eight patients  57   were completely free of stones after treatment  the other six  43   had residual debris  in 4 of 22 patients  18   cannulation attempts failed  in 3 patients due to cystic duct blockage by a calculus  endoscopic retrograde cannulation of the gallbladder  ercg  represents a promising alternative to the invasive percutaneous transhepatic catheterization procedure  
class6	expandable biliary metal stents for malignancies  endoscopic insertion and diathermic cleaning for tumor ingrowth  seventeen patients with malignant biliary strictures have been treated by endoscopic insertion of self expandable metallic prostheses  two patients received two prostheses inserted simultaneously in both the left and right hepatic ducts for klatskin tumor type iii  immediate results were satisfactory despite an operative mortality of 18   and neither early nor late clogging was observed even in patients who presented previously with sludge above plastic stents that were removed  however  among five patients followed for more than 4 months  two presented with obstruction due to tumor ingrowth into the stent through the metallic mesh  accordingly  initial enthusiasm concerning long term patency of these stents has decreased  however  we describe a technique of  diathermic cleaning  of tumor ingrowth which can easily restore the stent patency  the advantages of these wire mesh 30 f stents are their easier insertion  better immediate drainage  and absence of dislocation or perforation  
class6	pain on common bile duct injection during ercp  does it indicate sphincter of oddi dysfunction  the reproduction of a patient s biliary type pain upon initial injection of contrast material into the common bile duct during diagnostic ercp is a dramatic experience for both patient and physician  the significance of this phenomenon is not clear  but it is touted by some to be a provocative test for sphincter of oddi dysfunction  sphincter of oddi manometry was performed on 224 consecutive patients referred over a 2 year period for evaluation of post cholecystectomy syndrome and suspected sphincter of oddi dysfunction  all patients received only intravenous diazepam as premedication for ercp  delayed drainage time  greater than 45 min   bile duct dilation  greater than or equal to 12 mm   and a basal sphincter of oddi pressure of greater than 40 mm hg  mean     3 sd  were considered elevated  we observed a reproduction of pain in 15 of 224 patients  6 7   immediately following contrast injection  there was no correlation between pain on contrast injection and elevated basal sphincter of oddi pressure  delayed common bile duct drainage  bile duct dilation  or abnormal liver enzymes  therefore  we feel that reproduction of the patient s biliary type pain associated with contrast injection of ercp is not a provocative test for sphincter of oddi dysfunction  
class6	sphincter of oddi manometry  decreased risk of clinical pancreatitis with use of a modified aspirating catheter  this study was undertaken to determine whether routine use of a modified triple lumen five french sphincter of oddi manometry catheter would reduce the frequency and severity of post manometry pancreatitis and pancreatic enzyme elevation  seventy six patients were alternately assigned to undergo sphincter of oddi manometry  som  with a standard perfusion  infused group  catheter or the newly developed aspiration  aspirated group  catheter  after som  there were significantly more patients in the infused group with both amylase and lipase values elevated at least two times the upper limits of normal at 2  p less than 0 001   6  p   0 01   and 18 hours  p   0 03  after the procedure  as compared with the standard perfusion system  the aspiration catheter was associated with a decreased frequency of clinical pancreatitis  23 5  vs  3   p   0 01  reduced hospital stay  5     1 83 days  mean     se  versus 1 day  p   0 03  and milder pancreatitis  the aspiration manometry catheter should be considered for standard use for som  particularly if the pancreatic duct sphincter is being evaluated  
class6	the role of endoscopic injection sclerotherapy in the management of bleeding peristomal varices  peristomal varices usually occur in patients with enterostomies who develop portal hypertension  and represent a cause of recurrent or intractable gastrointestinal bleeding  treatment options for such bleeding include surgical ligation of varices  stoma revision with devascularization  injection sclerotherapy  portacaval shunt  or liver transplantation  we reviewed the records of seven patients with peristomal varices  who were followed for a mean of 17 months after diagnosis  fourteen episodes of clinically significant peristomal bleeding occurred in six patients  surgical ligation of varices was ineffective in controlling bleeding in two of three patients  although stoma revision with devascularization was temporarily effective in two other patients  injection sclerotherapy  used in three patients  effectively controlled acute bleeding without serious complications or need for surgery  definitive treatment for peristomal bleeding  portacaval shunt or liver transplantation  has prevented any further bleeding in three patients for a mean of 8 months after surgery  
class6	variceal sclerosis in schistosomotic patients  a 5 year follow up study  to assess the therapeutic possibilities of injection sclerosis in schistosomotic portal hypertension  a 5 year prospective study was conducted in northeast brazil  where this parasitosis is endemic  fifty patients undergoing endoscopy for upper gastrointestinal hemorrhage from rupture of esophageal varices from july through december 1981 were chosen for the study  the 32 consenting patients were submitted to injection sclerotherapy paravariceally  using ethanolamine oleate  the 18 refusing to participate were assigned to the control group  the incidence of rebleeding was 28 1  in the former and 44 5  in the latter  a difference which was not statistically significant  fisher s test  p   0 375   mortality from rupture of esophageal varices was 3 1  in the sclerotherapy group and 27 7  in the control group  a statistically significant difference  fischer s test  p   0 017   since sclerotherapy markedly improved the long term survival rate of the patients  this procedure is advocated for the treatment of esophageal varices in cases of portal hypertension due to schistosomiasis  
class6	schatzki s ring  long term results following dilation the purpose of this study is to report long term results of 61 patients with schatzki s ring who were dilated for relief of dysphagia  the severity of schatzki s ring was mild in 28 patients  46    moderate in 26  43    severe in 5  8    and indeterminate in 2  3    follow up information was available in 56 of 61 patients  mean  75 months   during follow up  35 patients  63   developed recurrent dysphagia and required repeated dilations  19 patients  34   had one to two dilations  9 patients  16   had three to seven dilations  6 patients  11   had more than seven dilations  1 patient underwent surgery for resection of the schatzki s ring  2    the mean  range  dilation free interval was 50 1 months  11 8 to 100 months  in mild cases  44 5 months  8 9 to 82 months  in moderate cases  and 28 6 months  9 to 76 months  in severe cases  there was no significant correlation between the severity of schatzki s ring on initial presentation and the subsequent dilation free interval  our data indicate that recurrent dysphagia is common among patients with schatzki s ring after a successful dilation  and that the severity of schatzki s ring is not a good prognostic indicator of the need for subsequent dilation  
class6	witzel pneumatic dilation for achalasia  safety and long term efficacy forceful dilation of the lower esophageal sphincter is considered primary therapy for achalasia  the witzel pneumatic balloon dilator  unlike fluoroscopically placed dilators  is placed over a standard gastroscope allowing positioning and dilation under direct vision  we report our experience with the witzel dilator in 45 patients with achalasia over a 5 year period  all patients had at least one major symptom score of 8 out of 10 for dysphagia and or regurgitation before dilation  after witzel dilation  symptomatic response was graded as excellent  score 0 to 2   good  score 3 to 5   fair  score 6 to 8   and poor  no improvement   symptom response was assessed after 1 week  1 month  6 month  1 year  and present  the mean period of follow up was 25 months  range  3 to 85 months   passage of the balloon across the gastroesophageal junction was technically unsuccessful in three patients  esophageal perforation occurred in two patients  4   and transient chest pain greater than 2 days in three patients  7    there was no bleeding or death  symptomatic long term improvement was excellent in 25 patients  63    good in 6 patients  15    fair in 4 patients  10    and poor in 5 patients  12    a repeat witzel dilation was performed in five patients but resulted in good excellent improvement in only one patient  we conclude that pneumatic dilation with the witzel balloon is a safe  effective procedure for achalasia  
class6	fatty liver hepatitis  steatohepatitis  and obesity  an autopsy study with analysis of risk factors  steatohepatitis  fatty liver hepatitis   histologically identical to alcoholic disease  occurs in some obese patients after jejunoileal bypass  a similar lesion occurs rarely in obese patients without bypass surgery  but the risk factors are poorly understood  hepatic steatosis  steatohepatitis and fibrosis were sought in 351 apparently nonalcoholic patients at autopsy and various risk factors were evaluated  incidence of steatosis and steatohepatitis correlated with the degree of obesity  steatohepatitis was found in 18 5  of markedly obese patients and 2 7  of lean patients  additional risk factors for steatohepatitis were type ii diabetes  weight loss in the preterminal period shortly before death and intravenous glucose therapy in the last week of life  severe fibrosis was found in 13 8  of markedly obese patients and in 6 6  of lean patients  this difference was largely explained by the higher prevalence of diabetes in obese groups  the risk factors defined in this study are known to be associated with abnormalities of free fatty acid metabolism  obesity  type ii diabetes and intravenous glucose therapy are associated with hyperinsulinemia  which may inhibit fatty acid oxidation  obesity and weight loss increase the presentation of fatty acids to the liver  similar metabolic changes may occur in obese patients after jejunoileal bypass surgery  thus this study supports the hypothesis that fatty acids have a role in the hepatocellular necrosis found in some obese individuals  
class6	immunological studies before and during interferon therapy in chronic hbv infection  identification of factors predicting response  lymphoblastoid interferon is effective therapy in some but not all patients with chronic hepatitis b virus infection  to assess whether immunological parameters were predictive of response to interferon therapy  we determined the human leukocyte antigen type  cd4 cd8 ratio  natural killer cell activity  igm anti hbc antibody levels and concanavalin a induced lymphocyte proliferative response in 30 patients before treatment  in addition  to investigate the mechanisms of action of interferon in promoting hepatitis b virus clearance  we serially measured the cd4 cd8 ratios  natural killer activity and lymphocyte proliferative response at wk 4  8 and 12 of treatment  a beneficial response to therapy was defined as the sustained clearance of hbeag and serum hepatitis b virus dna within 1 yr of commencing therapy  elevated igm anti hbc levels were associated with a beneficial response to therapy  but there was no correlation observed between response and pretreatment cd4 cd8 ratio  natural killer activity or lymphocyte proliferative response  six of seven human leukocyte antigen dr3 positive patients responded  no measurable changes in the immunological parameters studied were observed in the nonresponder group  whereas a significant rise in cd4 cd8 ratio  associated with a fall in peripheral cd8 number and a decline in measurable nk activity  was seen in the responder group  these changes were maximal at the time of hepatitis b virus dna clearance  which was associated with a transient increase in hepatic inflammation  
class6	hormonal and enzymatic parameters of hepatic regeneration in patients undergoing major liver resections  thirteen patients who underwent 40  to 80  removal of their livers had blood samples drawn initially and daily on postoperative days 1 to 7  the enzyme marker of heightened polyamine metabolism  ornithine decarboxylase  and the indicator of dna synthesis  thymidine kinase  were measured  in addition  the hormones  insulin  glucagon  estradiol and androgen   which in animals are known to reflect and possibly modulate regeneration  were measured  changes in all these indices followed the same pattern as in rats  dogs and swine but at a slower rate  ornithine decarboxylase and estradiol increased within 24 hr  but thymidine kinase and insulin rises did not become statistically significant until 3 to 5 days  using these plasma or serum indices as surrogate measures of biochemical events in the liver itself  regeneration reached a maximum after 4 or 5 days  by computed tomography scan analysis  restoration of hepatic cell mass was not complete until 3 wk  
class6	human hepatic regenerative stimulator substance  partial purification and biological characterization of hepatic stimulator substance from human fetal liver cells  current support or replacement therapies for fulminant acute hepatic failure are frequently very disappointing  in this study  human hepatic stimulator substance  a liver specific growth factor  was partially purified from human fetal liver cells and characterized by its biological effects  almost 70 fold protein content was purified with an approximately 80 fold increase in specific growth stimulator activity  human hepatic stimulator substance proved to be heat stable  protease sensitive  organ specific and species nonspecific  human hepatic stimulator substance produced a two  to threefold increase of 3h thymidine incorporation into hepatic dna when injected intraperitoneally into growing weanling mice  nonhepatectomized  or regenerating rats  34  hepatectomy   the effects of hhss in reversing the lethality of d galactosamine  1 6 gm kg body weight  induced hepatic necrosis in rats were further evaluated  a survival rate of 4   n   24   41   n   12  p less than 0 05   33   n   12  p less than 0 05   31   n   13  p less than 0 05  and 18   n   11  p greater than 0 05  was observed when the rats were injected with 4 ml of saline intraperitoneally  4 ml of human intact fetal hepatocytes  2 4 x 10 8  intraperitoneally  4 ml of human hepatic stimulator substance intraperitoneally  2 ml of twofold concentrated human hepatic stimulator substance intravenously and 1 ml of fourfold human hepatic stimulator substance intramuscularly  respectively  20 hr after poisoning  
class6	hepatic vascular disease and portal hypertension in polycythemia vera and agnogenic myeloid metaplasia  a clinicopathological study of 145 patients examined at autopsy  the pathogenesis of portal hypertension arising in patients with myeloproliferative disorders has been difficult to understand because liver biopsy findings often show minimal changes  it has been suggested that increased splenic blood flow  hepatic infiltration with hematopoietic cells or sinusoidal fibrosis may be important  we have reviewed the autopsy findings and clinical histories of 97 patients with polycythemia vera and 48 patients with agnogenic myeloid metaplasia collected from three institutions and from the polycythemia vera study group  cirrhosis was present in seven patients  one of whom had bleeding varices  esophageal varices were present clinically in 10 patients without cirrhosis  seven polycythemia and three agnogenic myeloid metaplasia   all of these patients had lesions in small or medium sized portal veins and four had stenosis of the extrahepatic portal vein with histology compatible with organized thrombi  nodular regenerative hyperplasia occurred in 14 6  and correlated closely with the presence of portal vein lesions  thirty patients had greater than 500 ml of ascites  seven of these patients also had varices and six of them had hepatic vein thrombosis  ascites also correlated with hepatic vein disease confined to small intrahepatic branches  no correlation was seen between hepatic hematopoietic infiltration and signs of portal hypertension  we conclude that esophageal varices are common and are almost always associated with portal vein lesions visible by light microscopy  these portal vein lesions  and the secondary effects of nodular regenerative hyperplasia and portal hypertension  are most likely a result of portal vein thrombosis in patients with myeloproliferative disorders  
class6	selective intestinal decontamination increases serum and ascitic fluid c3 levels in cirrhosis  selective intestinal decontamination for 7 days with norfloxacin was performed in 14 cirrhotic patients with ascites and low ascitic fluid total protein  variations in serum and ascitic fluid of c3 and c4 and ascitic fluid total protein after therapy were compared with those of a control group of 14 untreated patients with similar characteristics  after oral norfloxacin administration  we saw a significant increase of c3 in serum  p less than 0 05  and ascitic fluid  p   0 01   a significant increase was also observed in ascitic fluid total protein  p less than 0 05  but not in serum and ascitic fluid c4  there were no changes in serum c3  ascitic fluid c3  ascitic fluid c4 or in ascitic fluid total protein in group 2  these data demonstrate that selective intestinal decontamination increases serum and ascitic fluid c3 levels and  therefore  might be useful in preventing spontaneous infections in cirrhotic patients at high risk of infection  
class6	pathological observations of intrahepatic peribiliary glands in 1 000 consecutive autopsy livers  iii  survey of necroinflammation and cystic dilatation  pathological changes and significance of intrahepatic peribiliary glands  hitherto poorly recognized intrahepatic elements  have been evaluated in our laboratory  in this report  we surveyed necroinflammatory and cystic changes of the peribiliary glands in 1 000 consecutive autopsy livers because these two changes coexisted frequently in the same liver  the necroinflammatory change was found in 228 livers  22 8   and the cystic change in 202 livers  20 2    and 103 cases showed both changes in the same liver  the necroinflammatory change was frequently found in intrahepatic cholangitis and extrahepatic biliary obstruction with bacterial infection  suggesting that biliary bacterial inflammation extends into these peribilary glands  this change was also frequent in systemic infection or septicemia without biliary bacterial infection  implying that the peribiliary glands were also damaged in such conditions without direct infection  the cystic change was frequent in livers with portal hypertension or obstruction  adult polycystic disease and necroinflammation of the glands  suggesting that the cystic change of the glands could occur as the result of the disturbance of intrahepatic circulation or as the result of inflammatory destruction of the glandular conduits  some of peribiliary cysts may be of congenital origin  dysfunction related to these pathological changes in the glands may diminish seromucous secretion and cause alterations in hepatic bile composition  the cystic change of the glands may retard bile flow by compressing bile duct lumina  
class6	inflammatory abdominal aortic aneurysms  in a series of 517 operations for abdominal aortic aneurysm from 1971 to 1988 there were 45 cases  8 7   with an inflammatory aneurysm with a typical thick glistening whitish fibrous layer  almost two third of the patients had rather severe chronic or acute progressive pain in the abdomen  the back or the flank  unilateral  7  or bilateral  2  hydronephrosis due to ureteral compression occurred in 9 patients  20    a diagnosis of inflammatory aneurysm was made preoperatively only in 10 patients  in 8 of the 9 patients with hydronephrosis ureterolysis was done  unilaterally  6  or bilaterally  2   after ureterolysis all had complete resolution of the hydronephrosis  preoperative diagnostic methods are excretory urography  showing medial deviation  ultrasonography and ct scanning of the abdominal aorta  all patients with an inflammatory aneurysm should undergo aortic replacement to prevent rupture and achieve pain relief  ureterolysis in cases of hydronephrosis is strongly recommended and may be performed safely and with excellent results  
class6	left retroperitoneal exposure for distal mesenteric artery repair  distal disease in the mesenteric arteries has usually been repaired transabdominally since it is believed that only the proximal centimeter of each vessel is accessible through the retroperitoneum  we treated five patients with chronic visceral ischemia and lesions extending beyond the orifice using a retroperitoneal approach  exposure was obtained with a left flank incision through the tenth interspace  the left crus of the diaphragm was divided in order to control the supraceliac aorta  the mesenteric vessels were identified and dissected until their entrance into the peritoneum  there were no difficulties in exposing the superior mesenteric artery  sma  as it coursed under the pancreas and over the duodenum for an approximate length of 5 to 10 cm  the uncinate process of the pancreas was not a limiting factor for exposure of the sma in this region and further distal exposure could be obtained by incising the peritoneum  the trifurcation of the celiac artery and the splenic artery were accessible through this exposure  however  only the first centimeter of the hepatic and gastric branches could be reached  revascularization was performed with endarterectomy  2 patients  and bypass  3 patients   bowel viability was assessed at the conclusion of the procedure by incising the peritoneum  there were no complications from this exposure and no patient required reoperation for ischemic bowel  we conclude that the left retroperitoneal approach is not only acceptable for orifice lesions but is also applicable for distal disease  
class6	parathyroid hormone and cirrhosis of the liver  fifty patients with liver cirrhosis  36 alcoholic  1 drug induced  7 posthepatitic  and 6 cryptogenic  and normal renal function were investigated to determine whether pth levels in serum  measured using the common midregion human pth  44 68  ria  are elevated in such patients and whether this is related to impaired liver function rather than to the effect of secondary hyperparathyroidism  their data were compared with those from 25 control subjects  the median pth level of 462     18 ng l      sem  was significantly increased  p less than 0 01  in cirrhotics compared with that of 236     13 ng l in the control group  significant correlations were found between pth levels and parameters of liver function such as prothrombin time  r    0 40  p less than 0 01   albumin as a percentage of total protein  r    0 48  p less than 0 01   bilirubin  r   0 35  p less than 0 05   albumin  r    0 34  p less than 0 05   and cholesterol  r    0 32  p less than 0 05   but not for antipyrine clearance  suggesting increasing pth with decreasing liver function  the median calcium level  2 26     0 03 mmol l   corrected for changes in albumin  was near the lower limit of the normal range  2 25 2 60   but corrected calcium and pth were positively correlated  r   0 33  p less than 0 05   indicating that the elevation is not reactive to calcium depletion  a negative correlation existed between pth and 25 hydroxy cholecalciferol  r    0 49  p less than 0 05   the main circulating metabolite of vitamin d  normal values in an immunoradiometric assay that detects the whole sequence of human pth  1 84  suggest that fragments rather than the intact hormone are responsible for pth elevations in cirrhosis  the positive correlation between midregion pth and corrected calcium is probably an artifact of the correction formula  in conclusion  midregion pth fragments are increased in patients with liver cirrhosis  the reason for this elevation may well be the impaired liver function rather than secondary hyperparathyroidism  
class6	gastrointestinal side effects of octreotide during long term treatment of acromegaly  gastrointestinal side effects of prolonged therapy  greater than 2 yr  with the long acting somatostatin analog octreotide were studied in 10 acromegalic patients  after 2 yr of therapy  6 of 10 patients had newly developed gallstones  complicated by cholangitis and jaundice in 1  serum vitamin b 12 concentrations declined in all 10 patients  from 380     32 to 172     21 pmol l  mean     se   p   0 023  and became abnormally low in 4  gastric biopsy specimens  obtained during gastroscopy  9 patients   showed moderate to severe active gastritis  with damage to the superficial and deeper layers of the mucosa in 9 of 9 and focal atrophy in 7 of 9 patients  campylobacter pylori was found in the antral mucosa in 8 of 9 patients  although information is lacking on similar studies in untreated acromegalic patients  we suggest that patients receiving chronic octreotide therapy be closely monitored for these and possible other side effects related to gastrointestinal actions of octreotide  
class6	crypt cell proliferation and hla dr expression in pelvic ileal pouches  to investigate the nature of the morphological changes that occur in ileal pouches  26 biopsy specimens from patients with functioning ileo anal pouches  eight with pouchitis  were studied  normal ileum  n   10  was used as a control  mucosal morphometry  using linear measurements   crypt cell proliferation  ccp   using the monoclonal antibody ki67   and epithelial hla dr expression  monoclonal antibody cr3 43  were assessed  ccp  expressed as the percentage of ki67 positive nuclei for each crypt  was significantly higher in pouches with pouchitis  compared with those without  and in pouches without pouchitis compared with normal ileum  ccp values in some pouches without pouchitis approached values found in those with pouchitis  ccp was related inversely to villous height and an index of villous atrophy  vh tmt   and directly to crypt depth  in the presence of pouchitis there was intense epithelial hla dr expression that extended into the crypts  in some pouches with high ccp values  but without clinically important inflammation  surface epithelial hla dr expression was weak and patchy  it is concluded that villous atrophy and crypt hyperplasia in ileal pouches are associated with high ccp values  these may be increased even in the absence of active inflammation  and this increase may occur as a response to the new luminal environment  
class6	abnormal cardiac sensitivity in patients with chest pain and normal coronary arteries  the causes of chest pain in patients found to have angiographically normal coronary arteries during cardiac catheterization remain controversial  cardiac sensitivity to catheter manipulation  pacing at various stimulus intensities and intracoronary injection of contrast medium was examined in several groups of patients who underwent cardiac catheterization  right heart  especially right ventricular  catheter manipulation and pacing and intracoronary contrast medium provoked chest pain typical of that previously experienced in 29  81   of 36 patients with chest pain and angiographically normal coronary arteries and 15  46   of 33 symptomatic patients with hypertrophic cardiomyopathy  in contrast  only 2  6   of 33 symptomatic patients with coronary artery disease experienced their typical chest pain with these sensitivity tests  p less than 0 001   none of 10 patients with valvular heart disease but without a chest pain syndrome experienced any sensation with these tests  cutaneous pain threshold testing demonstrated that patients with chest pain and normal coronary arteries had a higher pain threshold to thermal stimulation compared with patients who had coronary artery disease or hypertrophic cardiomyopathy  no relation existed between cardiac sensitivity and cutaneous sensitivity testing  thus  patients who have chest pain despite angiographically normal coronary arteries may have abnormal cardiac sensitivity to a variety of stimuli  this increased sensitivity may be of causal importance to their chest pain syndrome or may contribute to their perception of ischemia induced pain  the same phenomenon was also commonly seen in symptomatic patients with hypertrophic cardiomyopathy  whether this phenomenon represents abnormal activation of pain receptors within the heart or abnormal processing of visceral afferent neural impulses in the peripheral or central nervous system is unknown  
class6	crohn s disease  what about the pancreas   editorial  crohn s disease  cd  is now accepted as a systemic illness  the importance of extraintestinal manifestations is underlined by the fact that such  complications  can be more prominent and even more difficult to control than the intestinal disease itself  lately  evidence for a more than accidental association of pancreatitis and exocrine pancreatic insufficiency with cd is growing  this might have a significant impact on the treatment of abdominal pain and diarrhea in cd  symptoms which have so far been attributed exclusively to the intestinal rather than the extraintestinal manifestations of the disease  
class6	can the blood urea nitrogen creatinine ratio distinguish upper from lower gastrointestinal bleeding  we wanted to know if the blood urea nitrogen to creatinine  bun cr  ratio could help distinguish upper from lower gastrointestinal bleeding  we analyzed retrospectively patients admitted to our hospital for gastrointestinal bleeding over the past 5 years  a total of 126 patients represented 74 upper bleeds and 52 lower bleeds  the mean bun cr ratio was significantly higher in upper than lower bleeders  34 8 and 17 8 respectively  p less than 0 001   no lower bleeder had a ratio of greater than or equal to 36  whereas 38  of upper bleeders had a ratio of greater than or equal to 36  the bun cr ratio may be an easy  cheap method of distinguishing upper from lower gastrointestinal bleeding in some cases  a bun cr ratio of greater than or equal to 36 suggests upper gastrointestinal bleeding  whereas a ratio of less than 36 is not helpful in locating the source of bleeding  
class6	stasis syndromes following gastric surgery  clinical and motility features of 60 symptomatic patients  we retrospectively reviewed the records of 60 patients who had been referred for gastrointestinal manometry because of stasis after gastric surgery  nausea  vomiting  bloating  abdominal pain  and weight loss were the most common symptoms  two thirds of these patients had a well documented history of peptic ulcer before their initial operations  in others  surgery was performed for other reasons  such as obesity  5   or reflux esophagitis  8    twelve patients had undergone truncal vagotomy and a  drainage operation  and 48 had received a partial gastrectomy with a gastroenterostomy  billroth i  n   8   billroth ii  n   11   roux en y  n   29   all patients had recordings of gastrointestinal manometry  16 also had a scintigraphic measurement of gastric emptying  measurements were compared with data from healthy controls  gastric manometry  which could be assessed only in the group with an intact antrum  was characterized by antral hypomotility  p less than 0 05   gastric emptying studies showed rapid early emptying of liquids and delayed emptying of solids  both p less than 0 05   in the whole group  fasting jejunal motility was characterized by absence of phase ii in 13  presence of bursts of phasic activity in 18  and abnormal propagation of phase iii in 8  a significantly increased frequency of phase iii of mmc was noted in the patients after billroth ii and roux en y operations  postprandially  19 patients failed to develop a  fed pattern    
class6	rosacea and ulcerative colitis  a possible association  although rosacea was formerly believed to be associated with gastrointestinal upsets  no one any longer finds a significant association between rosacea and the intestinal tract  we describe four patients with a combination of ulcerative colitis and rosacea  in all four  ulcerative colitis preceded the onset of severe papulopustular rosacea  and we therefore feel that the severity of rosacea could have been due to the associated bowel disorder  in one  the severity and poor initial response of rosacea to treatment was clearly related to the activity of the ulcerative colitis  and the rosacea improved only after proctocolectomy  while it is possible that this purported association is fortuitous  we report these cases in the hope that others may have seen this combination of diseases  to our knowledge previously unreported  
class6	limitations in the evaluation of therapy in inflammatory bowel disease  suggestions for future research  the current treatment of inflammatory bowel disease  ibd   though improved over earlier therapies  remains variable rather than consistent and supportive rather than curative  the similar management of ulcerative colitis  uc  and crohn s disease  cd   which are thought to be differing though related disorders  suggests that therapy is nonspecific  the variation in therapeutic practices results from the fact that the etiologies of the diseases are obscure  from limited knowledge of the biological and pharmacological actions of drugs commonly prescribed  sulfasalazine  5 asa compounds  steroids  6 mp and azathioprine   from an inadequate understanding of genetic differences influencing drug metabolism  from insufficient awareness of the factors influencing drug efficiency  concurrent use of antimotility drugs  cigarette smoking  food combinations   from the variability of the patient groups studied  extent and severity of disease   and from incomplete documentation of the clinical status of patients at the time of therapeutic trial  future advances in treatment will depend on gaining new information about the nature of ibd and of drug pharmacology and bioavailability  derived from collaborative studies by clinicians  clinical investigators  and basic scientists  important areas for ibd research include the biology of intestinal epithelium  the nature of the ibd inflammatory reaction and of gut mucosal immune regulation  via the application of new biotechnologies  and more representative experimental animal models  decisive multicenter therapeutic studies require agreement on definitions of ulcerative colitis and crohn s disease  accurate characterization of patient groups  acceptable objective criteria of ibd severity and activity  and reliable indicators of therapeutic response  
class6	frequency of recovery of blastocystis hominis in clinical practice  we examined the frequency of isolation of blastocystis hominis from stools of patients seen in an indigent care teaching hospital  over a 2 year period  2 744 stool specimens were examined prospectively  b  hominis was found in 262 stools  9 5  of all stool specimens and 53 5  of the positive specimens   clinical data were obtained from 80 patients with stools positive for b  hominis  b  hominis was the only parasite isolated in 39 of 47  83   of the adults  compared with 17 of 33  52   of the children  p   0 006   all but 2 of 52 patients without concomitant parasitic infection or bacterial pathogens in stool had gastrointestinal symptoms  41 abdominal pain  26 diarrhea  and 5 vomiting   but no association was seen with fever  peripheral leukocytosis  stool occult blood  fecal leukocytes  or endoscopic or radiologic evidence of colitis  therefore  b  hominis was frequently recovered from stools examined in a hospital clinical parasitology laboratory  the clinical presentations of patients in our series did not suggest that b  hominis was invasive  most patients with b  hominis probably do not require treatment since they will either have spontaneous resolution of symptoms or will be found to have an alternative explanation for their problem  
class6	clinical significance of cholelithiasis in patients with decompensated cirrhosis  there is general agreement that the prevalence of gallstones in cirrhotics is high  at least twice that in the general population   but the pathogenetic link between cirrhosis and cholelithiasis is still uncertain  the influence of cholelithiasis on survival in cirrhotics is also unknown  during an 8 year period  we observed 90 patients affected by decompensated cirrhosis  36 of them  40   turned out by cholecystographic cholangiographic or ultrasonographic examination to have cholelithiasis  we were not able to demonstrate any correlation between cholelithiasis and sex  age of patients  etiology of cirrhosis  severity of the illness  degree of portal hypertension  previous gastrointestinal bleeding  number of pregnancies  or levels of serum cholesterol  bilirubin  and triglycerides  during the follow up observation   range  1 91 months   30 patients died  survival curves analyzed by the log rank test did not show any difference between patients with or without gallstones  we therefore confirm that cirrhosis is a lithogenic condition  but we were not able to explain the reasons for the close relationship between cholelithiasis and cirrhosis  gallstones  however  did not affect the survival of these patients  
class6	risk factors for gallstones among chinese in taiwan  a community sonographic survey  a health survey of adults aged 30 years or more was carried out in southwest taiwan to determine the prevalence of gallstones and to study risk factors associated with gallstones  blood samples were collected and abdominal sonographic examination and anthropometric measurements were performed on a total of 923 people  the 40 gallstone cases detected resulted in a prevalence of 4 3   the risk factors explored included age  sex  hepatitis  obesity  hyperlipidemia  and diabetes mellitus  dm   age and dm were the only significant factors associated with gallstones in our study  with a reference group of 30 39 year olds as a comparison  multiple logistic regression analysis showed a trend effect with odds ratios of 1 73  3 74  and 6 32 for age groups of 40 49  50 59  and 60 or above  respectively  the odds ratio for dm was as high as 2 59  however  sex  body weight index  chronic hepatitis b  and hyperlipidemia were not significantly associated with gallstones  
class6	gallstone disease in north india  clinical and ultrasound profile in a referral hospital  we studied the prevalence of gallstones in patients with upper abdominal pain  heaviness  or discomfort by ultrasound examination of the gallbladder  the actual ultrasound examination was performed by a clinical gastroenterologist blinded to the symptoms  of 1 680 consecutive dyspeptic patients  500  29 8   had gallstones  the gallbladder was contracted in 450  91 2    normal size in 36  7 2    and distended in 8  1 6    biliary colic was more frequently the presenting complaint in patients with a contracted gallbladder than in those with normal size gallbladder  p less than 0 001   dyspepsia was more frequent in the presence of a normal size gallbladder than a contracted one  p less than 0 001   we conclude that ultrasonography of the gallbladder by the clinician has a high diagnostic yield  and the symptom complex has an excellent correlation with the sonographic appearance  
class6	tuberculous peritonitis  a study comparing cirrhotic and noncirrhotic patients  tuberculous peritonitis is a rare disease  which often goes unrecognized because of the subtle clinical clues and its insidous onset  we retrospectively analyzed the records of 37 cases of tuberculous peritonitis diagnosed over a 15 year period  and compared the clinical and diagnostic features of cirrhotic and noncirrhotic patients  in cirrhotic patients  tuberculous peritonitis can simulate ascites from liver disease or spontaneous bacterial peritonitis  the diagnosis is difficult in these patients because the ascitic fluid may not be of the exudative type as a result of the low albumin level in serum  and lymphocytes do not predominate in all cases  adenosine deaminase  ada  activity in ascitic fluid was elevated  higher than 40 u l  in all 11 patients  four patients with hepatic cirrhosis   the time required to achieve a correct diagnosis was significantly longer in cirrhotic than in noncirrhotic patients  the overall mortality was 13   with deaths occurring exclusively among cirrhotic patients  we emphasize that tuberculous peritonitis in cirrhotic patients can present an atypical picture  a considerable element of suspicion is necessary  
class6	small bile duct abnormalities in sarcoidosis  we report four patients with hepatic involvement of sarcoidosis manifested primarily by bile duct depletion  the patients developed fever  weight loss  anorexia  a markedly elevated alkaline phosphatase  and mildly abnormal serum levels of aspartate aminotransferase  endoscopic retrograde cholangiopancreatography showed slight intrahepatic irregularities but were not diagnostic of sclerosing cholangitis  liver biopsy showed predominantly bile duct depletion  ranging from an estimated 10 100  absence of bile ducts in portal areas  which correlated with the degree of fibrosis  the degree of bile duct depletion is useful as a histological marker in patients with sarcoid liver disease  steroids improve symptoms  but do not inhibit the development of  ductopenia    
class6	spontaneous reactivation in chronic hepatitis b  patterns and natural history  we identified spontaneous reactivation of hepatitis b virus  hbv  retrospectively by utilizing serum alanine aminotransferase and hbv dna in 19 men  79  homosexual   with an estimated annual incidence of 7 3   in 11 patients  spontaneous reactivation occurred as a single episode and in eight patients  reactivation was recurrent  with two to five episodes each  the mean serum alanine aminotransferase level was elevated over 10 fold at the peak of reactivation  serum anti hbc igm was detected during 73  of the reactivation episodes  actuarial analysis revealed that reactivation was long lasting with 45  and nearly 20  of episodes continued after 6 and 24 months  respectively  the course of 24 chronic hbv carriers with a negative serum hbv dna test and normal alanine aminotransferase levels at initial appearance was unremarkable  we could not identify clinical features predictive of reactivation or its resolution  severe reactivation hepatitis occurred in three patients  10    with two deaths  6    none of the patients lost hbsag  spontaneous reactivation in chronic hepatitis b can appear variably  persist long term  recur  and be fatal  therefore  accurate classification of chronic hbv infection requires prolonged observation  and spontaneous reactivation should be considered a variable in therapeutic trials for chronic hepatitis b  
class6	mallory weiss syndrome after cardiopulmonary resuscitation  we report hematemesis from mallory weiss tears after successful cardiopulmonary resuscitation  cpr   a computer search of the english language literature disclosed only 3 similar cases  and we review them  this complication of cpr may occur more frequently than recognized and should be prevented by careful technique  
class6	a nongastrin malignant ampullary tumor causing gastric acid and pepsin hypersecretion  a case report  we report a case of multiple duodenal ulcers with gastric hypersecretion due to a nongastrin secretagogue produced by a malignant tumor of the pancreas in a 78 year old man  the case resembled a zollinger ellison syndrome  zes  with high acid output  basal acid output 27  sham meal stimulated 37  maximum acid output 47 meq h   but with fasting gastrin 43 pg ml  nonresponsive to secretin  as in zes  pepsin output was comparatively low  and secretion was inhibitable by atropine  50  inhibited by 1 microm   the tumor removed at surgery contained less than 1 ng gastrin per gram  but was many times more potent than pentagastrin in stimulating acid from a lumen perfused rat stomach  the tumor also contained cholecystokinin  cck 8 and cck 33   motilin  insulin  and somatostatin  which were also present in adjacent normal pancreas  in addition  the tumor contained pancreatic polypeptide and pancreatic cancer associated antigen  this case represents a rare syndrome due to an as yet undefined peptide secreted by a  frequently malignant  pancreatic endocrine tumor and masquerading as zes  this is the first report of studies of pepsin secretion and of the effect of atropine  suggesting that the physiologic effects of the secretagogue resemble that of gastrin  
class6	chylous ascites should suggest constrictive pericarditis even in a patient with cirrhosis  chylous ascites  a milky  high triglyceride fluid is usually found in patients with lymphatic obstruction from malignancy  we describe a patient with cirrhosis who developed constrictive pericarditis and chylous ascites  long standing portal hypertension compounded by elevated central venous pressure provided several pathophysiologic contributions to the formation of the chylous ascites  chylous ascites even in a cirrhotic requires prompt assessment for conditions leading to elevated central venous pressure  
class6	morphological study of cholesterol hepatolithiasis  report of three cases  three cases of pure cholesterol intrahepatic stones are compared morphologically to those of calcium bilirubinate stones  cholesterol stones were found in the intrahepatic bile duct of the left lateral lobe in two cases and in both the left lateral and the right posterior lobe in one  although the chronic inflammatory reaction and fibrous thickening of bile duct wall were similar in both types of hepatolithiasis  the proliferation of intrahepatic periductal glands and the production of mucin were rather mild  compared to that is the liner containing calcium bilirubinate stones  multiple intramural cholesterol calculi and cholesterin granulomas  cholesterin crystals surrounded by foreign body giant cells  were found within the cystically dilated small bile duct branches and or conduits of periductal glands  the calculi and granulomas were characteristic for cholesterol hepatolithiasis  these findings suggest that the formation of the cholesterol stones differs from that of calcium bilirubinate stones  the perturbation of factors influencing cholesterol nucleation in the hepatic bile may be related to the changed microenvironment of the intrahepatic bile ducts  which is followed by the formation of cholesterol stones  
class6	portal venous gas in a patient with crohn s disease  portal venous gas usually occurs in the setting of an acute abdomen  several causes for benign portal venous gas  pvg  have been reported  we describe the finding of pvg by computed tomography in a febrile patient with crohn s disease and discuss the clinical implications of such a finding  
class6	cellular immune response to hepatitis b virus encoded antigens in acute and chronic hepatitis b virus infection  the proliferative response of pbmc to hepatitis b virus  hbv  envelope  core  and e ag was analyzed prospectively in 21 patients with acute self limited hbv infection and compared with the response of patients with chronic hbv infection and different levels of hbv replication  i e   hepatitis e ag  hbeag   or anti hbe positive  and liver damage  i e   chronic active hepatitis or chronic asymptomatic carriers   our results indicate that  1  hbv infected subjects who develop a self limited acute hepatitis show a vigorous pbmc response to hepatitis b core ag and hbeag  as expression of t cell activation  2  appearance of a detectable lymphocyte response to hbv nucleocapsid ag is temporally associated with the clearance of hbv envelope ag  3  in patients with chronic hbv infection the level of t cell responsiveness to hepatitis b core ag and to hbeag is significantly lower than that observed during acute infection  4  t cell sensitization to hbv envelope ag in acute and chronic hbv infection is usually undetectable and when measurable is expressed transiently and at low levels  these results may reflect immune events of pathogenetic relevance with respect to evolution of disease and viral clearance  
class6	evaluation of wc3 rotavirus vaccine and correlates of protection in healthy infants  the safety  immunogenicity  and efficacy of wc3 rotavirus vaccine was evaluated in a double blind  placebo controlled trial of healthy infants 2 12 months of age  103 received one dose of vaccine and 103 received placebo  vaccination appeared to be safe and induced an antibody response  wc3 neutralizing antibody  in 97  of vaccinees  only 9  9   of these  however  produced antibody to human rotavirus serotypes  at least 7 of the 9 were naturally infected before vaccination  neither the number of symptomatic episodes of rotavirus diarrhea  21 vs 25  nor the number of moderate to severe rotavirus illnesses  9 vs  15  was significantly different in vaccine or placebo recipients  respectively  during a predominantly serotype 1 rotavirus season  a slight but significant decrease in mean symptom score was detected in vaccine recipients  despite an overall lack of efficacy  protection could be correlated to previous rotavirus infection  high levels of wc3 neutralizing antibody  and preexisting  maternal  serotype 1 neutralizing antibody with a titer greater than or equal to 30  
class6	properties of strains of escherichia coli o26 h11 in relation to their enteropathogenic or enterohemorrhagic classification  thirty seven strains of escherichia coli o26 h11 from infants and calves with diarrhea were examined for properties associated with enteropathogenic  epec  or enterohemorrhagic e  coli  ehec   strains were heterogeneous with respect to vero cytotoxin  vt  production and hybridization with the ehec plasmid specific  cvd419  probe  26 strains produced vt1  1 produced vt2  twenty four of 27 vt  strains and 5 of 10 vt  strains hybridized with the cvd419 probe and produced enterohemolysin  these properties are characteristic of ehec  the strains did not hybridize with the epec adherence factor probe  a property characteristic of some epec  nevertheless  36 strains adhered to hep 2 cells in a localized manner and were positive by the fluorescence actin staining  fas  test that is considered to correlate with the ability to cause attaching and effacing lesions in vivo  epec and ehec cause these lesions  although the fas test appeared to be the most general pathogenicity test for the o26 h11 strains  it could not be used to assign strains specifically to epec or ehec groups  
class6	fucosylated oligosaccharides of human milk protect suckling mice from heat stabile enterotoxin of escherichia coli  human milk protects suckling mice from the diarrheagenic effects of heat stabile enterotoxin of escherichia coli  st   to identify the human milk fraction responsible for this protection  pooled skimmed  deproteinated milk was passed through charcoal  whereupon lactose was separated from the oligosaccharides  the oligosaccharides contained st protective activity  the lactose did not  the neutral  but not the acidic  fraction exhibited protective activity against st  22  vs  57  mortality  respectively  p less than  001   the fucosylated  but not the nonfucosylated  subfractions of the neutral fraction contained the factor protective against st  35  vs  50  mortality  respectively  p less than  05   an oligosaccharide isolation scheme based on different principles produced confirmatory results  the commercially available neutral fucosylated oligosaccharides of human milk did not significantly protect the mice from the effects of st  thus  the protective factor against st seems to be a minor neutral fucosyloligosaccharide of human milk  
class6	rotavirus specific antibody response in saliva of infants with rotavirus diarrhea  the reliability of saliva as an indicator of rotavirus infection was assessed among 15 infants  3 12 months  with rotaviral and 15 with nonrotaviral diarrhea  paired salivary samples collected during acute and convalescent phases were tested for rotavirus specific iga and igm by an elisa  the sensitivity of iga or igm alone to predict infection was 53 3  and 46 6   respectively  used in conjunction  the sensitivity rose to 80   it seems that infants with rotaviral diarrhea mount mucosal antibody responses as reflected in their saliva  possibly salivary antibodies could be used to evaluate vaccine  take  in rotavirus vaccine trials  
class6	adult immunization in a network of family practice residency programs  a substantial proportion of morbidity and mortality associated with vaccine preventable diseases occurs among adults  teaching residents about disease prevention is mandated in the curriculum guidelines for family practice programs  a cooperative study among the kansas city family practice residency programs was begun to look at immunization behaviors in these teaching programs  a retrospective audit of medical records and a prospective survey of residents and faculty were performed  from the medical records of 400 patients seen for health maintenance examinations  the frequency of tetanus diphtheria immunizations recorded was 4 75   the pooled immunization rate recorded for pneumococcal vaccine was 25   and for influenza vaccine  24   although 93  of respondents knew patients need tetanus diphtheria immunization every 10 years  on a written questionnaire giving clinical examples  they were less likely to elect to immunize older patients eligible for tetanus diphtheria vaccine  the following immunization criteria were listed by respondents  for pneumococcal vaccine  age over 65 years  86    for influenza vaccine  age over 65 years  85    chronic diseases  69    residence in a chronic care facility  7    and being a health care worker  28    educational interventions stressing the appropriate criteria and involvement of the patient are planned at the separate programs  
class6	phase i clinical and pharmacologic study of intraperitoneal cisplatin and fluorouracil in patients with advanced intraabdominal cancer  fluorouracil  5 fu  and cisplatin display marked therapeutic synergy in preclinical models and are effective in the treatment of a number of solid tumors when combined and administered intravenously  iv   each drug has also been administered intraperitoneally  ip  and displays a favorable pharmacologic profile and acceptable clinical toxicity  we therefore undertook a phase i study to determine the feasibility and toxicity of combination ip chemotherapy with these agents  thirty one patients with histologically documented malignancy confined to the peritoneal space were treated with cisplatin 90 mg m2 mixed with 5 fu in 2 l of lactated ringer s solution and given ip for 4 hours every 28 days  cohorts of at least three patients received starting 5 fu concentrations ranging from 5 mmol l  1 300 mg in 2 l  to 20 mmol l  the dose limiting toxicity was neutropenia with a median granulocyte nadir of 156 cells per microliter occurring at a 5 fu dose of 20 mmol l  intrapatient escalation of the 5 fu dose was permitted and 15 cycles of chemotherapy were delivered at 5 fu concentrations greater than 20 mmol l  the highest concentration being 30 7 mmol l  8 g of 5 fu in 2l   other toxicities included mild to moderate nausea during all cycles of therapy  vomiting in 54  of cycles  and diarrhea in 15  of cycles  abdominal pain  renal dysfunction  peripheral neuropathy  and oral mucositis occurred infrequently and were not related to the 5 fu dose  peritoneal fluid and plasma 5 fu concentrations were measured by high performance liquid chromatography  hplc  in selected patients  mean peak plasma 5 fu concentrations ranged from 6 19 mumol l to greater than 60 mumol l  and peritoneal fluid to plasma 5 fu area under the curve  auc  ratios ranged from 85 to 1 150  nine of 15 patients with nonbulky disease had resolution of malignant ascites or at least a 50  reduction of peritoneal studding by tumor at repeat laparotomy  we conclude that combination ip chemotherapy with cisplatin and 5 fu is technically feasible and has acceptable clinical toxicity and a favorable pharmacologic profile  the recommended starting 5 fu dose for phase ii trials is 3 900 mg mixed with 90 mg m2 of cisplatin in 2 l of isotonic fluid  
class6	transient renal acidification defect during acute infantile diarrhea  the role of urinary sodium  we studied urinary acidification daily during the hospital course of 16 infants with acute gastroenteritis and metabolic acidosis  urine ph value on admission was higher than 5 5 in 14  87   patients  we hypothesized that inappropriate urinary acidification was due to sodium deficiency and inadequate sodium delivery to the distal nephron  forty one urinary samples were collected during metabolic acidosis  the mean ph of 24 urine samples with sodium concentration less than 10 mmol l was significantly higher than the ph of 17 samples with sodium concentration greater than 10 mmol l  6 04     0 06 vs 5 19     0 1  p less than 0 001   the urine ratios of titratable acid to creatinine and of total acidity to creatinine were significantly higher in urine samples containing more sodium  p less than 0 02   whereas the ammonium creatinine ratio was not  after administration of furosemide or correction of the sodium deficit  appropriate acidification was observed  we conclude that impaired urinary acidification is frequently found during metabolic acidosis in infants with acute gastroenteritis and results from a sodium deficit rather than from transient distal renal tubular acidosis  
class6	azathioprine in the treatment of children with inflammatory bowel disease  during a 6 year period  we treated 21 patients with azathioprine  2 mg kg day  as an adjunct to their customary regimen  nine patients had ulcerative colitis and 12 patients had crohn disease  the patients  ages ranged from 3 to 17 years  the median duration of disease before the start of azathioprine therapy was 2 years  and median follow up was 2 years  sixteen patients seemed to respond to azathioprine therapy  six patients in each disease group had complete responses and four patients  one with ulcerative colitis and three with crohn disease  had partial responses  two patients with ulcerative colitis and three patients with crohn disease did not respond  the median time until patients responded was less than 3 months for patients with ulcerative colitis and 4 months for those with crohn disease  reduction of corticosteroid dose was possible for all patients who responded to azathioprine therapy  only minimal side effects were attributable to the drug  we conclude that azathioprine is an effective adjunctive agent for the treatment of inflammatory bowel disease in childhood  but because questions remain regarding its long term safety  its use should be reserved for children with refractory disease or severe and unacceptable side effects of corticosteroids  
class6	effects of cisapride in patients with cystic fibrosis and distal intestinal obstruction syndrome  in a double blind  placebo controlled  crossover trial  we investigated the effects of the prokinetic drug cisapride in patients with cystic fibrosis and chronic recurrent distal intestinal obstruction syndrome  dios   after a baseline period  17 patients  12 9 to 34 9 years  12 boys  received  in random order  cisapride  7 5 to 10 mg  and placebo three times daily by mouth  each for 6 months  gastrointestinal symptoms  flatulence  abdominal pain  fullness  abdominal distension  nausea  anorexia  heartburn  diarrhea  vomiting and regurgitation  were scored three times monthly and physical examinations assessed  at baseline and at each 6 month period  assessment included food intake for 7 days  3 day stool collection  pulmonary function tests  and abdominal radiographs  during cisapride therapy compared with placebo  there were significant reductions in flatulence  p less than 0 005   fullness  and nausea  p less than 0 05   patients with the worst symptom scores benefited most from cisapride  with cisapride  12 patients felt better and three worse  p less than 0 05   physicians judged 11 patients improved and two worse  p less than 0 05   no side effects were noted  there were no significant differences between cisapride and placebo periods in nutritional status  x ray scores  pulmonary function  food intake  fat  protein  calories   stool size and consistency  and fecal losses of fat  bile acids  chymotrypsin  and calories  for acute episodes of dios  intestinal lavage was needed 6 times in 4 patients during treatment with cisapride  and 11 times in 6 patients receiving placebo  in comparison with unselected patients with cystic fibrosis and pancreatic insufficiency who were receiving enzyme supplements and who had no distal intestinal obstruction  fecal fat losses  percentage of intake  were almost twice as high in the study group with dios  31 2     20 6  vs 16 2     17 6   p less than 0 01   we conclude that in the dosage used  long term treatment with cisapride appears to improve chronic abdominal symptoms in patients with cystic fibrosis and dios  but fails to abolish the need for intestinal lavage  cisapride treatment had no effect on digestion and nutritional status of cystic fibrosis patients with pancreatic insufficiency  
class6	prospective study of the frequency and size distribution of polyps missed by colonoscopy  an important determinant in interpreting the results of colorectal polyp chemoprevention trials is the rate of polyps missed during colonscopic examination  we prospectively examined 90 patients by tandem colonoscopy performed by two alternating examiners  in 69  76 7   patients  221 neoplastic lesions were documented histologically  of a total of 58 lesions detected in 31 patients  no neoplastic lesion greater than or equal to 10 mm in size was missed  16  of diminutive  less than or equal to 5 mm  neoplastic polyps and 12 3  of medium sized  6 9 mm  neoplastic polyps were missed by the first examiner  we conclude that an experienced colonoscopist will miss about 15  of colorectal neoplastic polyps less than 10 mm in size in the setting of adequate bowel preparation  large  greater than or equal to 10 mm  polyps were rarely missed  however  with the  miss  rate in our study equal to 0  with a 95  confidence limit of 4 64   
class6	effect of endotoxin and a burn injury on lung and liver lipid peroxidation and catalase activity  both endotoxin and a burn alone produce oxidant induced tissue lipid peroxidation  the endotoxin response is due in large part to hydrogen peroxide  the combination of endotoxin after a burn results in an increased liver  but not lung  oxidant injury  our purpose was to determine whether the burn oxidant injury inactivated endogenous liver tissue catalase  thereby amplifying a subsequent h2o2 insult  twenty six adult sheep were studied  twelve sheep had a 15  tbs burn  tissue catalase activity  measured in lung and liver 3 days postburn  was significantly decreased from a control of 3 58     1 8 and 193     63  respectively  to 1 72     0 63 and 148     33 k sec 1  0 5 gram tissue  the addition of endotoxin 3 days postburn resulted in an increase in liver malondialdehyde  mda  a measure of lipid peroxidation  from a control of 110     80 to 450     54 nmol gram tissue  this value was significantly greater than the 210     80 nmol gram tissue seen after endotoxin alone  lung tissue mda with burn and endotoxin was 65     8 compared to 42     7 for control and 80     6 nmol gram for endotoxin alone  we conclude that a decrease in liver catalase activity occurs after a burn  the decrease corresponds to an accentuated oxidant induced lipid peroxidation after an added endotoxin insult where h2o2 is known to be an etiologic agent  the catalase activity also decreases in postburn lung  but accentuated lung damage was not seen  indicating a variable tissue response from the burn induced decrease in antioxidant activity  
class6	the abdominal trauma index  a critical reassessment and validation  the abdominal trauma index  ati  was devised to quantify the risk of complications following abdominal trauma  with scores greater than 25  the risk of postoperative complications became exponential  the purpose of the present study was to determine if  1  the organ risk factors previously assigned were more statistically valid  and 2  the addition of physiologic variables would enhance the prediction of postinjury intra abdominal sepsis  fifteen abdominal organ systems and 17 physiologic variables in 300 consecutive patients were analyzed to determine ability to predict intraabdominal sepsis  there were no significant differences in predictive ability between the old and new organ risk factors  the addition of physiologic factors did not enhance the prediction of intra abdominal sepsis  this clinical study demonstrates that  1  the risk of intra abdominal sepsis increases with increasing ati score  2  the previous  1979 initial  organ risk grading concept is statistically valid  3  six of the 15 organ systems warrant a change in their relative rank order  1989 revision   4  the addition of demographic  physiologic  and immunologic variables did not significantly improve the prediction of intra abdominal sepsis  
class6	gastrointestinal pathology in adult iron overdose  the gastrointestinal effects of iron overdose have been described in children  they may occur acutely  ranging in severity from mucosal injury to complete infarction  or several weeks later  as obstruction due to stricture formation  they typically occur in the stomach or proximal small bowel  we describe an adult example of both  each occurring in the distal portion of the small intestine  both patients had ingested enteric coated iron preparations and both experienced significant  protracted abdominal pain  thus adults as well as children are at risk for severe gastrointestinal complications after iron overdose  significant protracted abdominal pain should alert the clinician of its possibility  damage to distal areas of the bowel can occur with complete sparing of proximal portions particularly if the iron is an enteric coated preparation  
class6	renal scintigraphy in the diagnosis and surgical management of a patient with caliceal colic  a case report  a patient with persistent renal colic and a caliceal stone is presented  furosemide renography  commonly used to differentiate functional stasis from mechanical obstruction of an entire kidney or duplicated collecting system  can make this determination at the caliceal level  as in this case such determination can affect clinical management of the patient  
class6	small cell carcinoma of the pancreas and biliary tract  four cases of anaplastic carcinoma of the pancreas or biliary tract were studied clinicopathologically and immunohistochemically  all four cases were intermediate cell type and contained a minimum amount of microscopic foci of differentiated glandular adenocarcinoma  argyrophilic tumor cells were not seen in any of the four tumors  immunohistochemically  no tumor was positive for hormonal products  but all tumors were positive for epithelial markers  these findings suggest that the anaplastic carcinoma are not derived from argyrophilic cells  but rather from adenocarcinomas which have the potential for anaplastic metaplasia  the long term survival of one patient emphasized the importance of chemotherapy in the treatment of small cell carcinoma of the pancreas and biliary tract  
class6	obstructing carcinoma of the cecum  carcinoma of the cecum  the third most common location for malignancy of the large bowel  was examined with attention centered upon cecal cancers producing obstruction  reviewing 136 patients revealed 11 obstructing lesions  8 1   presenting as distal small bowel obstructions  the mean age of the patients was 74 years  all but one patient had resection for cure which consisted of a right hemicolectomy with ileotransverse colostomy  there was no operative mortality or significant morbidity  bowel obstruction due to cecal carcinoma is an infrequent occurrence arising in elderly patients and carries a poor survival rate due to advanced disease at the time of diagnosis and treatment  
class6	complications of stapled anastomoses in anterior resection for rectal carcinoma  colorectal anastomosis versus coloanal anastomosis  postoperative results of 48 patients who underwent anterior resection using the eea stapler were evaluated  in all but 2 cases the indication for surgery was colorectal carcinoma  in 24 patients an anastomosis was created above the 5 cm level  above the anal verge  colorectal anastomosis  and in 24 at the 0 5 cm level  coloanal anastomosis   there was no perioperative mortality  the only complication observed in the colorectal anastomosis group was one case of late anastomotic stenosis  in the coloanal anastomosis group there were 4 cases with early anastomosis leaks  3 cases with late stenosis and 5 cases with various degrees of late fecal incontinence  ultimately resulting in a permanent diverting stoma in 5  10 4   patients  we conclude that for rectal tumors the eea stapled anterior resection provides excellent functional results in most cases  stapled coloanal anastomoses more often demonstrate various  early and late  complications  nevertheless in spite of chronic discomfort  many patients still prefer their complaints to a permanent stoma  
class6	assessment of functional gastrointestinal disease  the bowel disease questionnaire  a need exists for a self report questionnaire that reliably and accurately measures symptoms and that distinguishes patients with functional gastrointestinal disease from those with other conditions  we have developed such an instrument  the bowel disease questionnaire  and herein describe details of its discriminatory validity  data from 399 subjects were analyzed  patients with gastrointestinal symptoms were ultimately diagnosed as having functional gastrointestinal disease  82 with the irritable bowel syndrome and 33 with functional dyspepsia  or organic gastrointestinal disease  n   101   there were 145 healthy control subjects and 38 patients with a psychiatric disease  somatoform disorder  which includes those with a diagnosis of hypochrondriasis  psychogenic pain  and somatization or conversion disorder   all subjects completed the questionnaire before undergoing an independent diagnostic assessment by experienced physicians  functional gastrointestinal disease could be distinguished from organic disease  somatoform disorder  and health by using models derived from logistic discriminant analysis  with use of these models  the estimated probability of functional gastrointestinal disease was then calculated  descriptive symptom scores were of less value than the scores derived from the data sets by logistic discriminant analysis  age did not significantly affect the responses to the questionnaire items  we conclude that  in the population studied  the bowel disease questionnaire is a valid measure of symptoms of functional gastrointestinal disease  and this instrument may have clinical and research applications  
class6	impact of active immunisation against enteritis necroticans in papua new guinea  enteritis necroticans  known locally as pigbel  has been a major cause of illness and death among children in the highlands of papua new guinea  after a successful trial of active immunisation against the beta toxin of the causative organism  clostridium perfringens type c  immunisation of children was begun in 1980  the effects of the immunisation programme on pigbel admissions in 3 of the 5 major highland hospitals were assessed  in each of the centres studied the proportion of admissions due to enteritis necroticans dropped significantly after immunisation was introduced  p less than 0 001  and hospital admissions for pigbel in 1984 86  when immunisation was well established  were less than one fifth of previous figures  
class6	preliminary report  the antegrade continence enema  the principles of antegrade colonic washout and the mitrofanoff non refluxing catheterisable channel were combined to produce a continent catheterisable colonic stoma  the intention was that antegrade washouts delivered by this route would produce complete colonic emptying and thereby prevent soiling  the procedure has been successfully carried out in five patients with intractable faecal incontinence  
class6	increased cholecystectomy rates in saudi arabia gallstones have become increasingly prevalent in saudi arabia  where cholecystectomy is now one of the commonest major abdominal operations  2854 people underwent cholecystectomy in the 14 hospitals of the country s eastern province in the years 1977 to 1986  during this period the overall frequency of cholecystectomy increased by 978   a finding not explained by the 67  increase in population or the 87  increase in other operations  simultaneously  the average daily individual consumption of total calories  fat  and sugar increased by 81   197   and 164   respectively  and consumption of high fibre grain fell by 75   this striking increase in the frequency of cholecystectomy  which presumably reflects the incidence of gallstones  cannot be explained by demographic changes and seems more closely linked to the concomitant changes in dietary habits  
class6	binding to human jejunum of serum iga antibody from children with coeliac disease  jejunal histology and the presence of serum iga antibodies  jab  binding to human jejunum in vitro were studied in 139 children with severe malabsorptive symptoms  among 33 children with confirmed coeliac disease  espgan criteria   13  93   of 14 sampled before starting on a gluten free diet had jab  none of 21 sampled had jab while on a gluten free diet of long duration  and 90  of 30 sampled during gluten challenge had jab  53 children had severe jejunal villous atrophy  probable coeliac disease   71  of those younger than 2 years and 94  of those aged 2 18 years had jab during gluten intake  jab could not be detected in 53 disease control patients  normal jejunal histology  and in 3 coeliac disease patients with selective iga deficiency  simultaneous determination of antigliadin  aga  and antiendomysium  ema  levels  and gliadin and tissue absorption studies  showed that jab and aga are different  whereas jab and ema are probably identical  iga jab could be the target organ related autoantibodies in coeliac disease  
class6	a chronic granulomatous syndrome of unknown origin  a small clinically distinct group of patients with widespread tissue granulomata are described  the principal presenting symptoms are malaise  fever  and weight loss  although a wide variety of complaints are documented  pulmonary involvement is uncommon  the granulomata are noncaseating with a few multinucleate giant cells and some surrounding chronic inflammatory infiltrate  there is no evidence of an associated arteritis  the disease has a relapsing and remitting course and although it may require treatment with immunosuppressive drugs  particularly if the kidneys are involved  the prognosis is relatively good  we propose that this entity be called granulomatous syndrome of unknown origin  the characteristics that set this syndrome apart from the other granulomatous vasculitides are discussed  the current limited understanding of granuloma formation does not allow us to propose a definite etiology for this condition  it is emphasized that it is not helpful to encompass it within a label of sarcoidosis  first  it may only serve to confuse the doctor in assessing and treating this very particular group of patients  secondly  it may hinder future attempts to understand the different pathogenetic mechanisms underlying the various conditions in which granulomata may arise  
class6	pancreaticopleural fistula  report of 7 patients and review of the literature  pancreaticopleural fistula is an uncommon clinical condition  its presentation is often confusing because of the paucity of clues suggestive of pancreatic disease and the preponderance of pulmonary symptoms and signs  most patients are alcoholics but only one half will have a clinical history of previous pancreatitis  pleural effusions are large  recurrent  and highly exudative in nature  many patients go through extensive pulmonary evaluation before the pancreas is identified as the site of primary pathology  an elevated serum amylase may be the first clue to the diagnosis  however  the key to the diagnosis is a dramatically elevated pleural fluid amylase  effusions in association with acute pancreatitis  esophageal perforation  and thoracic malignancy are important to consider in the differential diagnosis of an elevated pleural fluid amylase but are usually easy to exclude  computed tomography is excellent in defining pancreatic abnormalities and should be the first abdominal imaging study in suspected cases  endoscopic retrograde cholangiopancreatography  ercp  is used as a diagnostic tool only in confusing cases  although no systematic study evaluates medical versus surgical therapy  we recommend an initial 2 to 4 week trial of medical therapy  including allowance of no oral intake  total parenteral nutrition  chest tube thoracostomy  and possibly a regimen of somatostatin or its analogs  the major complication in these patients is superinfection  which results in significant morbidity and mortality  failure of medical therapy should be considered failure of pleural effusion s  to clear  recurrence after reinstatement of oral intake  or superinfection  for those patients who fail to benefit from medical therapy  surgery is indicated  
class6	coccidioidomycosis during human immunodeficiency virus infection  a review of 77 patients  through a retrospective review  we identified 77 previously unreported cases of coccidioidomycosis during hiv infection  patients were classified into 1 of 6 categories based on their primary clinical presentation  20 had focal pulmonary disease  group 1   31 had diffuse pulmonary disease  group 2   4 had cutaneous coccidioidomycosis  group 3   9 had meningitis  group 4   7 had extrathoracic lymph node or liver involvement  group 5   and 6 has positive coccidioidal serology without a clinical focus of infection  group 6   coccidioidal serologies were positive on initial testing in 83  of the patients in whom such serologic testing was performed  sera from 39  of patients were positive for tp antibodies while 74  had cf antibodies  eleven of 12 seronegative patients had pulmonary disease  group 1 or 2   serologic results of other patients sent to a single reference laboratory were similar  with 26  positive for immunodiffusion tp antibodies and 79  positive for immunodiffusion cf antibodies  for the 77 patients in this study  the cd4 lymphocyte count was below 0 250 x 10 9  cells l in 46 of the 55 patients who had this test performed  and a low cd4 count was significantly associated with mortality  p less than 0 01   at the time of follow up  32 of the 77 patients  42   had died  there were significantly more deaths in those with diffuse pulmonary disease  group 2  than in other groups  p less than 0 001   amphotericin b  ketoconazole  fluconazole  and itraconazole were all used as antifungal therapies  outcome could not be related to the therapy used  of note  3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions  
class6	aspiration in bilateral stroke patients  seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations  34  48 6   aspirated  patients with aspiration were more likely to have posterior circulation strokes  abnormal cough  abnormal gag  and dysphonia  however  patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough  an abnormal gag reflex  or both  the prediction of patients at risk for aspiration was not improved by additional clinical information  ie  presence of dysphonia or bilateral neurologic signs   
class6	cyclic pelvic pain  cyclic pelvic pain is a common gynecologic problem caused by relatively few diseases  which usually can be diagnosed and remedied quickly  some complaints reflect normal physiologic aspects of the menstrual cycle  mittelschmerz  menstrual awareness   premenstrual syndrome can be diagnosed  but an effective and convenient treatment is lacking  dysmenorrhea is the commonest source of cyclic pain  diagnosed by its characteristic history and rapid relief on administration of antiprostaglandin agents  endometriosis is diagnosed surgically and best treated either surgically then  or medically by danazol or gnrh agonists  in contrast  adenomyosis is a problem commonly encountered in later life  and hysterectomy is usually needed for both definitive diagnosis and treatment  
class6	pelvic pain and infections  infectious etiologies of both acute and chronic pelvic pain are common and may involve multiple organ systems  in the evaluation of the acute pain  it is important to remember that rapidity of diagnosis is important because of the possibility of significant morbidity and even death if a condition is not attended to rapidly  in recent years  laparoscopic evaluation of the pelvis has provided a better understanding of the pathophysiology of some of these infections  as well as possible therapeutic maneuvers  the evaluation of chronic pelvic pain requires a thorough attempt at careful diagnosis with minds open to the possibility that other organ systems besides the genital tract may be involved  laparoscopy also may be an important diagnostic and therapeutic tool in the evaluation of the sequelae of pelvic inflammation leading to chronic pelvic pain  all therapeutic modalities that are instituted on the basis of the diagnostic evaluation must take into consideration that a strong emotional component is generally associated with chronic pelvic pain  such components must be addressed in order to achieve the best possible results for the patient  
class6	an epidemic outbreak of cryptosporidiosis  a prospective community study from guinea bissau  in the first year of a prospective community study of childhood diarrhea conducted in a semiurban area in the capital of guinea bissau  cryptosporidium sp  was found in 73  6 0   of 1216 episodes of diarrhea  the parasite was the second most prevalent intestinal parasite  and the only one significantly associated with diarrhea  or   2 79  p   0 0006   the seasonal distribution was striking  with a peak prevalence in the beginning of the rainy season  may 17 6   when an epidemic outbreak of diarrhea started  the prevalence was highest in children younger than 18 months  an age at which prevalences of other intestinal parasites were low  this reverse age pattern may possibly be explained by the small infective dose needed to create severe infections  by air borne transmission and by the development of protective immunity  
class6	case control study of cryptosporidium parvum infection in peruvian children hospitalized for diarrhea  possible association with malnutrition and nosocomial infection  a retrospective  hospital based case control study was used to investigate whether there were any clinical characteristics that could distinguish cryptosporidium parvum infected children with diarrhea from other non c  parvum infected children with diarrhea  ten percent  24 of 248  of children admitted to a rehydration ward at cayetano heredia university hospital  lima  peru  were infected with c  parvum  the 24 patients infected with c  parvum  cases  were matched to an equal number of noninfected patients  controls   c  parvum infected patients were more likely to be malnourished than were children without this infection  p less than 0 05   also nosocomial infection caused by c  parvum occurred in three severely malnourished patients  two of whom died  no other clinical or laboratory characteristics were found that would distinguish children with diarrhea caused by c  parvum from other children with diarrhea  in children hospitalized for diarrhea c  parvum infection occurs most frequently in malnourished children  
class6	clinical features of adenovirus enteritis  a review of 127 cases  we retrospectively analyzed the clinical features of 127 hospitalized pediatric patients whose fecal samples were positive for adenovirus  ad  by electron microscopy during an 18 month period  serotyping results obtained by microneutralization tests and restriction endonuclease analysis were available for 105 of 127 cases  there were 69 males and 58 females and 94  of patients were less than 4 years of age  the average body temperature was 38 degrees c rectal  range  36 2 40 8 degrees c  with an average duration of fever of 1 6 days  the average duration of clinical illness was 8 8 days  range  1 to 32 days   although ad 40 and ad 41 were isolated in the majority of cases  59 of 105  56    ad 31 was associated with 18 of 105 cases  17    of the 18 cases associated with ad 31  14 were nosocomial and associated with diarrhea  our survey confirms the importance of fastidious enteric ad in infantile diarrhea  ad 40  ad 41  and suggests that ad 31 produces a clinical syndrome indistinguishable from that caused by ad 40 and ad 41  the occurrence of ad enteritis in patients admitted for unrelated illnesses well after initial hospitalization suggests that ad is also an important cause of nosocomial enteritis in our hospital  
class6	advanced assessment of the abdomen and gastrointestinal problems  there are many unique physical assessment findings that are associated with specific gastrointestinal disorders  the detection of these findings enables the nurse to manage gastrointestinal emergencies on the patient unit in a timely fashion  preventing deterioration and maintaining the safety of the patient  these skills build well on the traditional  detailed  and comprehensive assessments the nurse makes when using the nursing process  specific abdominal assessments include detection of signs associated with appendicitis such as rebound tenderness and mcburney s  rosvig s  and aaron s signs  the nurse must always be alert to the possibility of peritonitis and the urgency of early detection and treatment  the patient with cirrhosis of the liver presents a distinct clinical picture  there is a need for subtle evaluation of mental status to detect early signs of hepatic coma  another extra abdominal assessment of this complication is asterixis  finally  the assessment of the patient is enhanced when the nurse is able to help identify the location of bleeding  improving abdominal and gastrointestinal system assessment leads to early detection of nursing problems and appropriate interventions  
class6	nausea  vomiting  and retching  although nausea  vomiting  and retching have plagued mankind since antiquity  limited attention has been given to the three symptoms as separate entities  although knowledge of symptom occurrence is essential to practice  nurses must focus on patients  response or distress to the occurrence of symptoms  the differentiation of symptom occurrence and symptom distress of nausea  vomiting  and retching is critical to the management and self care demands of patients and the enhancement of their quality of life  basic research on patterns of these individual symptoms and their components promises to provide a more progressive and fruitful approach to the patient response to these symptoms  
class6	diarrhea  diarrhea is one manifestation of gi disturbance  symptoms may be acute if caused by such things as infections  drug reactions  alterations in diet  heavy metal poisoning  or fecal impaction  chronic diarrhea is a symptom of gi diseases such as irritable bowel syndrome  lactase deficiency  cancer of the colon  inflammatory bowel disease  and malabsorption diseases  chronic diarrhea may also be associated with gi surgery  radiation therapy  laxative abuse  alcohol abuse  and chemotherapeutic agents  when interventions are required to deal with diarrhea  they may include such things as alteration in tube feeding products and methods of administration  fluid replacement by oral rehydration procedures  a rapid return to feeding  and education aimed at the health information clients need to prevent or control the symptom of diarrhea  
class6	colonoscopy in critically ill patients  what conditions call for it  indications for colonoscopy in the intensive care unit include acute lower intestinal bleeding  sigmoid volvulus  pseudo obstruction of the colon  and suspicion of pseudomembranous colitis  although the incidence of cardiorespiratory complications may be higher in these critically ill patients  the procedure can be done safely with proper attention to detail  because of colonic dilatation  endoscopy can often be done without bowel preparation  
class6	interventional radiologic alternatives to cholecystectomy  it has been estimated that 20 million people in the united states have gallstone disease  the choice of the optimal management strategy for a patient with symptomatic gallstones in the 1990s will take into account the clinical status of the patient  the characteristics of the gallstones  and the patient s preference  only patients whose doctors understand the advantages and disadvantages of the newer methods can make properly informed choices  when interventional radiologic alternatives to cholecystectomy are being contemplated  one approach is to first consider the patient s clinical presentation  acute or nonacute  and then their risk of death after cholecystectomy  low or high   figure 5 shows an algorithmic approach to the management of gallbladder stones based on this concept  this algorithm also can be used as a framework for discussion of treatment options with any individual patient  
class6	interventional radiology of the biliary tract  transcholecystic intervention  diagnostic and therapeutic biliary intervention by percutaneous access to the gallbladder is an important new area in interventional radiology  the anatomy of the gallbladder  biliary tree  and surrounding viscera is reviewed in this article as a preliminary to discussion of the diagnostic techniques of aspiration  cholangiography  biopsy  and the therapeutic techniques of gallbladder drainage and cholelithotomy  recently there has been a bewildering proliferation of procedures aimed at removal  fragmentation  and dissolution of gallbladder stones  several of these are discussed in this article  removal of common bile duct stones by percutaneous cholecystostomy also is discussed  
class6	interventional gallbladder procedures  interventional radiologic procedures in the gallbladder are influencing both the diagnosis and therapy of many gallbladder disorders  current diagnostic and therapeutic percutaneous techniques offer important alternatives for their management  this article highlights the spectrum of interventional radiologic techniques available for gallbladder diseases  
class6	intracorporeal biliary lithotripsy  most bile duct calculi can be removed with standard percutaneous or endoscopic techniques  very large stones are the most common cause for failure  intracorporeal lithotripsy  and ehl in particular  can be used safely in either the biliary tree or gallbladder to fragment these large stones and allow percutaneous removal or passage  intracorporeal ehl requires direct vision to prevent damage to the bile duct mucosa  intracorporeal laser lithotripsy may offer some safety advantages  but the laser requires much more expensive equipment than intracorporeal ehl  additional studies are needed to determine the technique that is better in each circumstance  
class6	technical aspects of biliary extracorporeal shock wave lithotripsy  radiologic imaging procedures play a major role in the evaluation of the potential patient for biliary extracorporeal shock wave lithotripsy  both during the procedure and in follow up evaluation  the treating physician must have a thorough knowledge of ultrasonography techniques  lithotripsy requires continual monitoring and frequent reassessment to optimize targeting and fragmentation of the gallstones while maintaining patient comfort  
class6	clinical experience with biliary extracorporeal shock wave lithotripsy  biliary lithotripsy is a new and important development in the nonsurgical management of gallbladder  cystic duct  and bile duct stones  most patients do not require general or epidural anesthesia with newer second generation machines  patient selection and the use of adjuvant therapy to aid fragment clearance are important issues that are discussed  results from different centers are compared but few long term results are yet available  i e   longer than 18 months  
class6	ablation of the cystic duct and the gallbladder  experimental basis and initial clinical observations  bipolar radiofrequency electrocoagulation of the cystic duct by catheter can be performed safely and reproducibly using fluoroscopic control and induces endoluminal scar formation  the scar within the cystic duct forms a reliable barrier between the gallbladder and the biliary system and avoids recanalization of the cystic duct at a later date  sclerotherapy of the isolated gallbladder with 95  ethanol and 3  sts can be performed without toxic or otherwise adverse effects and is suitable to ablate the porcine gallbladder  initial clinical trials with this new technique on a small number of patients are promising and have demonstrated that the protocol can be applied safely to humans  the electrocoagulation technique by catheter appears suitable to ablate the human cystic duct  follow up evaluation of our first patients is under way and must determine whether our regimen is appropriate to ablate the human gallbladder on a long term basis  further development of this new approach may eventually enable definitive nonoperative treatment of cholecystolithiasis in selected patients  
class6	combined radiologic and retrograde endoscopic and biliary interventions  methods of treating complex biliary duct problems by a team composed of an endoscopist and interventional radiologist are described  these procedures are of two types  those in which all manipulations are performed through the endoscope and those in which an antegrade transhepatic and a retrograde endoscopic approach are combined  
class6	a case of group b streptococcal pyomyositis the group b streptococcus is an opportunistic pathogen that causes a variety of serious infections including bacteremias  puerperal sepsis  and neonatal meningitis  group b streptococcal infections of muscle are rare  we report here an unusual case of group b streptococcal pyomyositis  pyomyositis arises predominantly from infections caused by staphylococcus aureus and  occasionally  streptococcus pyogenes  because of the rarity of pyomyositis in temperate climates  the common lack of localizing signs or symptoms  and the frequently negative blood cultures  considerable delay often precedes the diagnosis of pyomyositis  in fact  the infection has been initially misdiagnosed as muscle hematoma  cellulitis  thrombophlebitis  osteomyelitis  or neoplasm  diagnosis may be greatly aided by radiologic techniques that can demonstrate the sites of muscle enlargement and the presence of fluid collections  the response to antibiotics is usually rapid  but resolution of the infection may require aspiration of deeply situated muscle abscesses  this report describes a diabetic patient with an unusual presentation of pyomyositis that mimicked an acute abdomen  
class6	visceral protothecosis mimicking sclerosing cholangitis in an immunocompetent host  successful antifungal therapy  a healthy 39 year old man who had clinical findings consistent with sclerosing cholangitis was found to have systemic protothecosis at surgery  severe granulomatous inflammation and palpable nodules were found in the gallbladder  on the surface of the liver  and in the duodenum  prototheca wickerhamii was detected in biopsied specimens and stool  the titer of indirect fluorescent antibody to this organism was 1 2 000  the patient recovered after a short course of treatment with amphotericin b and 3 months of oral therapy with ketoconazole  he had no other concurrent illness and had no abnormality in his immune system  this is the second reported human case of systemic protothecosis  an elevated igg level  an elevated erythrocyte sedimentation rate  eosinophilia  and abnormal levels of enzymes in the liver were found in both cases  protothecosis should be considered in the differential diagnosis of hepatic and biliary inflammatory diseases of uncertain etiology  
class6	postoperative pancreatic abscess due to plesiomonas shigelloides  plesiomonas shigelloides is being recognized with increasing frequency as a human pathogen  the organism is ubiquitous in fresh and brackish water  and clinical illness has been associated with foreign travel and ingestion of inadequately cooked seafood  we describe a 64 year old filipino woman who presented 2 weeks after elective cholecystectomy and pancreatic biopsy with left upper quadrant pain  abdominal distention  and fever  computerized tomography of the abdomen revealed an abscess in the tail of the pancreas with fluid accumulation in the lesser omental sac  percutaneous aspiration yielded purulent material  and p  shigelloides was recovered in pure culture  to our knowledge  this is the first reported case of pancreatic abscess due to p  shigelloides  
class6	emphysematous gastritis  case report and review  emphysematous gastritis is a condition involving gastric wall inflammation  radiologic or intraoperative evidence of intramural gas  and systemic toxicity  a recent case of emphysematous gastritis in a 57 year old diabetic man is reported  and 27 cases published since 1889 are reviewed  predisposing factors include ingestion of corrosive substances  37   and alcohol abuse  22    diagnosis of emphysematous gastritis is based on the clinical presentation of an acute abdomen with systemic toxicity and on radiographs demonstrating gas bubbles within the stomach wall  for the case reported herein  computed tomography was useful both in establishing the diagnosis and in following the resolution of emphysematous gastritis  organisms most commonly involved were escherichia coli  six cases   streptococcus species  six cases   enterobacter species  five cases   and pseudomonas aeruginosa  three cases   the mortality was 61   17 of 28 patients   and morbidity with gastric contractures occurred in 21  of cases  6 of 28   optimal therapy has not been defined  however  antimicrobial chemotherapy and surgery  when appropriate  may improve survival rates  
class6	preventing colorectal cancer  knowledgeable patients should not die of colorectal cancer  increasing the intake of dietary fiber  decreasing fat consumption  and increasing the use of modern technology to detect adenomatous polyps and early cancer can greatly decrease the mortality associated with colorectal cancer  
class6	normeperidine induced seizures in hereditary coproporphyria  seizures are common in acute exacerbations of hepatic porphyria  even though the etiology is not identified in most cases  we have reported a case of normeperidine induced seizures in a patient with hereditary coproporphyria  although meperidine is commonly used for pain control during acute attacks in these patients  this report suggests that meperidine is not a good analgesic choice in porphyria  normeperidine induced seizures in patients with porphyria may be treated by withdrawal of meperidine therapy and selective use of anticonvulsants  
class6	traumatic diaphragmatic hernia and intestinal obstruction due to penetrating trunk wounds  we have reported two cases of intestinal obstruction due to traumatic diaphragmatic hernia  both resulting from apparently trivial knife wounds  when tdh is due to a penetrating injury  it tends to produce symptoms of intestinal obstruction  a high index of suspicion  a chest x ray film  and barium studies of the gastrointestinal tract are usually needed to make the diagnosis  though ct scans  ultrasonography  laparoscopy  and radionuclide scanning may also be useful  surgeons and emergency physicians should be aware of the potential for tdh when there is a history of a penetrating wound of the chest or abdomen  
class6	adenocarcinoma of the appendiceal stump  we have reported the case of a 58 year old woman with nonspecific abdominal complaints in whom barium enema and subsequent colonoscopy showed a 3 cm lobulated adenocarcinoma within a villous adenoma arising from the appendiceal stump  because such appendiceal malignancies have no specific clinical signs  symptoms  or radiologic features  preoperative diagnosis is extremely difficult  and colonoscopy may be required to clarify radiologically demonstrated irregularities  
class6	adenocarcinoma of the colon occurring with intussusception in an adolescent  hydrostatic reduction of intussusception is definitive therapy in most infants with this abnormality  in the older child  adolescent  and adult  a polyp or tumor is often present  operative intervention should be considered earlier in the clinical course both to relieve the intussusception and to define the nature of the lead point  
class6	preventing postoperative acute bleeding of the upper part of the gastrointestinal tract  two hundred and ninety eight critically ill patients at risk for the development of postoperative stress ulcers and bleeding were randomized into three groups  the first group comprised 85 patients who received meciadanol  a new bioflavonoid  500 milligrams every six hours through a nasograstric tube  the second group comprised 100 patients who received sucralfate  crushed tablets   1 000 milligrams every six hours through a nasogastric tube  and the third group comprised 113 patients who received an antacid  maalox  magnesium aluminum hydroxide gel   through a nasogastric tube at an initial dose of 15 milliliters every hour  the gastric ph was measured hourly and titrated to a ph greater than or equal to 4 0 in patients in the group receiving the antacid  the gastric ph was measured every two hours in the other two groups  bleeding in the upper part of the gastrointestinal tract was determined visually  frank blood in gastric contents  or by guaiac testing  bleeding occurred in seven patients receiving meciadanol  nine receiving sucralfate and six receiving the antacid  the difference in rates of bleeding was not statistically significant  correlation between the severity of illness index and the development of bleeding was poor  at least in the low and intermediate index range  in contrast  there was a strong correlation between the age of the patient and the development of bleeding  only one patient younger than 50 years had bleeding develop  apparently  meciadanol exerts its action by a mechanism other than ph control  it may  therefore  fill an important gap in the ability to prevent postoperative stress ulcers and bleeding  
class6	intraoperative scintigraphy for active small intestinal bleeding  localizing active sites of bleeding within the small intestine remains a difficult task  endoscopic  angiographic or scintigraphic studies may point to the small intestine as the site of blood loss  but at operation  without a palpable lesion  the exact site of bleeding remains elusive  patients are managed at laparotomy with intraoperative endoscopy  angiography  multiple enterotomies   blind  resections  or placement of an enterostomy  we describe two patients in whom intraoperative scintigraphy accurately identified active sites of bleeding in the small intestine when other modalities failed  intraoperative scintigraphy is rapid  easy to perform and is an effective means of identifying active sites of bleeding within the small intestine  
class6	high or low hepaticojejunostomy for bile duct strictures  the 19 patients who underwent 22 postoperative repairs of bile duct stricture in our institution between 1973 and 1984 were evaluated to assess whether the recognition of the tenuous blood supply of the supraduodenal bile duct in 1979 had improved the results thereafter  thirteen of these 22 operations followed a previous biliary tract repair  in 10 of the operations a low anastomosis had been performed without taking blood supply into account  follow up was complete and ranged from 5 to 15 years  there were no operative deaths and minimal morbidity  there were three deaths at a later time  five of the 11 patients treated by surgery to 1979 had a clinically unsatisfactory result  recurrent strictures developed in all five patients  all but one of the eight patients receiving a high hepaticojejunostomy from 1980 had a clinically satisfactory result with no recurrent strictures  the one exception was the patient who had a second repair with separate high right and left hepatic duct anastomoses and who has ongoing symptoms from preexisting secondary sclerosing cholangitis  the results in the five high repairs performed for low strictures were particularly striking  all five were asymptomatic  this study lends support to the hypothesis of an ischemic basis for biliary strictures and to the recommendation that strictures be repaired with a high hepaticojejunostomy  
class6	biliobiliary fistula  preoperative diagnosis and management implications  experience with cholecystohepaticodochal and cholecystocholedochal fistulas as a result of an erosion of gallstones from the gallbladder into the adjacent common duct in five patients is presented  the incidence was 1 4  in a population of 350 patients undergoing cholecystectomy  the condition was indicated clinically on the basis of a symptom triad of jaundice  fever  and pain with cholelithiasis in a small contracted gallbladder  in addition  proximal intra  and extrahepatic ductal dilatation  calculus in the common duct  and normal caliber  or unprofiled  distal common duct on ultrasound scan were present in all the patients  endoscopic retrograde cholangiopancreatography proved to be the most useful means of investigation  and it confirmed the diagnosis in four patients before surgery  a modified antegrade cholecystectomy was performed with the gallbladder opened inferiorly at the fundus  and the stones were evacuated  a partial cholecystectomy and choledochoplasty were accomplished with gallbladder flaps whenever feasible  other useful operative procedures are side to side hepaticodochojejunostomy and hepaticodochoduodenostomy  in the presence of high benign bile duct stricture  an approach to the left hepatic duct is now preferred for biliary bypass  
class6	the role of gastric resection in the management of multicentric argyrophil gastric carcinoids  a patient with pernicious anemia  atrophic non antral gastritis  hypergastrinemia  and widespread hyperplasia of enterochromaffin like cells and manifest enterochromaffin like cell carcinoma was followed up during 39 months  including 15 months after gastric resection  in this case normalization of gastrin levels did not prevent the development of multiple gastric carcinoids in the fundic mucosa  suggesting that factors other than gastrin are of importance in the pathogenesis  
class6	esophageal reflux before and after isolated myotomy for achalasia  four patients with achalasia underwent 24 hour esophageal ph measurements as ambulatory patients before and after limited myotomy without fundoplication  resting lower esophageal sphincter pressure was reduced from 24 3     1 3 mm hg to 7 5     4 3 mm hg  no significant differences  p greater than 0 05  were found before and after operation in the total 24 hour ph data distribution  ph 6 24     0 84 vs 5 75     1 03   the fraction of time below ph 4 0  4 8      5 3  vs 8 0      6 9    or the mean duration of reflux episodes greater than 5 minutes  22 8     18 8 minutes vs 23 0     10 minutes   all     sd  effective relief of esophageal obstruction in achalasia is feasible by isolated limited myotomy without producing gastroesophageal reflux  
class6	incisional parapubic hernias  a parapubic hernia  distinct from other lower abdominal wall hernias  is identified as a particular type of incisional hernia  this hernia results from the disruption of the musculotendinous elements of the abdominal wall as they insert into the pubis  this disruption is brought about by either the destruction of these musculotendinous tissues at their lower end or the resection of portions of the pubic bone as is sometimes done in suprapubic radical prostatectomies for easier access to the prostate  seven cases have been identified and reported  men and women were seen to make up a clinical picture that is suggestive of the diagnosis  namely  multiple previous operations through the lower abdominal wall  procedures of a gynecologic or urologic nature  a herniation that mimics an incisional or inguinal hernia  and a defect that cannot possibly be corrected without the use of a prosthesis  when the diagnosis is accurately established  the polypropylene mesh is inserted in the preperitoneal space and anchored laterally to the ligaments of cooper and in between to the arcuate pubic ligament and the periosteum of the posterior aspect of the pubis  excellent results have been obtained  and the success must be ascribed to the recognition of the parapubic hernia as a distinct entity  
class6	portal vein resection with a new antithrombogenic catheter  curative resection of pancreatic and hepatobiliary tumors is rarely possible because of local invasion  especially into the portal vein  we developed a new antithrombogenic catheter using a heparinized hydrophilic polymer to allow portal vein bypass during resection of tumors invading the portal vein  pancreatectomy or hepatectomy accompanied by portal vein resection was performed for pancreatic or hepatobiliary cancer  with an intraoperative shunt from the superior mesenteric vein to the femoral vein or from the superior mesenteric vein to the intrahepatic portal vein through the umbilical vein or the hepatic hilar portal vein  use of the shunt prevented stasis in the superior mesenteric vein and hepatic ischemia even during prolonged occlusion of the portal vein  and portal vein resection was performed in 81 patients with hepatobiliary and pancreatic disease with greater safety and ease  
class6	gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery  traumatic pseudoaneurysms of the superior mesenteric artery  sma  are extremely rare  we describe two cases of posttraumatic proximal sma pseudoaneurysms with symptoms of gastric outlet obstruction  repair was accomplished by aorta sma bypass with saphenous vein  injuries to the proximal sma are easily missed at laparotomy  especially if intestinal ischemia or hematomas are absent  recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation  
class6	high ethanol consumption as risk factor for intracerebral hemorrhage in young and middle aged people  we examined the prevalence of high ethanol intake  hypertension  and other risk factors for intracerebral hemorrhage in a case control study of 24 young and middle aged patients with intracerebral hemorrhage  we recorded ethanol consumption  history of hypertension  liver disease  cigarette smoking  and mild or severe coagulation disorder in each case of intracerebral hemorrhage and in 48 control patients matched by sex and age  in univariate matched analyses  the frequencies of high ethanol intake  p   0 009   hypertension  p   0 05   and coagulation disorder  p   0 05  were higher in the cases than in the controls  after controlling for possible confounding factors  we found that high ethanol intake and hypertension were the only independent risk factors for intracerebral hemorrhage  p   0 02 and p   0 05  respectively   the hemorrhagic lesion found in cases with a high ethanol intake tended to be located in the cerebral lobes  p   0 01   contrasting with the typical basal ganglia location of hypertensive hematomas  p   0 009   we conclude that chronic  high ethanol intake should be considered as an important risk factor for lobar hematomas in young and middle aged people  
class6	dietary predictors of symptom associated gallstones in middle aged women  in 1980  88 837 women aged 34 59 y completed a semiquantitative food frequency questionnaire and were followed for 4 y  four hundred thirty three women reported a cholecystectomy for recent cholecystitis  and 179 reported unremoved  newly symptomatic gallstones diagnosed by ultrasound or x ray  among the 59 306 women with quetelet s index of relative weight less than 25 kg m2  inverse associations were observed between intakes of vegetable fat and vegetable protein and the risk of reportedly symptomatic gallastones  after adjusting for age  quetelet s index in 1980  weight change between 1976 and 1980  energy intake  and alcohol intake  the relative risk in the highest quintile of vegetable fat intake  as compared with the lowest quintile  was 0 6  95  confidence interval  ci   0 4 0 9   and the corresponding relative risk for vegetable protein intake was 0 7  95  ci  0 6 0 9   no significant associations were found with energy adjusted intakes of cholesterol  animal fat  animal protein  carbohydrate  or sucrose  
class6	effects of common illnesses on infants  energy intakes from breast milk and other foods during longitudinal community based studies in huascar  lima   peru  to assess the effects of common infections on dietary intake  131 peruvian infants were observed longitudinally  home surveillance for illness symptoms was completed thrice weekly  and food and breast milk consumption was measured during 1615 full day observations  mean      sd  energy intakes on symptom free days were 557     128 kcal d  92 4     26 5 kcal kg 1 d 1  for infants aged less than 181 d and 638     193 kcal d  77 7     25 7 kcal kg 1 d 1  for infants aged greater than 180 d  statistical models controlling for infant age  season of the year  and individual showed significant 5 6  decreases in total energy intake during diarrhea or fever  there were no changes with illness in the frequency of breast feeding  total suckling time  or amount of breast milk energy consumed  by contrast  energy intake from non breast milk sources decreased by 20 30  during diarrhea and fever  and the small decrements in total energy consumption during illness were explained entirely by reduced consumption of non breast milk foods  
class6	inflammatory myofibroblastic tumor  plasma cell granuloma   clinicopathologic study of 20 cases with immunohistochemical and ultrastructural observations  twenty cases of inflammatory myofibroblastic tumor  imt  were studied  19 involved the lung and 1 the esophagus only  the patients  ages ranged from 3 to 72 years  there were 9 males and 11 females  involvement of a bronchus was seen in one case and of mediastinal structures in four  chest pain and dyspnea were common symptoms  eight patients were asymptomatic  seven patients underwent lobectomy  12 local excision  and 1 biopsy alone  the lesions were nonencapsulated and ranged from 1 2 to 15 cm  various proportions of plasma cells  histiocytes  and spindle cells were observed  the latter corresponded ultrastructurally to fibroblasts and myofibroblasts  were immunoreactive for vimentin and actin and focally for desmin  and were negative for epithelial markers  plasma cells were polyclonal for light chains  one patient had two recurrences  and in one case a large pleural imt was found eight years after the excision of a similar lesion in the lung  all patients with follow up  ten  were well as long as ten years after the diagnosis  average  3 7 years   
class6	computerized tomography in acute gastrointestinal disorders  in recent years  computerized tomography  ct  has become one of the most important imaging modalities in evaluation of patients with acute gastrointestinal disorders  its role  diagnostic accuracy  indications  and limitations in some of the most commonly encountered acute abdominal conditions are succinctly presented and reviewed  ct should not be used indiscriminantly  but is best considered a valuable primary or complimentary diagnostic tool in critically ill patients  its selective use in a variety of emergency abdominal diseases will significantly improve accuracy of clinical diagnoses  leading to a prompt and adequate medical or surgical management  
class6	effect of omeprazole and high doses of ranitidine on gastric acidity and gastroesophageal reflux in patients with moderate severe esophagitis thirty to fifty percent of patients with reflux esophagitis fail to heal after treatment with conventional doses of h2 receptor antagonists  whereas omeprazole administration induces more than 90  healing  to investigate the effect of omeprazole and higher than presently recommended doses of h2 blockers  we evaluated gastric acidity and gastroesophageal reflux in 17 patients with severe moderate esophagitis before and after treatment with 300 mg ranitidine twice daily or 20 mg omeprazole once daily  three ph metric studies were performed  in a cross over design  before and after 8 days of treatment with omeprazole or ranitidine  both drugs significantly reduced intragastric acidity  p less than 0 001  during both night and day hours  median hourly 24 h intragastric ph was 1 8 in the basal study  2 9 after ranitidine  and 3 4 after omeprazole  intragastric acidity fell from 84 0 mmol l in the basal study to 14 2 mmol l  79  inhibition  with ranitidine and 9 3 mmol l  84  inhibition  with omeprazole  patients with esophagitis were significantly more exposed to acid than healthy subjects  in both the supine and upright position  p less than 0 01   the time with esophageal ph less than 4 dropped from 23 9  in the basal study to 8 5  with ranitidine and to 7 2  with omeprazole  p less than 0 001   both drugs significantly reduced esophageal exposure to acid in both the supine and upright positions  p less than 0 001   whereas neither had any effect on esophageal acid clearance  
class6	esophageal 24 h ph monitoring  is prior manometry necessary for correct positioning of the electrode  in 24 h esophageal ph monitoring  the electrode is usually positioned 5 cm above the manometrically localized esophagogastric junction  in order to replace esophageal manometry for this purpose  we tested whether the esophagogastric junction can be identified correctly by fluoroscopy or the determination of the ph step between stomach and esophagus  compared with esophageal manometry  the distance from the nares to the esophagogastric junction was determined three times with each of the three methods in 46 patients and 14 volunteers  fluoroscopy assumed the esophagogastric junction 1 23     0 23 cm  mean     se  lower than the peak pressure point determined at manometry  ph step only 0 45     0 16 cm  with ph step  only one subject had a difference of more than 3 cm to the manometrically defined esophagogastric junction  whether gastroesophageal reflux disease  as proven by ph monitoring  was present or not  we conclude that the esophagogastric junction can usually be identified with sufficient accuracy by the measurement of the ph step between stomach and esophagus  fluoroscopy is far less accurate than ph step  and should not be used  
class6	dysphagia following fundoplication   slipped  fundoplication versus achalasia complicated by fundoplication  failure to obtain preoperative esophageal manometry in patients being considered for antireflux surgery can result in immediate persistent postoperative dysphagia due to a missed diagnosis of achalasia  we describe the clinical assessment and management of a case of delayed postoperative dysphagia due to a  slipped  fundoplication  which is contrasted with three patients with immediate postoperative dysphagia due to a missed diagnosis of achalasia  surgical revision was required to correct the  slipped  fundoplication  and pneumatic dilatation was successfully used in two of three cases of achalasia complicated by fundoplication  careful preoperative esophageal evaluation with manometry is essential to rule out the presence of a primary esophageal motor disorder  
class6	endoscopic management of chronic organoaxial volvulus of the stomach  endoscopic correction of the chronic organoaxial volvulus of the stomach was attempted in seven cases of primary and three cases of secondary volvulus  endoscopic correction was successful in six cases of primary volvulus and one case of volvulus secondary to duodenal carcinoma  this paper describes the details of the technique of endoscopic correction of gastric volvulus  and documentation of correction of the volvulus by barium meal study with a follow up of 5 26 months  
class6	recurrence of duodenal ulcer and elevated serum pepsinogen i levels in smokers and nonsmokers  we determined serum pepsinogen i  pg i  levels by radioimmunoassay in 472 patients with duodenal ulcer and 141 normal subjects to investigate whether serum pg i levels were related to cigarette smoking  and in 225 patients to determine whether the recurrence of duodenal ulcer was related to serum pg i levels or cigarette smoking  serum pg i levels were not influenced by cigarette smoking in either patients with duodenal ulcer or normal subjects  the recurrence rate of duodenal ulcer not under maintenance therapy was significantly higher in hyperpg i patients than in normopg i patients  regardless of their smoking habits  only in hyperpg i patients was the recurrence rate in smokers higher than in nonsmokers  patients under maintenance therapy showed similar results  multilogistic regression indicated that hyperpg i had a greater effect than cigarette smoking on ulcer recurrence  these findings indicate that serum pg i levels are not influenced by smoking  and the important characteristic in patients with recurrent duodenal ulcers is the increased serum pg i levels  
class6	adenocarcinoma arising in barrett s esophagus after total gastrectomy a 64 yr old japanese male who underwent a partial gastrectomy for a duodenal ulcer at the age of 21  a total resection of the remnant stomach for a stomal ulcer at age 25  and in whom barrett s esophagus was diagnosed at age 47  was found to have a tumor at the distal esophagus and was operated on by thoracic esophagectomy  the tumor was a well to moderately differentiated adenocarcinoma invading down to the muscularis propria  the entire esophageal mucosa in the resected specimen was lined by columnar epithelium  this tumor was thought to derive from the barrett s esophageal epithelium  
class6	 spontaneous sump syndrome   successful treatment by duodenoscopic sphincterotomy   sump syndrome  is a rare complication of side to side choledochoenterostomy operations which develops in the distal  nonfunctioning limb of the common bile duct where lithogenic bile  gastrointestinal contents  and debris accumulate  we report here a patient who developed spontaneous sump syndrome as a result of the formation of choledochoduodenal fistula  and who presented with multiple pyogenic liver abscesses  the patient s symptoms and liver abscesses resolved completely after treatment by endoscopic sphincterotomy and antibiotics  this case demonstrates that sump syndrome may occur spontaneously  that it can be a cause for pyogenic liver abscess formation  and that it may be treated effectively by endoscopic sphincterotomy  
class6	hepatic portal venous gas  an unusual presentation of crohn s disease  hepatic portal venous gas is associated with numerous conditions and traditionally has been regarded as an ominous prognostic sign  there are several reports of hepatic portal venous gas occurring in patients with inflammatory bowel disease after or during the performance of colonic diagnostic studies  we report an unusual case of crohn s disease whose initial presentation included hepatic portal venous gas  the literature of hepatic portal venous gas associated with inflammatory bowel disease is reviewed  
class6	oral dissolution therapy for cholelithiasis  mix and match  the authors conducted a prospective  randomized trial of chenodeoxycholic and ursodeoxycholic acid versus ursodeoxycholic acid alone in patients with cholelithiasis to determine their efficacy for dissolution of gallstones  one hundred and twenty patients with radiolucent gallstones  less than or equal to 15 mm and who had a functioning gallbladder were enrolled  the patients were divided into two groups based on the diameter of their largest stones  seventy patients had stones larger than 5 mm but less than 15 mm  whereas 50 patients had stones that measured 5 mm or less  the patients were randomly assigned to treatment with chenodeoxycholic acid plus ursodeoxycholic acid  5 mm kg of each  or ursodeoxycholic acid  10 mm kg  alone  oral cholecystography  plain abdominal x rays  and ultrasonography of the gallbladder were done at 6  12  and 24 months  dissolution was deemed to be complete if not stones were visualized on two examinations  partial dissolution was defined as a 50  reduction in stone size and or number  stones that were not detected by cholecystography but still detected during ultrasonography were considered to be partially dissolved  plasma triglycerides  serum cholesterol  hdl  and serologic liver function tests were determined at 1  3  6  12  18  and 24 months  in a select group of patients  bile rich duodenal aspirates were aspirated and analyzed for biliary lipid contents  in the group with small stones  defined as less than or equal to 5 mm  complete stone dissolution occurred significantly more often utilizing combination therapy at 6 months  52  vs 24    and this trend persisted  although no longer significant  at 12 and 24 months  combination therapy also achieved an improved rate of dissolution for large stones within 6 months  however  this did not persist at 12 and 24 months  although not statistically significant  stone calcification occurred less often with combined therapy  all treatment regimens were well tolerated  with only minor changes in bowel habits and mild elevations in serum transaminase levels  serum lipid levels did not change with either therapy  the authors concluded that the combination of chenodeoxycholic acid and ursodeoxycholic acid was the preferred therapy for gallstone dissolution  because it dissolves stones more rapidly  with a lower incidence of stone calcifications  and thus might reduce the long term cost of treatment  
class6	autosomal dominant polycystic kidney disease  more than a renal disease  autosomal dominant polycystic kidney disease  adpkd  is the most common genetic disease  affecting a half million americans  the clinical phenotype can result from at least two different gene defects  one gene that can cause adpkd has been located on the short arm of chromosome 16  this discovery has made possible new methods for diagnosing the disorder in gene carriers prior to the development of renal cysts  although renal cysts are clearly an important manifestation of the gene defect  other systemic manifestations are both common and clinically important  cardiac valvular lesions  intracranial aneurysms  hepatic cysts  and diverticula are included in the array of systemic manifestations  moreover  renal cysts are only one of a myriad of renal manifestations  although adpkd was long considered an adult cystic disease  it is also a common cause of childhood cystic disease and must be considered in the differential diagnosis in that setting  
class6	adult and pediatric peritonitis rates in a home dialysis program  comparison of continuous ambulatory and continuous cycling peritoneal dialysis  we reviewed our 115 month experience with continuous ambulatory peritoneal dialysis  capd  and continuous cycling peritoneal dialysis  ccpd  in adult and pediatric patients to determine whether there is a difference in the incidence of peritonitis between patients performing capd or ccpd  peritonitis rates were similar in patients performing capd or ccpd in both the adult and pediatric age groups  the overall capd peritonitis rate was significantly lower in adult patients when compared with pediatric patients  there was no difference in peritonitis rates for ccpd between adult and pediatric patients  when the data are divided into 3 year subgroups  the incidence of peritonitis is significantly lower in adult patients undergoing either capd or ccpd when compared with pediatric patients during the years 1986 to 1988  there is significant improvement over time in the incidence of peritonitis in both adult and pediatric patients performing ccpd  similarly  there is a trend toward improvement in patients performing capd  staphylococcus species organisms remain the most common bacterial cause of peritonitis  except in pediatric patients under the age of 2 years or with nephrostomies  where gram negative rod infections were more common  peritonitis resulted in discontinuation of peritoneal dialysis in a greater number of adult patients  these results suggest that the number of catheter manipulations is not important in determining the incidence of peritonitis  pediatric patients are more likely than adult patients to develop peritonitis with either capd or ccpd  adult patients are more likely than pediatric patients to discontinue peritoneal dialysis secondary to peritonitis  
class6	clinical and manometric aspects of diffuse esophageal spasm in a cohort of subjects evaluated for dysphagia and or chest pain  manometric criteria for diffuse esophageal spasm have recently been restated  in this study  a cohort of 358 subjects was evaluated in a gastrointestinal motility laboratory for dysphagia and or chest pain  applying the recently proposed criteria of richter and castell  18 subjects  5   were diagnosed as having des  dysphagia was the major complaint  89    while 44  of patients complained of chest pain and 33  of both symptoms  all patients shared more than 30  simultaneous contractions after wet swallows interspersed with normal peristaltic sequences  associated manometric findings were repetitive  greater than 3 peaks  contractions  67    high amplitude contractions  33    spontaneous activity  22    prolonged duration  11    and lower esophageal sphincter abnormalities  5    radiology disclosed significant abnormalities in only 27  of des patients  
class6	endometrioma of the liver  hepatic endometriosis is extremely rare  we describe a patient sent to us with epigastric pain as the only symptom and who was found to have associated endometrioma of the liver and left ovary  we suggest a gynecologic evaluation before surgery for hepatic cyst of unknown cause  
class6	hemoperitoneum as a result of coital injury without associated vaginal injury  hemoperitoneum as a result of coital injury without associated vaginal injury is an extremely rare entity  and evidence by only five cases that have been reported in the medical literature to date  we report five additional cases encountered in two medical centers  two of these were ruptured corpus luteum cysts  one was a laceration of the round ligament  another was a laceration of an ovary  and the fifth was rupture of a serous cystadenoma  this diagnosis should be considered in patients with hemoperitoneum after coitus  
class6	the associated anomalies that determine prognosis in congenital omphaloceles  cogenital abdominal wall defects such as omphaloceles can be recognized by fetal ultrasonography  to determine whether associated anatomic features may be useful in determining fetal prognosis  a retrospective study was performed over a 5 year period  there were 28 cases of omphalocele  16 were larger than 5 cm and classified as giant  and the remainder were considered small  eleven of the 12 infants with small omphaloceles survived with minimal neonatal complications  ten of the 16 infants with giant omphaloceles died because of associated congenital anomalies  these were congenital heart disease  central nervous system malformations  and diaphragmatic hernias  this review suggests that the prognosis is good when a prenatal diagnosis of giant omphalocele is made and careful fetal ultrasonography  including echocardiography  does not identify heart  central nervous system  or diaphragmatic malformations  even when there is liver herniation into the omphalocele  
class6	a clinicopathologic study of the eyes in familial adenomatous polyposis with extracolonic manifestations  gardner s syndrome   the eyes of a 51 year old woman with familial adenomatous polyposis and extracolonic manifestations  gardner s syndrome  were obtained postmortem and studied by light microscopy and by transmission and scanning electron microscopy  we found a generalized abnormality in melanogenesis of the retinal pigment epithelium and at least three types of pigmented lesions  the histologic findings in one type of lesion were consistent with congenital hypertrophy of the retinal pigment epithelium or benign pigmented nevus of the retinal pigment epithelium  the other two types of lesion were most consistent with hamartomatous malformations of the retinal pigment epithelium featuring cellular hypertrophy  hyperplasia  and rarely retinal invasion and formation of a minute mushroom shaped tumor  these histopathologic findings indicate a generalized effect of the familial adenomatous polyposis gene on the retinal pigment epithelium  this oncogene  which is responsible for tumor formation in the gastrointestinal tract  soft tissues  bone  and other locations in patients with familial adenomatous polyposis  also leads to a generalized defect in melanogenesis and focal lesions of the retinal pigment epithelium  
class6	histologic similarity of murine colonic graft versus host disease  gvhd  to human colonic gvhd and inflammatory bowel disease  in a study designed to determine which t cell subsets are involved in the development of murine graft versus host disease  gvhd   a prospective histologic analysis of gastrointestinal involvement was performed  in c57bl 6jxdba 2f1  b6d2f1  recipients of dba 2 donor spleen and bone marrow cells  the colonic histologic findings were found to be similar in many respects to the histologic findings reported in human colonic gvhd and were much more severe and diffuse than were the abnormalities of the small intestine  host irradiation before transplantation was found to play an additive or synergistic role in the development of gvhd  furthermore the histologic features noted in dba 2    b6d2f1 murine colonic gvhd suggest that bone marrow and spleen cell transplantation in this strain combination may be a useful model for studying the immunologic mechanisms involved in human inflammatory bowel disease  thus severe colonic disease noted during the course of dba 2    b6d2f1 murine gvhd was found to have significant histopathologic similarities to both human gvhd enteropathy and other inflammatory diseases of the human colon  
class6	development of multiple necrotizing enteritis induced by a tumor necrosis factor like cytokine from lipopolysaccharide stimulated peritoneal macrophages in rats  we report the development of an animal model of multiple necrotizing enteritis  mne  in rats  when rats were injected directly with a culture supernatant of lipopolysaccharide  lps  stimulated rat peritoneal macrophages into the abdominal aorta  the overt pathologic lesions of mne developed within 30 minutes after injection  the rats showed an elevated level of blood fibrinogen degradation product content even 30 minutes after injection  furthermore the rats that were pretreated intravenously with heparin sulfate did not develop mne  indicating the acute disturbances of blood microcirculation in the intestine  multiple necrotizing enteritis was developed also by the injection with recombinant tumor necrosis factor  rtnf  but rarely was observed with even a high dose of recombinant interleukin 1  ril 1  or platelet activating factor  paf   the supernatant was cytotoxic in vitro to tnf susceptible lm and many other cells but was less cytotoxic to the tnf resistant lr line  partial purification of the supernatant suggested that the supernatant contained a cytokine that has biochemical features of tnf  furthermore polyclonal anti tnf antibody could inhibit not only the cytotoxicity in vitro but also mne development in vivo by this factor  these data strongly indicate that mne possibly could be caused by a tnf like cytokine produced by macrophages that are stimulated by the endotoxin  
class6	association of hepatitis b surface antigen and core antibody with acquisition and manifestations of human immunodeficiency virus type 1  hiv 1  infection  we examined the associations between seropositivity for hepatitis b virus  hbv  with the presence or development of antibodies to human immunodeficiency virus  hiv 1  and with hiv 1 induced t helper lymphocyte deficiency or acquired immunodeficiency syndrome  aids   serologic data on hbv and hiv 1  cytometric enumeration of cd4  lymphocytes  clinical events  aids by centers for disease control criteria  and hepatitis b vaccination histories were available on 4 498 homosexual participants in the multicenter aids cohort study  men were classified as to previous infection with hbv and prevalent or incident infection with hiv 1  although there was an association between seropositivity for hbv infection and hiv 1 infection at enrollment  odds ratios anti hbc 2 6  hbsag 4 2   the relation between hbv seropositivity and subsequent seroconversion to hiv 1 was weaker  odds ratios 1 3 and 1 6   hiv 1 seroconversion was also associated with a history of certain other sexually transmitted diseases  but predisposing sexual practices did not account for the association between hbv and hiv 1 infection  seropositivity for hbv infection at entry was not related to initially low or more rapid subsequent decline in t helper lymphocyte counts and was not associated with an increased incidence of aids during 2 5 years of follow up  history of vaccination against hbv did not appear to decrease susceptibility to hiv 1 infection or to subsequent progression of immunodeficiency  we conclude that prior hbv infection is unlikely to be specifically associated with acquisition of hiv 1 infection and is unrelated to more rapid progression of hiv 1 induced immunodeficiency  
class6	human t cell lymphotropic virus infection in guaymi indians from panama  preliminary studies found that 9  of guaymi indians from bocas del toro province have antibody to human t cell lymphotropic virus  htlv i ii   the present study enrolled 317  21  of the population  guaymi indians from changuinola  the capital of bocas del toro province and 333  70  of the population  from canquintu  an isolated rural village  demographic information and family relationships were ascertained and subjects were screened for neurologic diseases  serum specimens were screened by an enzyme linked immunosorbent assay for htlv i ii antibody and positives were confirmed according to u s  public health service criteria  twenty five  8   guaymi residing in changuinola and 7  2 1   from canquintu were confirmed seropositive  in changuinola  antibody was virtually limited to residents greater than or equal to 15 years of age  24  16   of 153  and rates were slightly higher in males than in females  in canquintu  antibody rates did not increase significantly with age and appeared higher in females than in males  in changuinola  there was no evidence for household clustering of infection  in contrast  htlv antibody among canquintu residents clustered significantly by household  htlv associated neurologic disease was not detected in either population  the atypical seroepidemiology observed in both locations might be explained if the virus endemic to the guaymi differed from htlv i previously described in the caribbean basin and japan  
class6	recurrence rate after discontinuation of long term mebendazole therapy in alveolar echinococcosis  preliminary results   the recurrence rate was investigated in 19 patients with non resectable alveolar echinococcosis after discontinuation of a long term therapy with mebendazole  average treatment 4 3 years   a control group consisted of 14 patients who underwent radical surgery and finished a course of prophylactic postoperative mebendazole treatment of 2 years  in the controls  no recurrence was observed after a post therapy period averaging 3 5 years  in contrast  recurrence occurred in 7 19 patients  37   with non resectable alveolar echinococcosis an average of 1 6 years after discontinuation of the long term mebendazole therapy  the absence of clinically detectable recurrence in the remaining 12 patients seems to be due either to spontaneous inactivation of alveolar echinococcosis preceding chemotherapy or too short post therapy surveillance  the patients with recurrence responded favorably to reintroduction of chemotherapy  the data indicate that mebendazole therapy is parasitostatic rather than parasiticidal  
class6	high incidence of viral hepatitis among american missionaries in africa  protestant missionaries  n   360  serving in sub saharan africa between 1967 1984 were studied to determine the risk of hepatitis a virus  hav  and hepatitis b virus  hbv  infection  personnel were serologically screened for antibody to both the hepatitis a virus  anti hav  and the surface antigen to the hepatitis b virus  anti hbs  prior to departure  periodically during service abroad  and upon completion of their african tour  rates of seroconversion were used as measures of the incidence of infection  prior to service  16  of the staff had anti hav and 3  had anti hbs  post service rates were 42  and 26   respectively  over 90  of the staff with greater than 20 years of service were seropositive for anti hav  for both viruses  the infection rate was highest during the first 1 2 years of service  when 28  of those susceptible to hav and 11  of those susceptible to hbv became infected  over the next decade  the median annual attack rate was 5 4  for hav and 4 2  for hbv  differences in the missionary hbv infection rate among the various african nations served tended to reflect differences in the magnitude of chronic hbv carriage among indigenous population groups  we conclude that missionaries to sub saharan africa are at enhanced risk of both hav and hbv infection  and that all should receive passive immunization with immune globulin and active immunization with hepatitis b vaccine  
class6	outpatient laparoscopic laser cholecystectomy  laparoscopic laser cholecystectomy has been performed clinically in the united states since 1988  after refinement of the technique  the procedure was offered on an outpatient basis  eighty three patients underwent laparoscopic laser cholecystectomy during the study period  thirty seven  45   had the procedure as an outpatient  younger patients were more suited for the outpatient procedure and those without previous surgery were more likely to have the procedure done as an outpatient  weight  operating time  and gallbladder pathology were similar  although patients with acute inflammation of the gallbladder were more likely to require hospitalization  the primary reason for patient admission was patient preference  
class6	rectal prolapse in infants and children  rectal prolapse that is intractable to the usual medical therapy was successfully managed without significant complications in 10 patients by simple subcutaneous encirclement of the anus with a heavy nonabsorbable suture  which was in place until the suture was removed or broke after 4 to 6 months  four patients required two sutures and one needed a third insertion  since this procedure is simple  has no serious complications  and controls rectal prolapse  it is recommended as the preferred initial surgical treatment of this condition  
class6	prevention of pancreatic fistula by modified pancreaticojejunal anastomosis  a major cause of morbidity after pancreatoduodenectomy is leakage from the pancreaticojejunal anastomosis  to prevent this complication  we have employed mucosal stripping from the proximal jejunum prior to end to end anastomosis in 19 patients with good results  
class6	role of surgery in antibiotic induced pseudomembranous enterocolitis  with the increased use of prophylactic and broad spectrum antibiotics  pseudomembranous colitis has emerged as a significant clinical problem  management with specific anti clostridium difficile therapy  vancomycin or metronidazole  has reduced mortality to less than 2   nevertheless  the disease may progress to a fulminant toxic colitis or colonic perforation  additionally  another subset of patients will present with a dramatic clinical picture  suggesting acute peritonitis  eventuating in unnecessary laparotomy  this report reviews both the medical and surgical literature during the past 15 years of patients treated for pseudomembranous colitis  analysis of this clinical data has provided us with the opportunity to both define the role of surgery in this disorder and illustrate the necessity for a combined medical and surgical cooperative approach in the early management of this iatrogenic disease  
class6	blood contamination of anaesthetic and related staff the incidence of skin contamination of anaesthetic and related staff by patient s blood and saliva was studied during 270 anaesthetics in cardiff hospitals over seven continuous days in october 1989  a survey was also made of current hepatitis b immunisation status and glove wearing habits of 75 anaesthetists  blood from 35  14   patients caused skin contamination of 65 staff during 46 incidents  twenty eight  61   of the contamination incidents occurred during vessel cannulation  five  8   of the 65 staff contaminated by blood already had cuts on their hands  there were nine incidents  4   of skin contamination by saliva  fifty three  71   anaesthetists were immunised against hepatitis b  only seven  9   anaesthetists wear gloves for oral or nasal intubation  six  8   for insertion of peripheral venous cannulae  47  63   for insertion of arterial lines and 67  89   for insertion of central lines  all anaesthetic and associated staff should wear gloves on a routine basis  
class6	acute abdominal pain in the elderly  study objectives  to determine the incidences of both specific diagnosis and surgical diseases in patients more than 65 years old who present to the emergency department with nontraumatic abdominal pain of less than one week s duration  and to determine the ed staff s ability to diagnose and triage elderly patients with acute abdominal pain  design  a 12 month retrospective review of all elderly patients who presented to the ed with acute  nontraumatic abdominal pain  setting  a regional trauma center serving a predominately rural population in the midwest  the ed has 55 000 patient visits yearly  measurements and main results  of the 127 patients enrolled  30  24   had no specific diagnosis made in the ed  biliary tract disease  12   and small bowel obstruction  12   were the two most common specific diagnoses  overall  53 patients  42   required surgery  usually during the initial hospitalization  in four cases  the postoperative diagnosis differed significantly from the ed diagnosis  of the 74 patients  58   who did not undergo surgery  51 had follow up information available  in 14 patients  the follow up diagnosis differed from the original diagnosis  but most of these changes did not appreciably alter the treatment and outcome  conclusions  the incidence of surgical disease is high in elderly patients with acute abdominal pain  and ed staff are able to diagnose and triage these patients accurately  
class6	colobronchial fistula  a rare complication of crohn s colitis  a 29 yr old white woman presented with chronic pneumonia in the left lower lobe and with left pleural effusion  she was known to have inflammatory bowel disease  but she was asymptomatic under maintenance treatment with 5 asa  she received numerous antibiotic regimens according to susceptibility testing of microorganisms cultured from sputum and bronchial lavage and on an empiric basis was also given antituberculosis treatment  but there was no clinical improvement or change in the chest radiographic findings  sputum was repeatedly examined and yielded  among other organisms  clostridium inocuum  enterobacter  klebsiella pneumoniae  proteus mirabilis  and staphylococcus aureus  on one microscopic examination of sputum  the presence of feculent material was suspected  a subsequent gastrografin enema revealed a cologastric and colobronchial fistula between the splenic flexture of the colon and the greater curve of the stomach and the bronchial system  segmental resection of the colon and resection of the lower lobe of the left lung were performed  histologic findings of the resected colon were consistent with crohn s disease  after a long period of postoperative recovery  the patient returned to good general health and well being  to our knowledge  a colobronchial fistula caused by crohn s colitis has not been previously reported  
class6	gastroesophageal reflux and sclerotherapy strictures  the development of esophageal stricture is common following endoscopic variceal sclerotherapy  evs   gastroesophageal reflux may be at least partly responsible  twelve randomly selected male patients underwent chronic evs for the management of bleeding esophageal varices  six patients developed strictures during or after evs  six did not  there were no significant differences between stricture and nonstricture patients during 24 hour esophageal ph monitoring  three of the six stricture patients and four of the six nonstricture patients had an abnormal amount of reflux  gastroesophageal reflux occurs frequently in patients undergoing evs  and it is not likely to play a major role in evs stricture formation  
class6	starch peritonitis  a case report and clinicopathologic review  a case of starch peritonitis is presented with a review of the history of this continuing problem  the syndrome s presentation  diagnosis  histopathology and treatment are discussed  the rarity of starch peritonitis today may be due to more attention to glove washing by surgeons  fewer impurities in the glove powder or lack of recognition of the syndrome  in order to prevent a resurgence of the starch peritonitis syndrome we must continue to emphasize the importance of washing gloves  maintain the quality control and purity of the powder used  and be cognizant of the signs and symptoms so that such cases may be managed nonoperatively  
class6	cecal diverticulitis presented as a cecal tumor  seven patients diagnosed as having acute appendicitis were operated on and a cecal wall mass due to cecal diverticulitis was found  in two patients the mass could not be separated from the cecal wall and right colectomy was performed  in five patients  in whom the mass could be separated from the cecum  conservative operations  three diverticulectomies and two wedge resections  were performed  thus avoiding needless  more extensive surgery  
class6	intra abdominal abscesses in crohn s disease  we reviewed 22 patients who had intra abdominal abscesses secondary to crohn s disease  a total of 29 abscesses were discovered  these included superficial and deep intraperitoneal as well as pelvic and retroperitoneal abscesses  diagnosis was aided by ultrasound and computer tomographic scanning  barium studies continue to play an important role in delineating the extent of bowel involvement and fistulization  treatment varied depending on the location and size of the abscess  the need for ultimate bowel resection was determined in the majority of cases by the presence of fistulization between the abscess cavity and the bowel  the terminal ileum or neoterminal ileum were almost always involved  
class6	association of acute colonic pseudo obstruction  ogilvie s syndrome  with herpes zoster  ogilvie s syndrome  or acute pseudo obstruction of the colon is characterized by massive distension of the colon in the absence of organic distal obstruction  the syndrome is associated with various unrelated and  most often  extra abdominal causes  an association between ogilvie s syndrome and herpes zoster has been reported only once  by ceccese et al  in 1985  we present a second such case  this patient did not show evidence of any active illness other than the involvement of the t10 dermatome by herpes zoster  the patient s symptoms of colonic obstruction subsided with resolution of the zosteriform rash  
class6	jejunal rectal fistula as a complication of postoperative radiotherapy  we present the case of a patient with an unusual  complex enteric fistula with multiple tracts and associated abscesses  the fistula was a late complication of radiotherapy  administered three years earlier  after resection for carcinoma of the sigmoid colon  most of the small bowel was involved in the radiation induced disease  a wide resection was performed successfully  this report reviews current literature on intra abdominal postradiotherapy injuries  particularly intestinal fistulae  
class6	the role of endoscopic retrograde pancreatography  erp  in blunt abdominal trauma  the diagnosis of pancreatic injury is often difficult because it lies retroperitoneally in a protected area  delayed diagnosis and treatment of blunt pancreatic trauma can result in significant morbidity and mortality  endoscopic retrograde pancreatography  erp  is infrequently used in the diagnosis of pancreatic injury  we reviewed our experience with the use of erp in patients with blunt pancreatic injury  two stable patients with traumatic pancreatitis underwent erp shortly after injury  ct scans revealed a transverse fracture of the distal pancrease in one and fluid accumulation in the other around the pancreas extending to the right kidney and left hepatic lobe  the absence of ductal disruption on erp allowed nonoperative management of the pancreatitis  resolution was documented by the absence of symptoms on regular oral intake  normal serum amylase levels  and normal follow up ct scans  a third patient with persistent fistulae three months postinjury underwent preoperative erp revealing ductal obstruction  this facilitated the planning of a distal pancreatectomy and subsequently the fistulae healed  a fourth patient underwent an exploratory laparotomy on the basis of clinical and ct scan findings that could have been circumvented with preoperative erp  erp in selected patients allows nonoperative treatment in the absence of ductal injury or earlier operative treatment of ductal injury  it also aids the treatment of late complications by delineating ductal anatomy  
class6	risk for colon adenomas in patients with rectosigmoid hyperplastic polyps objective  to determine whether hyperplastic polyps found in the rectosigmoid area of the colon are associated with proximal adenomas  and to judge whether patients with distal hyperplastic polyps found during sigmoidoscopy might benefit from full colonoscopy  design  data on patients having colonoscopy collected prospectively according to a set protocol  the size and location of all polyps were noted  and all polyps were biopsied  setting  two university hospitals  patients  one thousand eight hundred and thirty six consecutive patients referred for colonoscopy between 31 december 1987 and 31 august 1989  results  of the 970 patients who met eligibility requirements  274  28 3   had adenomas and 108  11 1   had hyperplastic polyps  the proportion of patients with distal hyperplastic polyps and proximal adenomas  31 9   was similar to the proportion of those without distal hyperplastic polyps  23 0    crude odds ratio  1 57  95  ci  0 77 to 3 06   after adjusting for age and sex  the results were unchanged  adjusted odds ratio  1 53  ci  0 82 to 2 88   patients with distal adenomas  on the other hand  were three times more likely to have proximal adenomas than those without distal adenomas  adjusted odds ratio  3 42  ci  1 99 to 5 88   conclusions  distal hyperplastic polyps are not strong predictors of risk for proximal adenomas  based on the magnitude of the risk difference  we do not believe that finding a hyperplastic polyp during sigmoidoscopy justifies doing a full colonoscopy to search for proximal adenomas  because rectosigmoid adenomas are associated with proximal adenomas  however  small polyps seen during sigmoidoscopy should be biopsied to determine their type  colonoscopy should be reserved for patients who are proved to have adenomas  
class6	sexual and physical abuse in women with functional or organic gastrointestinal disorders  study objectives  to determine the prevalence of a history of sexual and physical abuse in women seen in a referral based gastroenterology practice  to determine whether patients with functional gastrointestinal disorders report greater frequencies of abuse than do patients with organic gastrointestinal diseases  and to determine whether a history of abuse is associated with more symptom reporting and health care utilization  design  a consecutive sample of women seen in a university based gastroenterology practice over a 2 month period was asked to complete a brief questionnaire  measurements  the self administered questionnaire requested information about demographics  symptoms  health care utilization  and history of abuse  physicians indicated the primary diagnosis for each patient and whether she had ever discussed having been sexually or physically abused  results  of 206 patients  89  44   reported a history of sexual or physical abuse in childhood or later in life  all but 1 of the physically abused patients had been sexually abused  almost one third of the abused patients had never discussed their experiences with anyone  only 17  had informed their doctors  patients with functional disorders were more likely than those with organic disease diagnoses to report a history of forced intercourse  odds ratio  2 08  95  ci  1 03 to 4 21  and frequent physical abuse  odds ratio  11 39  ci  2 22 to 58 48   chronic or recurrent abdominal pain  odds ratio  2 06  ci  1 03 to 4 12   and more lifetime surgeries  2 7 compared with 2 0 surgeries  p less than 0 03   abused patients were more likely than nonabused patients to report pelvic pain  odds ratio  4 05  ci  1 41 to 11 69   multiple somatic symptoms  7 1 compared with 5 8 symptoms  p less than 0 001   and more lifetime surgeries  2 8 compared with 2 0 surgeries  p less than 0 01   conclusions  we found that a history of sexual and physical abuse is a frequent  yet hidden  experience in women seen in referral based gastroenterology practice and is particularly common in those with functional gastrointestinal disorders  a history of abuse  regardless of diagnosis  is associated with greater risk for symptom reporting and lifetime surgeries  
class6	ondansetron compared with high dose metoclopramide in prophylaxis of acute and delayed cisplatin induced nausea and vomiting  a multicenter  randomized  double blind  crossover study  objective  to compare the efficacy and side effects of ondansetron with those of high dose metoclopramide in treating acute and delayed cisplatin induced nausea and vomiting  design  randomized  double blind  crossover trial  setting  conducted at two university hospitals  a cancer institute  and six community hospitals  patients  of 125 patients  95 were evaluable for the acute phase and 79 for the delayed phase  major reasons for not being evaluable were no second course  14 patients   protocol violation  5 patients   and change in cisplatin dose  3 patients  for the acute phase  and rescue medication on day 1  7 patients   protocol violation  3 patients   and inadequate data  4 patients  for the delayed phase  interventions  all patients received cisplatin  50 to 100 mg m2 body surface area  median  75 mg m2   none had previously received chemotherapy  thirty minutes before the cisplatin administration  ondansetron was given intravenously over 15 minutes  at a loading dose of 8 mg followed by a continuous infusion of 1 mg h for 24 hours  metoclopramide was given at a loading dose of 3 mg kg body weight  followed by a continuous infusion for 8 hours  4 mg kg   for the delayed phase  days 2 through 6   the first oral dose was given as soon as the infusion was completed  the oral dose consisted of either metoclopramide  20 mg three times daily  or ondansetron  8 mg three times daily for another 5 days  measurements and main results  in the acute phase  a major or complete response was seen in 72  of the ondansetron treated and 41  of the metoclopramide treated patients  p less than 0 001   nausea was significantly better controlled among the ondansetron treated patients  p   0 04   in the delayed phase  no statistically significant difference was seen between ondansetron  and metoclopramide treated patients  nausea was significantly better controlled with metoclopramide  p   0 016   conclusions  ondansetron is significantly more effective than metoclopramide in preventing acute nausea and vomiting  in the delayed phase  the results of both drugs were disappointing  although metoclopramide s effect on delayed nausea was superior  patients preferred ondansetron  
class6	polyneuropathy  ophthalmoplegia  leukoencephalopathy  and intestinal pseudo obstruction  polip syndrome  we describe 5 individuals  from three separate families  with a progressive neurological disorder characterized by sensorimotor peripheral polyneuropathy  cranial neuropathies  external ophthalmoplegia  deafness   and the syndrome of chronic intestinal pseudo obstruction  magnetic resonance imaging showed widespread abnormality of the cerebral and cerebellar white matter in the 2 patients studied  autopsy examination in 3 revealed widespread endoneurial fibrosis and demyelination in the peripheral nervous system  possibly secondary to axonal atrophy  and poorly defined changes in cerebral white matter  leukoencephalopathy   the cranial nerves and spinal roots were less severely involved and the neurons in the brainstem and spinal cord were intact  the fatal gastrointestinal dysmotility was due to a severe visceral neuropathy  we suggest that these patients manifested a hereditary disorder with distinctive clinical  radiological  and neuropathological features  and propose the acronym polip to emphasize the distinctive tetrad of polyneuropathy  ophthalmoplegia  leukoencephalopathy  and intestinal pseudo obstruction  
class6	preoperative stabilisation in congenital diaphragmatic hernia  between january 1983 and november 1986  26 newborn infants with congenital diaphragmatic hernia were treated by early operation at a mean of 7 hours of age  a further 23 infants admitted between december 1986 and december 1989 were stabilised for a mean period of 40 hours before operation  there was no significant difference in survival between the two groups  delayed operation is not detrimental to infants with congenital diaphragmatic hernia  
class6	the acutely affected abdomen in paraplegic spinal cord injury patients  the records of 145 paraplegic or quadriplegic patients were reviewed to identify those factors useful in the correct diagnosis of the acute abdomen in this population  twenty one patients had 22 episodes of acute or subacute abdominal problems  presenting complaints  physical findings  and laboratory results were useful in various ways  however appropriate radiographic studies led to the correct diagnosis in 77  of patients  although paraplegic and quadriplegic patients are predisposed to a distinct constellation of medical problems  including urinary tract infection and calculi  they also may present with other abdominal conditions that cause significant morbidity and mortality if not promptly recognized  
class6	results of a multicenter trial comparing imipenem cilastatin to tobramycin clindamycin for intra abdominal infections  we designed a multicenter study to compare tobramycin clindamycin to imipenem cilastatin for intra abdominal infections  we included the acute physiology and chronic health evaluation  apache ii  index of severity and excluded patients without established infection  two hundred ninety patients were enrolled  of whom 162 were evaluable  using logistic regression to analyze both outcome at the abdominal site of infection and outcome as mortality  we found a significant correlation for both with apache ii score  p less than 0 0001 for both   next we analyzed the residual effect of treatment assignment and found a significant improvement in outcome for imipenem cilastatin treated patients  p   0 043   the differences in outcome were explained by a higher failure rate for patients with gram negative organisms for tobramycin clindamycin treated patients  p   0 018   this was reflected in a significantly higher incidence of fasciitis requiring reoperation and prosthetic fascial replacement  maximum peak tobramycin levels were analyzed for 63 tobramycin clindamycin patients harboring gram negative organisms  for failures the maximum peak was 6 4     1 9 micrograms ml  and time to maximum peak was 4 6     5 2 days  for successes the maximum peak was 6 1     1 7 micrograms ml  occurring at 3 8     2 6 days  this study supports inclusion of severity scoring in statistical analyses of outcome results and supports the notion that imipenem cilastatin therapy improves outcome at the intra abdominal site of infection as compared to a conventionally prescribed amino glycoside based regimen  
class6	parietal cell vagotomy and dilatation for peptic duodenal stricture  gastric outlet obstruction due to peptic duodenal stricture  pyloric stenosis  was treated with parietal cell vagotomy and dilatation of the stricture in 32 patients  follow up is in the range of 5 years in 37 4  of the patients  while 6 to 10 years follow up is available in 62 4  of the patients  at their last follow up  74 9  of the patients were in either visick 1 or 2 clinical status  recurrence rates have been 3 1  at 1 year  9 3  at 5 years  and 21 8  after 6 to 10 years follow up  there has been only one instance  3 1   of restenosis  two patients required reoperation because of recurrence and one of them died  
class6	prognostic determinants in extracorporeal membrane oxygenation for respiratory failure in newborns  extracorporeal membrane oxygenation  ecmo  is becoming an accepted therapeutic modality for newborn respiratory failure  but there is little information available regarding the prognostic determinants with this technique  one hundred thirty five newborns treated with ecmo over a 4 year period were critically analyzed with regard to the influence that birth weight  gestational age  age at initiation of ecmo  best blood gases before ecmo  number of hours on ecmo  renal failure  intracerebral hemorrhage  and long distance air transport had on survival  infants with meconium aspiration and those undergoing long distance transfer showed significant differences in blood gases before ecmo  with survivors having more normal ph and carbon dioxide tension values  intracerebral hemorrhage and renal failure that developed during ecmo were grave prognostic signs  with few survivors in either group  these data show that ability to ventilate patients before ecmo  giving normal carbon dioxide tension and ph values  is an important prognostic sign in infants with meconium aspiration and undergoing long distance transfer for ecmo  whereas renal failure and intracerebral hemorrhage are usually lethal complications of ecmo  each center performing ecmo should continually reevaluate this invasive technique and its results and complications  
class6	acquired benign esophagorespiratory fistula  report of 16 consecutive cases  sixteen cases of acquired benign esophagorespiratory fistula were treated in a 20 year period  a delay in diagnosis was usual  and most patients were first seen with a pulmonary infection already developed  contrast esophageal x ray studies established the diagnosis in all patients  there were seven esophagotracheal and nine esophagobronchial fistulas  a fistula between the esophageal diverticulum and a bronchus considered to be of inflammatory origin developed in 7 patients  a fistula as the consequence of trauma developed in 9 patients  and these fistulas were situated at a higher level of the respiratory tree  all patients underwent surgical treatment  in 12 it was definitive  and in 4 temporary gastrostomy was performed to improve nutrition before definite repair  the definitive repair consisted of eventual diverticulectomy  division of the fistula  and suture of both esophageal and respiratory defects  two patients required esophageal resection and later reconstruction with colon interposition  one patient died  creating an operative mortality of 8 3  in the definitive repair group  the remaining 11 patients had a gratifying long term result  there were two deaths in the gastrostomy group due to an extremely poor condition of patients and debilitating pulmonary infection  early diagnosis of this rare condition is necessary if severe pulmonary complications are to be avoided  early direct repair gives excellent results  
class6	collis gastroplasty  origin and evolution  in 1957 j  leigh collis published his innovative operation for treating the difficult problem of the irreducible hiatal hernia  esophagitis  and stricture  the design of the operation was based on the relatively primitive understanding of hiatal hernia and the newly emerging concept of reflux esophagitis  a variety of antireflux operations by different surgeons emerged over the years to follow  the original collis gastroplasty has been subsequently modified with the addition of both partial and complete fundoplication procedures  the place of the modified collis gastroplasty fundoplication operations in today s approach to the problems of hiatal hernia and gastroesophageal reflux disease remains unsettled  
class6	congenital tracheoesophageal fistula associated with carcinoma of the lung in an adult  a rare case of adult congenital h type tracheoesophageal fistula was diagnosed  subsequently  at operation  large cell  undifferentiated carcinoma of the right middle lobe with extension to the right lobe and adherence to the diaphragm was documented  the diagnosis  surgical intervention  and 4 year follow up are presented  
class6	acute autonomic neuropathy  two cases and a clinical review  acute autonomic neuropathy is an uncommon syndrome  usually affecting healthy young people  presentation is often dramatic and initial misdiagnosis is common  we describe two young women with acute autonomic neuropathy who presented with gastrointestinal involvement heralding widespread dysautonomia and review 26 additional cases of acute autonomic neuropathy from the english language literature  acute autonomic neuropathy can be primarily cholinergic without orthostatic hypotension  26   or pandysautonomic  74   involving sympathetic adrenergic functions  onset has been temporally related to viral syndromes in 20  of cases  with autonomic deficits usually evolving over 1 to 3 weeks  gastroparesis  69   and syncope  12   are frequent presenting complaints  spinal fluid protein levels are often  75   elevated in pandysautonomic subtypes  prolonged and incomplete recovery is the rule  60    with persistent gastroparesis and orthostatic hypotension  other specific diseases that occasionally mimic acute autonomic neuropathy include botulism  porphyria  amyloidosis  and paracarcinomatous neuropathies  acute autonomic neuropathy shares several clinical features with acute idiopathic polyneuropathy  guillain barre syndrome   suggesting an immune mediated pathogenesis  
class6	primary malignant peritoneal mesothelioma  a report of seven cases and a review of the literature  mesothelioma of the peritoneum is a rare malignant neoplasm easily mistaken by both surgeon and pathologist for one of the more common neoplasms of the abdomen  review of our records from metropolitan area hospitals for the past 15 years identified seven patients with primary peritoneal mesotheliomas  their diagnosis  management  and survival is analyzed  we report a case of an extended survivor  7 years  and one of a long term survivor  15 years   as well as what we believe to be the only case in the literature presenting with a coexistent malignant neoplasm  prevention of this commonly fatal neoplasm is linked to avoiding occupational exposure to asbestos  long term survival for a few patients may be achieved with correct identification of the neoplasm and aggressive management  this report includes a review of the literature  
class6	management of perineal wounds following abdominoperineal resection with inferior gluteal flaps  our experience treating perineal wounds secondary to abdominoperineal resection  either for inflammatory bowel disease or cancer  is presented  a total of 16 patients were treated either on a delayed basis or at the same time as the abdominoperineal resection  all wounds were closed using the inferior gluteal myocutaneous flap  fifteen of 16 patients have achieved healing  eight of whom had no complications  only minor revisions or local wound care were required in the remaining patients  with only one patient failing to heal  our results compare favorably with previous reports of treatment of this difficult problem  
class6	extrahepatic biliary obstruction by lymphoma  extrinsic compression of the common bile duct by enlarged lymph nodes is an unusual cause of obstructive jaundice  we describe two patients with such a manifestation of lymphoma and the use of endoscopic retrograde cholangiopancreatography in distinguishing this rare complication from other causes of jaundice in lymphoma  patients may have rapid resolution of both symptoms and biochemical abnormalities by nonoperative biliary bypass combined with chemotherapy and or radiotherapy  lymphomatous obstruction should be considered a cause of potentially treatable jaundice in patients with known lymphoma  endoscopic retrograde cholangiopancreatography can be valuable as a diagnostic and therapeutic tool  
class6	plasma thrombomodulin in health and diseases  sodium dodecyl sulfate polyacrylamide gel electrophoresis followed by immunoblot analysis of plasma thrombomodulin concentrate revealed that four degraded forms of thrombomodulin with different molecular weights are present in plasma  plasma concentrations of thrombomodulin in patients with various diseases were measured by two methods of enzyme linked immunosorbent assay using monoclonal antibodies  one method measures intact thrombomodulin and degraded forms of thrombomodulin  the other does not detect the two smaller degraded forms of thrombomodulin present in plasma  the results indicated that thrombomodulin was increased in the circulating blood of patients with disseminated intravascular coagulation syndrome  pulmonary thromboembolism  adult respiratory distress syndrome  chronic renal failure  or acute hepatic failure  the different values obtained by the two methods indicate that the increase of plasma thrombomodulin found in these patients was mainly due to an increase of the smaller fragments of degraded forms  suggesting that the release of thrombomodulin from endothelial cells was accelerated in various disease states by proteolytic activity generated on the surface of the endothelium and may be removed from the circulation mostly by the kidneys and liver  
class6	ultrasonography in patients with suspected acute appendicitis  a prospective study  the diagnostic accuracy of high resolution real time ultrasonography was prospectively studied in 240 patients admitted to the hospital with suspected acute appendicitis  the criteria for ultrasound diagnosis of appendicitis included a sausage shaped  aperistaltic  hypoechoic structure when imaged along its longitudinal axis  with a target like appearance on transverse section  the ultrasonographic findings were correlated with surgical pathological outcome in 82 cases with proven appendicitis  with laparotomy findings in another 21 patients and with clinical follow up in the remainder  the overall sensitivity  specificity and accuracy of ultrasonography in the diagnosis of acute appendicitis were 78   92  and 87   respectively  the positive predictive value was 84  and the negative predictive value was 88   ultrasonography may significantly improve the diagnostic accuracy in patients with suspected acute appendicitis and should be performed in all patients in whom the clinical diagnosis is equivocal  the ultrasonographic findings must be interpreted in light of the clinical findings  
class6	a combined electromyographic and cineradiologic investigation in patients with defecation disorders  records from 20 patients on whom defecography and electromyography were performed simultaneously because of defecation disorders were analyzed  according to the electromyographic investigation  the patients could be divided into three main groups  1  normal sphincter reaction  2  paradoxical sphincter reaction  and 3  combined reaction  group a was characterized by a marked reduction of muscular activity during emptying and a pronounced closing reflex after emptying  this was followed by return of normal tonic activity  patients in group b had no relaxation of the sphincters during emptying but a pronounced increased activity in the external sphincter and the puborectalis muscle  they also had severe emptying difficulties at defecography  no closing reflex was seen  in group c the electrical activity in the sphincters increased during moderate straining and when emptying was complete a clear closing reflex was seen  in this study  a dynamic visualization of the defecation together with a registration of electromyographic activity in the striated anal sphincters was performed  it was shown that patients with paradoxical sphincter reaction were lacking a closing reflex after emptying was complete  this has not been reported previously and is important evidence for the paradoxical defecation pattern  it was also shown that the patients with rectoceles had paradoxical sphincter reaction  
class6	perianal abscess and fistula in ano in children  the authors present a retrospective review of 40 pediatric patients with perianal abscess and or fistula in ano  the total patient population could be divided clinically into 2 broad groups  the first group consisted of 22 infants younger than 2 years of age  all of whom were males  and 10 of whom presented with recurrences after previous incision and drainage  of the 14 infants presenting with an abscess  in 12  85 7 percent   a fistula in ano was discovered at surgery  in contrast  in the group of 18 children older than 2 years of age  there were 7 females and 11 males  and fistulas were identified in only 7 of 13 patients  54 8 percent  who presented with abscesses  surgical treatment consisted of examination under anesthesia and a diligent search for a fistulous tract  abscesses were primarily saucerized and fistulotomy and cryptotomy of the confluent crypt was performed if a fistulous tract was identified  the only recurrences with this form of treatment occurred in the two immunocompromised patients  
class6	nitrite from inflammatory cells  a cancer risk factor in ulcerative colitis  elevated levels of luminal nitrite and a lowered luminal ph were found in 77 percent of patients with acute ulcerative colitis  no luminal nitrite was found in healthy control subjects  nitrites are a secretory product of activated macrophages and neutrophils of the lamina propria  whereas the lowered luminal ph is due to diminished bicarbonate formation by impaired colonocytes  a hypothesis is put forward that nitrites  lowered ph  and bacterial amines are conducive to formation of carcinogenic n nitroso compounds  which reflect a cancer risk in patients with ulcerative colitis dependent on the type and extent of inflammatory cell activation as well as metabolic impairment of colonic epithelial cells  
class6	intestinal perforation due to cytomegalovirus infection in patients with aids  intestinal perforation due to cytomegalovirus  cmv  infection in patients with aids is the most common life threatening condition requiring emergency celiotomy in these patients  the authors describe a patient with aids with intestinal perforation due to cmv infection  and review 14 additional cases reported in the english language surgical literature  the diagnostic triad of pneumoperitoneum on x ray  evidence or history of cmv infection  and aids occurred in 70 percent of patients  the most common site of intestinal perforation was the colon  53 percent   followed in frequency by the distal ileum  40 percent  and appendix  7 percent   perforation usually occurred between the distal ileum and splenic flexure of the colon  colonoscopy  rather than sigmoidoscopy  is recommended as a screening examination in patients with aids suspected of having colonic ulceration due to cmv infection  multiple biopsies of ulcerated tissue should be obtained  gross and microscopic analyses of involved intestinal tissue reveal the characteristic findings of ulceration and cmv infection  despite aggressive therapy  the operative mortality rate in patients with aids with intestinal perforation due to cmv infection was 54 percent and the overall mortality rate was 87 percent  postoperative complications occurred in most patients and consisted mainly of systemic sepsis and pneumonia caused by pneumocystis carinii infection  an increased awareness of this syndrome by physicians frequently called on to manage patients with aids is recommended  
class6	anal ulcerations due to cytomegalovirus in patients with aids  report of six cases  lesions due to cytomegalovirus  cmv  are frequent in the immunocompromised patient  this is particularly the case in patients with aids  where the colon and rectum are the regions most often involved  the authors report six cases of anal ulcerations due to cmv in patients with aids  these lesions  confirmed histologically  were either isolated or associated with other localizations  treatment is based on specific antiviral agents but resistance and recurrence can occur  the current report underlines the importance of histologic examination of anal lesions in hiv infected subjects  
class6	sexually transmitted diseases of the colon  rectum  and anus  the challenge of the nineties  during the past two decades  an explosive growth in both the prevalence and types of sexually transmitted diseases has occurred  up to 55 percent of homosexual men with anorectal complaints have gonorrhea  80 percent of the patients with syphilis are homosexuals  chlamydia is found in 15 percent of asymptomatic homosexual men  and up to one third of homosexuals have active anorectal herpes simplex virus  in addition  a host of parasites  bacterial  viral  and protozoan are all rampant in the homosexual population  furthermore  the global epidemic of aids has produced a plethora of colorectal manifestations  acute cytomegalovirus ileocolitis is the most common indication for emergency abdominal surgery in the homosexual aids population  along with cryptosporidia and isospora  the patient may present to the colorectal surgeon with bloody diarrhea and weight loss before the diagnosis of human immunodeficiency virus  hiv  disease  other patients may present with colorectal kaposi s sarcoma or anorectal lymphoma  and consequently will be found to have seropositivity for hiv  however  in addition to these protean manifestations  one third of patients with aids consult the colorectal surgeon with either condylomata acuminata  anorectal sepsis  or proctitis before the diagnosis of hiv disease  although aggressive anorectal surgery is associated with reasonable surgical results in some asymptomatic hiv positive patients  the same procedures in aids  symptomatic hiv positive  patients will often be met with disastrous results  it is incumbent upon the surgeon  therefore  to recognize the manifestations of hiv disease and diagnose these conditions accordingly  
class6	pearson s marrow pancreas syndrome  a multisystem mitochondrial disorder in infancy  pearson s marrow pancreas syndrome  mckusick no  26056  is a fatal disorder of hitherto unknown etiology involving the hematopoietic system  exocrine pancreas  liver  and kidneys  the observation of high lactate pyruvate molar ratios in plasma and abnormal oxidative phosphorylation in lymphocytes led us to postulate that pearson s syndrome belongs to the group of mitochondrial cytopathies  since rearrangements of the mitochondrial genome between direct dna repeats were consistently found in all tissues tested  our results show that this disease is in fact a multisystem mitochondrial disorder  as suggested by the clinical course of the patients  based on these observations  we would suggest giving consideration to the hypothesis of a defect of oxidative phosphorylation in elucidating the origin of other syndromes  especially those associated with an abnormal oxidoreduction status in plasma  
class6	extracellular matrix gene expression increases preferentially in rat lipocytes and sinusoidal endothelial cells during hepatic fibrosis in vivo  whether parenchymal or nonparenchymal liver cells play a predominant role in the pathophysiology of hepatic fibrosis has not been firmly established in vivo  we have addressed this question by quantitating the relative abundance of specific mrnas for collagen types i  iii  and iv  and laminin in purified populations of hepatocytes  sinusoidal endothelial cells  and lipocytes from normal and fibrotic rat liver  in normal liver  type i collagen gene expression was minimal in all cell types  mrna for types iii and iv collagen were apparent in endothelial cells and lipocytes  but not in hepatocytes  laminin mrna was present in all cell types  induction of fibrogenesis by either bile duct ligation or carbon tetrachloride administration was associated with a substantial increase in mrna for types i and iii collagen in nonparenchymal cells  lipocytes from fibrotic animals exhibited a greater than 30 fold increase in type i collagen mrna relative to normal lipocytes  and greater than 40 fold relative to hepatocytes  type iii collagen mrna reached 5 times that in normal lipocytes and greater than 120 times that in hepatocytes  endothelial cells exhibited an isolated increase in type i collagen mrna  reaching five times that in normal liver  type iv collagen and laminin gene expression were not significantly increased in nonparenchymal cells during fibrogenesis  in fact  mrna for type iv collagen and laminin decreased by up to 50  in endothelial cells  despite the pronounced changes that occurred in matrix gene expression in nonparenchymal cells during fibrogenesis  no change was noted in hepatocytes  we conclude that nonparenchymal liver cells  particularly lipocytes  are important effectors of hepatic fibrosis in vivo  
class6	adverse mortality experience of a southwestern american indian community  overall death rates and underlying causes of death in pima indians  as part of an ongoing epidemiologic study  the death rate and causes of death during 1975 through 1984 were determined in pima indians who resided in the gila river indian community  gric  in 1965 and later  death certificates were available for 677 of the 681 deaths  in 78  of the deaths  the underlying cause recorded on the death certificate agreed with the cause determined after review of all available relevant records  the age  and sex adjusted average annual death rate for the gric population  1639 100 000  was 1 9 times  95  ci 1 7 2 0  the 1980 rate for the u s  all races  878 100 000   in pima males  whose death rate was substantially higher than that of pima females  the age adjusted death rate was 2 3 times that in u s  males  all races  moreover among males 25 34 years of age  the pima death rate was 6 6 times that for the u s  all races  diseases of the heart and malignant neoplasms caused 59  of u s  deaths in 1980  but only 19  of gric deaths  by contrast  the age  and sex adjusted mortality rate in the gric pima was 5 9 times the rate of the u s  all races for accidents  6 5 times for cirrhosis  7 4 times for homicide  4 3 times for suicide  and 11 9 times for diabetes  tuberculosis and coccidioidomycosis were important causes of death in the pima  for whom infectious diseases was the tenth leading cause of death  the findings indicate that programs to improve the adverse mortality experience of the gric population should emphasize factors related to fatal accidents  alcoholic cirrhosis  homicide  suicide  diabetes mellitus  and infectious diseases  young pimas  especially the males  should be the primary focus of such preventive efforts  these findings and recommendations probably apply to many native american populations  
class6	pharmacology of pravadoline  a new analgesic agent  pravadoline is a new chemical entity with analgesic activity in humans  this report describes the pharmacology of pravadoline and compares the activity of pravadoline with that of two major classes of analgesics  the opioids and the nonsteroidal anti inflammatory drugs  nsaids   like the nsaids  pravadoline inhibited the synthesis of prostaglandins  pgs  in mouse brain both in vitro  ic50  4 9 microm  and ex vivo  ed50  20 mg kg p o   and displayed antinociceptive activity in rodents subjected to a variety of chemical  thermal and mechanical nociceptive stimuli  administration of pravadoline prevented the writhing response induced by i p  administration of acetylcholine  ed50  41 mg kg p o   or pge2  ed50  24 mg kg p o   and prolonged the response latency induced by tail immersion in hot water at a temperature of 55 degrees c  minimum effective dose  100 mg kg s c    in the rat  treatment with pravadoline prevented acetic acid induced writhing  ed50  15 mg kg p o    brewer s yeast induced hyperalgesia  randall selitto test   minimum effective dose  1 mg kg p o    the nociceptive response induced by paw flexion in the adjuvant arthritic rat  ed50  41 mg kg p o   and bradykinin induced head and forepaw flexion  ed50  78 mg kg  p o    the antinociceptive activity of pravadoline cannot be explained by an opioid mechanism  because pravadoline induced antinociception was not antagonized by naloxone  1 mg kg s c   and pravadoline did not bind to opioid receptors at concentrations up to 10 microm  however  like the opioid analgesics  pravadoline diminished the electrically induced twitch response of mouse vas deferens preparations  but  in contrast to opioids  this action of pravadoline was not attenuated by naloxone  the possibility is discussed that this effect of pravadoline upon isolated tissues may contribute to its antinociceptive activity  in contrast to nsaids  pravadoline was more potent ex vivo as an inhibitor of the formation of pgs in brain vs  stomach  in addition  pravadoline failed to produce gastrointestinal lesions when administered p o  to rats or mice  and did not possess significant anti inflammatory activity at antinociceptive doses  also unlike nsaids  pravadoline inhibited rat gastrointestinal transit when administered at doses similar to those which were antinociceptive  the overall pharmacologic profile of pravadoline suggests that the compound may be capable of managing more diverse or more severe pain than is achieved by anti inflammatory analgesics  without producing side effects commonly associated with either the opioid or the nonopioid analgesics  
class6	effect of the leukotriene b4 receptor antagonist sc 41930 on colonic inflammation in rat  guinea pig and rabbit  inflammatory bowel disease is a chronic inflammatory disorder of the gastrointestinal tract that includes ulcerative colitis and crohn s disease  leukotriene b4 is thought to be a prominent proinflammatory mediator in these diseases  in that leukotriene b4 levels are increased in the colonic mucosa of inflammatory bowel disease patients and there is increased polymorphonuclear leukocyte infiltration of these tissues  we evaluated the efficacy of 7  3  4 acetyl 3 methoxy 2 propylphenoxy  3 4 dihydro 8 propyl  2h 1 benzopyran 2 carboxylic acid  sc 41930   a potent  orally active leukotriene b4 receptor antagonist  in a model of inflammatory bowel disease  colonic mucosal inflammation was induced in rats  guinea pig and rabbits by rectal instillation of a dilute solution of acetic acid  twenty four hours later  mucosal levels of myeloperoxidase  a marker enzyme for neutrophil infiltration  and extravasation of i v  administered evans blue dye  a marker of vascular disruption and increased permeability  were measured  tissues were also evaluated histologically  the animals received either sc 41930 or vehicle  intrarectally  30 min after or 1 hr before and 1 hr after the acetic acid  when given 30 min after acetic acid instillation sc 41930 prevented the rise in myeloperoxidase and dye extravasation observed in the acetic acid inflammed tissue  the sc 41930 treated tissues were less edematous and had fewer neutrophils within the subepithelial space  median effective dose  ed50  values for vascular protection were approximately 20 mg kg for both rat and guinea pig  ed50 values for inhibition of granulocyte accumulation were 20 mg kg for rat  24 mg kg for guinea pig and 30 mg kg for rabbit  these data indicate that sc 41930 is effective locally to prevent acute colonic inflammation  
class6	mucocele of the cystic duct remnant in eight liver transplant recipients  findings at cholangiography  ct  and us  the case histories and radiologic studies of eight liver transplant recipients who developed a mucocele of the allograft cystic duct remnant were retrospectively evaluated  all patients had clinical and or laboratory evidence of biliary obstruction or cholangitis from 2 weeks to 3 3 years following transplantation  cholangiographic  ultrasound  us   and computed tomography  ct  images were available for review in eight  five  and four patients  respectively  cholangiograms demonstrated an extrinsic mass compressing the common hepatic duct in seven of eight patients  us and ct showed fairly well  to well defined round fluid collections adjacent to the common hepatic duct in three and two patients  respectively  the findings of this study suggest that the detection at cholangiography of an extrinsic mass compressing the common hepatic duct appears to be specific for a mucocele of the allograft cystic duct remnant  ct and us images may offer confirmatory evidence  
class6	colonic stenoses  use of oral barium when retrograde flow is completely obstructed on barium enema studies  forty patients with complete obstruction to retrograde barium flow on barium enema examinations  without clinical or radiographic evidence of obstruction  were studied further with orally administered barium in the same session  all patients had undergone aborted double contrast barium enema studies and had received antispasmodics intramuscularly before the examination  the authors describe the technique  as well as the clinical and radiologic findings  that allows the safe ingestion of oral barium in patients with stenotic lesions of the colon  in all patients  oral barium passed through the small bowel and the stenotic site in an average of 148 minutes  with no complications  in seven patients  there were synchronous lesions in the colon and small bowel  and the findings were determined better with oral barium studies in 19 patients  if a barium enema study is done and retrograde passage of barium is obstructed by a lesion in the left side of the colon  additional diagnostic information can be obtained by giving the patients oral barium  this practice is safe if precise criteria are applied  
class6	feasibility of digital teleradiology for imaging evaluation of patients with acute right upper quadrant abdominal pain  to assess the utility of a commercially available digital teleradiology system in evaluating patients with acute pain in the right upper quadrant  hard copy images from 100 examinations  50 hepatobiliary scintigrams and 50 sonograms of the right upper quadrant  were digitized  transmitted via standard telephone lines  and viewed remotely on a video monitor  video and hard copy interpretations were then compared for degree of concordance  for the scintigraphic studies  hard copy and video images were equal in demonstrating gallbladder and bile duct activity  video images failed to depict the presence of bowel activity in one case  gallstones were depicted equally well on hard copy and video sonographic images  the video interpreters overestimated the presence of abnormal hepatic parenchyma and overlooked one case of right hydronephrosis  the video interpretations of the scintigrams and sonograms showed an overall error rate of 4   comparable to the rate obtained when radiographs are interpreted remotely with digital teleradiology systems  
class6	extracorporeal cholecystolithotripsy without oral chemolitholysis  one hundred thirty six patients completed extracorporeal biliary lithotripsy  ebl  for symptomatic cholecystolithiasis  sonographic evidence of complete clearance of all stone fragments was the only criterion for treatment success  which occurred in 32 of the 71 patients  45   followed up for 24 weeks and in 36 of the 59 patients  61   followed up for 52 weeks  the authors  protocol varied from protocols of other researchers primarily in that no adjuvant chemolitholysis was used  however  the number of treatment sessions and total number of shock waves  a maximum of 4 000 shock waves per treatment session  12 000 shock waves in a patient demonstrating no significant fragmentation  and 20 000 shock waves in a patient whose stones responded well to fragmentation  was higher than those in other reports  the results of treatment and complication rates in this study are comparable with those at centers using both shock wave lithotripsy and chemotherapy  the authors conclude that ebl is developing into an important alternative to surgery  which was obviated in all patients with complete clearance of fragments from the gallbladder  
class6	hypertrophic pyloric stenosis  volumetric measurement of nasogastric aspirate to determine the imaging modality the authors postulated that volumetric measurement of residual gastric aspirate in neonates and infants with nonbilious projectile vomiting could enable differentiation between patients with hypertrophic pyloric stenosis  hps  and those with gastroesophageal reflux  ger  and help to determine whether ultrasound  us  or fluoroscopy of the upper gastrointestinal tract would best confirm the diagnosis  in the 38 patients  all but two of whom had been fasting for 3 4 hours   10 ml or more of nasogastric aspirate was considered indicative of obstruction  hps occurred in 91 7  of patients with 10 ml of aspirate or more  whereas ger occurred in 85 7  of patients with less than 10 ml  the differences between the two groups were statistically significant  solely on the basis of residual volume  greater than or equal to 10 ml   the cause of vomiting could be differentiated  prior to standard radiologic studies  89 4  of the time  it is concluded that patients with projectile vomiting who have 10 ml or more of residual aspirate in the stomach should undergo us for confirmation of hps  those with less than 10 ml should undergo fluoroscopy for confirmation of ger  
class6	hilar malignancy  treatment with an expandable metallic transhepatic biliary stent  an expandable metallic transhepatic biliary endoprosthesis was used to treat 20 patients with hilar malignancy and isolated right and left intrahepatic ducts  in 12 patients  only one intrahepatic ductal system was drained  in eight patients  both systems were drained  in five patients  both systems were drained through a single transhepatic track by arrangement of two stents in a t configuration  the initial technical success rate in placing the stents and achieving internal drainage was 100   complications necessitating further intervention occurred in two of the 20 patients  short term clinical follow up was available for 19 of the 20 patients  two months after stent insertion  two patients complained of persistent jaundice  two patients died without jaundice  and 15 patients were free of symptoms of biliary obstruction  a variety of geometric configurations are possible with this endoprosthesis  the relative merits of these stent arrangements are discussed  and a new technique for placing the stents in a t configuration is described  
class6	emergency portosystemic shunt in patients with variceal bleeding  thirty five patients for whom emergency sclerotherapy or conservative treatment  or both  failed to arrest variceal bleeding  or who had early rebleeding and required emergency portosystemic shunts  epss  were studied  epss permanently controlled the variceal bleeding in all but one patient  in this patient  the shunt was patent as demonstrated by angiography  esophageal varices disappeared in 18 patients and were reduced in 14  three patients died before the endoscopic examination could be performed  the causes of death were hepatic failure in two and bleeding ulcerations of the gastric fundus in the other patient  one patient was classified in child s category b and two in child s category c  thirty two patients submitted to epss and were discharged alive  twelve of these patients subsequently died  at an average of 11 2 months after undergoing the shunt procedure  four of 12 patients died of hepatic failure  two patients died of hepatomas  two  other neoplasia  three  hemorrhaging duodenal ulcers  and one patient  renal failure  analysis of actuarial survival rates showed that the five year survival rate was 43 per cent  the long term survival rates were fewer for patients with child s category c than for those with combined child s categories a and b  five year survival rates were 21 versus 55 per cent  p less than 0 05   during the follow up period  none of the patients had variceal bleeding  chronic encephalopathy developed in six  which was mild in three  moderate in one instance and severe in two  it developed soon after epss  with onset in the first month after discharge in three  thus  when conservative treatment fails to arrest variceal bleeding  epss should be performed to guarantee definitive control of hemorrhage and prolong the survival period  
class6	neoplastic changes in the stomach after gastrectomy  partial gastric resection for benign ulcer disease has been associated with an increased incidence of mucosal dysplasia and invasive adenocarcinoma  particularly 15 to 20 years after resection  these remnant carcinomas are particularly virulent with little hope of resection or cure once symptoms occur  using a planned protocol of routine endoscopic surveillance with biopsy  the goal was to identify early markers of neoplasia  that is  dysplasia  and a diagnosis of adenocarcinoma of the gastric remnant  while both resection and cure were possible  between july 1980 and august 1988  yearly flexible gastroscopic examination and random biopsy have been performed on 163 patients at least ten years after gastrectomy for benign ulcer disease  all biopsy results were interpreted for findings of dysplasia and early gastric adenocarcinoma  results of this ongoing screening program revealed dysplasia of the gastric remnant in nine patients with eventual findings of adenocarcinoma in four of this group  these patients underwent total gastrectomy with findings of limited disease  five patients with mucosal dysplasia continue to be observed at six month intervals  three additional gastric carcinomas were found on initial gastroscopic screening  while one patient had adenocarcinoma diagnosed during a third yearly gastroscopic examination  these eight asymptomatic patients with adenocarcinoma in the gastric remnant had a postgastrectomy interval which ranged from 15 to 29 years  mean of 26 5 years   the results of this study support the concept of neoplastic change in the gastric remnant as a function of time from initial gastric resection  findings of dysplasia on random biopsy indicate a greater likelihood of development of carcinoma of the gastric remnant and identify a subset of patients requiring aggressive endoscopic surveillance  
class6	long term survival and severe rebleeding after variceal sclerotherapy  of 197 consecutive patients with cirrhosis admitted because of bleeding from esophageal varices  133 were included in a prospective study of elective sclerotherapy  we evaluated the incidence of extensive rebleeding and mortality rate  the period of study was 54 months and the mean follow up period was 21 months  forty one patients had severe rebleeding and a majority of the episodes occurred during the first year  only four patients had more than five sessions of sclerosis when rebleeding occurred  the probability rate for patients to be free of severe rebleeding after 48 months  according to pugh s classification  was 88 per cent for those with grade a  50 percent for grade b and 43 percent for grade c  the over all mortality rate was 38 8 per cent  53 patients   with the highest rate noted during the first year  the mortality rate of patients with severe rebleeding was much higher than that of those who did not rebleed  kaplan meier survival analysis at four years was 52 per cent  and survival rates in relation to pugh s classification were 73 per cent for a  53 per cent for b and 34 per cent for c  differences between the three groups were statistically significant  therefore  because of the high mortality rate associated with patients with cirrhosis and extensive rebleeding during the first year  it is important to achieve  as soon as possible  eradication of esophageal varices  
class6	the hazards of surgical glove dusting powders  surgical contaminants of many kinds  including glove powder  constitute a source of formation of granulomas  this is particularly well documented in the peritoneal cavity   starch peritonitis    but has been documented in most anatomic sites  the production of starch free gloves should remove this hazard  but the surgeon should remain aware that most particulate substances introduced into the body inevitably set up an inflammatory response  
class6	gallstones  cholecystitis and diabetes  published erratum appears in surg gynecol obstet 1991 jul 173 1  72  findings from studies showing an increased incidence of gallstones in diabetic patients do not control for other variables  such as obesity  there is no proof that diabetic patients have more gallstones  gallstones do not cause diabetes mellitus  the principal gallbladder pathologic feature in diabetic patients is a functional deficit of uncertain etiologic factors  creating a large  flaccid  poorly emptying organ  bile acid and lipid composition are usually increased in diabetic patients  cholecystitis seems to be a more serious disease in diabetic patients  with worse infectious sequelae and more rapid disease progression  this conclusion has not been examined statistically  even with modern care  the complication rate for operations upon the biliary tract in patients with diabetes is increased  those with diabetes are generally older than other patients requiring cholecystectomy  systemic changes of aging partly explain increased morbidity and mortality  diabetic patients with symptomatic gallbladder disease usually require operation  risk of cholecystectomy in diabetic patients is similar to that in nondiabetics  prophylactic cholecystectomy for diabetic patients with  silent  gallstones was formerly recommended because of an apparent high risk of cholecystitis  until the natural history of gallstones in those with diabetes has been defined  such patients should be considered in danger of serious illness  the risk of acute cholecystitis in diabetic patients with stones is probably significant enough to warrant the performance of early cholecystectomy  
class6	pathogenesis and treatment of intra abdominal infection  intra abdominal infection is considered potentially life threatening  such infection is frequently secondary to perforated viscera  trauma or inflammatory disease  simple abscesses may be drained percutaneously with roentgenologic guidance  complex abscesses often require open surgical drainage  secondary peritonitis is usually polymicrobial  broad spectrum antimicrobial therapy effective against aerobic and anaerobic gram negative bacteria  as well as gram positive organisms  is essential  newer antibiotics  administered either singly or in combination  have been used successfully to treat intra abdominal infection while avoiding the toxicity of aminoglycosides  
class6	a case of lisinopril induced lithium toxicity we describe a patient who developed lithium toxicity when lisinopril was substituted for clonidine  possible mechanisms of angiotensin converting enzyme  ace  inhibitor induced lithium toxicity are discussed  aggressive serum lithium concentration monitoring and a reduction in the dose of lithium is advised when using ace inhibitors because of disturbances and shifts in fluid and electrolyte balance  
class6	genital and anal conditions confused with child sexual abuse trauma  examination of a child with genital or anal disease may give rise to suspicion of sexual abuse  dermatologic  traumatic  infectious  and congenital disorders may be confused with sexual abuse  seven children referred to us are representative of such confusion  
class6	a pitfall in azygos vein cannulation in cirrhotic patients  mistaken cannulation of the mammary vein  azygos venous flow can be measured by a thermodilution catheter in patients with cirrhosis  this is a useful technique since azygos flow is thought to reflect the superior portosystemic collateral flow in these patients  the authors report 3 cases in which mistaken internal mammary vein cannulation mimicked azygos vein cannulation in the supine fluoroscopic view  a lateral fluoroscopic view confirmed internal mammary cannulation  they suggest that if the azygos arch is unpronounced or flow measurements are unexpectedly low in patients with portal hypertension due to cirrhosis  a lateral view be performed to rule out internal mammary vein cannulation  
class6	lymphomatoid granulomatosis presenting as ulcerodestructive gastrointestinal tract lesions in patients with human immunodeficiency virus infection  a new association  we describe cases of severe odynophagia  extensive oral ulcerations  and bowel perforation in patients with human immunodeficiency virus infection that were caused by lymphomatoid granulomatosis  such presentations in human immunodeficiency virus infected individuals are usually ascribed to other causes and may be incorrectly treated on an empiric basis  in addition  deep tissue specimens obtained at the margin of ulcerative lesions are often necessary for definitive diagnosis  we review our limited treatment experience with zidovudine  interferon alfa  and h2 blockers in our patients  based on the markedly increased frequency in which lymphomatoid granulomatosis is being diagnosed at our institution in the post human immunodeficiency virus era  we postulated an association between these two entities  
class6	amelioration of cholinergic induced pancreatitis with a selective cholecystokinin receptor antagonist  acute edematous pancreatitis follows excessive cholinergic stimulation in patients exposed to anticholinesterase containing insecticides  we describe the role of cholecystokinin and the benefits of cholecystokinin receptor blockade in this form of pancreatitis  a cholinergic mimetic  carbachol  was administered to rats weighing 300 to 350 g and produced a form of edematous pancreatitis that mimics that seen in humans  animals received carbachol intraperitoneally  either alone  250 micrograms kg of body weight  or with cholecystokinin receptor antagonist devazepide  3 mg kg of body weight  and were killed 4 hours later  carbachol administration resulted in a 19  increase in pancreatic weight  a fourfold increase in serum amylase levels  and a 14 fold increase in serum lipase levels  plasma cholecystokinin levels  however  were not altered  devazepide administered prior to cholinergic hyperstimulation blocked pancreatic weight increase and reduced elevations in serum amylase levels twofold and lipase levels fourfold  although cholecystokinin levels are not elevated in this model of pancreatitis  blockade of even low  background concentrations of this regulatory peptide is beneficial  
class6	percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections  operative drainage is the cornerstone of therapy for pancreatic abscess  recently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy  we undertook therapeutic  computed tomography directed percutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections  twenty three patients  79   were successfully treated with percutaneous drainage  of six patients  21   representing failures of percutaneous drainage  four died and two recovered after operative drainage  the four patients who died had a mean apache  acute physiology and chronic health evaluation  ii score of 23 and five of ranson s prognostic signs  ranson s signs and apache ii scores were predictive of success and mortality  we conclude that in selected patients  infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage  based on this experience  recommendations regarding patient selection are included  
class6	does somatostatin analogue prevent experimental acute pancreatitis  because somatostatin is a potent inhibitor of pancreatic secretion  we hypothesized that pretreatment with somatostatin analogue octreotide  sms 201 995  might prevent cerulein induced edematous pancreatitis  we studied 18 rats prepared with jugular vein catheters  the following agents were administered intravenously to groups of four rats for 6 hours  1 ml h  control  crystalloid solution  1 microgram kg bolus then 1 microgram kg per hour of octreotide  and 5 micrograms kg per hour of cerulein  also  in a fourth group of six rats  octreotide and cerulein were administered simultaneously  at the end of experiments  blood was drawn for plasma amylase determinations  rats were killed and pancreata were examined  supramaximal cerulein administration to conscious rats induced hyperamylasemia and edematous pancreatitis  confirming previous observations  in both groups of rats receiving cerulein  there was prominent interstitial edema  acinar vacuolization  and mild to moderate acute inflammation  while octreotide pretreatment of rats with cerulein induced acute pancreatitis was associated with a lesser increase of wet pancreas weight and plasma amylase concentration  there was little overall benefit of octreotide pretreatment in this form of experimental acute pancreatitis  
class6	calcium and calcium binding in human gallstone disease  precipitation of calcium salts from bile is important in pigment gallstone formation and may serve as a nidus for cholesterol precipitation  we compared gallbladder bile from patients with symptomatic gallstone disease  40 with cholesterol gallstones and 12 with pigment gallstones  with bile from 10 patients undergoing surgery for non biliary tract disease  bile from patients with gallstone disease was less concentrated  with decreased sodium  bile salt  and phospholipid concentrations  but elevated biliary calcium concentrations were not observed  the relationship between free ionized calcium and total calcium was similar in all groups  indicating no difference in calcium binding by gallstone containing bile  we cannot exclude elevated biliary calcium level as a factor in gallstone pathogenesis  as it could be a transient event  the importance of calcium precipitation was supported by our finding that more than half of the samples were saturated or supersaturated with at least one calcium salt  calcium carbonate  
class6	surgical aspects of sclerosing encapsulating peritonitis  sclerosing encapsulating peritonitis  sep  is associated with the administration of beta blocking agents as well as continuous ambulatory peritoneal dialysis  the predisposing factors in the latter group are recurrent peritonitis  presence of acetate in the dialysate  and antiseptics used during bag exchanges  we report a case of sep following chronic ambulatory peritoneal dialysis and review the literature on this benign yet potentially lethal condition  sclerosing encapsulating peritonitis frequently leads to intestinal obstruction  small bowel necrosis  enterocutaneous fistulas  and malnutrition  there is a high incidence of anastomotic failure when a resection and primary intestinal anastomosis is performed in patients with sep  although sep is not commonly reported in the surgical literature  its importance to surgeons is indicated by the fact that the overall mortality rate is close to 60  in patients with sep who develop surgical complications  
class6	ticlopidine treatment reduces the progression of nonproliferative diabetic retinopathy  the timad study group  the ticlopidine microangiopathy of diabetes study  timad   a randomized  double masked  placebo controlled trial  assessed the effect of this antiplatelet agent  ticlopidine hydrochloride  in reducing the progression of nonproliferative diabetic retinopathy in 435 patients followed up for 3 years  the mean yearly increase in definite microaneurysms on fluorescein angiograms was significantly higher  p    03  in the placebo group  1 44     4 67  than in the ticlopidine group  0 48     5 79   significance was limited to primary analysis using a quality angiographic coefficient for definite microaneurysms in patients with at least three readable angiograms over a 3 year period  ticlopidine was significantly beneficial to insulin treated diabetic patients  inducing a sevenfold reduction of the yearly microaneurysm progression  0 23     6 66  compared with the placebo  1 57     5 29   p    03   among insulin treated diabetic patients  fewer had development of new vessels in the ticlopidine group than in the placebo group  at borderline statistical significance  p    056   overall retinopathy progression was significantly less severe in the ticlopidine group  p    04   adverse reactions associated with ticlopidine included neutropenia  severe in one patient  with no clinical complications  diarrhea  or rash  this study demonstrated that ticlopidine slows down the progression of nonproliferative diabetic retinopathy  
class6	piroxicam decreases postirradiation colonic neoplasia in the rat  this study evaluated the effects of the nonsteroidal antiinflammatory agent piroxicam on chronic radiation proctitis in the rat  forty female wistar rats received a 2250 cgy dose of irradiation to the distal 2 cm of the colon  twenty received piroxicam 8 0 mg kg orally 30 minutes before exposure and 24 hours after exposure  20 rats served as irradiated controls  all animals were evaluated by colonoscopy 1 and 3 weeks postexposure and every third week until death or killing at 1 year  at killing  colons were removed for light microscopic examination  one year postirradiation results showed no differences in mortality  vascular changes  acute inflammation  colitis cystica profunda  or rectal stricture between the control and piroxicam treated groups  however  at 1 year postirradiation the control group demonstrated neoplasia in 15 of 19 animals compared with eight of 20 animals in the piroxicam treated group  the first endoscopic appearance of colonic neoplasm occurred at 15 weeks postirradiation in one control irradiated rat whereas the first evidence of endoscopic neoplasm in the piroxicam treated group did not occur until 36 weeks postirradiation  histologic examination documented a tendency toward a greater presence of adenocarcinomas in the control group compared with the piroxicam treated group  the authors conclude that piroxicam treatment significantly decreased the incidence of colonic neoplasia in general as well as delayed the endoscopic appearance of colonic neoplasia in rats after pelvic irradiation  
class6	clinicopathologic features of hepatocellular carcinoma in young patients  to investigate clinicopathologic characteristics of hepatocellular carcinoma  hcc  in young adults  excised tumors from 21 patients younger than 45 years  young group  were compared with findings in tumors from 204 patients older than 45  old group   in the young group hcc showed  1  a high incidence of positive hepatitis b virus surface antigen  hbsag   young 71 4  versus old 20 1     2  relatively well preserved hepatocellular function  indocyanine green test  young 10 7     8 8  versus old 20 6     10 8     3  low incidence of histologically verified concomitant cirrhosis  young 52 4  versus old 78 4    and  4  a more advanced stage of the disease in tnm classification  stage iii  young 52 4  versus old 18 1    with respect to survival rates achieved by surgery  there was no statistically significant difference between the two groups  thus  hepatitis b virus may relate to the occurrence of hcc in the young patients  despite the advanced stage in the young group  survival rate after surgery was comparable with that achieved in the old group  these observations mean that a close periodic surveillance of young adults with a positive hbsag is required to detect hcc at an early stage  treatment of patients with hbsag using interferon or vidarabine and hepatitis b vaccine should be made to convert hbsag to negative in these individuals  
class6	swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes  eleven patients were tested for swallowing dysfunction after prolonged orotracheal intubation  ten had a tracheostomy tube  mean duration of orotracheal intubation was 19 9 days  mean age 65 yr  and no patient had a concomitant neurologic deficit  all patients had a modified barium swallow with videofluoroscopy  all patients had at least one defect of 11 defects characterized  there was a mean of six defects patient  the most common defects were delayed triggering of the swallow response  present in all patients  and pharyngeal pooling of contrast material  n   9   follow up videofluoroscopy was performed in five patients  all had improved  with mean defects decreasing from 6 1 to 2 8 patient  with one exception  no patient had any defect that was worse than mild in severity  we concluded that prolonged orotracheal intubation with or without tracheostomy may cause prolonged and severe swallowing dysfunction  the deficits improve with time  the presence of a gag reflex does not confer protection against aspiration of pharyngeal contrast  
class6	melanosis of the esophagus  an endoscopic  histochemical  and ultrastructural study  endoscopic  histological  and ultrastructural features of 21 cases of esophageal melanosis are described  these cases were detected during 1000 consecutive routine upper gastrointestinal endoscopies  staining characteristics and ultrastructure of the pigment contained in the endoscopically visible lesions were found to be similar to those of true melanin  
class6	enteric neuronal autoantibodies in pseudoobstruction with small cell lung carcinoma  severe gastrointestinal dysmotility is a newly recognized paraneoplastic syndrome that occurs with small cell lung carcinoma  thirty four patients with small cell carcinoma  of whom 5 had chronic intestinal pseudoobstruction and 29 had no digestive symptoms  were studied serologically  four of the 5 patients with gut dysmotility had immunoglobulin g antibodies reactive with neurons of the myenteric and submucosal plexuses of jejunum and stomach in an indirect immunofluorescence assay  antibodies of this type were not found in any of the 29 patients who had no gut dysmotility  nor were they found in patients with chronic idiopathic intestinal pseudoobstruction  n   8   ovarian cancer  n   20   or epilepsy  n   4  or in normal subjects  n   9   in 4 of the patients with paraneoplastic pseudoobstruction  antibodies in highly diluted serum  1 4000 1 8000  bound selectively to nuclei and cytoplasm of neuronal elements in the gut  this novel autoantibody activity suggests that intestinal pseudoobstruction occurring in patients with small cell carcinoma may have an autoimmune basis  from a clinical standpoint  serological testing offers a simple means for determining which patients with gut dysmotility syndromes may have associated small cell carcinoma  thereby enabling earlier diagnosis and treatment of the tumor  
class6	geographic variation of inflammatory bowel disease within the united states  one approach to learn about possible environmental risks in inflammatory bowel disease relates to studying its geographic pattern of occurrence  the geographic variation of inflammatory bowel disease within the united states was analyzed using the accumulated 17 5 million hospital discharges of all u s  medicare beneficiaries during two consecutive years  to validate the geographic pattern shown by the medicare data  hospitalization was compared with mortality from inflammatory bowel disease among different states  mortality and hospitalization statistics both suggested that the occurrence of inflammatory bowel disease was determined by environmental factors that had a marked geographic variation within the united states  both crohn s disease and ulcerative colitis appeared to be more frequent in northern parts of the united states than in southern and in urban more than rural parts  these trends were observed for men and women and for blacks and whites alike  similar geographic patterns of crohn s disease and ulcerative colitis suggested the influence of one or more identical risk factors for both diseases  
class6	expression of leukocyte adhesion molecules by mucosal mononuclear phagocytes in inflammatory bowel disease  leukocyte adhesion molecules are important in cell cell interactions of the immune system  lymphocyte function associated antigen 1  cluster designation 11a  mediates interactions between t cells and mononuclear phagocytes through its ligand  the intercellular adhesion molecule 1  cd54   whereas complement receptors 3  cd 11b  and 4  cd11c  are involved in complement mediated phagocytosis  expression of cd11 molecules and intercellular adhesion molecule 1 was studied in colonic biopsy specimens from 20 patients with inflammatory bowel disease and 10 normal controls  in normal colon  few mononuclear phagocytes expressed lymphocyte function associated antigen 1 and intercellular adhesion molecule 1 at high densities  the major adhesion molecule was cd11c  thus  the largest population of normal colonic mononuclear phagocytes was represented by quiescent  resident macrophages with likely phagocytic function  in inflammatory bowel disease  mononuclear phagocytes showed only a slight increase in cd11a expression and no significant change in expression of cd11b and cd11c  by contrast  the percentage of mononuclear phagocytes expressing intercellular adhesion molecule 1 was increased from 6 9      3 9  in controls to 69 2      12 8  in ulcerative colitis  p less than 0 001  and to 45 7      22 8  in crohn s disease  p less than 0 01   showing a close relationship with histological activity  the increased expression of intercellular adhesion molecule 1 in inflammatory bowel disease indicates a state of immunological activation induced by local release of inflammatory cytokines  such induction of intercellular adhesion molecule 1 on mononuclear phagocytes may be important in the maintenance of chronic inflammation by facilitating interactions with t cells and t cell antigen recognition  
class6	prevalence of spontaneous hepatofugal portal flow in liver cirrhosis  clinical and endoscopic correlation in 228 patients  the prevalence of spontaneous reversal of flow in the portal venous system was non invasively evaluated by doppler ultrasound in 228 patients with liver cirrhosis and portal hypertension  reversed flow was detected in the portal vein in 7 patients  3 1    in the splenic vein in 7 patients  3 1    and in the superior mesenteric vein in 5 patients  2 1    with an overall prevalence of 8 3   19 228   this prevalence did not differ in relation to the etiology of liver cirrhosis  whereas hepatofugal flow was found in more patients classified as child s c  15 4   and b  12 5   than those classified as child s a  2 7    p less than 0 02  and was associated with a higher frequency of hepatic encephalopathy  21  vs  7 2   p less than 0 05   endoscopic evaluation of esophageal varices did not reveal any correlation between the presence and size of varices and hepatofugal flow  whereas red signs were detected more frequently in patients with this hemodynamic pattern  42 1  vs  24 4   ns   the rate of previous variceal bleeding was not significantly different in patients with and without hepatofugal flow  30 8  vs  24 4   ns   conversely  the prospective evaluation of 15 patients with hepatofugal flow and 29 matched patients with hepatopetal flow  derived from the group of 228 patients  followed up for a period of 12 18 months  showed that variceal bleeding occurred in 9 of 29 patients with hepatopetal flow and in none of the 15 patients with hepatofugal flow  p less than 0 02   however  no statistical difference was found in the survival rates  this study indicates that the actual prevalence of reversed flow in the portal  splenic  and superior mesenteric veins in a nonselected cirrhotic population is 8 3   from a clinical point of view  the data suggest that this finding might be considered an important prognostic factor because  while occurring in cirrhotic patients with more severe functional impairment  it might play a protective role against the risk of bleeding  
class6	detection and direct sequencing of hepatitis b virus genome by dna amplification method  hepatitis b virus  hbv  dna was detected with amplification by the polymerase chain reaction method  cloned hbv dna equivalent to one virus genome  3 x 10  6  pg  was detectable by ethidium bromide staining after 50 cycles of polymerase chain reaction  by applying this method  presence of hbv dna was studied in 23 hepatitis b surface antigen  hbsag  positive and 11 hbsag negative sera from patients with chronic liver disease  hepatitis b virus dna was positive in 8 of 8 hepatitis b e antigen  hbeag  positive  in 2 of 2 hbeag  and anti hbe negative  and in 12 of 13 anti hbe positive sera  hepatitis b virus dna was undetectable in all hbsag negative sera even with amplification  to confirm specificity  the amplified product was directly sequenced  sequences around 122nd and 160th codon of hbs gene  which determines subtypes d y and w r  respectively  were analyzed  the results were compatible with recent reports regarding the relation between hbv subtypes and hbv dna sequence at those codons  hepatitis b virus dna could be detected at the level of one virion by gene amplification method  and its sequence could be determined by direct sequencing in a few days  
class6	effects of short term pancreatic duct obstruction in rats  the short term effects of rat pancreatic duct obstruction were evaluated and compared with those recently reported to follow obstruction of the rabbit pancreatic duct  in both species pancreatic edema and hyperamylasemia are noted  and the lysosomal hydrolase cathepsin b is redistributed from the lysosome enriched to the zymogen granule enriched subcellular fraction  theoretically  this redistribution phenomenon might lead to digestive enzyme activation because cathepsin b is known to be capable of activating trypsinogen  the hyperamylasemia and pancreatic edema  but not the cathepsin b redistribution  that follow rat pancreatic duct obstruction were increased by infusion of a submaximally stimulating dose of the cholecystokinin analogue cerulein  administration of the cholecystokinin receptor antagonist l 364 718 reduced the hyperamylasemia but did not alter the pancreatic edema or cathepsin b redistribution  these observations indicate that cholecystokinin may modulate some but not all of the effects of duct obstruction  secretin administration increased the degree of pancreatic edema and had no demonstrable protective effect  the rat duct obstruction model described in this report may prove particularly useful in future studies designed to clarify the early events underlying the development of acute pancreatitis  
class6	conjugates of ursodeoxycholate protect against cholestasis and hepatocellular necrosis caused by more hydrophobic bile salts  in vivo studies in the rat  the protective effect of ursodeoxycholate conjugates against bile salt hepatotoxicity was studied in chronic bile fistula rats  taurochenodeoxycholate or taurodeoxycholate  infused intraduodenally at 24 or 16 mumols 100 g rat per hour  respectively  caused cholestasis and severe hepatocellular necrosis within 8 hours  in contrast  tauroursodeoxycholate or taurocholate at 48 mumols 100 g rat per hour were choleretic  tauroursodeoxycholate was not hepatotoxic  whereas taurocholate produced moderate hepatocellular necrosis  simultaneous infusion of tauroursodeoxycholate to rats receiving taurochenoxycholate or taurodeoxycholate preserved bile flow and ameliorated hepatic injury in a dose dependent manner  tauroursodeoxycholate protected equally by intravenous and intraduodenal routes  intravenous glycoursodeoxycholate also was protective  the hydrophobicity index of infused bile salts correlated well with their toxicity  concurrent administration of ursodeoxycholate conjugates did not reduce biliary recovery of intraduodenally infused  24 14c  taurocholate  biliary alkaline phosphatase secretion was stimulated by infusion of taurocholate  taurodeoxycholate  or taurochenodeoxycholate  simultaneous infusion of ursodeoxycholate conjugates failed to prevent this increase  we conclude that ursodeoxycholate counteracts hepatoxicity of more hydrophobic bile salts via a direct effect at the level of the liver  
class6	physicochemical determinants of in vitro shock wave biliary lithotripsy  human gallstones were studied by visual inspection  computerized tomographic imaging  and chemical analysis to assess physicochemical characteristics that may determine the outcome of in vitro shock wave fragmentation  eighty five stones  mean diameter  13 2     5 mm  were each collected from different patients  fifty five  65   calculi were angular and 30  35   round or oval shaped  three easily obtained measures were derived from each stone s optimal computerized tomographic image including the mean stone density  a measure corresponding to the standard deviation of the mean stone density value which we termed the stone density distribution index and which may reflect the physicochemical heterogeneity of a given gallstone  as well as the density range  after the administration of 2500 shock waves using an electrohydraulic generator  fragmentation was noted in 68 calculi  80   and was satisfactory in 27  32    where the largest resulting fragment diameters were all less than or equal to 5 mm   strong determinants of satisfactory fragmentation on multivariate analysis included a stone diameter of less than or equal to 15 mm  the presence of an angular stone shape  and a stone density distribution index of greater than or equal to 60 hounsfield units  the other parameters did not independently determine satisfactory fragmentation  prospective clinical trials are needed to assess whether these findings result in a better prediction of the success of extracorporeal biliary lithotripsy and a broadening of its indications  
class6	intrahepatic cholesterol stones  a rationale for dissolution therapy  a case of primary cholesterol hepatolithiasis is reported  stone composition was documented by infrared spectroscopy  and the presence of cholesterol saturated bile was demonstrated using standard biochemical techniques  the patient was treated with operative stone extraction  choledochoscopy  biliary enteric anastomosis  and oral dissolution therapy  the administration of oral dissolution agents has altered the composition of the patient s bile and may prevent further stone formation  we advocate the use of both stone and biliary biochemical analysis for patients with primary hepatolithiasis to facilitate optimal therapy  
class6	insulin resistance in noncirrhotic idiopathic portal hypertension  to explore further the pathogenesis of glucose intolerance and insulin resistance observed in patients with cirrhosis and portal hypertension  we studied a 35 year old woman with presinusoidal portal hypertension without cirrhosis due to nodular regenerative hyperplasia of the liver  after oral glucose ingestion  glucose tolerance remained normal  however  this occurred at the expense of a markedly hyperinsulinemic plasma response  suggesting the presence of insulin resistance  to examine this question more directly  we performed a stepwise euglycemic insulin clamp study in combination with an infusion of  6 3h glucose and  1 14c palmitate and indirect calorimetry  the ability of insulin to promote total body  primarily muscle  glucose uptake was markedly impaired  whereas its effect to suppress hepatic glucose production was normal compared with results obtained in nine healthy subjects  moreover  insulin failed to normally suppress plasma free fatty acid turnover and oxidation in this patient  this informative case demonstrates that portal hypertension alone  without hepatic dysfunction from cirrhosis  is associated with impaired insulin mediated glucose and plasma free fatty acid metabolism and may also play a predominant role in the development of insulin resistance in many cirrhotic patients  
class6	persistent hepatitis b virus following interferon alfa therapy and liver transplantation  a 44 year old man with chronic hepatitis b virus infection and cirrhosis was treated with recombinant human interferon alfa for 67 days immediately before orthotopic liver transplantation and immunoprophylaxis with hyperimmune globulin to hepatitis b virus in the peritransplant period  dot blots for hepatitis b virus dna demonstrated marked reduction in viremia after 41 days of interferon alfa treatment  southern analysis for hepatitis b virus in liver showed a pronounced decrement in actively replicating forms in the explant  although hepatic infection was still detectable  after liver transplantation  tests for serum hepatitis b virus dna and hepatitis b surface antigen remained negative  the patient died 32 days after transplantation of causes unrelated to hepatitis b virus  dna isolated from liver and other visceral organs at autopsy showed infection of the engrafted liver and the persistence of monomeric relaxed circular forms of hepatitis b virus dna in pancreas  kidney  and spleen  thus  graft reinfection occurred despite aggressive antiviral therapy and immunoprophylaxis combined with liver transplantation  existing viral serological markers appear insufficiently sensitive to assess residual infectivity  
class6	hepatic fibrin ring granulomas in a patient with hepatitis a  hepatic fibrin ring granulomas were found in a 30 year old patient with serologically confirmed hepatitis a  other causes associated with the presence of fibrin ring granulomas in the liver  such as hodgkin s and non hodgkin s lymphoma  cytomegalovirus infection  visceral leishmaniasis  and consumption of allopurinol  were ruled out  it is suggested that hepatitis a must be included in the differential diagnosis of a patient with hepatic fibrin ring granulomas  
class6	light microscopic diagnosis of human microsporidiosis and variable response to octreotide  microsporida are protozoan parasites that have recently been identified as a cause of human disease in immunocompromised patients  because of their small size  they have been recognized primarily by electron microscopy  this has limited the study of their prevalence  incidence  and association with large volume diarrhea  the present report describes two cases of enterocytozoon bieneusi infection of the small intestine in patients with intractable diarrhea in whom the diagnosis was made by light microscopy and confirmed by electron microscopy  both patients were treated with octreotide  and one had a good response  
class6	expression of class ii molecules on intestinal epithelial cells in humans  differences between normal and inflammatory bowel disease  expression of class ii antigens on human intestinal epithelial cells was assessed using a sensitive avidinbiotin peroxidase technique  hla dr was present predominantly in the normal small bowel with diminished but evident expression in the colon  hla dp staining was less prominent  and hla dq was absent  in inflammatory bowel disease the expression of both hla dr and hla dp was increased  but that for hla dq remained absent  suggesting an inherent defect in the ability of intestinal epithelial cells to express hla dq  in related experiments  an interferon gamma treated malignant epithelial cell line t84 also failed to stain for hla dq and hla dp despite the presence of hla dr  isolated rnas for all three subclasses of hla d were detectable by slot blot analysis  suggesting that the lack of hla dq expression relates to posttranscriptional defects in intestinal epithelium  these and other differences with conventional class ii antigen positive accessory cells  macrophages b cells  may help to explain the unique properties of intestinal epithelial cells as antigen presenting cells  
class6	injection or heat probe for bleeding ulcer  a prospective randomized trial was performed to compare the efficacy of endoscopic epinephrine injection and heat probe treatment in actively bleeding peptic ulcers  emergency endoscopy in 1758 patients over an 18 month period identified 132 patients with active ulcer bleeding  they were randomized to receive either endoscopic epinephrine injection or heat probe treatment  after endoscopy  the patients were transferred to the surgical gastroenterology ward and were managed by surgeons unaware of the treatment option  bleeding was initially controlled in 96  by epinephrine injection and in 83  by heat probe  p less than 0 05   there was no significant difference in outcome as measured by transfusion requirement  4 5 units vs  3 8 units   emergency surgery  20  vs  22    hospital stay  8 days vs  7 days   and mortality  2 vs  4  between the injection group and the heat probe group  two patients in the heat probe group experienced perforation  we conclude that both endoscopic epinephrine injection and heat probe treatment are effective in stopping bleeding from actively bleeding ulcers  epinephrine injection is technically easier to perform and has a higher initial success rate  
class6	screening colonoscopy in asymptomatic average risk persons with negative fecal occult blood tests  colonoscopy was performed on 210 asymptomatic average risk persons  aged 50 75 years  who had negative fecal occult blood test results  colonoscopy was complete to the cecum in 209 subjects  fifty three subjects  25   had adenomas and two had cancer  all of the adenomas greater than or equal to 1 cm in size and both cancers occurred in subjects aged greater than or equal to 60 years  fifty one percent of subjects with adenomas and one with cancer had no neoplasms distal to the sigmoid descending colon junction  one subject had a major postpolypectomy hemorrhage that stopped spontaneously  screening colonoscopy  therefore  has a high yield for detection of neoplasms in asymptomatic average risk persons aged greater than or equal to 60 years with negative fecal occult blood test results  the yield is low in persons aged 50 54 years and intermediate in persons aged 55 59 years  
class6	airway responsiveness to inhaled methacholine in patients with irritable bowel syndrome  we examined whether patients with irritable bowel syndrome have increased airway responsiveness by measuring forced expiratory volumes in 1 second  fev1  after inhalation of increasing concentrations of methacholine  responses obtained in 11 ibs patients were compared with those obtained in 11 normal subjects and in 11 subjects with organic disease of the gut or its related organs  all subjects were selected so that other factors that might contribute to increased airway responsiveness were excluded  the methacholine concentration that caused a 20  fall in the fev1  pc20   as well as the reduction in fev1 induced by each methacholine concentration  were used to assess airway responsiveness  the geometric mean pc20 was 197 6 mg ml   sem  1 15  for normal subjects  83 9 mg ml   sem  1 51  for subjects with organic bowel disease  p   0 012   and only 12 8 mg ml   sem  1 74  for ibs patients  p less than 0 0001   the 22 5      2 5  decrease in fev1 induced by 64 mg ml of methacholine in ibs patients was significantly greater than that of 12 3      1 5  observed in healthy subjects  p   0 003   in contrast  the 15 7      2 0  decrease in fev1 observed in patients with organic disease was not different from that seen in normal subjects  p   0 189   we conclude that ibs is associated with increased airway responsiveness following challenge with methacholine  
class6	plasma vasoactive intestinal polypeptide concentration determination in patients with diarrhea  determination of plasma levels of vasoactive intestinal polypeptide  vip  has been used for screening patients with chronic diarrhea to identify potential neuroendocrine tumors  this 6 year blinded study from 1981 to 1986 examines the causes of elevated vip levels in patients  in healthy volunteers   n   144   vip concentrations ranged from 14 to 76 pg ml  mean     se  28     12   whereas in chronic renal failure  4 of 34 patients or 12   serum creatinine 4 5   9 0 mg dl  397 795 mumols l   had an elevation to greater than 100 pg ml  no patient with idiopathic hepatic cirrhosis  n   12  had elevation of serum concentration of this peptide  among 588 consecutive unselected patients undergoing evaluation for chronic diarrhea  n   362  62   or possible neuroendocrine tumor  n   214  36    23 patients  3 9   had concentrations greater than 76 pg ml  in this group  5 patients had functioning  vip  160 5975 pg ml  and 5 had nonfunctioning  vip  80 120 pg ml  pancreatic islet cell carcinomas  all 10 patients had hepatic metastases  other known cases of elevated levels of vip  ranging from 80 to 340 pg ml  included other neurogenic tumors  n   3   small  bowel resection  n   2   inflammatory bowel disease  n   2   chronic renal failure  n   1   and prolonged fasting  n   1   patients with diarrhea in which vip secreting tumors were identified had plasma vasoactive intestinal peptide concentrations greater than 140 pg ml  in patients with chronic diarrhea  determination of plasma vasoactive intestinal peptide levels did identify tumors secreting this peptide  but the results from this referral institution did not show identification of these tumors early in their clinical course  
class6	pathogenesis and therapy of peptic ulcer disease  the epithelial cells of the stomach and duodenum are normally protected from the damaging effects of acid and pepsin by a balancing mechanism of mucosal resistance  if an imbalance occurs  peptic ulcer may result  traditional teaching has emphasized the importance of acid  and pepsin  as the cause of this imbalance  however  it is clear that acid and pepsin are not the only important factors in the pathogenesis of peptic ulcer  more recent investigative efforts have been directed at what constitutes mucosal resistance and how it can be disrupted to produce  in the presence of gastric acid  a peptic ulcer  depletion of endogenous prostaglandins and helicobacter pylori gastritis have emerged as prominent theories  as evidence exists both to support and refute these theories in humans  any definitive conclusions cannot be made at this time  the acute management of peptic ulcer disease is directed at relieving pain  accelerating ulcer healing  and preventing complications  peptic ulcers can be healed with antisecretory agents  i e   h2 receptor antagonists  omeprazole   antacids  prostaglandins  and sucralfate  because they are effective  safe  and convenient  the h2 receptor antagonists are the most widely used agents for the management of peptic ulcer disease  because the h2 receptor antagonist agents are equally effective in their indicated uses and are equally safe based on scientifically valid data  selection should be based primarily on cost  omeprazole is the newest antisecretory agent  a single morning dose of 20 mg suppresses acid secretion for 24 h  the agent offers little advantage over h2 receptor antagonists for the majority of patients with peptic ulcer  
class6	nsaid induced gastrointestinal damage  a critical review of prophylaxis and therapy  nonsteroidal anti inflammatory drugs  nsaids  cause acute diffuse injury to the gastroduodenal mucosa  and also cause chronic focal ulcers that may bleed or perforate without warning symptoms  acute and chronic lesions are distinct  are pathogenetically different  respond differently to drugs  and require different management strategies  the principal rationale for antiulcer therapy in nsaid users is to prevent or reduce potentially fatal outcomes  to date no evaluated drug meets this criterion for efficacy  antacids and h2 receptor antagonists  based on open uncontrolled studies  appear to heal both gastric and duodenal ulcers  and maintain them healed during continued nsaid use  larger gastric ulcers show delayed healing with conventional doses of h2 receptor antagonists during nsaid therapy  no such delay occurs with omeprazole therapy  the suggests that if nsaid associated gastric ulcers are treated with h2 receptor antagonists  larger doses should be given for longer periods  in patients with no pre existing ulcer disease  h2 receptor antagonists given prophylactically prevent duodenal but not gastric ulcers  sucralfate does the same  in individuals without peptic ulcer disease taking nsaids  misoprostol  given as prophylaxis  reduces the development of gastric ulcers  its beneficial effects on ulcer healing or symptoms during continued nsaid therapy  or its ability to prevent duodenal ulcers or ulcer complications  are not established  because of diarrhea  the 400 micrograms day dosage is recommended  especially in the elderly  
class6	gastroesophageal reflux disease  an update on management  gastroesophageal reflux is commonplace  all humans experience it  for many patients  gastroesophageal reflux disease  gerd  is a manageable condition  for others  gerd can progress to severe symptoms  inflammation  and disruption of the mucosal lining  effective therapy calls for a clear understanding of the pathogenesis of gerd  the final common denominator to gerd is a lower esophageal sphincter mechanism that relaxes or is incompetent and allows gastroesophageal reflux to occur  key factors associated with gerd are  a  gastric content   b  potency of refluxate   c  esophageal clearance   d  tissue resistance  and  e  disruption of the anatomic hiatus  gerd is generally a chronic condition characterized by recurrent symptoms  treatment goals for the gerd patient need to be defined  is therapy directed toward eliminating the symptoms or is therapy designed to eliminate gastroesophageal reflux  unfortunately  effective therapy for gerd usually does not affect the mechanism s  underlying the problem  the broad goals of therapy in gerd are to decrease gastroesophageal reflux and neutralize it  to enhance esophageal clearance  and to protect esophageal mucosa  the therapeutic modalities related to each of these situations are numerous and overlap  but treatment strategies for managing the gerd patient can be used in clinical  stages  or as the clinical situation dictates  h2 receptor antagonist therapy has become the  keystone  in management of gerd  unfortunately  not all gerd patients respond to conventional h2 receptor antagonist dosage treatment  high dose h2 receptor antagonist therapy recently has been demonstrated to be more effective in a greater number of gerd patients with severe esophagitis  
class6	cimetidine 800 mg twice daily for healing erosions and ulcers in gastroesophageal reflux disease  although h2 receptor antagonists have been the mainstay of therapy for gastroesophageal reflux disease  gerd   none of these agents has been approved by the fda as effective in healing lesions  since proton pump inhibitors may be associated with long term disadvantages  a healing regimen with cimetidine would be useful clinically  this multicenter  randomized  double blind study was conducted to evaluate the efficacy of cimetidine 800 mg b i d  in healing lesions and in providing symptomatic relief in patients with ulcerative or erosive esophagitis  patients with greater than or equal to 8 heartburn episodes during a 1 week screening period  reflux confirmed by esophageal ph monitoring  and esophageal ulcers or erosions confirmed by endoscopy were randomized to treatment with placebo or cimetidine for 12 weeks  cimetidine provided significantly greater  p less than 0 01  improvement  74  vs  51   and complete healing  67  vs  36   of esophageal lesions than did placebo  in these patients with erosive or ulcerative esophagitis  the median time to achieve 24 h without heartburn was 13 days with cimetidine and 30 days with placebo  p   0 01   the mean heartburn severity score in the cimetidine group decreased rapidly during the first week and was consistently lower than in the placebo group  cimetidine  800 mg twice daily  is effective in promoting healing of esophageal ulcers and erosions and in providing heartburn relief in patients with symptomatic erosive ulcerative gerd  
class6	stress related mucosal damage  review of drug therapy  the increased awareness of stress related mucosal damage  srmd  that accompanied the widespread use of fiberoptic endoscopy and the increased incidence of srmd that accompanied the advances in caring for critically ill patients resulted in the recognition that the majority of patients in the intensive care unit  icu  setting wil develop mucosal damage  complications of gastrointestinal hemorrhage in these patients may contribute significantly to their morbidity and mortality  and the consequences of this bleeding may be more severe than the underlying predisposing conditions  because of the importance of gastric acid in the pathogenesis of srmd  therapy has focused on reduction of the intraluminal acid concentration  acid neutralization  while effective  is laborious and associated with side effects  h2 receptor antagonists have been used successfully in the prophylaxis and treatment of srmd and offer the potential for an effective parenteral as well as oral agent  they obviate the need for frequent antacid administration and eliminate some of the troubles and side effects that accompany an intensive antacid regimen  of the available h2 receptor antagonists  cimetidine has been the most thoroughly evaluated  it is equivalent to antacids in the prevention of overt bleeding and offers the advantage of dosing flexibility  ease of administration  and a remarkable safety profile  cimetidine has also been shown to be effective when administered by intermittent bolus infusions given every 8  6  or 4 h or by primed continuous infusion  which has proven to be the most successful method of controlling intragastric ph  
class6	should safety concerns with available ulcer treatment influence drug selection  with the identification of the parietal cell receptors for gastric acid secretion coupled with the introduction of cimetidine in 1977  treatment of acid peptic diseases was transformed from empiric therapy to an approach based on a clearer understanding of human physiology  today  physicians are confronted with an array of antiulcer agents that differ within their drug class  e g   the h2 receptor antagonists  as well as in their mechanisms of action  e g   neutralize acid  alter mucosal defensive factors  or suppress acid secretion   with minor exceptions  the clinical efficacy of the available antiulcer drugs can be regarded as comparable  thus  the safety profile becomes the next consideration when choosing among similarly effective drug products  of the available antiulcer agents  the h2 receptor antagonists as a class have an excellent safety profile  as indicated by more than 25 years of cumulative clinical experience and postmarketing surveillance  important safety issues with currently available antiulcer drugs  i e   h2 receptor antagonists  sucralfate  prostaglandin e analogues  and the newest antiulcer agent  omeprazole  are reviewed to place them into perspective for the clinician  
class6	the clinical importance of drug interactions with antiulcer therapy  the overall safety of a given drug is determined by its toxicity  side effects  and drug drug interactions  thus  a clarification of the mechanisms  importance  and clinical implications of any drug drug interaction with antiulcer therapy is critical to the use of antiulcer medications  drug drug interactions may occur as a result of changes in absorption  metabolism  distribution  or excretion  fortunately  drug distribution or protein binding is unchanged by antiulcer therapy  antiulcer drugs may affect absorption by several mechanisms  ionized medications may bind to the divalent cations of antacids and sucralfate to result in poorly absorbed complexes  reduced gastric acid may decrease the absorption of medications that are weak bases while enhancing the absorption of weak acids  drug absorption may be impaired by delayed gastric emptying  several h2 receptor antagonists  including cimetidine and to a lesser extent ranitidine  and the proton pump inhibitor  omeprazole  may reduce the hepatic degradation of drugs metabolized by the cytochrome p450 system  the degree to which such agents alter drug metabolism is determined by the patient s age  genetics  duration of therapy  degree of cytochrome p450 binding  and the regimen  because the clinical importance of this interaction cannot always be predicted  caution is recommended whenever drugs metabolized by this system are used concurrently  development of an understanding of the ways in which drug metabolism interactions occur may lead to more effective and safe use of these medications  
class6	the gastrin hypothesis  implications for antisecretory drug selection  newer potent and long acting inhibitors of acid secretion  such as the proton pump inhibitor omeprazole  are becoming available for general use  these drugs promise to control acid peptic disease effectively in patients who do not respond adequately to conventional short acting h2 receptor antagonists  the safety of chronic administration of these drugs has come into question  however  lifelong profound inhibition of acid secretion in rats induced by superpotent inhibitors of acid secretion or subtotal fundectomy is associated with the development of carcinoid tumors of enterochromaffin like  ecl  cells in the gastric corpus  available evidence supports a role of gastrin  which becomes chronically elevated in animals subjected to prolonged and profound hypochlorhydria  in humans  hypergastrinemic states such as zollinger ellison syndrome and atrophic gastritis are associated with an increased risk of ecl cell carcinoid tumors  such observations have raised concern that humans may also be susceptible to carcinoid tumor formation in response to potent inhibitors of acid secretion  to date  however  no cases of carcinoid tumor have been attributed to the use of omeprazole in humans  if achlorhydric doses are not used  significant hypergastrinemia can be avoided while effectiveness of treatment is maintained  such measures should minimize any risk of ecl cell carcinoid tumors in humans taking potent long term antisecretory drugs  
class6	requirement of endogenous tumor necrosis factor cachectin for recovery from experimental peritonitis  by intrasplenic immunization we raised a rat mab  mab v1q  igg2a  kappa  with a potent neutralizing activity against natural mouse tnf  1 microgram ml mab v1q 100 u ml tnf   mab v1q was used to study the role of endogenous tnf in experimental peritonitis induced by sublethal cecal ligation and puncture  mab v1q persisted for over 5 days in the serum of mice injected with 100 micrograms of the antibody and  therefore  proved useful for in vivo experiments  as little as 20 micrograms mab v1q mouse prevented lethal shock of the animals by 400 micrograms lps mouse  in sublethal cecal ligation and puncture i p  injection of mab v1q directly and up to 8 h after induction of experimental peritonitis lead to death of the animals within 1 to 3 days  the lethal effect of mab v1q was compensated by injection of recombinant mouse tnf  similar mab v1q effects as in immunocompetent mice were shown in severe combined immune deficiency mice deficient of mature functional b and t cells  taken together  these data suggest that during the early phase of peritonitis endogenous tnf may stimulate nonlymphoid cells such as granulocytes  macrophages  platelets  and fibroblasts to ingest bacteria and to localize inflammation  respectively  these beneficial effects of tnf may determine survival  thus  our data may have implications for the therapeutic management of a beginning peritonitis  
class6	glutathione s transferase  novel vaccine against fasciola hepatica infection in sheep  the potential of gst as a vaccine candidate against liver fluke infection in ruminants was studied by vaccinating sheep  n   9  with gst purified from adult worms of fasciola hepatica and challenging with 500 f  hepatica metacercariae  the immunization induced a high antibody response to gst in contrast to the poor or undetectable response to this ag observed in naturally infected sheep  throughout the trial  the progress of the fluke infection was monitored by measuring rbc hemoglobin levels  the extent of liver damage and the fecal egg output in the sheep  this analysis indicated that a subpopulation  n   4  of the gst vaccinated animals exhibited no anemia  reduced liver damage and a lower mean fecal egg count relative to the infected control group suggesting a lower fluke burden in these animals  worm burdens in the livers of the gst vaccine group  107     22  were 57  lower than in the infected control group  250     25   the subpopulation of the gst vaccine group demonstrated a 78  reduction in mean worm burdens relative to the control group  these results show that gst of adult f  hepatica is a novel ag that can significantly protect sheep against liver fluke infection  the results suggest that the immune response to gst is directed to the juvenile worm reducing the number of worms that can establish in the liver of the vaccinated animals  
class6	liver disease in alpha 1 antitrypsin deficiency  prognostic indicators  we reviewed the clinical presentation  subsequent course  and outcome of 98 patients with alpha 1 antitrypsin deficiency seen at our institution during the past 20 years to obtain answers to the following questions   1  what prognostic factors aid in determining the course of liver disease in affected patients   2  when is the appropriate time for referral to a liver transplant center   3  does breast feeding prevent chronic liver disease   4  what is the incidence of severe liver disease in family members  our analysis revealed that the initial values of alanine aminotransferase  prothrombin time  and trypsin inhibitory capacity may have prognostic value  during clinical follow up the recurrence or persistence of hyperbilirubinemia along with deteriorating results of coagulation studies indicated the need for liver transplantation because of imminent poor outcome  girls had a worse prognosis than boys  initial breast feeding versus feeding of commercial formulas did not influence overall overcome  the incidence of significant liver disease among  at risk  siblings was 21   3 14   if one assumes mendelian inheritance from heterozygous parents  the overall risk for siblings in our families was 5   
class6	effect of extracorporeal membrane oxygenation on survival of infants with congenital diaphragmatic hernia  to determine the effect of extracorporeal membrane oxygenation  ecmo  on the survival of infants with congenital diaphragmatic hernia  we undertook a retrospective review of 31 infants with congenital diaphragmatic hernia treated at children s national medical center  infants were categorized by means of the bohn quadrant analysis to determine the impact of ecmo on infants with congenital diaphragmatic hernia and a  poor prognosis   all infants assigned to the bohn 100  mortality quadrant required ecmo  the survival rate in this group was 86   6 7  when assessed preoperatively and 67   6 9  when assessed postoperatively  comparison of the change occurring in ventilation index and arterial carbon dioxide pressure demonstrated that after repair the clinical condition of 48  of infants deteriorated  40  improved  and 12  remained unchanged  of the 12 infants whose condition was worse after surgery  11 eventually required ecmo  our review demonstrates that ecmo improved survival significantly in infants with congenital diaphragmatic hernia who had a  poor prognosis  by the criteria of bohn et al  we recommend consideration of ecmo for all infants with congenital diaphragmatic hernia for whom maximal medical therapy has failed  
class6	prochlorperazine and transdermal scopolamine added to a metoclopramide antiemetic regimen  a controlled comparison  cisplatin induced nausea and vomiting occurs both acutely and over a prolonged period of time  these symptoms may be incapacitating and are frequently given as a reason to discontinue therapy  we compared prochlorperazine and transdermal scopolamine when added to a standardized metoclopramide antiemetic regimen  twenty seven patients receiving cisplatin at 100 mg m2 were randomly assigned to one of the two treatment arms  patients were observed during chemotherapy and answered a standard questionnaire 24 26 hours later  among similar treatment groups no differences were seen regarding the number of emetic events  level of nausea  degree of sedation or overall acceptability of one treatment arm or another  while not superior to prochlorperazine  transdermal scopolamine is a useful antiemetic agent and can be combined with metoclopramide in an attempt to reduce cisplatin induced nausea and vomiting  further evaluation of this approach is needed  
class6	laparoscopic tubal sterilization  the potential for thermal bowel injury  one of the most severe complications of laparoscopic tubal sterilization is bowel burns  although they often go undetected at the time of laparoscopy  controversy remains over whether these injuries are caused directly by operator error or indirectly from a hot oviduct s or instrument s inadvertently touching and burning the intestine  a study was performed to determine the potential for direct or indirect bowel burns using bipolar electrocoagulation in rabbits  the results indicate that neither a hot tube nor hot  recently used  forceps could cause injuries to the serosal surface of the intestine  that was true both of immediate injury and after one to five days of recovery  it was observed that the hot uterine tube caused significant bowel adhesions by five days after the procedure  direct electrocoagulation of the bowel using 40 w for three seconds caused a minor  noticeable blanch on the bowel that was not detectable with gross or histologic means after one day of recovery  a direct bowel injury did result when 80 w was used for three seconds  the bowel became perforated after one day  these findings indicate that it is unlikely that one can produce a bowel burn indirectly from a hot uterine tube or instrument and that only a direct insult to the bowel appears to cause an injury  however  adhesions could be a complication of the procedure and should be considered  
class6	diagnostic significance of carcinoembryonic antigen in the differential diagnosis of malignant mesothelioma  the histologic and cytologic distinction of malignant mesothelioma from carcinomas metastatic to the pleura or peritoneum is often problematic  for this reason immunologic methods are being increasingly used as diagnostic adjuncts  this review summarizes 40 studies on the expression of carcinoembryonic antigen in mesotheliomas and in lung and other carcinomas involving the pleura or peritoneum  carcinoembryonic antigen was identified immunohistochemically in 11  of mesotheliomas and in 84  of carcinomas examined and immunocytochemically  in serous effusions  in 4  and 58   respectively  in serum and in pleural or ascitic fluid  significantly elevated levels of carcinoembryonic antigen are commonly associated with  lung  carcinomas but rarely with mesotheliomas  thus  together with identification of the antigen in serum  pleural fluid  or ascitic fluid  immunohistochemical and immunocytochemical techniques for detecting carcinoembryonic antigen provide a valuable aid for distinguishing malignant mesothelioma from metastatic carcinomas  
class6	genital herpes simplex virus infections  there has been a dramatic increase in patient visits to physicians for evaluation and treatment of genital herpes infections  this has resulted in part from an increase in genital herpes infections  particularly severe  first episode genital herpes infections in adults without prior hsv 1 infection  virus culture remains the most sensitive and specific method for diagnosis  and use of viral cultures is encouraged  type specific antibody tests have been employed in studies documenting the role of asymptomatic shedding of hsv in transmission of genital infections  the role of genital hsv in transmission of hiv  the predominance of asymptomatic and unrecognized infections in those infected with hsv 2  and the presence of past asymptomatic or unrecognized acquisition of hsv 2 in 25  of persons presenting with first episode genital herpes  unfortunately  commercially available serologic tests do not reliably differentiate between antibody to hsv 1 and hsv 2  recent studies suggest that the annual risk of transmission from a sexual partner with genital herpes is about 10  in heterosexual couples  currently  promotion of  safe sex  is the only available approach for prevention of transmission  however  ongoing research is focused on the development of an effective vaccine  acyclovir should be used routinely in persons with first episode genital herpes  but careful evaluation is needed in persons with recurrent genital herpes to determine whether episodic or suppressive treatment is indicated  acyclovir should also be used routinely for episodic or suppressive treatment of hsv infections in persons with aids  additional antiviral agents are needed for more effective suppressive therapy and for treatment of acv resistant hsv infections in the immunocompromised host  
class6	the emergence of hepatitis b as a sexually transmitted disease  in the united states  approximately 300 000 cases of hepatitis b virus infection occur annually  and heterosexual activity is one of the most commonly reported risk factors for acquiring disease  until the number of infections transmitted through heterosexual contact can be reduced through hepatitis b vaccination  there is little chance of controlling this infection  
class6	sexually transmitted arthritis syndromes  sexually transmitted infections may provoke a wide variety of rheumatic lesions  disseminated n  gonorrhoeae infection leads to septic arthritis  which may be rapidly destructive but which responds promptly to appropriate antibiotic therapy  in contrast  both gonococcal and nongonococcal infections may lead to aseptic  reactive  arthritis or reiter s syndrome  inheritance of hla b27 confers a relative risk of 30 to 50 times for the development of this condition  the demonstration of c  trachomatis antigen in joint material from a minority of patients suggests that direct interaction between microbial components and class i hla antigens in the joint may be central to the pathogenesis of this disease  arthralgia and arthritis occur in up to 50  of individuals in the prodrome of hepatitis b infection  joint symptoms may be accompanied by urticarial or cutaneous vasculitic lesions  especially on the legs  both features resolve with the onset of jaundice  hepatitis b infection is also a major cause of necrotizing vasculitis  which may or may not be associated with overt hepatitis  seronegative arthritis  including reiter s syndrome  psoriatic arthritis  and undifferentiated arthritis  a sjogren s like syndrome  vasculitis  and myopathies have been described in association with hiv infection  it is clear that synovitis occurs in those patients despite the fact that hiv is present in immune cells within the joint during inflammatory arthritis and that both antigen presentation and lymphocyte responsiveness within the joint are impaired  nevertheless  synovitis may occur in the presence of marked cd4 positive lymphocyte depletion  rheumatic syndromes  including arthralgia  inflammatory arthritis  and neuropathic arthritis  may occur during any stage of congenital or acquired syphilis  syphilitic synovitis responds well to antibiotic therapy  but neuropathic lesions cannot be treated effectively  septic arthritis has rarely been described as a complication of disseminated mycoplasma or urea plasma infections  and joint lesions sometimes associated with erythema nodosum have also been reported in lymphogranuloma venereum and granuloma inguinale  
class6	sexually transmitted causes of gastrointestinal symptoms in homosexual men  the possible etiologic agents that may cause gastrointestinal complaints in homosexually active men are multiple  and their diagnosis is complex  this article presents a logical approach to the work up and diagnosis of gastrointestinal complaints in homosexually active men and to discuss their treatment and disease intervention  
class6	acute axonal polyneuropathy associated with anti gm1 antibodies following campylobacter enteritis  we report 2 patients with guillain barre syndrome  gbs  following campylobacter jejuni enteritis  electrophysiologic studies indicated that the predominant process was axonal degeneration of motor nerves  and clinical recovery was poor  serum testing by thin layer chromatography and enzyme linked immunosorbent assay revealed that the sera from both patients contained high titers of igg antibody against gm1 ganglioside  these cases may represent a subgroup of gbs as acute axonal polyneuropathy following c jejuni enteritis associated with anti gm1 antibodies  
class6	pathogenesis of gallstones  the many developments in nonoperative methods for the treatment of gallstone disease underscore the importance of understanding the pathogenesis of these stones  elucidation of the factors responsible for nucleation of crystals and the mechanism by which it occurs would appear to be the challenge if we are to define the cascade of events that results in gallstone formation  
class6	gallstone dissolution  many methods are available for gallstone dissolution  including oral bile salts  cholesterol solvents such as mono octanoin or methyl tert butyl either  and calcium or pigment solvents such as edta and polysorbate  which of these approaches will be appropriate for an individual patient depends on the type of stones  whether they are in the gallbladder or the bile ducts  whether access to the biliary tree is available  the patient s age and general medical condition  and the availability of necessary expertise  in the us  both chenodeoxycholate and ursodeoxycholate are now available  ursodeoxycholate is more expensive but appears to produce fewer side effects and may be more efficacious  these agents are most effective in thin women with small floating  radiolucent cholesterol stones in a functioning gallbladder  only about half of the small subset of patients will experience partial or complete dissolution of stones within a year  stone recurrence and the potential toxicity of long term therapy are problems with this approach  therefore  for most patients  cholecystectomy  either in the traditional fashion or using a laparoscopic approach  see article later in this issue by gadacz et al   is the most cost effective and perhaps the safest option  intragallbladder instillation of methyl tert butyl ether probably will be applicable only to a small subset of patients  and treatment is likely to be followed by a high recurrence rate  in patients with retained common duct cholesterol stones and access to the biliary tree  mono octanoin therapy is advantageous in that it can be initiated as soon as cholangiography demonstrates no extravasation  in properly selected patients  a 90  success rate with this technique can be expected within 7 days  
class6	extracorporeal shock wave lithotripsy for biliary stones  extracorporeal shock wave lithotripsy is a noninvasive technique for treatment of patients with gallbladder and bile duct stones  selected patients with gallbladder stones can be treated on an outpatient basis without general anesthesia and may return to full activity within 1 or 2 days  stone free rates of 40  to 60  at 6 months have been achieved in most reported series with minimal morbidity  bile duct stone lithotripsy has achieved stone clearance in 80  of patients in whom conventional methods were unsuccessful and therefore constitutes a valuable second line treatment for these patients  
class6	surgery for acute and chronic cholecystitis  cholecystostomy and cholecystectomy remain appropriate and effective therapy for acute and chronic cholecystitis  cholecystectomy is the gold standard against which all alternative methods of treatment of inflammatory biliary stone disease should be judged  the pathogenesis  diagnosis  and surgical treatment of acute and chronic cholecystitis have been described  techniques of cholecystostomy  cholecystectomy  and intraoperative cholangiography used by the author have been given  our results and those generally described in the literature indicate that the overall mortality rate for cholecystectomy  in all age groups  is approximately 0 5   this rate increases slightly in patients with acute cholecystitis and in those over the age of 65 years  cholecystectomy remains the most effective and the definitive treatment for acute and chronic cholecystitis  
class6	gallstone pancreatitis  gallstone pancreatitis is caused by transient obstruction of the ampulla of vater by a migrating gallstone  intraglandular activation of pancreatic enzymes occurs  by an unclear mechanism   and their entry into the circulation causes most of the local and systemic events of pancreatitis  the diagnosis is based on history and physical examination  an elevation of serum amylase above 1000 iu l  and ultrasound and ct scans  endoscopic retrograde cholangiopancreatography can be used in less certain cases to confirm the presence of common bile duct stones  because of the absence of an agent that can abort progression of the disease  therapy should consist of adequate resuscitation  nutritional support  and careful monitoring to detect early complications  in patients with mild pancreatitis  surgery usually can be performed within 48 or 72 hours of admission or as soon as symptoms and amylase levels return to normal  for patients with severe disease  endoscopic sphincterotomy is emerging as the therapeutic modality of choice  elective treatment of the associated biliary disease should be performed during the same hospitalization after the acute phase of the disease has subsided  
class6	acute cholangitis  cholangitis is an infection of the biliary ductal system that results from the combination of bactibilia and biliary obstruction  choledocholithiasis has been the leading cause of cholangitis  however  in recent years  especially at tertiary referral centers  nonoperative biliary manipulations  often in patients with unresectable malignancies  have become the most common cause of cholangitis  as a result  the complete triad of fever and chills  jaundice  and abdominal pain  as originally described by charcot  is now seen less frequently  most patients still have leukocytosis and abnormal liver function tests  but many patients with indwelling tubes may develop cholangitis without significant jaundice  e  coli  klebsiella species  and the enterococci remain the most frequently isolated organisms  and anaerobes including bacteroides fragilis are recovered in 15  to 30  of patients  however  enterobacter and pseudomonas species  as well as yeasts  are now being isolated more frequently from patients with indwelling tubes  who often have been treated previously with antibiotics  computed cholangiography usually is necessary to determine the cause and site of biliary obstruction  in the majority of patients with cholangitis  cholangiography can be delayed until the patient has been afebrile for a minimum of 24 to 48 hours  initial therapy includes bowel rest  intravenous fluids  and antibiotics  many antibiotic regimens are now available to cover the gram negative aerobes  the enterococcus  and the anaerobes that are likely to be causing the biliary infection  the combination of a penicillin and an aminoglycoside has been the gold standard  however  recent studies suggest that the newer broad spectrum penicillins provide adequate therapy for these patients  only a small percentage  5  10   of patients with toxic cholangitis require emergency biliary decompression  the choice of percutaneous or endoscopic drainage should be made on the basis of the presumed site and cause of obstruction as well as local expertise  the nature of the biliary obstruction may be the most important determinant of outcome  at present  patients with end stage malignant obstruction account for most of the deaths  whereas approximately 95  of patients survive an episode of cholangitis  
class6	nonoperative management of bile duct stones  the treatment of choice for most retained bile duct stones is by nonoperative means  if a t tube is in place  percutaneous techniques via the t tract are indicated  percutaneous access via puncture of a roux en y loop is also practical  in the absence of a t tube  retrograde endoscopic techniques should be used  both techniques are very effective and safe  stones in the intrahepatic and extrahepatic ducts also can be treated nonoperatively  endoscopic sphincterotomy has a role in the treatment of selected patients with gallstone pancreatitis  acute cholangitis  and choledocholithiasis with in situ gallbladders  in difficult cases  endoscopic and percutaneous techniques are employed in combination  
class6	surgical management of bile duct stones  the biliary surgeon in the 1990s must be familiar with all of the available techniques for the treatment of bile duct stones  experience and judgment are important in the successful management of the individual patient with intrahepatic or extrahepatic stones  knowledge of the nonsurgical methods of stone removal is important in the decision making process  however  the biliary surgeon must resist the temptation to do less than a thorough removal of all stones at the operation lest the patient be subjected to additional procedures  which carry their own risks of morbidity and death  the goal should be to clear the stones from the biliary system with the fewest procedures offering the lowest morbidity and mortality risks to the patient  
class6	stenosis of the sphincter of oddi   stenosing papillitis  is a descriptive term for an anatomic deformity of the papilla of vater that is characterized by narrowing of the lower end of the bile duct and the proximal end of the duct of wirsung  the defect is secondary to inflammation and fibrosis from the chronic passage of gallstones  episodes of acute pancreatitis  chronic pancreatitis  sclerosing cholangitis  peptic ulcer disease  and cholesterolosis  patients with papillary stenosis from gallstones may present with episodes of severe upper abdominal pain several years after cholecystectomy  the pain is often incapacitating  and patients are often addicted to narcotic analgesics  the work up includes abdominal ultrasonography and ct scanning and endoscopic retrograde cholangiopancreatography even though the findings usually are normal  liver and pancreatic enzymes are not frequently elevated with the painful episodes  transendoscopic manometry may reveal elevated pressures within the papillary portion of the distal bile duct  some patients are relieved of their pain by transduodenal sphincteroplasty and transampullary septectomy  thereby ablating the sphincter of oddi around the bile and pancreatic ducts and enlarging their openings  
class6	primary sclerosing cholangitis  primary sclerosing cholangitis is a rare disease of unknown etiology  sclerosis of the bile ducts may actually be the final result of multiple factors such as autoimmune  bacterial  congenital  drug  or viral injury  the most commonly associated diseases are ulcerative colitis and chronic pancreatitis  except in the earliest stages of the disease  liver histologic findings are not specific  most patients present with jaundice  pain  and pruritus  although an increasing number of asymptomatic patients with inflammatory bowel disease and abnormal liver function are being identified  cholangiography is key to the diagnosis and is usually pathognomonic except in the unusual case where primary sclerosing cholangitis is confused with cholangiocarcinoma  many forms of medical therapy have been tried  including antibiotics  azathioprine  cholestyramine  colchicine  cyclosporine  d penicillamine  steroids  and ursodeoxycholic acid  to date  none of these medications has been proved to alter the course of this disease  recent reports of ursodeoxycholic acid trials have been encouraging  but long term results of ongoing randomized trials have yet to be published  in recent years  balloon dilatation of biliary strictures has been accomplished via endoscopic and percutaneous transhepatic approaches  however  in patients with primary sclerosing cholangitis  these nonoperative manipulations must be done repeatedly  may entail multiple general anesthetics  and are difficult to perform  we believe that a direct surgical approach to the biliary tree with long term transhepatic stenting is indicated in selected patients with severe hilar or extrahepatic stricturing  persistent jaundice or recurrent cholangitis  and no evidence of cirrhosis  hepatic transplantation should be reserved for patients with primary sclerosing cholangitis who have well established cirrhosis and have not responded to other therapeutic measures  
class6	congenital biliary tract disease  jaundice in the pediatric patient requires prompt and directed evaluation  this dictum is highlighted in infants with biliary atresia  in whom the progressive sclerosing process results in complete obliteration of patent but microscopic hilar biliary structures by 4 months of age  kasai s operation  if done before that time  will re establish bile drainage in 90  of infants  one fourth to one third of patients achieve long term jaundice free survival  complications of cholangitis  portal hypertension  and fat malabsorption are experienced by many patients  in children with early or late operative failure  liver replacement now offers legitimate hope for extended survival  choledochal cyst is a conglomerate of pancreaticobiliary anomalies consisting of a choledochal cyst  a common channel type pancreaticobiliary junction  intrahepatic cystic disease  and partial obstruction of the distal common bile duct  many patients have one or more of these malformations  it is now widely accepted that the preferred treatment of choledochal cyst is total excision of the diseased biliary duct with reconstruction by roux en y choledochojejunostomy   internal  excision avoids injury to other structures in the hepatoduodenal ligament  particularly if pericystic inflammation is present  congenital perforation of the common bile duct responds in most cases to simple peritoneal drainage of the perforation  retention of the tube cholecystostomy is useful for subsequent cholangiographic follow up  tube cholecystostomy may also be useful for irrigation of the biliary tract in infants with inspissated bile syndrome  
class6	carcinoma of the gallbladder  gallbladder cancer remains difficult to diagnose preoperatively  however  recent work suggests that ultrasound may be effective  gallbladder cancer remains highly lethal despite aggressive therapy  extension of the disease beyond the mucosa predicts a poor chance of long term survival  
class6	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  
class6	persistent mullerian duct syndrome  persistent mullerian syndrome is rare  a case of phenotypically normal male with persistent mullerian structures that consisted of a bicornuate uterus  fallopian tubes  and upper third of the vagina is reported  these unusual structures were found in association with bilateral cryptorchidism and a right inguinal hernia  and were diagnosed while repairing the hernia in the neonatal period  the uterus and fallopian tubes were removed via laparotomy when the child was eighteen months old  at the same time a bilateral orchiopexy was performed  to avoid damage to the vas deferens  which lay in closely to the mullerian structures and could not be separated from the vaginal wall  a small segment of the upper third of the vagina was retained  the testicles  although normal on pathologic examination  have shown poor response to hormonal stimulation with human chorionic gonadotropin  long term follow up for these patients is necessary because they have an increased risk of testicular tumors developing  
class6	asymptomatic rhabdomyolysis of unknown etiology  a 7 year old boy developed rhabdomyolysis with a peak creatine phosphokinase level of 261 400 iu l after his appendectomy  these abnormalities occurred following a 2 3 day illness consisting of upper respiratory tract symptoms  fever  and abdominal pain mimicking acute appendicitis  at the time of operation  a normal appendix was removed  and mesenteric lymphadenitis was noted  the myoglobinuria and elevation of creatine phosphokinase were transient  and the patient remained asymptomatic  we review various causes of right lower quadrant pain and rhabdomyolysis and address the roles of malignant hyperthermia and infectious agents  the possible cause of the phenomena observed in this patient is discussed  
class6	penetration of the pericardium by a gastric ulcer  survival after pericardiocentesis  elderly patients often have unusual manifestations of common illnesses  we describe a geriatric patient having a pneumopericardium from pericardial penetration by a gastric ulcer  benign gastric ulceration causing perforation of the pericardium or other cardiac structures was recognized as early as 1854  however  until 1964  the condition was invariably fatal  our patient survived the episode after early pericardiocentesis and medical treatment  aspects of this uncommon clinical entity and a brief review of the literature are described  
class6	cimetidine suppresses chemically induced experimental hepatic porphyria  the ability of cimetidine to reduce the activity of hepatic aminolevulinic acid synthase  ala s  was examined in allylisopropyl acetamide  aia  treated porphyric adult rats  a dose of 20 mg cimetidine 100 gm body weight resulted in a 50  decrease in the aia induced hepatic ala s activity compared to rats treated with aia alone  heme oxygenase activity was decreased 25  compared to rats treated with aia alone  the effects of aia and cimetidine on cytochrome p 450 were not additive  suggesting competition for a common site of interaction  the results suggest that cimetidine may prove to be useful in treating porphyria in humans  
class6	treatment of chronic liver disease caused by 3 beta hydroxy delta 5 c27 steroid dehydrogenase deficiency with chenodeoxycholic acid  deficiency of 3 beta hydroxy delta 5 c27 steroid dehydrogenase  the second enzyme in the sequence that catalyses the synthesis of bile acids from cholesterol  leads to chronic liver disease in childhood as well as to malabsorption of fat and fat soluble vitamins  a 4 year old boy with this condition has been successfully treated by oral administration of a bile acid  chenodeoxycholic acid  he had been jaundiced since birth  grew poorly because of rickets  and had severe pruritus  plasma transaminase activities were persistently raised  chenodeoxycholic acid 125 mg twice daily for two months  and then 125 mg daily  cured his jaundice and pruritus  returned his transaminase activities to normal  and eliminated the need for calcitriol for prevention of rickets  on this treatment he has so far remained well for two years  a diagnosis of 3 beta hydroxy delta 5 c27 steroid dehydrogenase deficiency should be considered in any child with unexplained chronic hepatitis or cirrhosis  especially if the liver disease is accompanied by a clinically obvious malabsorption of fat soluble vitamins  a simple colorimetric test of the urine confirms the diagnosis and effective treatment can be started  
class6	normal small bowel biopsy followed by coeliac disease  we report four patients  two children  one adolescent  and one adult  having normal small bowel mucosa shown on a biopsy specimen taken before the initial diagnosis of coeliac disease was made  the first biopsy was undertaken in two cases because of suspected malabsorption  in the third because of suspected dermatitis herpetiformis  and in the fourth as part of a coeliac disease family study  after a further 2 6 to 9 years on a diet containing gluten  small bowel villous atrophy with crypt hyperplasia compatible with coeliac disease was found on a second biopsy specimen  the hla type of the patients was that typical for coeliac disease  all were dr3 positive  within the families three other patients with coeliac disease have been diagnosed  two earlier and one at the time the first biopsy was undertaken  four other hla dr3 positive haploidentical first degree relatives were found and had biopsies  all four had normal small bowel villous architecture  one had an increased intraepithelial cell count  and another was positive for reticulin and endomysium antibodies  coeliac disease may exist latent in patients having normal mucosa when eating a normal diet containing gluten  
class6	helicobacter pylori and associated duodenal ulcer  twenty three children with coexistent duodenal ulcer and helicobacter pylori infection were treated with either two weeks of amoxycillin  25 mg kg day  in addition to six weeks of cimetidine  or cimetidine alone  endoscopy with antral and duodenal biopsies for urease test  microaerophilic culture  and histological studies were performed at entry  six weeks  12 weeks  and at six months  children with persistent h pylori infection at six weeks were given a further two weeks  course of amoxycillin  h pylori persisted in all children not receiving amoxycillin treatment but cleared in six of the 13 children  46   treated with amoxycillin  with failure of h pylori clearance at six months  only two out of six  33   ulcers had healed and 50  of patients had experienced ulcer recurrence  in contrast  when h pylori remained cleared all ulcers healed and no ulcer recurred  persistent h pylori infection was associated with persistent gastritis and duodenitis despite endoscopic evidence of ulcer healing  detection and eradication of h pylori deserves particular attention in the routine management of duodenal ulceration in children  
class6	severe hypertension after liver transplantation in alpha 1 antitrypsin deficiency  five children with alpha 1 antitrypsin deficiency and terminal liver disease received liver grafts  all five became hypertensive and four developed hypertensive encephalopathy  there was evidence of renal disease preoperatively and renal biopsy specimens showed variable glomerulonephritic histology with iga nephropathy in one  mesangial proliferative changes in two  and mesangio capillary glomerulonephritis type i in two  four hypertensive episodes were preceded by a fall in creatinine clearance  the association of glomerulonephritis with alpha 1 antitrypsin deficiency in children is more common than has been recognised  affected patients are prone to severe hypertension of probable renal origin after liver transplantation and the renal lesion may affect long term prognosis  
class6	perianal appearances associated with constipation  the perianal appearances were studied prospectively of 136 constipated children  mean age 3 9 years  67 boys  69 girls   anal dilatation  fissures  tags  warts  perianal oedema  redness  blueness  and veins were recorded  it was noted whether dilatation occurred immediately or at 30 and 60 seconds with the buttocks minimally separated  and on subsequent firm lateral traction of the buttocks  the degree of faecal loading was assessed in all children  anal dilatation was found in 24  18   and first appeared on lateral traction in eight  6    in three quarters of the children with dilatation faecal loading or perianal signs were present  fissures were found in 35  26   children and tags in seven  5    perianal redness was more likely to be associated with fissures  and blueness with dilatation  we conclude that there are no pathognomonic perianal signs in childhood constipation and that the technique of anal examination should be standardised  
class6	reproducibility of 24 hour oesophageal ph studies in infants  thirteen infants who had undergone 24 hour oesophageal ph monitoring to diagnose gastro oesophageal reflux had a second study carried out to see if the results were reproducible  the studies were done without restricting the babies  activities  appreciable differences were found  the percentage of the total time during which the ph was less than 4 varying by up to 3 7 fold between the two tests  the differences were largely the result of biological rather than technical variability  from these results estimates were made of the reliability of a single diagnostic study and the size of changes that would be necessary to show the effect of treatment  these findings have a considerable impact on the diagnosis of abnormal gastro oesophageal reflux and its response to treatment whether using 24 hour ph monitoring or any other method of measurement  
class6	bronchial asthma and acid reflux into the distal and proximal oesophagus  the prevalence of pathological gastro oesophageal reflux in children and adolescents with asthma was studied by 24 hour two level oesophageal ph monitoring in 42 subjects aged 9 20 years with moderate or severe bronchial asthma  the importance of oesophagobronchial nerve reflexes and of aspiration of gastric acid as triggers in asthma was assessed by studying whether episodes of reflux into the distal and into the proximal oesophagus were followed by asthma attacks  twenty one subjects  50   had a pathological total reflux time in the distal oesophagus and six  16   in the proximal oesophagus  nine patients had pathological gastro oesophageal reflux into the distal oesophagus together with symptoms of asthma during the day on which the recording took place  in three of them the episodes of asthma symptoms were significantly correlated with preceding episodes of reflux into the distal oesophagus  and in one subject to reflux into the proximal oesophagus  we conclude that pathological gastro oesophageal reflux is common in children and adolescents with asthma  but it seems to provoke symptoms of asthma in only a few  symptoms of asthma were more often elicited by exposure of the distal oesophagus to gastric acid  possibly by a vagal reflex  than by aspiration of gastric juice  
class6	crohn s disease of the lung two years after developing colonic crohn s disease  a 17 year old boy presented with focal pulmonary consolidation  a lung biopsy specimen showed areas of non caseating epithelioid granuloma  although some respiratory abnormalities appear to be associated with inflammatory bowel disease  granulomatous disease affecting the lung has not previously been reported in a child  
class6	treatment of severe acne with isotretinoin in patients with inflammatory bowel disease  four patients with inflammatory bowel disease and severe cystic acne were treated with isotretinoin  two patients had a successful course of treatment without any gastrointestinal side effects  one patient had two episodes of profuse rectal bleeding that were probably related to pre existing haemorrhoids  the fourth patient had a flare up of his crohn s disease after starting isotretinoin  
class6	aerobic work capacity in patients with chronic fatigue syndrome objective  to determine the aerobic work capacity of patients with the chronic fatigue syndrome and compare it with that of two control groups  and to assess the patients  perception of their level of activity before and during illness  design  a symptom limited exercise treadmill test with on line gas analysis and blood sampling was used  subjects were assessed by one investigator  who was blind to the group which they were in  setting  department of medicine  royal victoria hospital  belfast  subjects  13 patients  10 women  three men  who fulfilled the diagnostic criteria for chronic fatigue syndrome  two control groups of similar age  sex  and body weight  13 normal subjects  10 women  three men  and seven patients  five women  two men  with the irritable bowel syndrome  main outcome measures  aerobic work capacity as assessed by several variables such as length of time on treadmill  heart rate  and biochemical measurements  borg score  and visual analogue scores of perceived level of physical activity  results  the patients with the chronic fatigue syndrome had a reduced exercise capacity compared with that of the other subjects  spending a significantly shorter time on the treadmill  they had a significantly higher heart rate at submaximal levels of exertion and at stage iii exertion had significantly higher blood lactate concentrations  using a borg score  they showed a significantly altered perception of their degree of physical exertion with a mean score of 8 2 compared with 6 6 and 5 3 for the normal subjects and patients with the irritable bowel syndrome respectively  using a visual analogue scale they indicated that they had a greater capacity for activity before illness than had the patients with the irritable bowel syndrome  but the scores were not significantly different between the two groups  both groups of patients indicated reduced activity at the time of testing  normal controls and patients with the irritable bowel syndrome aspired to a greater level of activity than their current level  but the patients with the chronic fatigue syndrome aspired to a level similar to that which they had had before their illness  conclusions  patients with the chronic fatigue syndrome have reduced aerobic work capacity compared with normal subjects and patients with the irritable bowel syndrome  they also have an altered perception of their degree of exertion and their premorbid level of physical activity  
class6	serial prothrombin time as prognostic indicator in paracetamol induced fulminant hepatic failure  objective  to find out whether changes in the daily prothrombin time are of prognostic importance in patients with paracetamol induced fulminant hepatic failure  design  retrospective study  setting  the liver unit  king s college hospital  london  patients  150 consecutive patients with paracetamol induced fulminant hepatic failure admitted between october 1986 and february 1989  main outcome measure  death  results  of the 150 patients  72  48   died  in all  34 of the 37  92   patients with a peak prothrombin time of greater than or equal to 180 seconds died as did 20 of the 41  49   with a time of 130 179 seconds  nine of the 25  36   with a time of 90 129 seconds  and nine of the 47  19   with a time of less than 90 seconds  of the 42 patients with a continuing rise in prothrombin time between days 3 and 4 after overdose  39 died  93   compared with 21 of the 96  22   in whom the prothrombin time fell  conclusions  these data indicate that a continued increase in prothrombin time on day 4 after overdose and a peak prothrombin time of greater than or equal to 180 seconds identify at an early stage those patients with a less than 8  chance of survival  liver transplantation should be considered in patients meeting either of these criteria  
class6	response to treatment of detrusor instability in relation to psychoneurotic status  a total of 53 females who entered a double blind crossover trial of oxybutynin and placebo for idiopathic detrusor instability were questioned about life events and associated medical disorders and were given a psychometric test  their response to treatment was studied in relation to these factors  it was found that 11  of patients had nocturnal enuresis beyond age 8 and 25  had irritable bowel syndrome  their response to treatment was generally poor  life events were not consistently related to treatment response  the mean psychoneurotic score of  poor responders   43 7  was similar to that of female psychoneurotic out patients  47 7   although one third of poor responders were normal  patients who responded well to simple anticholinergic treatment had a mean score  30 7   which was similar to that of normal urban females  33 5   most good responders and one third of poor responders showed little evidence of psychoneuroticism  a further search for neurophysiological abnormality in idiopathic detrusor instability is needed  
class6	helicobacter pylori and gastric carcinoma  serum antibody prevalence in populations with contrasting cancer risks  this investigation examined the correlation between helicobacter pylori  hp  infection  as reflected in immunoglobulin g serum antibodies  and the risk of gastric cancer  serum samples were obtained from populations with contrasting gastric cancer risks  the highest prevalence of hp infection  93   was observed in the adult population at highest gastric cancer risk  the residents of pasto  colombia  in the lower risk colombian city of cali  a 63  overall prevalence rate was found  both children and adults were sampled in new orleans  louisiana  where gastric cancer rates are high for blacks but not for whites  the prevalence of hp infection was significantly higher in black than in white adults  70  versus 43   p   0 0001  a higher prevalence was also detected in black compared with white children  49  versus 32   p   0 01  however  an even greater disparity was noted when comparing children from two hospitals  regardless of race  which serve different socioeconomic groups  a prevalence rate of 54  was found at charity hospital compared with 24   p   0 0001  at children s hospital  our findings indicate that socioeconomic conditions  known to influence gastric cancer risk  are also important determinants of hp infection  
class6	xipamide disposition in liver cirrhosis  the pharmacokinetics of the sulfonamide type diuretic xipamide was studied in patients with liver cirrhosis and ascites and compared with healthy control subjects  after oral administration of 40 mg xipamide  the diuretic was rapidly distributed in the blood and the ascites  the ratio of the area under the concentration time curve  auc  of plasma and ascitic fluid was 7 2  as was the protein content in the respective compartments  the auc in plasma of cirrhotic patients was significantly greater than in control subjects  p less than 0 001   the most striking finding was the increase of the amount  ae  of parent drug and main metabolite excreted into the urine  p less than 0 001   the renal clearance of xipamide was only moderately reduced in patients with liver cirrhosis  both auc and ae were positively correlated to the plasma concentration of direct bilirubin of the patients  p less than 0 05   we concluded that nonrenal drug clearance in patients with liver cirrhosis was reduced as a result of the blockade of hepatobiliary excretion during cholestatic conditions  
class6	approaches to the patient with aspiration and swallowing disabilities  aspiration  or soiling of the tracheobronchial tree  can produce life threatening pulmonary disease  intermittent or persistent aspiration may cause symptoms including cough  intermittent fever  recurrent tracheobronchitis  atelectasis  pneumonia  and or empyema  the pulmonary disease may be associated with weight loss  cachexia  and dehydration  in many cases the aspiration is caused by laryngeal dysfunction  allowing pulmonary contamination by swallowed material  in other cases the aspiration is caused by a dysfunction of the oral  pharyngeal  or esophageal phases of swallowing  in some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction  geriatric patients are more likely to experience aspiration  since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group  therefore  with the ever increasing aging of our population  these disabilities will be on the rise  with an associated increase in pulmonary disease and death  the approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment  
class6	esophageal motility in an adult with a congenital h type tracheoesophageal fistula  congenital h type tracheoesophageal fistulas  tef  are rare  long standing respiratory symptoms are the most common presenting complaints  patients with these fistulas have a congenital esophageal motor abnormality characterized by uncoordinated  low amplitude peristalsis of the esophageal body  both low and normal lower esophageal sphincter pressures have been described  these findings persist despite fistula repair  a case history of an adult patient with congenital tef is presented and the literature is reviewed  this patient is unusual in that esophageal symptoms  dysphagia  were more prominent than the usual respiratory symptoms  
class6	effects of a multidisciplinary management program on neurologically impaired patients with dysphagia  dysphagia is a major problem in patients with neurologic disorders  aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates  assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively  this prospective study was conducted to determine if a dysphagia program would improve patients  caloric intake and body weight  decrease the instances of aspiration pneumonia  or improve patients  feeding ability  patients were referred from a 26 bed neurology neurosurgery unit  a time series design was utilized  the control group consisted of 15 patients  mean age   46 1 years   managed according to the existing ward routine  subsequently  nursing staff attended a dysphagia training program  following this  the treated group of 16 patients   mean age   49 3 years  was assessed by the dysphagia team  using bedside and videofluoroscopic examinations to determine the specific swallowing disorder  an individualized treatment program was designed for each patient  the groups were compared on the basis of deviation from their baseline weight  deviation from ideal energy intake  and the incidence of aspiration pneumonia  statistical analysis revealed that the groups were comparable in age  number of days on the study  and glasgow coma scale score  and that a significant weight gain and increase in caloric intake occurred in the treated group  no incidence of aspiration pneumonia was reported in either group  we speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups  
class6	motility changes in primary achalasia following pneumatic dilatation  the changes in esophageal motility after pneumatic dilatation were evaluated prospectively in 51 patients with achalasia  the patients were evaluated for a median of 14 months  pneumatic dilatation led to a clinical improvement in 41 patients  on manometric evaluation  a significant decrease in lower esophageal sphincter pressure was observed  28 4     14 9 mmhg vs  13 5     7 2 mmhg  p   0 001   the resting pressure of the esophageal body dropped from 4 8     4 2 mmhg above gastric baseline to 0 1     3 9 mmhg below gastric baseline  after therapy  peristaltic activity was present in 10 51  20   patients  in 1 case  complete relaxation of the lower esophageal sphincter was recorded  treatment induced motility changes could not be predicted by clinical history or the lower esophageal sphincter pressure before or after therapy  however  the resting pressure of the esophageal body before and after therapy was significantly lower in these patients in whom peristalsis recurred after therapy than in patients with an unchanged motility pattern  the reappearance of peristaltic activity after pneumatic dilatation was unrelated to lower esophageal sphincter pressure  in conclusion  motility disturbances of the esophageal body in patients with achalasia do not simply reflect the functional obstruction of the lower esophageal sphincter  these findings support the hypothesis that achalasia is not a distinct motility disturbance but should be regarded as part of a broad spectrum of different interrelated esophageal motility disorders  
class6	breast feeding and diarrheal morbidity  this study used a unique longitudinal survey of more than 3000 mother infant pairs observed from pregnancy through infancy  the sample is representative of infants from the cebu region of the philippines  the sequencing of breast feeding and diarrheal morbidity events was carefully examined in a longitudinal analysis which allowed for the examination of age specific effects of feeding patterns  because the work controlled for a wide range of environmental causes of diarrhea  the results can be generalized to other populations with some confidence  the addition to the breast milk diet of even water  teas  and other nonnutritive liquids doubled or tripled the likelihood of diarrhea  supplementation of breast feeding with additional nutritive foods or liquids further increased significantly the risk of diarrhea  most benefits of breast feeding alone or in combination with nutritive foods liquids became small during the second half of infancy  benefits of breast feeding were slightly greater in urban environments  
class6	high fat semielemental diet in the treatment of protracted diarrhea of infancy  the capacity for greater fat absorption relative to carbohydrate absorption in protracted diarrhea of infancy was studied in a developed and a developing country  buffalo  ny  and bangkok  thailand   fifty patients with protracted diarrhea in the first year of life  defined as liquid stools of more than 20 ml kg per day with more than a 14 day duration  were randomly assigned to receive either a standard semielemental diet  pregestimil  or a high fat semielemental diet that contained 40  more fat  the increased fat was largely in the form of medium chain triglycerides  with the new diet providing 60  of the fat as medium chain triglycerides compared with 40  in the standard diet  tolerance to both diets was good in both studies  both groups showed adequate weight gain and an improvement in anthropometric and biochemical parameters  the patients receiving the high fat diet showed no initial weight loss  however  and their weight gain was initiated earlier  cumulative weight gain was also higher in the group receiving the high fat semielemental diet  fecal fat analyses were performed after 1 week of therapy  there was no difference observed in the coefficient of fat absorption between the groups receiving the two formulas  indicating that infants with protracted diarrhea may be able to tolerate a higher fat intake than is normally provided  as carbohydrate intolerance is known to be a complicating factor when using semielemental enteral feeds for infants with protracted diarrhea  a higher fat semielemental diet may be the most appropriate way to provide adequate caloric intake  
class6	angiodysplasia  characterization  diagnosis  and advances in treatment  gastrointestinal bleeding accounts for 2  of all adult hospital admissions each year  angiodysplasia is one of the most frequently reported causes of lower gastrointestinal bleeding  in 80  of patients with bleeding angiodysplasia  the bleeding will stop spontaneously  but will often recur  although angiography may detect bleeding in 86  of actively bleeding patients  the bleeding rate must be at least 0 5 ml min  the treatment of choice for control of bleeding has been resection of the suspected segment of bowel  but this procedure is associated with a 10  rebleeding rate and 7  to 8  mortality  superselective catheterization with infusion of vasoconstrictors has been used to control bleeding  but effects are short lived  superselective embolization occludes an offending vessel  but is difficult to perform accurately and is associated with risk of infarction  laser photocoagulation controls bleeding in 84  of patients  with a 6  complication rate  this method of controlling bleeding offers distinct advantages  especially for the hemodynamically unstable patient  except for cases in which surgical resection is indicated  nd yag laser photocoagulation is the safest  least invasive  and probably most effective means of treating angiodysplasia  
class6	complete jejunoileal necrosis due to torsion of the superior mesenteric artery  we have reported a case of small bowel volvulus in which complete jejunoileal necrosis resulted from torsion of the superior mesenteric artery  this case was unusual not only because of the extent of necrosis but also because primary small bowel volvulus is rare in adults  despite nearly total small bowel resection  the patient continues to do well 6 months postoperatively  
class6	helicobacter pylori infection  a simplified diagnostic approach  we evaluated the diagnostic accuracy of endoscopic finding of nodular antritis and rapid urease test  rut  in order to simplify the approach to the diagnosis of helicobacter pylori  h  pylori  infection  forty four consecutive patients  mean age 7 9 yr  range 6 13 yr  referred because of recurrent abdominal pain as the main symptom  were prospectively investigated for the presence of h  pylori  h  pylori positivity or negativity was defined as the concordance of two of the following tests  rut  microbiologic culture  and histologic examination on bioptic samples  rut sensitivity was 100   whereas specificity was 87 5   the presence of nodular antritis had a sensitivity of 96 4  and specificity of 87 5  in h  pylori infection diagnosis  the predictivity value of combined rut and nodular antritis  whether positive or negative  was 100   only in case of discordance do we suggest the utilization of other expensive tools for diagnosis of h  pylori infection  
class6	helicobacter pylori infection in patients with acquired immune deficiency syndrome  a controlled study was conducted on patients with human immunodeficiency virus  hiv  infection referred for upper endoscopy to evaluate the prevalence of helicobacter pylori  h  pylori  infection  four different stains and culture for h  pylori were performed on biopsy specimens from the gastric antrum  sixteen  40   of 40 patients with acquired immune deficiency syndrome  aids  or aids related complex  arc  were diagnosed to be infected with h  pylori versus 14  39   of 36 age matched control patients  eight of 15 aids arc patients without aids related esophagogastroduodenal findings  53   were infected with h  pylori versus 8 25  32   with endoscopic findings typical of aids  no invasion of the lamina propria by h  pylori was noted in any patient  active chronic gastritis was present in 60  of aids arc patients and 61  of controls  fifty eight and 59   respectively  of active chronic gastritis cases were infected with h  pylori  all the h  pylori infections  except one  were found in patients with chronic gastritis  in aids arc patients  h  pylori infection and active chronic gastritis are as common as in other patients referred for upper endoscopy  they may play a pathogenic role  especially when endoscopic aids related findings are lacking  cell mediated immune deficiency does not appear to increase the risk of infection with h  pylori  
class6	incidence and prevalence of ulcerative colitis in the upper galilee  northern israel  1967 1986  an epidemiological study of ulcerative colitis was performed in the upper galilee  israel  over a 20 yr period  1967 1986   the average annual incidence of ulcerative colitis was 2 23 per 100 000 population  and the prevalence on december 31  1986  was 44 58 per 100 000  considering the fact that strict steps were taken to include only definite cases  these figures are probably an underestimation  an increase of the average annual incidence from 0 88 in the period 1967 1976 to 3 79 in 1977 1986 was found  when the data were stratified according to ethnic groups  the highest average annual incidence and the highest point prevalence was found in israeli born jews  6 9 and 138 2 per 100 000 population  respectively   when jewish residence patterns were compared  the highest average annual incidence and point prevalence were found among kibbutz members  5 52 and 110 39  respectively   and the lowest  1 94 and 38 76  among moshav inhabitants  there were 10 arab patients with an average annual incidence of 0 96 and a point prevalence of 19 27  there were 25 women and 28 men  female male ratio of 0 89   among the jews  the female male ratio was 1 04  peak incidence was found in the 25  to 34 yr old range  no second peak was noticed  anemia was demonstrated in 66 6  of the women and 27 5  of the men in our study  we suggest that the increase in uc incidence and prevalence in israeli and asia africa born jew and in arabs in the upper galilee points toward environmental factors in the etiology of this disease  
class6	failure of hepatitis b immunization in liver transplant recipients  results of a prospective trial  twenty patients with advanced liver disease  in need of transplantation  were given three injections of 20 micrograms and three injections of 40 micrograms hepatitis b vaccine to see if an antibody response could be obtained  only 20  of patients developed measurable anti hbs  one who failed to develop anti hbs developed chronic hepatitis b after exposure to her infected sexual partner  type of liver disease in the native liver  age  sex  sexual preference  timing of immunization  before or after transplantation   and dosage of hepatitis b vaccine did not seem to explain the lack of immunologic response to hepatitis b vaccine  it is presumed that immunosuppression  both from the underlying disease and from immunosuppressive medications  best explains our findings  liver transplantation patients infrequently benefit from hepatitis b vaccine  it is possible that other vaccines given to prevent viral and bacterial illness may also fail to elicit immunologic response in such patients  
class6	increasing prevalence of gallstones in male veterans with alcoholic cirrhosis  cases of alcoholic cirrhosis identified at necropsy were studied for the prevalence and type of gallstones  compared with age  and race matched autopsy controls  data were examined from 1970 1977 and 1980 1987  in the early sample of 460 cirrhotic patients  33  had gallstone disease  contrasted with 12  in the controls  in the 1980s  among 299 patients  46  had gallstone disease  whereas it was present in 13  of the controls  the prevalence of stones was significantly greater in the patients than in the controls for both time periods and  among the patients  was significantly greater in the 1980s than in the 1970s  p less than 0 05   a comparison of cirrhotic patients with and without gallstones indicated a significantly higher incidence of ascites in the patients with gallstones  the gallstones in cirrhotics were more frequently pigmented than in the controls in both time periods  in 100 living patients with advanced cirrhosis studied by sonography during 1987 and 1989  the prevalence of gallstones was 43   almost the same as the autopsy sample from 1980 1987  in these cirrhotics  ascites  encephalopathy  and varices were more prevalent in the patients with stones than those without  we conclude that pigmented gallstones are increasing in cirrhosis of the liver related to the severity of the liver disease  
class6	plasma fatty acid profile in advanced cirrhosis  unsaturation deficit of lipid fractions  fatty acid  fa  profile of plasma total lipids  phospholipids  pl   cholesteryl esters  ce   and triglycerides  tg  were measured in 101 patients with advanced liver cirrhosis and in 44 age  and sex matched healthy controls  plasma levels of lipidic phosphorus  esterified cholesterol  and tg also were measured  and the unsaturation index  ui  was calculated for each fraction  total plasma concentrations of saturated fa  linoleate  and polyunsaturated fa  pufa  were lower in cirrhotics than in controls  this profile was also found in plasma levels of pl  and ce associated fa  no detectable amounts of c20 3n9 were found in cirrhotic patients  percent fa distribution of lipid fractions showed a lower percentage of linoleate and pufa and a higher relative amount of saturated and monoenoic fa in cirrhotics than in controls  as a consequence  the ui of pl and ce was diminished in liver cirrhosis  linoleate and pufa deficiency was more marked in ce than in pl  as shown by the number of patients with values below the 5th percentile of the control group  suggesting an attempt to maintain the unsaturation of pl as the most important component of cell membranes  hepatic failure  poor essential fa intake  and malnutrition are some of the possible etiologic factors for pufa deficiency in cirrhosis  their relative contribution to plasma fa abnormalities  as well as the clinical and pathophysiological consequences of pufa deficit in cirrhotic patients  requires further investigation  
class6	comparison of two ascitic fluid culture methods in cirrhotic patients with spontaneous bacterial peritonitis  the conventional method of ascitic fluid culture detects bacteria in only 50  of cirrhotic patients with neutrocytic ascites and suspected spontaneous bacterial peritonitis  sbp   we have prospectively compared two ascites culture methods in cirrhotic patients with spontaneous bacterial peritonitis  1  conventional  on chocolate agar  blood agar  mac conkay agar  and thioglycolate broth   and 2  modified  inoculation of 10 ml of ascites in a tryptic soy broth  tsb  blood culture bottle at the patient s bedside   in a 21 month period  70 episodes of sbp were diagnosed according to our criteria in 60 cirrhotic patients  both culture methods were performed simultaneously  the conventional grew bacteria in 40 episodes  57    whereas the modified grew bacteria in 54 episodes  77    a significantly higher sensitivity  p   0 0001   in 16 cases  23    ascitic culture was negative by both methods  the mortality rate was higher among patients with culture positive sbp than those with culture negative sbp  46  vs 37    but did not reach statistical significance  we conclude that ascitic fluid inoculated into a tsb blood culture bottle at the patient s bedside should be used routinely for ascites culture in cirrhotic patients  
class6	hemodynamic changes in splenic blood flow during and after distal splenorenal shunt  the purpose of this study was to examine the hemodynamic changes of the spleen and the subsequent influence on the numbers of blood cells both during and 1 month after distal splenorenal shunt  dsrs  with splenopancreatic disconnection in 20 patients with portal hypertension  the intraoperative splenic blood flow  measured with an electromagnetic flowmeter  significantly increased after shunt insertion  the mean percentage increases within the splenic vein and artery were 60   p less than 0 01  and 37   p less than 0 05   respectively  the splenic venous blood flow  measured with a pulsed doppler flowmeter  had not changed significantly 1 month postoperatively  676     501 to 540     306 ml min   the wbc and platelet counts significantly  p less than 0 05 and p less than 0 01  respectively  increased 1 month postoperatively  whereas there was a small  but significant  p less than 0 05   decrease in rbc count  we concluded that splenic blood flow increases immediately after dsrs with splenopancreatic disconnection  but this increase may be only short term  the influence of the postoperative hemodynamic changes on blood cell count is uncertain  
class6	peritoneal mesothelioma  an unusual cause of esophageal achalasia  secondary esophageal achalasia due to malignancy is a rare condition  only 53 such cases have been reported to date  sixty two percent of the cases were due to gastric adenocarcinoma  mesothelioma of the peritoneum is an uncommon neoplasm  the usual presenting symptoms are abdominal pain  abdominal mass  or abdominal distention  the patient we are reporting had peritoneal mesothelioma which presented with dysphagia and weight loss  in addition to the radiological and manometric picture of achalasia  secondary achalasia was suspected clinically  and was confirmed by computed tomography and laparotomy  the diagnosis of peritoneal mesothelioma was made only by histopathological examination  we are not aware of any other report documenting the association of peritoneal mesothelioma and achalasia  
class6	primary adrenal insufficiency  a new cause of reversible gastric stasis  primary adrenal insufficiency is known to cause a wide spectrum of sometimes severe upper gastrointestinal symptoms  however  it has not previously been shown to be the cause of reversible gastric stasis  we have documented such a case in which the symptoms and physiologic abnormalities associated with gastric stasis were reversed by steroid replacement  a follow up radionuclide gastric emptying study after physiologic steroid replacement showed complete normalization of gastric emptying  although gastric stasis has long been suspected of being present with primary adrenal insufficiency  this represents the first case in which it has been documented  and so should be included in the differential diagnosis of patients presenting with chronic nausea and vomiting  
class6	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  
class6	maternal feeding behavior and child acceptance of food during diarrhea  convalescence  and health in the central sierra of peru  feeding patterns by mothers and child acceptance of food were measured in a peruvian village to determine changes on days when children had diarrhea as compared to days of convalescence and health  morbidity surveillance identified 40 children  aged 4 36 months  with diarrhea  children were followed using twelve hour in home structured observations during two to four days each of diarrhea  convalescence  and health  using scales of maternal encouragement to eat and child acceptance of food and cumulative logistic regression analyses  maternal encouragement to eat decreased significantly during convalescence compared to diarrheal days  or  0 54  90  ci  0 35  0 82  and health compared to diarrhea  or  0 65  90  ci  0 46  0 93   in contrast  child acceptance of food increased during health compared to diarrhea  or  1 55  90  ci  1 02  2 35   results illustrate the importance of carefully examining the behavioral aspects of nutritional intake  decreases in intake during diarrhea are due to anorexia and not withdrawal of food by mothers  in response to reductions in child appetite during illness  mothers are more likely to encourage children to eat  while they tend to become more passive feeders after the diarrhea has stopped  program efforts should focus on messages to feed children more actively especially after diarrhea episodes  when appetite levels increase  
class6	the course of the hiv epidemic among intravenous drug users in amsterdam  the netherlands  to determine if behavioral changes in intravenous drug users in amsterdam have retarded the hiv  human immunodeficiency virus  epidemic in this group in recent years  we report that  hiv antibody seroprevalence in annual samples of injectors has been constant over the years 1986 89  hiv antibody incidence in a cohort of injectors appears to have decreased from 1986 to 1987 and stabilized after that until 1989  acute hepatitis b incidence in all drug users in amsterdam declined rapidly between 1985 89  it is concluded that changes in drug use behavior so far appear to have resulted in a stabilization of the epidemic among injectors  at a level with a still disturbingly high incidence rate of 5 6 per 100 person years  
class6	antibiotic use among children in an urban brazilian slum  a risk factor for diarrhea   published erratum appears in am j public health 1991 apr 81 4  417  among a cohort of children in a poor urban setting in brazil  the relative risk for the occurrence of a new episode of diarrhea in the two weeks following antibiotic use vs all other weeks was 1 44  95  confidence interval  ci    1 33  2 45   among children ever  corrected  exposed to antibiotics  the odds ratio was 1 34  95  ci   0 84  2 16  after stratifying by individual child and controlling for previous diarrhea  further research is needed to confirm whether antibiotics are a risk factor for diarrhea in such settings  
class6	surgical complications of continuous ambulatory peritoneal dialysis  surgical experience with 260 consecutive patients with chronic renal failure receiving continuous ambulatory peritoneal dialysis  capd  at one medical center from 1980 to 1989 is reviewed  patients received capd for a mean of 24 2 months  range  3 days to 91 months   catheter longevity consistently improved in all but 1 year from 1984 to 1989  as did exit site and tunnel infections  of 311 catheters inserted  151  49   required removal  of which 111  74   were attributed to peritonitis  cumulative patient survival was 80   60   and 53  at 1  2  and 3 years  respectively  diabetic patients had statistically significant lower survival rates  additional complications including catheter leakage  catheter malposition  catheter obstruction  and abdominal wall hernias were negligible  although capd is not free from serious complications  our data show remarkable improvement since 1980 in catheter longevity  hospital stay  and infection rates  
class6	acute appendicitis in the pregnant patient  acute appendicitis is the most common surgical problem in pregnancy requiring emergent intervention  to establish a contemporary patient profile and formulate an effective management strategy  a retrospective review was conducted of 84 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis  gestational stage at presentation included the first trimester in 27 patients  32    the second trimester in 37 patients  44    the third trimester in 13 patients  16    and the puerperium in 7 patients  8    fifty four patients  64   had pathologically proven acute appendicitis  the incidence did not vary by trimester  other intra abdominal conditions were detected in 15 patients  18    there were no significant differences between patients with positive and negative laparotomies  or among trimesters  regarding frequency of presenting symptoms and signs or laboratory results  operation occurred within 24 hours of symptom onset in 19 of 54  35   instances of proven acute appendicitis  perforation occurred in 23 of 54 patients  43    all of whom had symptoms exceeding 24 hours  p less than 0 0005   five instances of perinatal death and one case of extreme perinatal morbidity were associated with negative laparotomies  only one of these was attributed to operation itself  no adverse long term maternal morbidity or mortality occurred  wound infection developed in seven cases of acute appendicitis  six perforated  and two negative explorations  we conclude that  1  gestational physiologic changes obscure the accurate diagnosis of acute appendicitis   2  the natural history of acute appendicitis is not affected by trimester of presentation  and  3  adverse sequelae of acute appendicitis are obviated by prompt operative exploration and prevention of appendiceal perforation  
class6	current status of duplex doppler ultrasound in the examination of the abdominal vasculature  duplex doppler ultrasound has come to play a central role in the diagnosis of a broad spectrum of vascular diseases such as carotid artery occlusive disease and deep vein thrombosis  the role of duplex doppler in the evaluation of intra abdominal vascular disease remains unclear  this article summarizes the current status of duplex scanning in the investigation of the mesenteric arteries  the renal arteries  and the portal venous system  the examination is technically demanding  operator dependent  time consuming  and frequently unsatisfactory due to bowel gas  obesity  complex anatomy  or postoperative alterations in the normal anatomic patterns  its advantages reside primarily in the absence of toxicity and in the generation of physiologic as well as anatomic information  in centers with the proper instrumentation and a skilled technician  duplex examination can be useful in the diagnosis and management of abdominal vascular disease and avoids the inherent dangers of contrast angiography  
class6	choledochotomy for calculous disease in the elderly  to determine the risk of operations on the biliary tract in the elderly  we retrospectively examined 56 patients 80 years of age or older undergoing choledochotomy for calculous disease and compared their outcomes with those of a contemporary group of 257 patients undergoing similar surgery  thirty of 56 elderly patients  54   required urgent surgery for acute cholangitis  acute cholecystitis  or obstructive jaundice  serum bilirubin greater than 5 mg dl   compared with 97 of 257 younger patients  38    p   0 029   mortality in elderly patients was significantly higher  5 of 56  than in younger  6 of 257  patients  p   0 015   in three of the five patients who died  urgent surgery was performed for obstructive jaundice  reflecting the higher mortality experienced by jaundiced patients in the entire series  9 4    biliary cultures grew organisms in 25 of 27 elderly patients  93    this is in contrast to findings of bactibilia in 62 of 118 patients  53   under the age of 80  p   0 001   similarly  preoperative blood cultures were positive more often in elderly  63   than in younger patients  26    p   0 007   mean postoperative hospital recovery was longer in the elderly group  16 2     8 5 days  than in the younger group  12 2     9 3 days   p   0 002   in conclusion  elderly patients  particularly those with obstructive jaundice  are at higher risk for complicated biliary tract disease necessitating choledochotomy  they appear to be more susceptible to bactibilia and bacteremia  and require longer hospital recovery than younger patients  
class6	when is polypectomy sufficient treatment for colorectal cancer in a polyp  eighty seven patients with a carcinoma in a polyp were reviewed over a 12 year period  ten histologic criteria were analyzed for an association with the presence of residual carcinoma  four factors were identified as having prognostic value  size greater than 1 5 cm  sessility  cancer of at least 50  of the adenoma volume  and invasive carcinoma  polypectomy alone is adequate treatment unless the carcinoma invades deeper to the muscularis mucosa and is associated with one or more of these characteristics  
class6	aggravation of myasthenia gravis by erythromycin  erythromycin is not currently recognized as causing clinical aggravation of myasthenia gravis  we report the case of a patient who experienced exacerbations of myasthenia gravis subsequent to each of several doses of intravenous erythromycin  we suggest that erythromycin can cause clinical worsening in patients with disease of the neuromuscular junction  
class6	hepatic cyst associated with peutz jeghers syndrome  a solitary hepatic cyst  associated with peutz jeghers syndrome  is described  to our knowledge  this association has not been previously reported  a developmental anomaly or hamartomatous nature of this lesion is suggested  knowledge of this association may be helpful in the clinical diagnosis of this benign entity  
class6	cholangiocarcinoma in association with multiple biliary microhamartomas  the rarity of cholangiocarcinoma occurring in von meyenburg complexes is well appreciated  we describe the case of a 35 year old man found to have cholangiocarcinoma in association with multiple biliary microhamartomas of the liver  areas of ductal proliferation and atypia within the bile duct hamartomas suggest malignant transformation to cholangiocarcinoma  
class6	palliative treatment of bile duct tumoral compression by an endoprosthesis  clinical results  the palliative therapy of stenoses of the biliary tract is a difficult choice  because percutaneous or endoscopic drainage methods are fraught with complications  an endoprosthesis for surgical intubation of the biliary tract has been developed  thirty patients were treated by this method  after choledochotomy  the endoprosthesis is positioned surgically above the sphincter of oddi  thereby avoiding ascending cholangitis  twenty nine patients  13 with gallbladder cancer  11 with cholangiocarcinomas  5 with metastases  presented with neoplastic compression  and one patient had an early postoperative stricture with loss of substance after right hepatectomy for hepatic metastases  the operative mortality was 3 3   one pulmonary complication   resolution of jaundice was obtained in all but two patients  and pruritus always resolved  the mean survival time for the patients with cholangiocarcinoma was 12 2 months and 6 33 months for those with gallbladder cancer  indices of satisfaction  bismuth s method  were 71   gallbladder cancer   93 5   hilar cholangiocarcinoma   and 92   metastatic compressions   this new type of surgical endoprosthesis is an alternative in the palliative treatment of neoplastic hilar compression because it is well tolerated  has a low rate of operative mortality or morbidity  and affords an acceptable quality of life for the patients  
class6	 a typical symptoms during single needle dialysis  in 5 elderly patients  an abnormally high occurrence of some symptoms was noted during dialysis  all patients were dialyzed with biocompatible membranes  bicarbonate dialysate  and a blood flow of 250 to 300 ml min by a single needle system  on a fistula 14 gauge catheter needle  these symptoms were  1   angina   resistant to o2 and nitrates  with biochemical stigmata of infarction  but without electrocardiogram  ecg  localization  2  intractable persistent hypotension  not hypovolemic  lasting 1 or 2 days  3  esophagal spasms  with inability to swallow solid food  because we knew that these symptoms were compatible with hemolysis  biochemically proven by the increase in serum ldh during dialysis and by a fall in haptoglobin  due to red cell fragmentation  rcf   we switched these patients from fistula dialysis  a  to central catheter dialysis  b   with the same apperture  blood flow  etc  the total number of sessions of a versus b were 512 and 891  the mean ldh ratios  serum ldh postdialysis divided by predialysis  were 1 8 and 1 0    no rcf   angina events were 132  26   for a  and 25  3   for b  persistent hypotension was seen 37  7   times in a and 5  0 6   times in b  esophagal spasms were noted 65  13   times for a  and 0 times for b  this clinical improvement was so overwhelming that 3 patients refused to be dialyzed again using their well functioning fistulae  this study also proved the need for a better designed and manufactured peripheral dialysis catheter needle  
class6	peritoneal macrophage beta 2 microglobulin production and bacterial peritonitis in capd patients  to evaluate the role of bacterial peritonitis in peritoneal macrophage  pm  beta 2 microglobulin  b2m  production  and its relationship with pm interleukin 1  il 1  and leukotriene b4  ltb4  release  the authors studied 20 capd patients  10 with peritonitis   1  in vivo plasma and peritoneal dialysis effluent  pde  b2m  il 1  and ltb4 levels  2  in vitro b2m  il 1  and ltb4 release by pm  values were compared with those seen in the plasma or with peripheral blood monocytes of 30 hemodialysis  hd  patients  10 treated with cuprophan  cu   10 with polyacrylonitrile  pan   and 10 with cellulose acetate  ca    results showed that in capd patients with bacterial peritonitis b2m  il 1 and ltb4 concentrations in the pde were significantly higher than those seen in capd patients without peritonitis  or in the plasma of hd patients treated with pan or ca  but were similar to those seen in hd patients treated with cu  at the same time  in vitro pm from capd patients with bacterial peritonitis produced more b2m  il 1  and ltb4  than did pm from capd patients without peritonitis  or peripheral blood monocytes from hd patients treated with pan or ca  the authors conclude that in capd patients  bacterial peritonitis is able to induce pm b2m production  probably via a cytokine mediated process  which may be analogous to what occurs with peripheral blood monocytes of hd patients treated with cu  
class6	a prospective randomized evaluation of chronic peritoneal catheters  insertion site and intraperitoneal segment  the insertion site  midline or through the lateral rectus muscle  and type of chronic dialysis catheter  straight or spiral intraperitoneal segment  were evaluated in a prospective randomized trial  dialysis catheter complications and catheter survival were the endpoints of evaluation  eighty five first catheters were evaluated  neither race  gender  renal diagnosis  type of catheter  nor insertion site was a determinant of dialysis catheter survival  overall median catheter survival was 308 days  there were 40 catheter complications  70   n   28  that occurred during the first 61 days following insertion  median time to the first complication occurring within the first 61 days was 3 days  late catheter removals were due to peritonitis episodes that failed to resolve  complications are frequent with peritoneal dialysis catheters  and care of the peritoneal dialysis catheters requires constant vigilance  
class6	complications of tenckhoff catheters post removal  complications due to tenckhoff catheters can occur at prolonged intervals after their removal  from january 1979 to october 1989  431 patients at our center began continuous ambulatory peritoneal dialysis  capd   278 of whom subsequently transferred to another form of renal replacement therapy  we identified 12 patients  4 3  or 12 278  with post removal catheter complications  there were 14 post removal complications  two each in two patients  and one in each of 12 others  the mean time to complication was 541     143 days  27 2 040   in 71   10 14  of the complications  an abscess was found at the site of the previously removed tenckhoff catheter  in 29   4 14  of the complications  foreign body material consistent with a retained cuff was recovered  documentation at the time of tenckhoff catheter removal should include a statement regarding the presence of the tenckhoff catheter cuffs  and patients with retained cuffs should be monitored closely for the development of abscesses or other complications  immunocompromised patients are at high risk for these complications  
class6	pancreatic ischaemia in experimental acute pancreatitis  mechanism  significance and therapy  much clinical and experimental evidence suggests that pancreatic ischaemia in the early phase of acute pancreatitis is important in the development of pancreatic necrosis  while depletion of intravascular volume has often been assumed to be the main circulatory defect  an additional disturbance of pancreatic microcirculation has been demonstrated experimentally  possible contributory mechanisms include chemical induced vasoconstriction  direct injury of vessel wall  intravascular coagulation and increased endothelial permeability resulting in pancreatic oedema  haemoconcentration and impaired venous drainage  pancreatic ischaemia as a consequence of these local effects seems to be responsible for the transition of mild pancreatitis to parenchymal necrosis  in experimental models the beneficial effect of various drugs and of sympathetic blockade has been ascribed to an improvement in pancreatic perfusion  although effective volume therapy is generally accepted as the mainstay of conservative treatment in acute pancreatitis  the efficacy of different fluid preparations is still controversial  and simple fluid resuscitation has not been shown to prevent the development of parenchymal necrosis  the specific impairment of pancreatic microcirculation cannot be prevented merely by replenishment of intravascular volume with crystalloids  albumin or plasma despite normalization of macrohaemodynamics  in contrast  partial replacement of blood by dextran preparations has been shown to increase pancreatic perfusion by improving blood fluidity  isovolaemic haemodilution in conjunction with conventional fluid therapy may provide a new and effective means of protecting the pancreas from secondary injury due to the early ischaemic phase of acute pancreatitis  
class6	impaired polymorphonuclear leucocyte function in patients undergoing hepatectomy  adenylate energy charge and superoxide anion production in relation to hepatic mitochondrial redox state  patients undergoing hepatectomy have an increased susceptibility to infection  we therefore studied the energy metabolism of the polymorphonuclear leucocyte  pmn   focusing on energy charge and function  especially superoxide anion  o2   generation  in relation to the hepatic mitochondrial redox state  by labelling the pmn adenine nucleotide pool with radioactive adenine and by superoxide dismutase inhibitable reduction of ferricytochrome c  the energy charge and o2  production was measured in 18 patients with hepatoma  non cirrhotic  seven  cirrhotic  11  undergoing hepatectomy  their arterial ketone body ratios  kbrs   reflecting the hepatic mitochondrial redox potential  were above 0 7 before operation  after surgery  the 18 patients were divided into two groups  group a  kbr greater than 0 7  n   10  and group b  kbr less than 0 7  n   8  the energy charge and o2  release in group b decreased significantly from preoperative values  p less than 0 001 and p less than 0 01 respectively  and when compared with group a  p less than 0 05 and p less than 0 01 respectively   these results suggest that impaired hepatic energy metabolism  kbr less than 0 7  in hepatectomized patients leads to impaired energy charge and o2  production in the pmns  
class6	effective intraperitoneal antiprotease therapy for taurocholate induced pancreatitis in rats in canine pancreatitis  irreversible hypotension and death follow saturation of the antiprotease molecules in peritoneal exudate by activated proteolytic enzymes which are released from the pancreas  this study has examined  in rats with taurocholate induced pancreatitis  the efficacy of removal of the peritoneal exudate by aspiration and a single lavage  followed by instillation of an exogenous antiprotease solution  instillation of human fresh frozen plasma  containing alpha 2 macroglobulin and alpha 1 antiprotease  was associated with the longest median survival  aprotinin  although possessing a much greater trypsin inhibitory capacity  just failed to significantly improve the median survival time compared with the control group  intraperitoneal antiprotease therapy is simple to perform  has a beneficial effect on survival time in this model and merits investigation in man  
class6	free radical inhibition and serial chemiluminescence in evolving experimental pancreatitis  oxygen free radical activity and inhibition were examined in experimental pancreatitis  twenty five rats were randomized to five groups  controls received intravenous saline  to simulate pancreatitis one group received intravenous caerulein  5 micrograms kg 1 h 1   and three groups received sodium taurocholate via the pancreatic duct  0 2 ml  5 per cent   either alone  following allopurinol or immediately before superoxide dismutase  chemiluminescence  a phenomenon based on the emission of light during chemical reactions and which is dependent on oxygen free radical activity  was used as an index of oxygen free radical activity and was measured in tissue samples at 5 min intervals following induction of pancreatitis  the control mean s e m   serum amylase level 1 h after induction of pancreatitis was 635 13  units  it was significantly elevated in caerulein induced pancreatitis  1833 118  units  p less than 0 05  and exceeded 3000 units in all taurocholate infused animals  mean s e m   chemiluminescence ranged from 44  8  mv 100 mg 1 at time zero to 404 113  mv 100 mg 1 at 1 h in controls  in caerulein induced pancreatitis mean s e m   chemiluminescence peaked at 20 min  1399 239  mv 100 mg 1  p less than 0 02  and in taurocholate induced pancreatitis at 15 min  2316 95  mv 100 mg 1  p less than 0 004   superoxide dismutase significantly reduced chemiluminescence and hyperamylasaemia in taurocholate groups  increasing oxygen free radical activity paralleled evolving pancreatitis  superoxide dismutase may have a therapeutic role in pancreatitis  
class6	prediction of outcome in acute pancreatitis  a comparative study of apache ii  clinical assessment and multiple factor scoring systems  the apache ii severity of disease classification system has been examined prospectively in 160 patients with acute pancreatitis  using clinical and simple laboratory data apache ii was able to provide useful discrimination between uncomplicated  complicated and fatal attacks within a few hours of admission  peak apache ii scores  recorded during the first 3 days  had a prognostic accuracy similar to the multiple factor scoring systems  but then incurred a similar delay  patients could be graded according to their risk of death or of developing a major complication  no deaths occurred in patients with a peak apache ii score less than 10  apache ii can be repeated daily  uncomplicated attacks demonstrating falling scores in association with clinical improvement  in contrast to the rising scores associated with clinical deterioration in those dying early  apache ii appears to reflect any continuing disease activity and may prove a useful means of monitoring the course of the illness and response to therapy  
class6	gallstone clearance  a randomized study of extracorporeal shock wave lithotripsy and chemical dissolution following extracorporeal shock wave lithotripsy it is not known whether gallstone fragments are cleared from the gallbladder without the use of oral dissolution therapy  to assess the efficacy of lithotripsy and dissolution therapy  alone or in combination  35 patients were randomized to one of three treatment groups  lithotripsy alone  dissolution therapy alone or combined lithotripsy and dissolution therapy  all patients had symptomatic gallstones  functioning gallbladders and comparable stone profiles  lithotripsy was administered using a piezoelectric lithotripter  dissolution therapy consisted of combined bile acid and terpene  clearance was assessed at 6 months using ultrasound and oral cholecystography  patients with less than 50 per cent stone clearance at the end of 6 months were considered failures  the number of patients with total or partial clearance in the combined group  7 10  was significantly greater than those in the lithotripsy alone group  0 10  p less than 0 002   gallstone clearance following lithotripsy appears to be dependent upon dissolution therapy  
class6	gallbladder surgery following cholecystlithotripsy  suggested guidelines for treatment twenty three of 229 symptomatic patients undergoing cholecystlithotripsy underwent surgical intervention  22 of the patients had cholecystectomy performed  five also undergoing choledochotomy  and one patient had a cholecystostomy  of these 23 patients  five were lithotripsy failures  five developed acute pancreatitis  one had acute cholecystitis  and one had cholangitis  one patient had her gallbladder removed incidentally at the time of surgery for a bleeding gastric ulcer  ten patients underwent surgery for recurrent biliary pain  probably related to fragment passage via the cystic duct  we suggest that up to 16 of these 23 patients did not necessarily require cholecystectomy  i e  five patients with pancreatitis  one patient with cholangitis and ten patients with recurrent biliary colic  conservative and or endoscopic management may be successful in the first instance to allow further treatment with lithotripsy in the majority of patients  if  however  the expertise to perform endoscopic sphincterotomy is not available or the patient declines further lithotripsy  then resort to surgery may be necessary  we propose that it is the responsibility of the management team in charge of the lithotripsy unit to inform both the patient and the referring clinicians of the possible side effects and outcome of treatment in an attempt to avoid unnecessary surgical procedures  
class6	surgical presentation of kawasaki disease  mucocutaneous lymph node syndrome   five patients with kawasaki disease  mucocutaneous lymph node syndrome  are reported whose varied presentations included acute abdominal pain  peripheral arterial aneurysms  digital gangrene and sterile pyuria and whose presenting pathology ranged from hydrops of the gallbladder to enteric pseudo obstruction  as the complications of the disease can usually be managed without resort to surgery  which is associated with a mortality rate of up to 25 per cent  the recognition of kawasaki disease will prevent hazardous and unnecessary laparotomy  
class6	intraluminal pressure adjacent to left colonic anastomoses  a cumulative total of 89 h of pressure data was acquired from both sides of a left colonic anastomosis in 15 patients over a median period of 7 postoperative study days  patients had a colonic ileus lasting 3 10 days and during this proximal and distal inactivity the intraluminal pressure remained within 6 mmhg of atmospheric pressure  after recovery of activity  pressures proximal to the anastomosis in excess of 10 mmhg occurred during less than 1 per cent of the recording time  distal peak pressures were significantly elevated with respect to the proximal site  p less than 0 001   two thirds of the distal pressures recorded were between 10 and 20 mmhg and 98 per cent were less than 50 mmhg  the peak distal pressure was 90 mmhg  four patients had distal repetitive tonic contractions creating a pressure difference across the anastomosis with a mean of 20 mmhg and a peak of 45 mmhg  each contraction persisted for 15 20 min  intraluminal pressures are unlikely to play a role in anastomotic dehiscence  
class6	duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplasty  sixteen patients who had undergone cholecystectomy plus sphincteroplasty  14 cholecystectomized patients and ten control patients were studied to evaluate whether differences existed in duodenogastric reflux and whether these were related to morphological damage of the gastric mucosa  duodenogastric bile reflux during fasting was evaluated by measuring the concentration of total bile acids  by an enzymatic method  and single bile acids in the gastric juice by high performance liquid chromatography  the damage was evaluated histologically by systematic endoscopic biopsy of the antrum and body of the stomach  there was a statistically significant difference in fasting bile reflux between the three groups  kruskal wallis test  p less than 0 001   and the group that underwent cholecystectomy plus sphincteroplasty had a significantly higher median value than the cholecystectomized group  p less than 0 05  and the control group  p less than 0 01   the distribution of chronic antral atrophic and superficial gastritis was different in the three groups  chi 2 test  p less than 0 005   chronic atrophic gastritis was associated with cholecystectomy plus sphincteroplasty  p less than 0 01   while chronic superficial gastritis was more frequent in cholecystectomized patients  these results suggest that there may be more duodenogastric reflux after cholecystectomy plus sphincteroplasty than after cholecystectomy alone  and that there may be a correlation between the amount of duodenogastric reflux and the severity of mucosal damage  
class6	success of a program of routine prenatal screening for hepatitis b surface antigen  the first 2 years  prenatal screening for hepatitis b surface antigen  hbsag  restricted to women with defined risk factors for chronic hepatitis b virus  hbv  infection fails to identify many carriers  a centralized program of routine hbsag screening for all pregnant women in alberta was introduced in 1985  we collected and analysed data for the first 2 years of the program in edmonton to determine the frequency of risk factors for hbsag positivity  the proportion of multiparous hbsag positive women not identified in previous pregnancies  the efficiency and cost effectiveness of providing immunoprophylaxis to infants at risk of hbv infection and the degree of success in inducing adequate protection  a total of 149 women  158 pregnancies  were found to be hbsag positive  risk factors were readily ascertainable for 85  of the women  the remaining 15  would not have been identified through risk selective screening  the most common risk factors were oriental ethnic origin  history of hepatitis  jaundice or multiple transfusions of blood or blood products  and occupational exposure to blood  although 86  of the multiparous hbsag positive women had risk factors  only 7  had been identified in previous pregnancies  the alberta program appears to be cost effective  we conclude that only routine prenatal screening will identify all infants at risk of perinatal hbv infection and that a comprehensive public health program involving central laboratories  private physicians and public health staff can be highly effective and efficient in protecting infants against hepatitis b  
class6	amyloidosis associated bleeding diatheses in the surgical patient  the coagulopathies associated with amyloidosis have not been widely appreciated  we encountered a patient with amyloidosis and mildly abnormal coagulation studies who presented for an emergency laparotomy for acute bowel obstruction  upon gentle manipulation of the bowel  an unexpected bleeding diathesis was manifested by the formation of several large haematomas resulting in a large amount of blood loss  approximately 800 ml   numerous defects of platelet function and coagulation have been associated with amyloidosis  including abnormal platelet aggregation  increased vascular fragility  factor ix and x deficiencies  decreased levels of alpha 2 plasmin inhibitor  and increased levels of plasminogen  intraoperative therapy for our patient included the rapid administration of four units of fresh frozen plasma and ten units of platelet concentrate  a review of the pathology and therapeutic modalities for this potentially life threatening complication is presented  
class6	the indian experience with hypertrophic pyloric stenosis  a study of 58 consecutive indian infants operated for congenital hypertrophic pyloric stenosis revealed an accentuated male predominance in the incidence of the disease and far less preoperative hemetemesis as compared to that in their western counterparts   pyloric tumor  was palpable in 89  of cases  only 34 5  of these infants were first born  postoperative vomiting occurred in 13 8  of patients and wound sepsis was not encountered  air contrast radiography confirmed the diagnosis in clinically doubtful cases  
class6	edrophonium provocative test in noncardiac chest pain  evaluation of testing techniques  edrophonium chloride is used frequently as a provocative agent in the assessment of noncardiac chest pain  nccp   however  the optimum dose and most appropriate method of interpreting test results is controversial  we studied 150 consecutive nccp patients and 50 age matched controls who alternately received either 80 micrograms kg or 10 mg intravenous bolus doses of edrophonium preceded by saline placebo injections  distal esophageal pressures were measured before and after drug injection in response to ten 5 cc wet swallows  following 10 mg of edrophonium  33  of patients and 4  of controls reported chest pain  while 29  of patients and no controls receiving the 80 micrograms kg dose complained of chest pain  amplitude changes after either dose were not significantly different for all comparisons  but the duration of response did distinguish the two doses in patients with chest pain  a significantly greater  p   0 01  increase in distal contraction duration occurred after 10 mg  74     12       se  compared to 80 micrograms kg dose  43     6    however  individual responses to the two doses overlapped considerably  if a positive test is redefined to include both chest pain and manometric changes that are significantly different from controls  the positivity rate changes drastically  33  to 9  in the 10 mg group and 30  to 3  in the 80 micrograms kg group  side effects were similar between doses  but there was a significant  p   0 02  linear relationship between intensity of side effects and the edrophonium dose per kilogram of body weight  
class6	pyloric deformation from peptic disease  radiographic evidence for incompetence rather than obstruction  we have used double contrast radiographic techniques to clarify what changes in the configuration and movements of the gastroduodenal junction result when peptic lesions involve the distal gastric segment between the proximal  ppl  and the distal pyloric muscle loop  dpl   among 50 cases of pyloric ulceration diagnosed during a four year study period  18 cases fulfilled all study criteria  ulcers maintained a consistent location with regard to the muscular structures of the pylorus  and by affecting these structures  led to many strange deformations of the gastric outlet including permanent pseudodiverticula and reversal of pyloric angulation  the most common site for peptic lesions in the pyloric segment was the protuberance of the lesser curvature called the pyloric torus  many torus lesions extended into and destroyed the dpl  this led to widening of the gastric outlet and radiographic evidence of increased duodenogastric reflux  pyloric closure was further impaired in this setting because the mucosa no longer prolapsed into the gastric outlet and did not occlude the pyloric lumen as it normally does  less common lesions involved the greater curvature and the ppl  in one patient  scarring of the ppl led to an antral web and gastric hyperperistalsis  this was the only patient who required operation for chronic gastric outlet obstruction  one third of the 18 patients had reflux esophagitis in addition to peptic pyloric disease  in most patients without additional ulcerogenic risk factors  treatment with antisecretory agents led to the healing of ulcer craters  we conclude that the morphologic and functional changes of the gastric outlet caused by peptic lesions depend  in part  on the effect the ulcer has on the underlying pyloric musculature  
class6	antimony and glass ph electrodes can be used interchangeably in 24 hour studies of gastric acidity  antimony and glass ph electrodes show almost identical experimental errors in continuously measuring buffer solutions at constant temperature over 24 hr  these errors are lower than the nominal quantization error of the instruments and are not properly described by the 24 hr drift determination  the addition of food particles to the solutions can induce severe reading artifacts  the longer response time reported in vitro of antimony electrodes when moving from ph 1 to ph 7  3 4 sec vs 0 8 sec with glass electrodes  is irrelevant during in vivo ph metry studies  because we found that the greatest absolute difference between raw fast acquired  4 6 sec  consecutive ph readings of two commonly used devices was 0 7 ph units in circadian profiles obtained from 413 subjects with various clinical conditions  in our in vivo studies  gastric acidity was monitored continuously with two side by side minielectrodes  which were variously combined  antimony glass  a g  antimony antimony a1 a2  glass glass  g1 g2  and applied on groups of 27 subjects matched for clinical condition  the 24 hr ph means and the 24 hr  h   means calculated from the acidity profiles obtained with the three electrode combinations  lie on the identity line in each group  using the bland altman technique for assessing measurement agreement  the differences between the 24 hr ph means and the 24 hr  h   means obtained with the three combined systems are similar  p    903 and p   0 824  respectively  and their 95  confidence limits are comprised within the range       of the reading error of the measuring systems  namely      0 3 ph units and     12 mmol liter in terms of  h     
class6	cigarette smoking  gastric acidity and peptic ulceration  what are the relationships  the influence of cigarette smoking on intragastric acidity was assessed in duodenal ulcer patients in symptomatic remission and in healthy volunteers in a retrospective study  continuous 24 hr ph recordings in 150 nonsmokers and 174 smokers receiving placebo treatment were compared  daytime intragastric acidity was higher in smokers with a median ph  interquartile range  of 1 56  1 34 1 80  than in nonsmokers  who had a median ph of 1 70  1 45 1 97   p less than 0 001   there was no difference in 24 hr and nighttime median ph between the two groups  the small difference in daytime intragastric acidity in smokers and nonsmokers is unlikely to account for the increased prevalence of peptic ulcer disease in smokers  the analysis of smoking status in duodenal ulcer patients and healthy controls and males and females supports the general trend towards higher daytime acidity in smokers  again  no differences in ph during the 24 hr or night period were found between the groups  the epidemiological and clinical correlation between smoking and duodenal ulcer disease is not adequately explained by increased intragastric acidity  
class6	endoscopic comparison of cimetidine and sucralfate for prevention of naproxen induced acute gastroduodenal injury  effect of scoring method  nonsteroidal antiinflammatory drug induced gastroduodenal mucosal damage observed endoscopically is usually categorized as hemorrhages  erosions  or ulcerations  we undertook this study to determine whether the injury produced by a commonly prescribed nsaid  naproxen  could be reduced by cotherapy with sucralfate or cimetidine and to determine how dependent the differences in the degree of protection against mucosal injury measured were on the scoring system used  four groups of 20 healthy volunteers with endoscopically normal gastric and duodenal mucosa received naproxen  500 mg twice a day  plus cimetidine  300 mg four times a day or 400 mg twice a day   sucralfate  1 g four times a day   or placebo for seven days  after seven days of therapy  a second endoscopy was performed  separate scoring systems were used for the presence of hemorrhages  erosions  and a combination of both types of injury  there were significantly fewer mucosal hemorrhages present when naproxen and cimetidine were administered than when naproxen was administered with placebo or sucralfate  placebo vs 300 mg cimetidine  p   0 04  and placebo vs 400 mg cimetidine  p   0 006  placebo vs sucralfate  p   0 26   both cimetidine dosages resulted in significantly fewer hemorrhages than were present following cotherapy of naproxen and sucralfate  p less than 0 05   in contrast  there was no discernible difference in the mucosal injury between placebo and any drug or between any two active therapies when the injury was evaluated based on the presence of gastric erosions  
class6	primary peritoneal sarcoidosis  a 14 year old male was admitted for the evaluation of tense exudative ascites  despite thorough evaluation  the diagnosis remained cryptic until peritoneoscopy revealed diffuse studding of the entire visualized peritoneum with multiple miliary nodules  and peritoneal biopsy demonstrated multiple noncaseating epithelioid granulomas  after other causes were excluded  a diagnosis of sarcoidosis was considered and confirmed with classic endobronchial findings at bronchoscopy  involvement of the peritoneum with sarcoidosis is rare and  to our knowledge  only one other case describes this as the initial manifestation of this disease  
class6	esophageal adenocarcinoma in a patient with surgically treated achalasia  although squamous cell carcinoma of the esophagus occurs with increased incidence in primary achalasia  esophageal adenocarcinoma has been considered rare in this condition  we report a patient with long standing achalasia in whom adenocarcinoma of the esophagus occurred many years after heller esophagomyotomy  presumably related to barrett s esophagus complicating gastro esophageal reflux disease  
class6	development of acute myelocytic leukemia in patients with crohn s disease  in our hospital within one year two patients with crohn s disease were seen who developed an acute myelocytic leukemia  a review of the literature reveals eight previously reported patients with both crohn s disease and leukemia  six of the reported 10 patients have had acute myelocytic leukemia and  interestingly  three of them  including our two patients  have shown monocytic differentiation  fab type m4   it has been suggested that the relative risk of leukemia  especially acute myelocytic leukemia  is increased in patients suffering from ulcerative colitis  more data of patients with crohn s disease and acute leukemia are needed to evaluate the possible association between these diseases  
class6	closure of refractory perineal crohn s lesion  integration of hyperbaric oxygen into case management  a case is reported in which a comprehensive program of hyperbaric oxygen  hbo   surgical debridement and reconstruction  and continuing medical management resulted in complete and sustained closure of an extensive perineal crohn s lesion refractory to conventional medical and surgical management  it is emphasized that in this case healing occurred in the setting of previous removal of all diseased intestinal tissue and only with the combined use of all three treatment modalities  hbo may be a useful adjunct in the therapy of large nonhealing perineal lesions post proctocolectomy in patients who are unresponsive to metronidazole or to immunosuppressant therapy or who experience limiting side effects from continued medical therapy  
class6	epstein barr virus associated oesophageal ulcers in aids  epstein barr virus  ebv  associated ulceration has not previously been included in the differential diagnosis of oesophageal ulcers in aids  we report five cases of oesophageal ulceration in homosexual men with advanced human immunodeficiency virus infection in whom this was considered to be the most likely cause  dna in situ hybridisation studies showed ebv in biopsy material from three of four patients with oesophageal ulcers and in none of three controls  of other viruses studied  only human papillomavirus was present  and this was found in both patients and control subjects  these findings support the hypothesis that ebv is an aetiological factor in some cases of aids associated oesophageal ulceration  
class6	relation of helicobacter pylori to the human gastric mucosa in chronic gastritis of the antrum  the spatial relations between bacteria and the affected tissues can indicate pathogenic mechanisms  this study was undertaken to define the spatial relation of helicobacter pylori to the human gastric mucosa  antibodies against gastric mucus and ruthenium red were used to stabilise the glycoprotein structure of the mucus and glycocalyces in antral biopsy specimens from eight patients infected with h pylori  the location of organisms and ultrastructural features were assessed using systematic scanning and transmission electron microscopy  92  2    mean  se  of h pylori were in the pit mucus  and 7  3   were in the surface mucus  60  12   of h pylori were close to epithelial cells  with only 5  2   located near the epithelial intercellular junctions  fine filamentous strands extended between organisms and nearby epithelial cells  with few organisms in membrane to membrane contact  h pylori were not observed between  beneath  or within cells of the gastric mucosa  the preferred location of h pylori in the gastric antrum is within the pit mucus close to the epithelial cell surface  with no evidence that they have a direct toxic effect on the mucosa  
class6	paf acether synthesis by helicobacter pylori  clinical studies suggest that helicobacter pylori may play a role in the pathogenesis of gastroduodenal ulcers in man but direct evidence of mucosal injury by this microorganism is still lacking  paf acether  paf  causes a number of disorders including ischaemic bowel necrosis and gastroduodenal ulceration  since paf is produced by escherichia coli  we investigated whether it could be synthesised by h pylori  five h pylori isolates were collected from antral biopsy specimens from patients with gastritis and duodenal ulcer and cultured with selective antibiotics  colonies obtained from both blood agar and brucella broth medium were used  paf was determined by platelet aggregation assay after ethanolic extraction and subsequent purification by high performance liquid chromatography  paf was detected in h pylori in blood agar plates  680  390  pg paf 1 x 10 6  organisms  but not in bacteria cultured on brucella broth medium  supplementation of the latter medium with lyso paf and acetyl coa  two paf precursors present in high amounts in the mammalian intestine  induced paf production in three of five isolates  the platelet aggregating material extracted from h pylori exhibited biological and physiochemical characteristics identical to those of paf released from eukaryotic cells  these findings suggest that h pylori may add to the local production of paf in inflamed gastric mucosa  
class6	cathepsins d and e in normal  metaplastic  dysplastic  and carcinomatous gastric tissue  an immunohistochemical study  immunohistochemical distributions of cathepsins d and e were determined in normal mucosa  metaplastic  dysplastic  and cancerous lesions of the human stomach  cathepsins d and e were localised in the foveolar epithelium and parietal cells of the normal gastric mucosa  but their intracytoplasmic distributions were different   cathepsin e distribution was even and diffuse in the cytoplasm while cathepsin d was found in coarse intracytoplasmic granules  chronic inflammation and ulcer did not influence the distribution of these enzymes  no positive staining was obtained in the incomplete type of intestinal metaplasia  dysplasia  and well differentiated adenocarcinoma  tumour cells of signet ring cell carcinoma and poorly differentiated adenocarcinoma cells  however  gave strong and diffuse stainings for cathepsins d and e in the cytoplasm  the results suggest that the distribution of cathepsins d and e is related to each specialised function of the foveolar epithelium and the parietal cells  and that their disappearance is associated with development of well differentiated adenocarcinoma from intestinal metaplasia  
class6	modulation of fluid absorption and the secretory response of rat jejunum to cholera toxin by dietary fat  to study the effects of dietary fat on jejunal water and ion absorption and on cholera toxin induced secretion  3 week old sprague dawley rats were fed isocaloric diets  forty per cent of the total calories were given as fat  as butter  high saturated fat   olive oil  high monounsaturated fat   or corn oil  high polyunsaturated fat   with one group on low fat  10  of calories  standard laboratory diet as controls  during in vivo jejunal perfusion studies we found that  i  a polyunsaturated fat  corn oil  supplemented diet improves jejunal absorption of water and electrolytes and these changes are independent of the observed concentrations of luminal prostaglandins   ii  high dietary fat appreciably reduced the secretory response to cholera toxin  probably without fundamentally changing the mechanism by which cholera toxin induces secretion  we conclude that dietary fat composition altered the permeability and transport characteristics of the small intestine  this observation might have relevance to some human diarrhoeal disorders  
class6	crohn s disease in the city of derby  1951 85  an epidemiological survey of crohn s disease in the city of derby showed that the incidence of the condition increased from 0 7 10 5  per year between 1951 and 1955 to 6 67 10 5  per year between 1981 and 1985 but seemed to reach a plateau between 1976 and 1985  large bowel crohn s disease was more common in patients presenting aged 60 79 years than in those aged 20 39 years  the increase in incidence was not solely due to the detection of milder disease  there was no evidence that the asian  indian subcontinent  population of derby was resistant to the development of crohn s disease  
class6	microspectrophotometric dna analysis in ulcerative colitis with special reference to its application in diagnosis of carcinoma and dysplasia  the deoxyribonucleic  dna  content was measured by microspectrophotometry in 100 specimens from 60 patients with ulcerative colitis  including six patients in whom the colitis was associated with carcinoma  some 23 of 30  77   specimens of dysplastic tissue showed aneuploidy or polyploidy  whereas 50 of 53  94   specimens of non dysplastic tissue showed diploidy  the difference was statistically significant  p less than 0 001   polyploidy was often observed in non dysplastic mucosa from patients who had carcinoma or dysplasia  in the non dysplastic patients all samples of inflamed tissue showed diploidy  some 10  of samples without inflammation  however  also showed polyploidy  a good correlation was found between the frequency of polyploid cells and the grade of dysplasia  microspectrophotometric measurement of dna content proved useful in the assessment and diagnosis of dysplasia in ulcerative colitis and could be considered for screening high risk patients  
class6	disposition of 5 aminosalicylic acid by olsalazine and three mesalazine preparations in patients with ulcerative colitis  comparison of intraluminal colonic concentrations  serum values  and urinary excretion  to compare the disposition of 5 aminosalicylic acid  5 asa  and its acetylated metabolite during treatment with olsalazine and mesalazine  14 patients with inactive ulcerative colitis were randomly assigned to olsalazine  1 g twice daily  and the mesalazines  asacol  800   400   800 mg daily   pentasa  750   500   750 mg daily   and salofalk  750   500   750 mg daily  in a crossover design trial so that all received each drug for seven days  intraluminal colonic concentrations of 5 asa were estimated after five days by the method of equilibrium in vivo dialysis of faeces  a predose serum sample and a 24 hour urine collection were obtained on day seven  the 5 asa and acetyl 5 aminosalicylic acid  ac 5 asa  values were determined by high performance liquid chromatography  olsalazine almost doubled the colonic concentrations  mean 23 7  sem   1 9  mmol l  of its therapeutically active ingredient  5 asa  compared with equimolar doses of pentasa  12 6  2 2  mmol l  p less than 0 0003  and salofalk  15 0  2 0  mmol l  p less than 0 003   at the same time  olsalazine treatment was associated with lower serum concentrations and urinary excretions  p less than 0 05  of 5 asa and ac 5 asa compared with the mesalazine preparations  the low systemic load of 5 asa provided by olsalazine reduces the potential risk of nephrotoxicity during long term treatment  
class6	role of upper gastrointestinal investigations in a screening study for colorectal neoplasia  should patients with positive faecal occult blood screening tests who are free of colorectal neoplasia undergo upper gastrointestinal investigation  altogether 16 985 faecal occult blood tests were completed in a group of 18 818 asymptomatic patients  45 75 years  offered screening at two yearly intervals  a total of 447  2 6   were positive and underwent large bowel investigations  no neoplastic disease was identified in 283  63   of them  fourteen  5   also underwent gastroscopy for upper gastrointestinal symptoms  benign conditions were identified in five and a gastric carcinoma in one  no further investigations were instituted in the remaining 269 subjects who have now been followed up for a median period of 5 years  2 8 years   five have been referred for benign upper gastrointestinal conditions  but none for upper gastrointestinal malignancy  thirty one subjects have died   one from gastric cancer  a patient who had undergone a previous partial gastrectomy for a duodenal ulcer and who had persistent upper gastrointestinal symptoms   the remaining deaths were unrelated to the upper gastrointestinal tract  nineteen people who have left the trial area have been monitored for the development of malignant disease  none have presented with upper gastrointestinal malignancy  these data support the view that upper gastrointestinal investigations need not be performed routinely in this group of subjects  but may be reserved for those with relevant symptoms  
class6	incidence of large oesophageal varices in patients with cirrhosis  application to prophylaxis of first bleeding  because several studies have suggested that beta blockers are effective in the prophylaxis of first variceal bleeding in cirrhosis  screening for oesophageal varices might be appropriate  we prospectively studied 84 cirrhotic patients without obvious evidence of large oesophageal varices and previous bleeding during a mean follow up of 16 months  at entry to the study 41 patients had no oesophageal varices and in 43 these were grade 1  the subsequent percentages of patients without large oesophageal varices were 74  at one year and 52  at two years  univariate analysis showed that a longer duration of cirrhosis  p less than 0 05  and grade 1 oesophageal varices at entry  p less than 0 001  were predictive factors for the occurrence of large oesophageal varices  whereas  multivariate analysis showed that the initial size of the oesophageal varices  p less than 0 001   a high initial child pugh score  and a smaller improvement in child pugh score during the study were independent risk factors  among patients with grades 0 and 1 oesophageal varices at the start of the study the proportions with large oesophageal varices at two years were 31  and 70  respectively  we have calculated that  accepting a maximum risk of first bleeding of 10  without prophylactic treatment  a patient without oesophageal varices should be screened endoscopically every other year  while a patient with grade 1 disease should benefit from one annual upper gastrointestinal endoscopy  
class6	lipid peroxidation and hepatic antioxidants in alcoholic liver disease  the generation of hepatic liver peroxidation by free radicals has been proposed as a mechanism for ethanol induced hepatotoxicity  to investigate this hypothesis  lipid extracts from hepatic needle biopsy specimens from alcoholic subjects were examined for evidence of lipid peroxidation by measuring total conjugated dienes by derivative spectroscopy and  after hydrolysis of hepatic lipid extract and reverse phase high performance liquid chromatography  the molar ratio between a diene conjugated linoleic acid isomer  18 2  9 11   and the parent linoleic acid isomer  18 2 9 12    changes were related to hepatic histology  iron deposition  glutathione and vitamin e values  derivative spectroscopy minima suggestive of diene conjugation were identified at 233 and 242 nm and correlated weakly  suggesting these two minima may represent different classes of lipid dienes  there was a weak relation with inflammatory histological changes in the biopsy specimen but no correlation with hepatic iron grade  glutathione  or vitamin e lipid ratio  the proportion of 18 2 9 11  linoleic acid in hepatic lipids correlated significantly with inflammatory histological features and inversely with hepatic glutathione  furthermore  hepatic glutathione was lower in biopsy specimens with greater iron staining  the ratio of vitamin e to lipid was not related to histological group  inflammation  or iron grade  these findings suggest that excess alcohol consumption leads to hepatic inflammation and lipid peroxidation  
class6	monitoring enzyme replacement treatment in exocrine pancreatic insufficiency using the cholesteryl octanoate breath test  the cholesteryl 14c octanoate breath test was used to monitor the intraluminal enzymatic activity of pancreatin preparations in six patients with severe pancreatic insufficiency  conventional enzyme replacement  with cimetidine as an adjunct  was compared to supplementation with enteric coated microspheres  in healthy control subjects  14co2 excretion rose rapidly and peaked at 90 120 minutes  mean  sd  cumulative recovery at four hours was 51  8    in patients with pancreatic insufficiency on no treatment mean  sd  cumulative recovery was only 6  4    after pancreatin  with previous administration of cimetidine  it increased to 27  11   with a time course resembling that in controls  with 2 mm enteric coated microspheres  14co2 excretion did not rise significantly before 120 minutes and cumulative recovery after four hours was 15  11    in a control study  2 mm radio opaque microspheres did not empty from the stomach until two hours after ingestion  the results suggest that the cholesteryl octanoate breath test can be successfully used to monitor the intraluminal enzymatic activity after treatment with different forms of enzyme replacement in pancreatic insufficiency  in contrast to treatment with conventional pancreatin and cimetidine as an adjunct  2 mm enteric coated microspheres did not show in vivo enzymatic activity until two hours after administration  
class6	stomal adenocarcinoma in crohn s disease  malignant change occurring at the site of a stoma in two patients with proved crohn s disease is described  patients with ulcerative colitis have an increased risk of colonic malignancy and crohn s disease is also associated with both small and large bowel carcinoma  most previous reports of stomal carcinoma have been associated with ulcerative colitis although crohn s disease seems to carry a greater risk of associated small bowel carcinomas  this is the first report of stomal carcinoma complicating crohn s disease  epithelial dysplasia is associated with gastrointestinal carcinomas in both ulcerative colitis and crohn s disease and a dysplasia carcinoma sequence has been suggested as the origin of these tumours  in both our patients with stomal adenocarcinoma  dysplasia was identified in adjacent tissues  which suggests a similar mechanism  malignant change should be suspected if epithelial dysplasia is discovered in a biopsy specimen from the mucosa of an ileostomy in crohn s disease  and this risk is increased if the dysplasia is of a high grade  
class6	squamous carcinoma in the liver  squamous carcinoma of the liver has only rarely been reported  we present a case which highlights not only the difficulties in diagnosis but also how it can closely mimic sclerosing cholangitis  
class6	metabolic studies of radioiodinated serum amyloid p component in normal subjects and patients with systemic amyloidosis  125i serum amyloid p component  sap   injected intravenously into 10 normal subjects  remained predominantly intravascular with mean  sd  t1 2  half time  in plasma of 24 5  5 9  h  the fractional catabolic rate of 68  19   of the plasma pool per day was more rapid than other reported human plasma proteins  all radioactivity was excreted in the urine by 14 d  in 16 patients with monoclonal gammopathy or chronic inflammatory diseases  but without amyloidosis  125i sap metabolism was normal  however  among 45 patients with biopsy proven systemic amyloidosis  25  amyloid a type  20  amyloid l type   125i sap was cleared from the plasma more rapidly  accumulated in the amyloid deposits  and persisted there  the t1 2 in amyloid  measured directly with 131i sap  was 24 d  repeat studies after 6 18 mo were notably consistent in normals but changed significantly in amyloid patients  generally correlating with clinical signs of disease progression  measurements of 125i sap turnover may thus be of value for diagnosis and monitoring of amyloidosis  analysis of sap metabolism in amyloidosis suggests that plasma sap is in dynamic equilibrium with a very large amyloid pool  and in two autopsies the total mass of sap in the amyloid deposits was 2 100 and 21 000 mg  respectively  
class6	carbohydrate malabsorption  its measurement and its contribution to diarrhea  the major purpose of this research was to gain insight into the effect of carbohydrate malabsorption on fecal water output  to do this we measured daily fecal output of total carbohydrate  reducing sugars  and organic acids  a product of bacterial fermentation   normal subjects were studied in their native state and when diarrhea was induced by mechanisms that did and did not involve carbohydrate malabsorption  patients with malabsorption syndrome were also studied  we concluded that   a  excretion of carbohydrate and its breakdown products can be expressed as a single number by converting organic acids to their monosaccharide equivalents   b  diarrhea per se causes only a trivial increase in fecal carbohydrate excretion   c  the molar output of osmotic moieties in feces due to unabsorbed carbohydrate can be determined by adding fecal reducing sugars to organic acids and their obligated cations  this expression parallels almost exactly the effect of increasing doses of lactulose  a nonabsorbable sugar  on fecal water output  one excreted millimole obligates 3 5 g of stool water  this relationship can be used to predict the effect of carbohydrate malabsorption on stool water output in patients with diarrhea   d  12 of 19 patients with malabsorption syndrome due to various diseases had excessive fecal excretion of carbohydrate and its breakdown products  of the diseases that cause malabsorption syndrome  combined small and large bowel resection is most likely to result in excessive fecal excretion of carbohydrate and monosaccharide equivalents  in 6 of these 19 patients carbohydrate malabsorption appeared to be the major cause of diarrhea  
class6	prevention of a false diagnosis of sexually acquired reactive arthritis by synovial lymphocyte responses  three cases are reported in which a diagnosis of sexually acquired reactive arthritis might have been made erroneously from the history  but the enteric origin of the reactive arthritis was evident from synovial lymphocyte responses  the importance of making the correct diagnosis and the avoidance of unwarranted spousal dysharmony is stressed  
class6	septic streptococcus milleri spondylodiscitis  we describe 2 patients presenting lumbar spondylitis due to streptococcus milleri  in both cases origin was related to preexistent intestinal pathology  surgical drainage of a collection of pus was necessary in one case  longterm antibiotic therapy led to full recovery  despite confused nomenclature streptococcus milleri must be considered a serious pathogen mainly associated with purulent infection with osteoarticular affinity  
class7	salivary gland cancer  a case control investigation of risk factors  unlike most upper aerodigestive tract cancers  salivary gland cancers are relatively infrequent  are characterized by a diversity of histologic subtypes  and have never been etiologically associated with tobacco exposure  we present the results of a case control study of risk factors for these cancers  with risk estimates derived from self administered comprehensive risk factor questionnaires distributed to patients at the university of texas m  d  anderson cancer center  houston  cases were 64 patients with histologically confirmed salivary gland cancer  control subjects  randomly selected from the same patient population excluding patients with cancer of the head and neck or nonmelanoma skin cancer  were frequency matched to the cases by age  sex  and ethnicity to achieve a 2 1 control subjects cases ratio  on multivariate analysis  prior radiotherapy was a significant risk factor for both men  odds ratio  or    2 1  and women  or   2 3   among women  higher educational attainment  or   2 4   alcohol use  or   2 0   and hairdye use  or   2 5  were also significantly associated with risk  there were no significant differences between cases and control subjects with respect to tobacco exposure or specific occupational or leisure time exposures  there is biological plausibility for associations with hairdye use and alcohol exposure  
class7	periodontal disease and niddm in pima indians  the goal of this study was to determine the prevalence and incidence of periodontal disease and its relationship with non insulin dependent diabetes mellitus  niddm   two thousand two hundred seventy three pima indians  949 men  1324 women  aged greater than or equal to 15 yr from the gila river indian community in arizona were examined between 1983 and 1989  periodontal disease was diagnosed by tooth loss and by percentage of interproximal crestal alveolar bone loss ascertained from panoramic radiography  subjects with little or no evidence of periodontal disease were classified as nondiseased  thus  the incidence of advanced periodontal disease was determined  the age  and sex adjusted prevalence of periodontal disease at first dental examination was 60  in subjects with niddm and 36  in those without  twenty two new cases developed in a subset of 701 subjects  272 men  429 women  aged 15 54 yr who initially had little or no evidence of periodontal disease and had at least one additional dental examination  the incidence of periodontal disease in this group was similar in men and women  incidence rate ratio 1 0  95  confidence interval  cl  0 5 1 9  controlled for age and diabetes   higher age predicted a greater incidence of periodontal disease  chi 2   30 6  df   3  p less than 0 001  controlled for sex and diabetes   the rate of periodontal disease in subjects with diabetes was 2 6 times  95  cl 1 0 6 6  controlled for age and sex  that observed in those without  although periodontal disease was common in nondiabetic pima indians  in whom most of the incident cases occurred  diabetes clearly conferred a substantially increased risk  thus  periodontal disease should be considered a nonspecific complication of niddm  
class7	cutaneous lesions of disseminated histoplasmosis in human immunodeficiency virus infected patients  disseminated histoplasmosis is being diagnosed more frequently in persons infected with the human immunodeficiency virus and is often the initial manifestation of the acquired immunodeficiency syndrome  aids   disease related cutaneous features of hiv associated disseminated histoplasmosis are defined as mucocutaneous lesions from which fungal organisms were either cultured or demonstrated histopathologically  we report four hiv seropositive patients with disseminated histoplasmosis who had culture positive skin or oral lesions of histoplasmosis and review the specific cutaneous manifestations of hiv associated disseminated histoplasmosis  including our patients  disease related skin and or mucosal lesions were present in 11  of patients  26  of 239  with hiv associated disseminated histoplasmosis  the possibility of disseminated histoplasmosis should be considered in all hiv infected persons and in persons with aids risk factors who have fever  weight loss  hepatosplenomegaly  and new cutaneous lesions  an early skin or mucosal biopsy specimen for crushed tissue preparation  histologic evaluation  and fungal culture is a simple  rapid diagnostic procedure  
class7	treatment of aggressive keratoacanthomas by radiotherapy  keratoacanthomas infrequently are treated by radiotherapy  however  keratoacanthomas that are recurrent after surgical excision or whose resection would result in cosmetic deformity may benefit from radiotherapy  between january 1970 and june 1988  29 such keratoacanthomas in 18 patients were irradiated  doses ranged from 3500 cgy in 15 fractions to 5600 cgy in 28 fractions  measured end points of therapy were  1  initial response   2  freedom from recurrence  and  3  quality of the subsequent cosmetic appearance  scored as good  fair  or poor   no lesion progressed and all eventually regressed completely  cosmetic results generally were considered good by both the patient and the referring dermatologist  none of the results was considered poor  our results demonstrate that radiation is an effective means of treating keratoacanthomas  
class7	multiple oral and skin lesions occurring after treatment with penicillin  a case of erythema multiforme has been presented  erythema multiforme may be a self limiting or chronic disease  of varying severity  the disease is of significance to dental practitioners who may be called on to establish a diagnosis and provide appropriate referral or treatment  especially when lesions are limited to the mouth  the prognosis is generally good  although recurrence is common  
class7	diagnosing periodontal diseases  at present  the diagnosis of periodontal disease requires a clinical evaluation of the patient including visual findings  the use of the periodontal probe  and radiographs  no test is available to evaluate disease activity  in specific cases  adjunctive procedures may also be useful  the identification of pathogenic microorganisms may aid in evaluating the periodontal status of special patients  however  these are not required for an adequate diagnosis of the common adult form of chronic periodontitis  
class7	reviewing nonsurgical periodontal therapy  selection of the appropriate case and clinical competency in treatment modalities results in success in nonsurgical periodontal therapy  the patient with early periodontitis with significant local factors in the form of professionally accessible plaque and calculus is the most receptive to nonsurgical periodontal treatment  the clinician must make decisions centering around the important question   can the patient  or moreover  can the therapist delivering the debridement  gain access to the microbial subgingival plaque on a frequent basis below the host defense threshold of the respective patient   if the answer is  yes   nonsurgical periodontal therapy will be rewarding  if the answer is  no   other modalities such as periodontal surgery must be instituted  
class7	surgical pocket reduction  it is not possible within the scope of this paper to describe in any detail each of the aforementioned procedures  these can be found in the various textbooks and journals on clinical periodontology  instead  the objectives of treatment  the spectrum of techniques available  and the rationale for their use have been described  periodontal surgery should be performed only under certain conditions  the patient must be physically and mentally competent to undergo any type of surgery  and should understand and agree to the procedure and to postoperative management  finally  periodontal surgery should only be considered when nonsurgical therapy will not accomplish the desired result  when periodontal surgery for pocket elimination is performed for selected defects that have been properly evaluated after a debridement and healing period  and is executed with technical competence and proper postoperative care  it can preserve the dentition affected by periodontal disease  
class7	using periodontal plastic surgery techniques  in the 1980s  mucogingival surgery evolved into periodontal plastic surgery with various techniques designed to produce root coverage in areas of marginal tissue recession  to augment deficient ridges  and to lengthen crowns in cases of excessive gingival display  periodontal plastic surgery not only enables the dentist to reconstruct but also to regenerate lost tissues  
class7	maintaining periodontal treatment  dental maintenance  or supportive periodontal treatment  spt   can keep the periodontium and peri implant tissues healthy after active therapy  patients who comply to suggested spt fare better periodontally and keep their teeth longer  data should be gathered by examinations  talking with patients  and reviewing personal oral hygiene  then sub  and supra gingival deposits should be removed  the average spt visit should last 1 hour and should be scheduled every 3 months  supportive periodontal treatment for patients with more advanced periodontal or peri implant destruction should be the responsibility of the periodontist  
class7	regenerating bone in clinical periodontics  bone autografts and allografts  various alloplastic materials  and guided tissue regeneration are used to reconstruct lost periodontal tissues  this paper focuses on controversies related to these therapeutic modalities as well as their role in periodontal regeneration  
class7	dental implants used for periodontal patients  for those performing implant treatment  continued research and reports of long term successful results are essential to evaluating the validity of implants  especially when variables such as design and surface treatment are introduced  the dental profession has enthusiastically embraced the clinical results of implant treatment and its benefits to the patient  however  just as patients who undergo periodontal and restorative treatment must continue a regular long term routine of maintenance therapy to ensure their dental health  so must those patients who receive dental implants  both the periodontist who places the implants and the dentist who fabricates the prosthetic replacement must work cooperatively to deliver a healthy restoration that will function for many years  
class7	premolarization of a fractured maxillary first molar  a multidisciplinary treatment  the diagnosis and treatment of a fractured maxillary first molar are described in this case report of a 28 year old male  successful treatment of the retained palatal root of the fractured molar  referred to as premolarization  ensued from integration of endodontic  orthodontic  periodontic  and fixed prosthodontic care  
class7	an esthetic approach to vertical root extrusion in a patient with an anterior open bite  report of case  a previous attempt to locate the root canal system in the maxillary left central incisor with a bur created a perforating root defect at the level of the alveolar crest  the patient received root canal therapy  next  vertical root extrusion was chosen to expose sound tooth structure apical to the defect so that a crown could be constructed  with an anterior open bite  the natural crown was left intact and it was possible to position the anchor bar in an incisal and lingual position  maintaining esthetics for the patient during both the extrusive and stabilization phases of treatment  
class7	type 2 diabetes mellitus and periodontal disease  the relationship between type 2 diabetes mellitus and periodontal disease was evaluated in 2 878 pima indians of the southwestern united states  two independent measures of periodontal disease  probing attachment loss and radiographic bone loss  were used to compare prevalence and severity of periodontal disease in diabetic and nondiabetic subjects  in all age groups studied  subjects with diabetes had a higher prevalence of periodontal disease  indicating that diabetes may be a risk factor for periodontal disease  
class7	proliferative mass found in the gingiva  the clinical course of peripheral ossifying fibroma is slow and the growth of most lesions is limited in size  usually up to 1 5 cm  complaints are rare unless the surface becomes ulcerated  or the lesion compromises oral function or esthetic appearance  treatment is surgical excision with close postoperative follow up  tooth extraction is seldom necessary  proper surgical intervention  which includes excision of reactive tissue down to periosteum  affords a low recurrence rate of 14  to 16   
class7	needle aspiration biopsy in salivary gland lesions  the value of needle aspiration biopsy in the evaluation and management of salivary gland pathology is controversial  the major reasons for this controversy are the difficulty in cytologic evaluation and the fact that the extent of surgery can be easily defined based on clinical judgement  however  a preoperative diagnosis is helpful in discussions with patients regarding the extent and type of surgery  apart from the fact that needle biopsy can distinguish benign from malignant conditions  it is also very useful in distinguishing between salivary and other nonsalivary pathology  over the past 7 1 2 years  we have performed 160 needle aspirations of parotid  submandibular  and submucosal lesions  adequate specimens for cytologic evaluation were obtained in 155 patients  97    a total of 84 parotid lesions  70 submandibular lumps  and 6 submucosal abnormalities were detected  a cytologic diagnosis of benign pathology was made in 120 patients  twelve patients had lymphoma and the diagnosis was suspected based on needle aspiration  there were 10 patients with tuberculosis and 30 patients with hyperplastic lymph nodes or benign lymphoepithelial disease of the parotid  there were three false positive and two false negative reports  no complications such as hematoma  nerve injury  or infection developed  the major difficulty was in distinguishing between malignancy and obstructive sialadenitis in the submandibular region  needle aspiration was helpful in evaluating lesions in the tail of the parotid and submandibular area  the cytologic distinction between salivary and nonsalivary pathology was useful in planning the appropriate surgery and the extent of surgical resection  from a clinical standpoint  the distinction between benign and malignant salivary and nonsalivary pathology was very helpful  preoperative diagnosis of warthin s tumor  lymphoma  or benign lymphoepithelial disease was essential to the correct management of these patients  
class7	whole organ sectioning of mixed parotid tumors  a pathologic study involving 15 standard formal parotidectomy specimens was carried out using the whole organ sectioning technique  histopathologic characteristics noted included the presence of exposed capsule  breaks of the capsule  capsular incompleteness  tumor ingrowth and thickness  cellularity  and lymphocytic infiltration  tracings of histopathology slides were used to reconstruct the three dimensional configuration of each tumor as viewed from different angles  no tumor had a smooth surface  at the extreme  two tumor lumps were connected by just a narrow waist  separated tumors were not seen  in only one specimen did a lymph node contain an additional tumor in the form of an adenolymphoma  all tumors showed some exposed capsule or  bare area  to a degree affected mainly by the position of the tumor  capsular damage was occasionally seen and was usually minor  capsular incompleteness and tumor ingrowth make global capsular dissection unsafe  it is concluded that formal parotidectomy remains the operation of choice for pleomorphic adenoma of the parotid gland  although capsular dissection  otherwise termed enucleation  cannot be entirely avoided during the procedure  
class7	early facial reanimation following radical parotid and temporal bone tumor resections  a retrospective study of 35 patients who underwent early facial reanimation following extirpative parotid and temporal bone surgery requiring facial nerve sacrifice was performed  regional facial reanimation performed immediately or within several days included 16 patients who underwent temporalis muscle transposition and 27 who underwent gold weight or eyespring lid reanimation with lower lid tightening  simultaneous nerve grafts or nerve crossover procedures were performed in 22 patients  the authors  favored approaches to facial reanimation are discussed  with an emphasis on the value of early reanimation using properly selected techniques  
class7	reconstruction of mandibular defects in irradiated patients  in this prospective study  mandibular reconstruction using titanium plates was evaluated in 31 patients treated between july 1988 and january 1990  sixteen patients had prior surgery  13 had prior radiotherapy  in 11 patients  prior radiation and surgery had failed  sixteen patients received postoperative radiotherapy either in standard or accelerated fractions  twelve patients had complications of either intraoral  8   extraoral  5   or combined  1  plate exposure or fistula formation  2   factors significantly related to complications were poor nutrition  accelerated radiation  and recurrence  sixty one percent of all patients healed uneventfully  when patients with complications secondary to recurrence who subsequently died were excluded  the success rate was 73   only one patient had an unacceptable result that produced a cosmetic and functional deformity despite secondary repair  
class7	long term fate of the vascularized iliac crest bone graft for mandibular reconstruction  vascularized bone grafts  such as the iliac crest  have become a major tool for mandibular reconstruction  due to the growing trend toward immediate bone replacement followed by implant osseointegration and dental rehabilitation  further understanding of the long term characteristics of these grafts is essential  early postoperative bone scans demonstrate increased activity within the vascularized graft relative to surrounding bone  this study addressed the use of bone spect  single photon emission computed tomography  scintigraphy as a long term method of evaluating the integrity of vascularized bone grafts  
class7	sequential connection of flaps  a logical approach to customized mandibular reconstruction  microsurgery has improved the success rate for reconstruction of composite defects in the head and neck  restoration of mandibular continuity alone is not adequate for reconstruction  replacement of the oral lining with thin tissue is necessary to improve tongue mobility and to set the stage for later dental restoration  there is currently no ideal osteocutaneous free flap that provides unlimited length of bone  can undergo multiple osteotomies to produce the proper curve to the reconstructed mandible  and provides thin skin for oral lining  combining free flaps can take advantage of the strengths of the individual donor sites and eliminate some of the problems with current osteocutaneous flaps  in six patients  a fibular osseous free flap was combined with either a radial forearm flap or a lateral arm flap to provide bone and oral lining in reconstruction of mandibular composite defects  in these selected patients  the fibula provided the blood supply for the second free flap  which was placed sequentially  the distal peroneal vessels were used to anastomose to the radial forearm vessels or the lateral arm pedicle  this approach allows the surgeon to customize the defect by improving both the functional and aesthetic aspects of reconstruction and is of use in cases where vascular access is limited  such as following head and neck surgery and radiation  
class7	treatment selection for carcinoma of the base of the tongue  between 1974 and 1984  173 patients were treated for squamous cell carcinoma of the tongue base  fifty four patients had t1 or t2 primaries  while 115 patients had t3 or t4 tumors  4 were not staged   lymph node metastasis was present in 120 patients  early primary tumors treated with surgery or radiotherapy had a control rate of 83   5 of 6 tumors  and 89   40 of 45 tumors   respectively  for advanced primary tumors  definitive radiotherapy produced a local control rate of 55   42 of 76 tumors   compared with 79   23 of 29 tumors  for surgery and postoperative radiotherapy  if primary control was obtained  the regional failure rate was less than 10   tumor growth patterns were predictive of the response to radiotherapy  the primary control rate at 2 years for 21 patients with exophytic tumors was 84  as opposed to 58  for 62 patients with ulcerative infiltrative tumors  p   0 04   radiotherapy is effective for early stage or exophytic tumors  whereas for advanced or deeply invasive tumors combined therapy enhances local control  
class7	histopathologic grading of salivary gland neoplasms  i  mucoepidermoid carcinomas  histopathologic grading of salivary gland neoplasms has been done with various degrees of success and hence various degrees of acceptance among pathologists and otolaryngologists head and neck surgeons  given their histopathologic diversity  three carcinomas  mucoepidermoid  adenoid cystic  and acinic cell  would seem to be suitable candidates for grading  in this  the first of a three part series  the authors present a three level grading scheme for mucoepidermoid carcinomas  it combines histocytologic and growth features of the carcinomas that independently or together  in other grading proposals  have shown prognostic value  
class7	intravenous pulse cyclophosphamide therapy in myositis and sjogren s syndrome  we describe a patient with primary sjogren s syndrome who developed myositis  the results of muscle pathologic analysis before and after treatment with monthly pulses of cyclophosphamide  intravenously   are presented  
class7	characterization of a macrophage tropic hiv strain that does not alter macrophage cytokine production yet protects macrophages from superinfection by vesicular stomatitis virus  macrophages  unlike cd4  t cells  can be productively infected by human immunodeficiency virus  hiv  without prior cellular activation  cytopathic infection ensues without the induction of tumor necrosis factor alpha  tnf alpha   interleukin 1 beta  il 1 beta   interleukin 6  il 6   or tissue factor genes  in detailed studies on tnf alpha  hiv infection did not affect the regulation of tnf alpha in response to bacterial lipopolysaccharide  in an effort to examine the interferon responsiveness of hiv infected macrophages  the cells were challenged with vesicular stomatitis virus  vsv  with or without interferon pretreatment  surprisingly  hiv infected macrophages were completely resistant to vsv induced lysis even in the absence of interferon  however  no interferon was detected in the supernatants of these infected cells  the resistance of hiv infected macrophages to superinfection with vsv indicates a previously undescribed effect of hiv upon macrophage cellular metabolism  
class7	expression of major histocompatibility complex class ii antigens and interleukin 1 by epithelial cells of warthin s tumor  the immunoreactivity for class ii antigens of the major histocompatibility complex and interleukin 1  il 1  in warthin s tumor  wt  cells was studied  in addition to macrophages  dendritic cells  and capillary endothelia  the luminal tumor cells and some keratinocytes in the metaplastic squamous foci exhibited immunoreactivity for both class ii antigens and il 1  the distribution of the class ii antigens in the luminal tumor cells was limited to their basolateral membrane  these data  together with previous findings  strongly suggest that the luminal tumor cells of wt introduce the luminal antigen to the underlying lymphoid tissue and  thus  act as an antigen presenting cell  
class7	intraoral adenoid cystic carcinoma  the presence of perineural spread in relation to site  size  local extension  and metastatic spread in 22 cases  twenty two patients with an intraoral adenoid cystic carcinoma  acc   initially treated by surgery with or without postoperative radiotherapy  were examined for the presence of perineural spread in relation to primary site  size  local extension  histologic status of the surgical margins  and metastatic spread of the tumor  there seems to be no correlation between perineural spread and the primary site or size of the tumor  however  perineural spread occurred more often in tumors with local extension and in cases with surgical margins with positive results  there seems to be no statistically significant correlation between perineural invasion and distant metastatic disease  
class7	repair of salivary fistulae after laryngectomy  a new surgical technique is described for the repair of salivary fistulae  it has been used in three patients  the fistulae occurred after laryngectomy and had been unsuccessfully treated with local and regional flaps  the principle of the technique is to use a bipedicled jejunal patch as a free microvascular transfer  one patch is used for reconstruction of the pharynx and after excising the mucosa the skin defect is closed with the other patch  the mucosa is excised to expose the muscle and to create a recipient site for a split skin graft  
class7	balancing dental service requirements and supplies  epidemiologic and demographic evidence  as a counterpoint to negative interpretations of recent trends  this article presents a positive picture of dentistry in the 1990s and 21st century  reported trends show large increases in older dentate adults who are retaining more of their natural dentition  new diagnosis and treatment technologies  increased incidence of dental caries in older adults  increased awareness of periodontal diseases  greater interest in esthetic dentistry  and generally higher expectations for health and fitness in our society  all of these factors point to a greater need for adult dental services  therefore  in the next 30 years  the dental profession should be prepared to provide increased amounts of diagnostic  preventive  adult operative  fixed prosthodontic  and endodontic and orthodontic services  declines in need should be expected in children s operative dentistry  extractions  and complete dentures  
class7	life threatening hemorrhage after placement of an endosseous implant  report of case this article reports an unusual but dangerous complication of implant surgery  minimal perforations of the lingual plate and inferior border of the mandible had been considered previously to be benign occurrences  this report demonstrates the importance of managing acute airway problems resulting from perforations  
class7	evaluating tooth eruption on sealant efficacy  for patients aged 5 to 9 and 11 to 14  100 occlusal surfaces on newly erupting permanent molars were treated with a self curing pit and fissure sealant  all teeth were categorized according to stage of eruption and sealant thickness of the coating applied  after 36 months  75 surfaces were examined for a final evaluation  52 surfaces  70   did not need retreatment  of the 23 surfaces retreated as a result of sealant loss or marginal deterioration  18 were retreated only once in the six recall evaluations  those molars treated originally with the operculum covering the distal marginal ridge of the occlusal surface had twice the probability for retreatment as teeth not treated until the entire marginal ridge was exposed  the thickness of the sealant coating did not affect the early signs of sealant failure  
class7	the prevalence of periodontitis in a military treatment population  a group of 1 984 males and females  age range 13 to 84  at a military dental clinic were given oral examinations with full mouth circumferential periodontal probing  diagnoses were made both for individual quadrants and for the entire mouth using clearly defined diagnostic criteria  the results showed 37  of the subjects had gingivitis only  33  had early periodontitis  14  had moderate periodontitis  15  had advanced periodontitis  0 5  had juvenile periodontitis  and 0 5  had necrotizing gingivitis  the prevalence of periodontitis increased with age to a peak in the 45  to 50 year age group  the proportion of periodontitis affected quadrants  although initially lagging behind the overall case diagnoses  also increased with age  
class7	periodontics in general practice  professional plaque control traditionally the primary emphasis of preventive periodontics was daily patient performed plaque control  recent studies indicate that frequent professional subgingival toothcleaning is a mandatory treatment for prevention of recurrent periodontitis  pathogenic subgingival bacterial complexes are disrupted by frequent cleaning and require time to reestablish  disease progression is prevented if the recall interval does not exceed the time required for reestablishment of a pathogenic plaque  legally  patients have acquired the duty to comply with the prescribed recall interval  both the patient and the practitioner will benefit from a preventive program that includes frequent professional subgingival toothcleaning  
class7	lip paresthesia associated with a jaw mass  a case is reported in which mandibular swelling and lower lip numbness were the first signs of a metastatic adenocarcinoma of the lung  the development of paresthesia  with or without other oral symptoms  requires that a diagnosis of malignancy be considered until confirmed or ruled out by tissue biopsy  a thorough head and neck examination in all patients  especially in those whose history or habits may indicate increased risk of malignancy is necessary  
class7	rhinosporidiosis associated with squamous cell carcinoma in the tongue  the peritumoural region of a squamous cell carcinoma of the tongue when examined with light and electron microscope showed nodular bodies in the submucosa with all the distinctive features of  sporangium and  spores  of rhinosporidiosis  the occurrence of rhinosporidiosis in the tongue along with malignancy has not been reported hitherto  some interesting observations and causal relationships are discussed  
class7	malignant adenolymphoma of the parotid gland  report of carcinomatous transformation  malignant transformation of an adenolymphoma  warthin s tumour  is a rare event  this paper presents a case of carcinoma arising in an adenolymphoma of the parotid gland  
class7	benign parotid tumour enucleation  a reliable operation in selected cases  the method of surgical treatment for benign tumours of the parotid gland had not yet been rationalized  but many authors recommend parotidectomy as the most appropriate procedure  a series of 289 operations for parotid swelling is reported  the majority of mixed and warthin s tumours underwent enucleation without either complications or recurrence  the rationale of parotidectomy versus enucleation is discussed but in fast growing  deeply infiltrating and recurrent tumours  parotidectomy appears to be the best choice  in the other group of more commonly occurring tumours  enucleation represents a reliable time saving option  
class7	unusual lymphoproliferative oropharyngeal lesions in heart and heart lung transplant recipients  three unusual cases of oropharyngeal lympho proliferative lesions were seen in recipients of heart and heart lung transplants  two caused acute upper respiratory obstruction necessitating urgent ent intervention  all patients were receiving immunosuppressive drugs including cyclosporin  the two obstructive cases were adenotonsillar enlargement in a 6 year old  and a tumour of the tonsil and tongue base with cervical lymph node enlargement in a 32 year old male  both were caused by epstein barr virus associated lymphoproliferative disorder  the third patient  a 32 year old female  had a presumed low grade t cell lymphoma that regressed spontaneously  histopathological diagnosis of these lympho proliferative disorders after transplantation usually requires immunocytochemistry to distinguish polyclonal proliferative disorders from true lymphoma  polyclonal lymphoproliferative disorders after transplantation do not usually require aggressive cytoreductive therapy  but respond to simple measures such as the reduction of immunosuppression  
class7	the problem of the bifid mandibular condyle  in a survey of 1 882 prehistoric and historic skulls with 2 077 condyles  7 double  bifid  mandibular condyles were found  one mandible with bilaterally bifid condyles is presented in detail  possible causes and consequences of the anomaly are discussed  it is assumed that bifid mandibular condyles with anteroposteriorly situated heads are caused by early childhood fractures  whereas those with mediolaterally situated heads are caused by the persistence of connective tissue septa  
class7	speech  velopharyngeal function  and hearing before and after orthognathic surgery  articulation  voice  resonance  hearing sensitivity  and middle ear function were examined in 34 patients before and 3  6  9  and 12 months after orthognathic surgery  thirty of the 34 patients had articulation errors before surgery  errors on the sibilants  s  and  z  occurred most frequently  followed by those on  j zh ch  and  sh   errors were predominantly distortions with both visual and acoustic components  after surgery  articulation improved spontaneously in the absence of intervention  most of the preoperative articulation errors were eliminated by 3 months postoperative  but  thereafter  a gradual decline was noted so that by 12 months  errors occurred on  s  and  z   voice  resonance  velopharyngeal port area  and hearing sensitivity were not altered by surgery  this study suggests that severe skeletal malocclusions requiring surgical correction have deleterious effects on the patients  articulation of consonants and that surgical alteration leads to the correction of most of these errors  
class7	pedunculated soft tissue mass on the alveolar gingiva  clinical conference  a case of peripheral ameloblastoma  a rare intraoral neoplasm  has been presented  the lesion appears most commonly as a mass on the mandibular lingual gingiva of patients in their fifth and sixth decades of life  the peripheral ameloblastoma does not share the aggressive nature of the intraosseous variant  the lesion has been overtreated in the past and warrants only a local supraperiosteal excision  
class7	central adenoid cystic carcinoma of the mandible  a patient with adenoid cystic carcinoma arising centrally within the mandible  a rare location for this malignant salivary gland tumor  is described  current concepts regarding the etiology  diagnosis  histology  and treatment of central intramandibular salivary gland tumors are discussed and the literature is reviewed  
class7	parotid gland and facial nerve trauma  a retrospective review  included in this study are all patients with trauma to the parotid region seen at our center from 1979 to 1989  there was a total of five patients with injury to the parotid area  two patients with isolated facial nerve injury  one with isolated parotid duct injury  two with combined duct and nerve injury  there were four males and one female  with a mean age of 34 years  range  16 to 62 years   the three patients with parotid duct injury required other procedures for associated trauma  a total of eight nerve branches were severed in four patients  seven of the eight nerve branches  82 5   were primarily repaired  with excellent functional results  two of the three ductal injuries were repaired primarily over a stent  and one was ligated  no complications resulted from either treatment  based on our clinical experience and review of the literature  we suggest that the treatment of parotid region injuries should include  1  a complete initial assessment  2  primary repair of parotid duct transection within 24 hours when possible  3  primary repair of all facial nerve injuries  although delayed nerve repair remains a viable alternative  and 4  nonsurgical treatment of sialoceles and fistulae  
class7	association of group c beta hemolytic streptococci with endemic pharyngitis among college students throat cultures were performed throughout 2 school years to determine whether non group a beta hemolytic streptococci  nga bhs  could be isolated more frequently in 232 college students who had symptomatic pharyngitis than from 198 age matched controls with noninfectious problems  duplicate throat swabs were inoculated onto plates that contained sheep blood agar  one plate being incubated in a 5  co2 atmosphere and the other in an anaerobic environment  the bhs were grouped using latex agglutination  among the nga bhs  only those from group c were isolated significantly more often among the patients compared with the controls  26  vs 11    quantitative colony counts of isolates of group c bhs were generally higher among patients than controls  patients with group c bhs had fever  exudative tonsillitis  and anterior cervical adenopathy significantly more frequently than did patients who had throat cultures that were negative for group c bhs  group c bhs were epidemiologically associated with endemic pharyngitis in this college student population  
class7	angioedema from angiotensin converting enzyme inhibitors  a cause of upper airway obstruction  angiotensin converting enzyme  ace  inhibitors have several side effects of concern to the otolaryngologist  angioedema is a rare  but potentially lethal adverse effect when associated with upper airway obstruction  four cases of ace inhibitor induced angioedema  three with significant upper airway obstruction  are reported  angioedema secondary to ace inhibition appears to be mechanism based  the probable link is the potentiation of bradykinin  which results in vasodilation  increased vascular permeability  and angioedema  since angioedema can progress to upper airway obstruction  otolaryngologists must be aware of this association  the differential diagnosis and treatment of this adverse effect is discussed  as well as a review of ace inhibitors and other causes of angioedema  
class7	a study of the comparative efficacy of four common analgesics in the control of postsurgical dental pain  four common oral analgesics were tested in a single blind trial to determine their relative efficacy in the management of postsurgical pain in 103 patients who had their impacted third molars surgically removed under general anesthesia  the analgesics tested were acetylsalicylic acid  26 patients   ibuprofen  26 patients   a paracetamol codeine caffeine combination  solpadeine   25 patients   and dihydrocodeine  26 patients   the paracetamol codeine caffeine combination  ibuprofen  and acetylsalicylic acid preparations produced equally effective analgesia  dihydrocodeine was found to be a poor analgesic in this pain model  there were no adverse reactions to any of the preparations  
class7	comprehensive dental care and general anesthetic management of hereditary epidermolysis bullosa  a review of fourteen cases  dental management of persons with epidermolysis bullosa remains challenging because of the severe hard and soft tissue manifestations of these diseases  this study reviews the dental treatment of 14 cases requiring 24 general anesthetics  twenty three of the cases were managed with oral tracheal intubation to accomplish full mouth dental rehabilitation  dental therapy consisted of preventive  restorative  and surgical procedures  with extractions and stainless steel crowns being the most common treatment modalities  there were no serious postoperative complications  and no airway problems were experienced  although extensive intraoral mucosal blistering did occur in several cases  postoperative healing progressed normally  soft tissue trauma may be lessened through the use of small suction tips  flat tissue retractors  and extensive lubrication of all tissues requiring manipulation  this study provides further evidence that even the most severely affected patients with epidermolysis bullosa can receive comprehensive dental treatment directed at maintaining a functional dentition  
class7	the myelodysplastic syndromes  case report and review  the myelodysplastic syndromes are a heterogenous group of hematologic disorders of myeloid progenitor cells  oral manifestations may be among the first signs and often reflect degrees of neutropenia or neutrophil dysfunction  a patient with persistent herpes labialis and severe oral mucosal ulceration in myelodysplastic syndrome is reported  the features of myelodysplasia are reviewed and their oral manifestations and significance to dental management outlined  
class7	propolis allergy  a cause of oral mucositis with ulceration  propolis has been used since ancient times in folk medicine for its alleged beneficial effects  it is a potent sensitizer and is well recognized as a cause of occupational allergic eczematous contact dermatitis in apiarists  recently  there has been an increase in allergic eczematous contact dermatitis because of nonoccupational exposure to propolis in  natural products  and biocosmetics  this report describes a patient who had acute oral mucositis with ulceration as a result of using propolis containing lozenges  
class7	multiple myeloma and bullous lichenoid lesions  an unusual association  many associations of lichenoid reactions have been described but this case appears to be a previously unreported association  with multiple myeloma  this case also demonstrates the necessity of a mucosal biopsy with adequate hematologic and serologic investigations to obtain a definitive diagnosis  
class7	nitrendipine induced gingival hyperplasia  first case report  drug induced gingival hyperplasia is well documented within the literature  it has been associated with phenytoin  cyclosporine  and calcium channel blocking agents  nitrendipine is an experimental calcium channel blocking agent that also appears to cause the side effect of drug induced gingival hyperplasia  the clinical and histologic presentation of this side effect and possible biochemical mechanisms of pathogenesis are discussed  
class7	thermally induced  nicotine  stomatitis  a case report  a palatal lesion resembling  nicotine  stomatitis was found in a woman who did not smoke  however  the patient frequently drank extremely hot beverages  after she was instructed to reduce the temperature of the beverages  the lesion almost completely resolved  this suggests that heat was the primary cause of this lesion and also implicates heat as the major cause of nicotine stomatitis  
class7	diagnosis of oral hairy leukoplakia by ultrastructural examination of exfoliative cytologic specimens  lingual exfoliative cytologic specimens  scrapings  were obtained from 18 patients positive for human immunodeficiency virus with clinical oral hairy leukoplakia  buccal mucosal scrapings were obtained from 12 of these patients  the specimens were processed for examination by transmission electron microscopy  tem   sixteen  89   of the lingual specimens revealed infection of keratinocytes by herpes type virus  there was no evidence of virus infection in the 12 buccal mucosal scrapings  fungal hyphae were seen by tem in 14  78   of the lingual scrapings and two  17   of the buccal scrapings  one exfoliative specimen and two biopsy specimens were stained for epstein barr virus dna with a dna probe  the demonstration of herpes type virions by tem in keratinocytes from a lesion clinically suspected to be hairy leukoplakia provides direct  objective diagnosis  furthermore  use of exfoliative cytologic specimens provides a clinically simple  noninvasive technique  
class7	the cellular composition of basal cell adenoma of the parotid gland  an immunohistochemical analysis  four cases of basal cell adenoma of the parotid gland were examined immunohistochemically to characterize their cellular composition  in all cases epithelial membrane antigen and keratin were detected in the inner luminal cells  some cells also showed positive staining for secretory functional markers  indicating their differentiation toward secretory epithelium  in tubular and trabecular types the outer cells consistently displayed an intense staining for vimentin and some were also positive for actin  indicating their myoepithelial nature  in the solid type  most tumor cells resembled the ductal cells or basal cells of larger ducts in normal gland with regard to their immunoreactivity  our results may suggest that the proportion and arrangement of heterogeneous tumor cells are responsible for different histologic patterns of the salivary basal cell adenoma  
class7	primary malignant melanoma in the parotid gland  reports of primary malignant melanoma arising from the parotid salivary gland are extremely rare and  to date  have been sporadic  we report a pertinent case  and tabulate and correlate the clinical findings of the 13 cases reported thus far in the literature  the most common symptom is a progressively enlarging  asymptomatic  firm  and fixed mass  total excision has been the established treatment of choice  the contribution of radiotherapy  chemotherapy  and immunotherapy remains unclear  and it is not possible at present to predict the outcome of treatment in individual patients  although rare  primary malignant melanoma should be considered in the differential diagnosis of parotid tumors  the clinical significance of establishing the diagnosis of primary malignant melanoma of the parotid gland is emphasized  
class7	oral histoplasmosis as a presenting disease in acquired immunodeficiency syndrome  published erratum appears in oral surg oral med oral pathol 1991 jan 71 1  76  a 43 year old homosexual man visited his dentist with painful  nodular  ulcerated lesions on the soft palate  right buccal mucosa  and right posterior maxillary gingiva  serologic studies for exposure to human immunodeficiency virus  performed before biopsy  were positive  biopsy of the maxillary gingiva demonstrated sheets of histiocytes containing small intracellular yeasts  which on culture were identified as histoplasma capsulatum  bilateral leukoplakic lesions with some vertical furrowing involving the lateral borders of the tongue were also noted  histologically  hyperkeratosis and fungal hyphae were identified  the patient was treated for histoplasmosis with amphotericin b  which resulted in significant improvement of the oral lesions  he was subsequently hospitalized for fatigue and dyspnea and was found to have pneumocystis carinii pneumonia  pulmonary status deteriorated within a 3 week period  and the patient died  autopsy findings were negative for histoplasmosis but positive for necrotizing and cavitary p  carinii pneumonia  pulmonary and hepatic herpes simplex infections  and pulmonary and intestinal cytomegalovirus infection  
class7	epithelial rests  function in replantation  is splinting necessary in replantation  the problem of resorption during replantation in relationship to the epithelial rests and a lack of splinting was studied  ten mongrel dogs were used  two dogs served as control subjects  while eight had their mandibular incisors intentionally replanted and studied histologically  it was observed that where rests of malassez were present we did not see resorption  and the lack of splinting did not result in resorption or loss of teeth  it appears we can stain epithelial rests of malassez with immunofluorescent antibodies and use this technique for further study of this tissue  
class7	replantation  an analysis of 29 teeth  the results of replantation of 29 teeth are described  maxillary incisors constituted 85  of 27 permanent teeth  the period between avulsion and replantation ranged from within an hour to 86 days  but the actual extraoral period was within 5 hours in all but one case  nineteen of the 27 permanent teeth were functioning for 7 months to 6 years and 7 months postoperatively  root resorption was the cause of tooth loss in five cases  the incidence of root resorption seemed to increase with the increase of the extraoral period  but it was not affected by the period between avulsion and replantation  the condition of supporting tissues  the degree of root formation  and the type and period of splinting  indicating multiple factors involved in determining the prognosis of replanted teeth  in conclusion  every effort should be made to preserve avulsed teeth even in unfavorable conditions  
class7	apical closure of mature molar roots with the use of calcium hydroxide  calcium hydroxide may induce apical root closure in affected mature teeth as well as in immature teeth  once an apical hard tissue barrier is formed  a permanent root canal filling can be safely condensed  two cases are described in which calcium hydroxide induced apical root closure in mature molar teeth where the apical constriction was lost because of chronic inflammatory process  
class7	when a patient with a bleeding disorder needs dental work  how you can work with the dentist to prevent a crisis patients with bleeding disorders need close cooperation between their physician and their dental practitioner to receive safe  comprehensive dental care  when indicated  physicians must advise a compromised treatment plan to avoid deep injections or surgical procedures that may initiate a bleeding crisis in patients at risk  the conditions most commonly seen that require special consideration are long term use of antithrombotic agents  platelet dysfunction caused by chronic renal failure  and congenital clotting factor deficiencies  even these patients may undergo a high risk procedure  such as periodontal surgery  with adequate precautions and preparation  
class7	improved primary surgical and dental treatment of clefts  the improved combination of surgical and dental teamwork in the primary treatment of clefts presented here is consistent with principles  in fact  this is a staged design for correction of classic clefts of the lip and palate that  based on biological principles  facilitates the continuance of the failed embryonic  migrations  toward a normal end point  positioning of the alveolar segments  dissection of mucoperiosteum out of the cleft  and union of mucoperiosteum across the alveolar and anterior hard palate cleft make it possible to create a periosteal tunnel across the bony gap and set up a condition conducive to bone formation and eventual tooth eruption in the cleft area  lip closure by adhesion reduces the tension of the primary lip closure and allows gentle molding until solidification of the arch occurs  thus a complete cleft has been rendered an incomplete cleft  with a balanced  stabilized maxillary platform  the definitive lip and nose corrections can be carried to completion early  by 2 to 4 years of age   these planned actions bypass a persistent cleft  fistulas  raw areas  malposition of alveolar segments  and probably the necessity for later bone grafting  the only question not totally answered is the effect of this approach on final growth  although most reports seem to indicate that growth has and will proceed within normal limits  another 10 years of careful follow up is indicated and  in fact  is in progress  
class7	experience with the functional cleft lip repair  the first 12 functional cleft lip repairs performed on unselected consecutive patients immediately following the completion of training by the author are presented  previous reports on this cleft lip repair have shown excellent results but have always been based on patients operated on by the originator of the procedure  this report gives credence to the ease with which a cleft lip repair that gives reproducible good results can be taught and learned even by plastic surgeons with limited experience  it reviews the technical steps of the procedure  which emphasizes wide undermining and release of the orbicularis oris muscle on the lateral side of the cleft to allow redraping and lengthening of the lip skin  step by step layered closure of the mucosa  muscle  and skin  and further vertical lengthening of the lip with a z plasty skin closure  three elements that are difficult to achieve or restore with cleft lip revision are evaluated   1  achievement of a good skin scar   2  maintenance of the alar facial groove  and  3  achievement of adequate lip height without sacrificing horizontal lip length  ten of the 12 patients had a satisfactory scar  9 patients had a good alar facial groove  and all patients had a normal appearing horizontal lip length  nine patients required secondary surgery  however  in six patients  this included correction of the nasal deformity that was not corrected at the time of cleft lip repair  
class7	primary repair of the bilateral cleft lip nose  a 15 year review and a new treatment plan  for 15 years a forked flap has been used for columella reconstruction in primary repair of the bilateral cleft lip nose  with the adolescent growth spurt  three unfavorable features have become apparent   1  the columella may grow too long and the nostrils too large   2  often the nasal tip remains broad  and  3  there is a drift of the columellar base and the lip columellar angle is transgressed by scar  this procedure has therefore been discontinued  a new treatment plan is presented in which the columella is reconstructed from tissues in the splayed out nasal tip  
class7	secondary correction of the unilateral cleft lip nose using a conchal composite graft  the secondary deformity of the unilateral cleft lip nose has many components  one is the dorsal dislocation of the lateral crus of the alar cartilage  we used a conchal composite graft positioned between the piriform aperture and the lateral crus and the upper lateral cartilage to correct this dislocation in nine patients  we believe that this graft is effective because it elevates the lateral crus of the alar cartilage off the depressed piriform aperture  this technique is very simple to perform  and it is easy to achieve nasal symmetry  our results have been quite satisfactory  with no recurrence of dorsal dislocation  the donor site was covered by a subcutaneous pedicled flap from the cephaloauricular sulcus  leaving an inconspicuous deformity  
class7	arteriovenous malformation of the tongue  polyvinyl alcohol particles used to embolize an arteriovenous malformation of the tongue were only temporarily successful  additional embolization therapy was necessary and was complicated by ischemic ulcers of the tongue  we conclude that embolization therapy can be used  but the efficacy of this therapy in the longer term remains to be determined  
class7	nasolaryngoscopy for family physicians  nasolaryngoscopy is easy to learn and safe and convenient to perform  it is readily accepted by patients and is a rich source of clinical information  the flexible nasolaryngoscope allows the physician to directly observe the anatomy of the nasal passages  pharynx and larynx  the procedure is helpful for identifying the etiology of chronic nasal complaints and hoarseness  other possible indications for nasolaryngoscopy include suspected nasal foreign body  recurrent nasal or pharyngeal bleeding  and epiglottitis  with the use of this instrument  treatment of otolaryngologic conditions may be more specific  thereby reducing unnecessary referral or delay in treatment  
class7	toxic streptococcal syndrome  the streptococcal toxic shocklike syndrome is a recently recognized  multisystem disorder that shares many of the features of staphylococcal toxic shock syndrome  but is caused by toxins elaborated by group a beta hemolytic streptococcus  we describe a patient who fulfilled the major criteria for the clinical diagnosis of toxic shock syndrome  fever  hypotension  multisystem dysfunction  and diffuse macular erythroderma followed by desquamation  and who demonstrated serologic evidence suggesting streptococcal infection  in patients presenting with clinical findings consistent with a toxic shocklike syndrome  the emergency physician should consider streptococcal infection as a potential etiology  
class7	occipital condyle fracture presenting as retropharyngeal hematoma  reported is the case of a 30 year old male motorcycle accident victim who was found on plain cervical spine radiography to have prevertebral soft tissue swelling  although subsequent computed tomography demonstrated no cervical spine fracture  it did reveal a fracture of one occipital condyle  the mechanism  diagnosis  and treatment of occipital condyle fractures are reviewed  as is the ligamentous and fascial anatomy of the cervicocranium  dissection of fracture hematoma inferiorly along vertically oriented tissue planes is hypothesized as the pathogenesis of our patient s retropharyngeal hematoma  in addition to being a sign of potential cervical spine injury  post traumatic prevertebral soft tissue swelling may also indicate occipital condyle fracture  to avoid overlooking such fractures  computed tomography undertaken to investigate upper cervical spine prevertebral soft tissue swelling should always include slices up to the level of the basal skull so as to visualize the condyles  
class7	histopathologic grading of salivary gland neoplasms  ii  acinic cell carcinomas  acinic cell carcinomas display varied cytoarchitectural patterns of growth that should allow for formulation of histopathologic grading  grading of these carcinomas may serve to identify subsets whose biologic behavior is more aggressive than the usually accepted low grade behavior of acinic cell carcinomas as a group  to that end  a three level histopathologic grading scheme is presented  
class7	activation of t cell subsets in the peripheral blood of patients with sjogren s syndrome  multicolor flow cytometric analysis  using 3 color flow cytometry  we determined the proportions of activated t cells  dr    including cd4  cells  cd8  cells  and their subsets  in the peripheral blood of 17 patients with sjogren s syndrome  ss   activated t cells were significantly increased in cd4  cells  cd8  cells  and t suppressor inducer  cd4   leu 8    t helper  cd4   leu 8    and t cytotoxic  cd8   cd11   subsets  but not the t suppressor natural killer subset  cd8   cd11    in patients with ss as compared with the controls  furthermore  the proportions of activated t cells in the cd4   leu 8  subset  the cd8  subset  or the cd8   cd11  subset showed a positive correlation with serum gamma globulin levels in the ss patients  our findings suggest that a certain immunoregulatory balance between t helper and t suppressor activities is maintained in ss patients  although this balance seems to occur at highly activated levels  and that quantitative changes of some lymphocyte subsets are important factors in maintaining this balance  we discuss the possibility that cd4   leu 8  cells recirculate into peripheral lymph nodes  while cd4   leu 8  cells migrate into inflammatory tissues such as salivary glands  since the leu 8 antigen is reported to be a homing receptor in peripheral lymph nodes  this process might be accelerated in ss  and each t cell subset may further participate in immunologic activation in the lymph nodes or target tissues  
class7	association of labial salivary gland histopathology with clinical and serologic features of connective tissue diseases  focal sialadenitis is now widely accepted as an objective criterion for the oral component of sjogren s syndrome  xerostomia   we investigated the association between labial salivary gland histopathologic changes and the clinical and serologic features of 192 patients with suspected connective tissue disorders  a retrospective review of the medical records of all patients was performed  and historical  physical  laboratory  histologic  and roentgenographic data were abstracted  each patient had undergone labial salivary gland biopsy as part of a rheumatologic evaluation  there were significant associations between positive findings on lip biopsy and the presence of keratoconjunctivitis sicca  p   0 013   positive antinuclear antibodies  titer greater than or equal to 1 80   p   2 x 10  8    and positive ro antibodies  p   1 x 10  8    however  sicca symptoms and glandular enlargement were not statistically associated with positive findings on lip biopsy  features predictive of a positive lip biopsy included ro antibodies  p   0 914   keratoconjunctivitis sicca  p   0 700   and positive antinuclear antibodies  p   0 590   
class7	family cancer syndrome  a study of the kindred of a man with osteogenic sarcoma of the mandible  several familial cancer syndromes have been identified  the syndrome of sarcomas  breast cancer and other neoplasms  known as li fraumeni syndrome  is characterized by several different neoplasms presenting at young ages with autosomal dominant transmission and a high incidence of second primaries  in this paper  we studied six generations  51 people  of the family of a 24 year old man with osteogenic sarcoma of the mandible  twelve malignancies in 11 people  including several rare tumors  were revealed  mean age of presentation was 24 years old  nine of the 11 patients died of disease  one developed a second primary  two tumors presented in the head and neck  transmission was autosomal dominant  the karyotypes of two family members were normal  identification of li fraumeni syndrome in a family is important in determining appropriate follow up for the patient and family  such families are models for studying carcinogenesis  
class7	the surgical management of chronic parotitis  chronic parotitis is a disorder characterized by recurrent painful swelling of the gland with purulent sialorrhea  occasionally  the condition fails to respond to medical management and definitive surgical therapy is necessary  sialolithiasis is the usual etiology in cases of parotitis  although occasionally severe recurrent parotid infections are superimposed on underlying sjogren s disease  total parotidectomy with facial nerve dissection has been used in such cases in our department and has proved to be an excellent way to manage this disease  a summary of our results indicate that the recurring infections were eradicated and that the complication rate is tolerable  considering the magnitude of the problem  we feel that it is better to use surgical management early rather than wait for the formation of fistulae or abscesses  
class7	calvarial sutural abnormalities  metopic synostosis and coronal deformation  an anatomic  three dimensional radiographic  and pathologic study  the purposes of this study were  1  to evaluate the histologic differences between synostotic versus deformational suture abnormalities and  2  to correlate these histologic findings with anatomic and three dimensional computed tomographic  ct  scans  we examined three infants with premature metopic synostosis  one infant also had microcephaly trisomy 13 and curious overriding of the coronal sutures  the three dimensional ct scans demonstrated obliteration of the metopic suture inferiorly  histologic sections of this suture showed complete bony stenosis  the same pattern was found in all three infants  including the two infants with trigonocephaly who did not have trisomy 13 or microcephaly  in the trisomy 13 infant  the overlapped inferior coronal suture was obliterated on ct examination  however  histologic sections in this region showed a merging of bone  there was no synostosis  in summary  three dimensional ct re formation correlated with metopic suture histology   stenotic  fusion existed in all infants with trigonocephaly  those with normal and abnormal karyotypes  with and without microcephaly  however  three dimensional ct re formation of the trisomic infant showed opacification of the coronal suture in the areas of greatest overlap  whereas histology revealed a curious bone remodeling pattern  possibly a precursor to  deformational  craniosynostosis  
class7	parotid gland  plain and gadolinium enhanced mr imaging  the purpose of this study was to show the typical appearance of lesions of the parotid gland with plain mr imaging and mr imaging enhanced with gadopentetate dimeglumine  seventeen patients with inflammatory changes and 43 with benign and malignant tumors were studied  the examinations were carried out with plain t1 weighted sequences with a repetition time  tr  of 500 msec and an echo time  te  of 25 msec  tr te   500 25   t2 weighted sequences  1 600 90   and gadolinium enhanced t1 weighted sequences in axial  coronal  and sagittal orientations  for identifying normal anatomic structures such as the facial nerve and the main duct  the administration of gadopentetate dimeglumine was helpful  in inflammatory changes  gadolinium enhanced images showed no diagnostic advantages  gadopentetate dimeglumine proved helpful in delineating tumorous lesions and in differentiating benign and malignant lesions  however  an exact differentiation of the different histologic types was not possible  post operative fibrosis could be differentiated from recurrent tumors after administration of gadolinium  if a question regarding infiltration or definition of the boundaries of a lesion cannot be answered with non enhanced mr imaging  gadopentetate dimeglumine administration is advised  however  for routine imaging of the parotid gland  its use is not recommended  
class7	controversies in the treatment of streptococcal pharyngitis an increasing number of cases of sore throat caused by group a beta hemolytic streptococci occur with concomitant colonization by organisms that may  protect  the streptococci through beta lactamase inactivation of penicillin at the site of infection  the failure of penicillin to eradicate many of these bacteria  which include staphylococcus aureus  haemophilus influenzae  moraxella  branhamella  catarrhalis and a multitude of pharyngeal anaerobes  may help to explain why penicillin is sometimes ineffective for acute and recurrent group a streptococcal infections  therapeutic alternatives currently include cephalosporins  erythromycin  rifampin combined with penicillin  amoxicillin clavulanate potassium and others  
class7	myofibroblastoma of the tongue  an immunohistochemical  ultrastructural  and flow cytometric study  a case of myofibroblastoma arising in the tongue of a 77 year old man is described  the patient presented with a submucosal tongue mass without other associated symptoms  the tumor was 2 cm in diameter  well circumscribed  and composed of uniform spindle cells arranged in fascicles  electron microscopic examination and immunohistochemistry demonstrated a myofibroblastic origin for the tumor cells  dna flow cytometric analysis showed a diploid dna content of this tumor  to the authors  knowledge  this is the first report of myofibroblastoma occurring in the tongue  
class7	histopathologic grading of salivary gland neoplasms  iii  adenoid cystic carcinomas  histopathologic grading of adenoid cystic carcinomas can provide valuable prognostic information  particularly when the presence or absence of a solid growth architecture is noted  other growth patterns  exemplified by a tubuloductal or cribriform cylindromatous differentiation  are associated with a more protracted biologic course and less rapid mortality  a three tiered grading system based on the three growth patterns of the carcinoma is presented  
class7	histologic study of eustachian tube cartilage with and without congenital anomalies  a preliminary study  we investigated histopathologically the development of the eustachian tube  et  cartilage at a cellular level in individuals with and without congenital anomalies  fourteen specimens were obtained from 14 individuals ranging in age from 24 weeks  gestation to 3 years who had cleft palate or trisomy 21  down  syndrome  the 49 specimens in the nonanomaly  control  group were from 49 individuals ranging from 26 weeks  gestation to 85 years of age  all temporal bone specimens included the et and its accessory structures  and all were processed and stained with hematoxylin and eosin for histologic study in a routine manner  the number of cartilage cells in the midcartilaginous portion of the et was determined by light microscopy  in all groups  cartilage cell density of the et decreased with increasing age  however  cell density tended to be higher at all ages for individuals with cleft palate and microtia versus controls  and tended to be lower at all ages for individuals with down syndrome  
class7	lymphomatoid granulomatosis presenting as ulcerodestructive gastrointestinal tract lesions in patients with human immunodeficiency virus infection  a new association  we describe cases of severe odynophagia  extensive oral ulcerations  and bowel perforation in patients with human immunodeficiency virus infection that were caused by lymphomatoid granulomatosis  such presentations in human immunodeficiency virus infected individuals are usually ascribed to other causes and may be incorrectly treated on an empiric basis  in addition  deep tissue specimens obtained at the margin of ulcerative lesions are often necessary for definitive diagnosis  we review our limited treatment experience with zidovudine  interferon alfa  and h2 blockers in our patients  based on the markedly increased frequency in which lymphomatoid granulomatosis is being diagnosed at our institution in the post human immunodeficiency virus era  we postulated an association between these two entities  
class7	the role of herpes simplex virus in the development of oral mucositis in bone marrow transplant recipients  herpes simplex virus  hsv  has been implicated as a major etiologic factor in the development of ulcerative mucositis in bone marrow transplant  bmt  recipients  in this study  60 patients who received bmts were evaluated for at least 30 days post transplant for ulcerative mucositis and the presence of culturable hsv  fifty nine patients received prophylactic acyclovir  forty six patients developed ulcerative lesions and 45 of these were culture negative for hsv  neither the source of transplant  autologous versus allogenic  nor the hsv antibody status of the patient affected the frequency of mucositis  the conditioning regimen appeared to be the most significant factor contributing to the severity of ulcerative mucositis  while the majority of ulcers occurred on movable nonkeratinized mucosa in bmt recipients  the usual sites of reactivation of intraoral hsv are nonmovable  keratinized mucosa  we conclude that hsv is probably not a major etiologic agent of mucositis in bmt recipients and that acyclovir is an effective agent in preventing hsv reactivation  
class7	complete spontaneous regression of multiple basal cell carcinomas in the basal cell nevus syndrome  the possible role of transepithelial elimination  a 36 year old latin american man with the basal cell nevus syndrome had multiple  soft  hairless  depressed scars of the face  scalp  neck  and back  ranging in size from 0 3 x 0 5 cm to 3 5 x 3 9 cm  these areas had never been treated and previously were sites of basal cell carcinomas that underwent complete spontaneous regression 4 5 years from the date of onset  pathology of these spontaneously regressed sites was consistent with the criteria established by curson and weedon  1979   type iii transepithelial elimination was demonstrated for a basal cell carcinoma  type iii transepithelial elimination may play a role in the spontaneous regression of basal cell carcinomas  
class7	new primary basal cell carcinomas arising in skin flaps following mohs micrographic surgery for primary and recurrent basal cell carcinoma  two patients developed new primary basal cell carcinomas  bccs  in skin flaps used to reconstruct wounds that followed an earlier primary bcc and a recurrent bcc treated by mohs micrographic surgery  criteria for distinguishing a new primary bcc arising in a skin flap or full thickness skin graft at a previous treatment site for bcc from a truly recurrent bcc are presented  the distinction between a new primary bcc and true tumor recurrence is important for accurate clinical assessment and may have a dramatic impact on the type of subsequent treatment  in addition  there may be less medicolegal liability in the case of a new primary bcc arising at the site of a previously treated bcc than for a bcc that is determined to be recurrent  
class7	the association of xerostomia and inadequate intake in older adults  recent studies indicate that nearly one in five older adults has xerostomia  dry mouth   salivary gland dysfunction and or inadequate saliva increases the difficulty of these older adults in obtaining proper nutrition  problems in lubricating  masticating  tolerating  tasting  and swallowing food contribute notably to the complex physiological and psychological manifestations of aging  to our knowledge  the literature has not demonstrated an association between xerostomia and malnutrition in the elderly  we randomly selected 67 older adults from institutionalized and free living geriatric populations  nutritional intake analysis was performed on both groups of study subjects  who were found to have xerostomia by use of sialometry  and on control subjects matched for age  sex  and physical status  intake of total energy  protein  dietary fiber  total fat  saturated fat  cholesterol  sodium  potassium  vitamin a  vitamin c  thiamin  riboflavin  vitamin b 6  calcium  iron  and zinc was compared with the 1989 recommended dietary allowances  subjects  intakes were also compared with that of a control group  medical systemic information and number and types of medications were compared among the groups  statistical analysis of the data indicated significant  p less than  001  inadequacies in the nutritional intake patterns of institutionalized and free living older adults with xerostomia  subjects with xerostomia  more than 75  of the free living and institutionalized seniors  had significant deficiencies of fiber  potassium  vitamin b 6  iron  calcium  and zinc  taste and food perception were significantly reduced in the elders with xerostomia  our study indicates the potential contribution of xerostomia to the high prevalence of geriatric malnutrition in the united states  
class7	oral diseases in older adults  clinical conference  in the case presented  a 65 year old man with multiple dental  medical  and social problems benefited from interdisciplinary assessment and treatment  despite his poor oral health status and oral health behaviors upon admission  patient education and dental therapy resulted in improved daily oral hygiene  elimination of oral diseases  and improved oral function  the overall quality of life of any individual  particularly an older one  can be enhanced through oral disease prevention  health promotion  and  when indicated  dental therapy  this patient was treated in a hospital environment with a well established team approach to geriatric care  however  regardless of the care setting  the physician can play a key role in improving the oral health status and quality of life of older adults by including an oral screening examination as part of the periodic comprehensive geriatric assessment  recognizing oral pathology  requesting dental consultations and encouraging appropriate dental service utilization  
class7	mapping of epitopes on the la ss b  autoantigen of primary sjogren s syndrome  identification of a cross reactive epitope  autoepitopes on the ribonucleoprotein la ss b  were identified by using recombinant la ss b  polypeptides and sera from 166 patients with the antinuclear autoantibody anti la ss b   the la ss b  polypeptides were encoded by polymerase chain reaction derived overlapping or nonoverlapping fragments of the la ss b  gene  which encodes a protein of 408 amino acids  aa   of the 166 sera tested  99  reacted with a fusion protein comprising the first 107 n terminal aa  laa   91  reacted with a fusion protein comprising aa 111 to 242  lac   and 91  reacted with a fusion protein comprising aa 346 to 408  lal2 3  at the c terminus of la ss b   the order of immunodominance as assessed by the number of sera reacting with each epitope and the strength of the reactivity was laa  aa 1 to 107  greater than lac  aa  111 to 242  much greater than lal2 3  aa 346 to 408   cross reactivity was observed between antibodies eluted from lac  aa 111 to 242  and lal2 3  aa 346 to 408   but there was no significant primary sequence homology between the two regions  the lac region contained at least two epitopes  one encompassing a putative rna binding motif  aa 112 to 187  which was recognized by 83  of patient sera  serial serum samples from three patients showed that the antibody response to la ss b  was initially directed to the n terminus  laa  aa 1 to 107   but over a period of time all three major epitopes  including that encompassing the putative rna binding motif  were recognized  this result suggests that the primary immune response to la ss b  is restricted to an immunodominant epitope  as the specificity of the autoantibody response broadens  it includes the rna binding motif  which may have important implications for the expression of disease  
class7	monomorphic adenomas of the major salivary glands  clinicopathological study of 44 cases  we report 44 cases of monomorphic adenoma  ma  of the major salivary glands observed during the years 1979 1989  all of these tumours were reviewed and classified on the basis of the world health organisation  who  criteria  histological type  site  sex and age were considered  34 cases of adenolymphoma were observed  all of them located in the parotid glands  10 ma without lymphoid stroma were located in both parotid and submandibular glands  distinctive histological and clinico pathological features of the latter group of tumours are discussed  as well as the diagnostic criteria in distinguishing these tumours from pleomorphic adenoma and adenoid cystic carcinoma  
class7	giant enterocystoma within an infant s tongue  a rare developmental cyst within the tongue and submandibular triangle of a male infant containing heterotopic gastric and intestinal epithelium  enterocystoma  is described and its derivation discussed  this cyst was of such a size as to cause feeding difficulties and partial airway obstruction during sleep  following c t  scanning  total obstruction necessitated an emergency tracheostomy  successful enucleation via a median labiomandibulotomy was performed without further complication and two years later there is no sign of recurrence  
class7	temporal arteritis presenting as a submandibular swelling  temporal arteritis  giant cell arteritis  is a disease of protean manifestation  a case which presented as a submandibular swelling is reported  
class7	parapharyngeal abscess and torticollis  the combination of a parapharyngeal abscess and torticollis in an adult  due to a spastic contraction of the sterno cleido mastoid muscle is an extremely rare condition  we have recently been exposed to such case  in which it was very difficult to make the diagnosis and where ct of the neck gave us the answers without any difficulty  the indication for ct at an early stage in unexplained neck infections is stressed  
class7	parotid duct communicating with a labial pit and ectopic salivary cyst  labial pits are usually described as blind epidermal invaginations of lip mucosa with occasional drainage of minor salivary gland secretions  a case of an aberrant parotid duct in communication with both a unilateral  commissural labial pit and an interposed salivary cyst is presented  a 7 year old boy who had experienced lifelong clear drainage from a congenital pit at his right oral commissure developed fever  pain  and a submucosal mass of the right cheek over a 6 week period  a preoperative sialogram through the pit demonstrated a communication between the oral commissure fistula  an intervening salivary cyst  and a proximal tract from the cyst to the parotid gland  an en bloc resection of the pit  fistula tract  and cyst was performed through a transoral approach  the dissection was medial to the buccinator muscle  there has been no recurrence of the cyst after 1 year follow up  a description of labial pits and parotid duct anomalies is presented  however  to our knowledge  this combination of anomalies has not been previously described  
class7	radiobiological studies in the naevoid basal cell carcinoma syndrome  the naevoid basal cell carcinoma syndrome is described in a 43 year old male  the response of dividing fibroblasts from this patient to the lethal effects of ionizing radiation was indistinguishable from that of a normal control  mean inactivation dose  d    1 74 gy and 1 68 gy  respectively  however  these cells were defective in the repair of potentially lethal damage  d   2 36 gy and 3 26 gy  respectively   the response to radiation of go t lymphocytes derived from the patient was similar to that of the control  the frequency of mutant circulating t lymphocytes resistant to 6 thioguanine was 17 x 10  6  which was elevated when compared with age matched controls  these results suggest an abnormality in the response of the fibroblasts to ionizing radiation damage  
class7	oxybutynin hydrochloride  3 mg  in the treatment of women with idiopathic detrusor instability  oxybutynin hydrochloride  3 mg  was compared with placebo by randomised  double blind crossover trial in 53 females with idiopathic detrusor instability  symptoms were cured or markedly improved in 60  of patients on oxybutynin and 2 3  on placebo  during the first treatment period  oxybutynin reduced the frequency of voiding by 35   compared with 9  for placebo  oxybutynin gave a significantly greater improvement than placebo in volume at the first desire to void  70 ml increase versus 7 7 ml   maximum filling phase detrusor pressure  17 cm h2o reduction versus no benefit  and cystometric capacity  104 ml increase versus 7 0 ml   a marked oxybutynin carry over effect was seen during the second treatment period  side effects from the 3 mg dose of oxybutynin caused 7 5  of subjects to discontinue therapy  
class7	dentofacial development in long term survivors of acute lymphoblastic leukemia  a comparison of three treatment modalities  ninety seven children who were diagnosed with acute lymphoblastic leukemia before 10 years of age and treated with chemotherapy alone  chemotherapy plus 1800 cgy cranial irradiation  rt   or chemotherapy plus 2400 cgy rt were evaluated for effects of therapy on dentofacial development  all patients were seen at least 5 years postdiagnosis  dental abnormalities were determined from panoramic radiographs  and craniofacial evaluations were made from lateral cephalometric radiographs  ninety one  94   of all patients and 41  100   of patients younger than 5 years of age at diagnosis had abnormal dental development  the severity of these abnormalities was greater in children who received treatment before 5 years of age and in those who received rt  observed dental abnormalities included tooth agenesis  arrested root development  microdontia  and enamel dysplasias  craniofacial abnormalities occurred in 18 of 20  90   of those patients who received chemotherapy plus 2400 cgy rt before 5 years of age  mean cephalometric values of this group showed significant deficient mandibular development  the results of this study suggest that the severity of dentofacial developmental abnormalities secondary to antileukemia therapy are related to the age of the patient at the initiation of treatment and the use of cranial rt  
class7	causes  diagnosis  and treatment of pharyngitis  pharyngitis is a common disease of the respiratory tract that can be caused by several different viruses and bacterial organisms  clinically speaking  the most important causative agent is group a streptococcus  streptococcus pyogenes   although rare  postpharyngitis complications arise as a result of disease caused almost exclusively by group a streptococcus  because group a streptococcal pharyngitis usually responds well to antimicrobial treatment  it is important to diagnose it  penicillin  erythromycin  and peroral first generation cephalosporins have been documented to be effective  in addition to group a streptococcus  c  pneumoniae and m  pneumoniae have also been detected in patients with pharyngitis  the possibility of diagnosing these organisms is limited at the present  clinical surveys are still needed  moreover  to evaluate the effect of antimicrobial treatment on the disease caused by these organisms  although routine viral diagnostic methods do not help primary care physicians in treating patients with pharyngitis  information on bacteria and viruses in the immediate environment could prove to be of great help in daily clinical work  
class7	detection of a human intracisternal a type retroviral particle antigenically related to hiv  sjogren s syndrome is an autoimmune disease that is characterized by dryness of the mouth and eyes  the loss of salivary and lacrimal gland function is accompanied by lymphocytic infiltration  because similar symptoms and glandular pathology are observed in certain persons infected with human immunodeficiency virus  hiv   a search was initiated for a possible retroviral etiology in this syndrome  a human intracisternal a type retroviral particle that is antigenically related to hiv was detected in lymphoblastoid cells exposed to homogenates of salivary tissue from patients with sjogren s syndrome  comparison of this retroviral particle to hiv indicates that they are distinguishable by several ultrastructural  physical  and enzymatic criteria  
class7	postoperative sore throat  topical hydrocortisone forty patients undergoing tracheal intubation and controlled ventilation of the lungs for elective surgical procedures were studied  they were allocated randomly into one of two groups  the tracheal tubes used for group a patients were lubricated before insertion with water soluble 1  hydrocortisone cream  those for group b patients were lubricated with ky jelly  the incidence of postoperative sore throat was found to be significantly greater in group a  topical 1  hydrocortisone cream is therefore ineffective in the prevention of postoperative sore throat  
class7	basis for defective proliferation of peripheral blood t cells to anti cd2 antibodies in primary sjogren s syndrome  anti cd2 induced t cell proliferation was analyzed in the peripheral blood samples of 31 primary and 8 secondary untreated sjogren s syndrome patients  anti cd2 stimulated pbmc proliferation was very low in about one third of primary sjogren s syndrome samples  despite the number of cd2  cells being similar in primary and secondary sjogren s syndrome and normal pbmc samples  the depressed response to anti cd2 was mainly found in anti ro  la  patients  experiments on purified t cells demonstrated that a defect at the t cell level was responsible for the anti cd2 unresponsiveness  cell proliferation failure was associated with poor il 2 and il 2 receptor mrna expression and  consequently  il 2 and il 2 receptor synthesis  since defective anti cd2 induced mitogenesis could be reversed by phorbol myristate acetate  but not calcium ionophore a23187  it is probably correlated with impaired protein kinase c activation  comparison of anti cd2 triggered pbmc proliferation in treated and untreated patients and a long term study of nine patients showed that the defect is a stable characteristic in primary sjogren s syndrome patients  but that it can be reversed by pharmacological immunosuppression  
class7	sialolithiasis  case studies and review  three cases of sialolithiasis are presented  each representative of acute and chronic presentations of this problem  the evaluation and treatment of salivary gland and duct stones are outlined  the primary axiom is   treat the gland  not the stone   and the essential aspects of emergency medical management are antibiotics  sialogogues  warm compresses  mechanical stimulation  and appropriate referral to an otolaryngologist  
class8	functional upper airway obstruction in adolescents  functional upper airway obstruction is an uncommon manifestation of a conversive reaction characterized by recurrent stridor attacks caused by adduction of the vocal cords during inspiration  the oxygen saturation never drops to pathologic levels  the stridor is not accompanied by an appropriate degree of anxiety and is not associated with other symptoms  patients benefit from verbal reassurance and speech therapy  but stridor attacks tend to recur and psychiatric consultation seems necessary in most cases  we present the case histories of three adolescent patients with nonorganic upper airway obstruction and describe the features that may facilitate the diagnosis of this condition  early diagnosis and intervention may prevent unnecessary and potentially harmful investigations and therapy  
class8	influence of doppler sample volume location on the assessment of changes in mitral inflow velocity profiles  previous studies that have validated doppler indexes of mitral inflow have used pulsed wave sample volume locations either at the level of the mitral valve anulus or at the tips of the mitral valve leaflets  although significant differences between absolute values for peak velocities and velocity time integrals at these sample volume locations have previously been reported  no information exists that has compared changes in inflow profiles after an intervention to improve left ventricular filling  to address this question  13 patients with severe pulmonary hypertension  mean pulmonary artery pressure  50     13 mm hg  caused by chronic thromboembolic disease were studied with use of doppler echocardiography immediately before and after surgical reduction of pulmonary hypertension  pulmonary vascular resistance decreased from 916     413 to 233     89 dynes sec cm5   this clinical model has been shown to have abnormal mitral inflow velocity profiles that improve markedly after surgery  doppler measures of early and late peak velocities were significantly lower both before and after surgery when sampling at the mitral anulus compared with the leaflet tips  although late filling parameters and the deceleration of early flow velocity tended to differ little  with surgery  the significant increase in peak early velocity and the ratio of early to late velocity was present regardless of the sample volume location  peak e at leaflet tips  47 1     16 0 to 68 9     15 4  p less than 0 001   and at anulus  40 7     11 3 to 56 2     14 6 cm sec  p less than 0 001   peak e a at leaflet tips  0 95     0 4 to 1 55     0 9  and at anulus  0 78     0 3 to 1 32     0 7  both p less than 0 02    
class8	hyponatraemia secondary to an inappropriately high release of antidiuretic hormone in cardiac tamponade  a spontaneous intrapericardial haemorrhage caused cardiac tamponade in a 29 year old paraplegic man who was being treated with warfarin  the associated persistent hyponatraemia  which was believed to be caused by an inappropriately high release of antidiuretic hormone  rapidly resolved after pericardiocentesis  
class8	reproduction of transfusion related acute lung injury in an ex vivo lung model leukoagglutinins are implicated in transfusion related acute lung injury  trali   in the present study  severe lung vascular leakage was reproduced by application of a leukoagglutinating antibody of anti 5b specificity in an ex vivo lung model  the antibody originated from a multiparous donor plasma  observed to cause noncardiogenic edema during transfusion therapy  heated full plasma  anti 5b titer 1 128  or purified immunoglobulin g fraction was used for the studies  ex vivo isolated rabbit lungs were perfused with albumin buffer  and human granulocytes  pmn  were admixed to the recirculating perfusate  in presence of anti 5b antibody plus 5b positive pmn plus rabbit plasma as complement source  severe lung edema occurred after a latent period of 3 to 6 hours  pulmonary artery pressure was only transiently and moderately increased  and the leakage reaction could be traced back to a several fold increase in lung vascular permeability  in contrast  no vascular leakage was noted in lungs perfused in the absence of anti 5b antibody  pmn  or rabbit plasma  moreover  no permeability increase occurred on use of 5b negative pmn  this reproduction of trali in an ex vivo lung model corroborates the role of leukoagglutinating antibodies in initiating pmn dependent respiratory distress and suggests a contribution of concomitant complement activation  
class8	human t cell leukemia virus type 1 associated with small cell lung cancer  a patient with small cell lung cancer  sclc  whose serum contained high levels of soluble interleukin 2 receptors is reported  soluble interleukin 2 receptors in the supernatant of cultured sclc cells obtained from the patient s pleural effusion while he had malignant pleuritis  increased almost linearly from the time of cell seeding  the expression of interleukin 2 receptors  tac  on the sclc cells were demonstrated by an immunofluorescence study  however  other lymphocytic markers  including okt 11  okt 4  okt 8  b 1  and b 4  were not found on the cells with the exception of the natural killer cell marker  nkh 1  southern blot analysis indicated the rearrangement of the t cell receptor of the cancer cells  moreover  monoclonal integration of human t cell leukemia virus type 1  htlv 1  provirus in dna from the cancer cells was also demonstrated  these observations suggest that some sclc in htlv 1 endemic areas are associated with htlv 1  
class8	immunocytochemical characterization of lung tumors in fine needle aspiration  the use of cytokeratin monoclonal antibodies for the differential diagnosis of squamous cell carcinoma and adenocarcinoma  in the current study  immunocytochemical typing of intermediate filaments was used for a differential diagnosis of human lung tumors from transthoracic fine needle aspiration biopsies  tfnab   the authors have compared the cytologic diagnosis of 53 lung cancer cases with the immunofluorescence patterns obtained using a panel of monoclonal antibodies  five of which  kg 8 13  km 4 62  ks b 17  ks 8 12  kk 8 60  react with specific cytokeratin polypeptides and one with vimentin  vim 13 2   only in six of 23 samples cytologically diagnosed as squamous cell carcinoma did the immunocytochemical typing of cytokeratins  ictc  confirm the cytologic diagnosis  in seven cases some of the tumor cells stained positively with antibody ks b 17 specific for simple epithelial keratin  no  18   suggesting the presence of some cells of glandular origin  in ten additional cases the ictc was in conflict with the cytologic diagnosis of squamous cell carcinoma  i e   antibodies ks 8 12 and kk 8 60 were negative  and antibody ks b 17  positive  supporting a diagnosis of adenocarcinoma  in 14 of 18 cases cytologically diagnosed as adenocarcinoma  the ictc confirmed the diagnosis whereas in four cases additional presence of some squamous cells was noticed  the ictc labeling of cases cytologically diagnosed as undifferentiated and large cell carcinomas was similar to that of the group of adenocarcinomas  thus  the application of cytokeratin typing for tfnab samples seems to provide a vital complementation to routine cytologic study  especially for cases cytologically diagnosed as squamous carcinoma  
class8	low dose sufentanil in major surgery  the purpose of this study was to assess the efficacy of sufentanil 1 micrograms kg 1 during n2o o2 and intermittent isoflurane anaesthesia in major non cardiac surgery  thirty one patients  18 females  13 males  mean age 47 yr   undergoing cholecystectomy received a 1 microgram kg 1 bolus of sufentanil before the induction of anaesthesia with thiopentone  on average  three sufentanil increments were administered  to a total  bolus   maintenance  dose of 1 5 micrograms kg 1  cardiovascular stability was not achieved in eleven patients who then were given isoflurane  the arterial pressure decreased after sufentanil  p less than 0 05   reaching a nadir  mean 108 65 mmhg  heart rate 63 bpm  at one minute post incision  clinically important hypertension or hypotension did not occur in any patient  one patient  receiving beta blocker therapy  required atropine to control bradycardia  postoperative respiratory depression did not occur in patients who received less than one micrograms kg 1 hr 1 with the last increment being given more than 20 minutes before the end of anaesthesia  slight respiratory depression in the recovery room was reported in one patient  who had received a total of 1 3 micrograms kg 1 hr 1 of sufentanil  and the last sufentanil increment 24 min before the end of surgery  the most frequently reported side effects were nausea  35 per cent  and vomiting  23 per cent   induction  maintenance and recovery from anaesthesia were rated as  good  in 87  87  and 74 per cent of the cases  respectively  and  satisfactory  in the remainder  we conclude that this technique is valuable to assure good protection of the cardiovascular system without undue respiratory depression during recovery  
class8	epidural morphine for analgesia after caesarean section  a report of 4880 patients this retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following caesarean section under epidural anaesthesia  the morphine was administered as a single bolus  following delivery  in doses ranging from 2 to 5 mg  the charts of 4880 caesarean sections  performed on 4500 patients  were reviewed  the duration of analgesia and the occurrence of any symptoms which might be side effects of the epidural morphine were recorded  the duration of analgesia was 22 9     10 1 hr and was not correlated with the dose of epidural morphine  eleven per cent of the patients required no supplemental analgesia during the first 48 hr  twelve patients  0 25 per cent  had respiratory rates less than 10 breaths per minute  on at least one occasion  no serious sequelae resulted from these periods of bradypnoea  pruritus occurred in 58 per cent of patients  nausea and vomiting in 39 9 per cent and dizziness in ten per cent  herpes simplex labialis was recorded in 3 5 per cent of patients  epidural morphine is thus confirmed as an effective analgesic technique post caesarean section with 3 mg being the optimal dose  even in this young healthy patient population  clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated  
class8	pulmonary edema induced by phagocytosing neutrophils  protective effect of monoclonal antibody against phagocyte cd18 integrin  we studied the changes in pulmonary hemodynamics and lung wet weight induced with opsonized zymosan  oz  in isolated guinea pig lungs perfused with ringer albumin solution containing neutrophils  pmns   addition of oz to the pmn perfused lungs caused pulmonary vasoconstriction and weight gain  neither oz nor pmns added individually to the perfusate altered pulmonary vasomotor tone or wet weight  the steady gain in lung weight by 1 588     464 mg over the 45 minute study period was associated with pulmonary capillary hypertension and an increase in the capillary filtration coefficient  indicative of increased lung vascular permeability  these responses may not be due to generation of oxygen radicals  because the alterations in pulmonary hemodynamics and lung weight were not reduced by addition of superoxide dismutase  catalase  or superoxide dismutase plus catalase  we examined the basis of the pmn mediated effects by layering pmns on bovine pulmonary artery endothelial monolayers  challenge with oz resulted in increased endothelial permeability to 125i albumin  the monoclonal antibody ib4  directed against cd18  the common beta subunit of structurally related adhesion receptors on phagocytes  lfa 1  mac 1  and p150 95  prevented the oz mediated increase in pmn adherence to endothelial cells and the increase in endothelial permeability to 125i albumin  ib4 also inhibited the lung weight gain mediated by the oz stimulated pmns in intact lungs  the protective effect of ib4 could be ascribed neither to inhibition of uptake of oz by pmns nor to inhibition of release of oxygen radicals  myeloperoxidase  and elastase  
class8	flow and volume dependence of respiratory system mechanics during constant flow ventilation in normal subjects and in adult respiratory distress syndrome  seven control subjects and seven patients with adult respiratory distress syndrome  ards  were artificially ventilated and flow  volume  and tracheal pressure were monitored  respiratory system resistance  rrs max  was partitioned into its homogeneous  rrs min  and uneven  rrs u  components  respiratory system elastance  ers  was also measured  in both groups ers did not vary with different inspiratory flows and volumes  but was significantly higher in ards  with increasing volume  isoflow maneuvers   rrs max and rrs u increased but rrs min remained unaltered in ards  in control patients  however  resistances did not vary but rrs max and rrs u were smaller and rrs min equaled their corresponding values in ards  hence  stress relaxation seems to be increased in ards  during isovolume maneuvers rrs max and rrs u decreased with increasing flows  both groups   although they were significantly higher in ards  rrs min was not modified by different flows and was similar in both groups  thus  pendelluft is also increased in ards  in conclusion  the mechanical profile of ards is characterized by increased ers and rrs max  the latter being secondary to augmented mechanical unevenness within the system  
class8	role of prostaglandin e1 in reducing pulmonary vascular resistance in an experimental model of acute lung injury  to determine the role and efficacy of prostaglandin e1  pge1  on the cardiopulmonary derangements induced by glass bead embolism  two studies were performed  in the first study  a dose response of pge1 was tested in six animals that were first embolized with sufficient glass beads to double the pulmonary artery pressure  pap   this study demonstrated that pge1 reduced pap and cardiac output by a preload mediated mechanism  as evidenced by a reduction in the right ventricular  rv  end diastolic segment length  at doses of 15 and 30 ng kg min  the second study was performed in two groups of animals  the control group  n   6   and the treated group  n   6   which were given pge1 at 15 ng kg min after the pap had been doubled by glass bead embolism  rv preload was kept constant  this study demonstrated that there was no difference in pulmonary vascular resistance between either the treated group or the control group  there were no other significant differences between the two groups  the results of both of these studies suggest that there is little afterload reducing effect of pge1 in this model and at these dose ranges  part of the mechanism of pge1 that improves pulmonary edema and gas exchange may be the reduction of filtration surface area and hydrostatic pressures in the lungs  
class8	aspiration and the elderly  aspiration is prevalent in the elderly but its association with impairment of oral intake and gastroesophageal reflux is often misunderstood  this paper describes the causes  pathophysiology  and consequences of aspiration and their unique features in aged persons  it also explains how videofluoroscopic evaluation can assess current function while limiting factors that result in misinformation  the management of aspiration is discussed  emphasizing the importance and difficulties in maintaining functional well being and possible complications of therapy  
class8	transient neuromuscular impairment resulting from prolonged inhalation of halothane and enflurane  inhalation anesthesia first with halothane followed by enflurane relieved a patient with status asthmaticus who was refractory to conventional therapy including mechanical ventilation  after 13 days of anesthesia while on mechanical ventilation and employing nondepolarizing muscle relaxants  significant neuromuscular impairment  manifested by tetraplegia and sensory disturbance  developed  anesthesia was discontinued on day 14  and the patient was weaned from mechanical ventilation on day 16  over the next two months  the neuromuscular impairment markedly improved  halothane was associated with cardiac arrhythmias and hepatitis necessitating replacement by enflurane  enflurane appeared to be as effective a treatment for refractory asthma as halothane  the most probable cause of the neuromuscular impairment in our patient was the long term use of inhalation anesthetics or nondepolarizing muscle relaxants  
class8	mucoid impaction of upper lobe bronchi in the absence of proximal bronchiectasis  mucoid impaction is a complication of asthma and is frequently recurrent in patients with allergic bronchopulmonary aspergillosis  abpa   this report describes a patient with asthma and recurrent bilateral well circumscribed densities on chest roentgenogram in the absence of abpa  recognition of this clinical presentation may avoid the need for invasive diagnostic procedures or steroid therapy  
class8	confluence of pulmonary veins simulating a pulmonary mass  confluence of the pulmonary veins commonly appears on the frontal view of the chest and generally is easily recognized as such  on plain film tomography  computerized tomography  and pulmonary angiography  the anatomy of convergence of pulmonary veins prior to common entry into the left atrium is clearly displayed  in this report  attention is called to the occasional appearance of confluence of the pulmonary veins on the lateral view of the chest as a clearly circumscribed round opacity mimicking a lung or mediastinal mass  
class8	cyclosporine and chronic sarcoidosis  two patients with progressive sarcoidosis who had poor responses and side effects from corticosteroid therapy were treated with cyclosporine  cyclosporine suppressed conventional markers of inflammation and there was clinical improvement in one patient  but the disease recurred when therapy was discontinued  the second patient who had diabetes mellitus developed unstable glucose metabolism when given cyclosporine  this unstable diabetes mellitus together with side effects of nausea and vomiting resulted in weight loss and inadequate serum therapeutic levels that was associated with a poor therapeutic response to the cyclosporine  the major side effects in both patients were headache and gastrointestinal symptoms  but there was no renal dysfunction  we conclude that while corticosteroids remain the mainstay of sarcoid therapy  when these drugs have not been successful for the skin manifestations of the disease  a trial of cyclosporine may be justified  
class8	resolution of the adult respiratory distress syndrome following colectomy and liver transplantation  a 32 year old woman with liver failure from end stage cirrhosis and ulcerative colitis developed septicemia and severe ards  subtotal colectomy and a successful liver transplantation resulted in complete resolution of the ards  
class8	cytomegalovirus pneumonia in allogeneic bone marrow transplantation  an immunopathologic process  recent literature suggests that cmv pneumonia is an immunopathologic process  this case report summarizes the clinical course of a patient which supports this hypothesis  the patient is the recipient of an allogeneic bmt who recovered from an episode of cmv pneumonia that occurred about two months after the transplant  despite recovery from the viral infection  follow up bals revealed persistent lymphocytosis in an apparent asymptomatic patient  he subsequently developed boop about four months after the initial cmv infection  these observations suggest that the viral infection may have resulted in the activation of the host s cell mediated response and provides evidence to support the hypothesis that cmv pneumonia is an immune mediated process  
class8	pathologic involvement of the left ventricle in chronic cor pulmonale  to determine whether or not the left ventricle is pathologically involved in patients with chronic cor pulmonale  right and left ventricular weights  wall thickness  myocyte diameters  and percentage of fibrosis in 18 autopsied hearts were examined in patients with chronic pulmonary disease  cpd   ten had right ventricular hypertrophy on their electrocardiograms  and eight were without right ventricular hypertrophy  five with extracardiopulmonary disease were used as controls  the weight of the right ventricle was significantly increased in cpd when compared to control subjects  walls of both ventricles were significantly thicker in cpd  myocyte diameters of both ventricles were significantly greater in cpd  the percentage of fibrosis in the right ventricle was significantly greater in cpd  the percentage of fibrosis in the left ventricle was significantly greater only in patients with right ventricular hypertrophy  we concluded that the left ventricle was also involved pathologically in patients with chronic cor pulmonale in the end stage of the disease  
class8	pulmonary alveolar proteinosis associated with pneumocystis carinii  ultrastructural identification in bronchoalveolar lavage in aids and immunocompromised non aids patients  pneumocystis carinii  pc  has been recognized as frequently responsible for most opportunistic pulmonary infections occurring in immunocompromised aids and non aids patients  moreover  these patients can be considered at risk for secondary pulmonary alveolar proteinosis  therefore  we have investigated the occurrence of associated secondary alveolar proteinosis and pc pneumonitis in aids and non aids immunocompromised patients  in a series of 26 bronchoalveolar lavages  bal  in patients with pc pneumonitis  19 aids and seven non aids patients   we observed on light microscopy  in addition to the honeycombed material  areas of an extracellular material that had a different pattern which was suggestive of that described in alveolar proteinosis  a systematic ultrastructural study of these 26 bal fluid samples demonstrated in each of them an accumulation of phospholipid surfactantlike extracellular material mixed or not with the pc cysts  in nine cases  the observation of lipoproteinaceous material on light microscopy and abundant phospholipid material with myelinlike and myelin tubular laminated structures on electron microscopy was highly suggestive of an associated pulmonary alveolar proteinosis  pap   such an accumulation of extracellular material was not observed in the 11 bal fluid samples collected in immunocompromised patients  seven aids and four non aids patients  without pc pneumonitis  these findings demonstrated a particular frequency of associated pap with pc pneumonitis  these results raise important questions concerning  1  the consequence of such an alveolar accumulation of lipoproteinaceous material on the clinical status and prognosis of the pneumonitis  and  2  the mechanisms responsible for this accumulation  
class8	differential therapy with calcium antagonists in pulmonary hypertension secondary to copd  hemodynamic effects of nifedipine  diltiazem  and verapamil  in 53 patients with copd and precapillary pulmonary hypertension  we investigated the effect of three typical calcium antagonists on hemodynamics at rest and during bicycle ergometer exercise  in the responders  the decrease in pulmonary vascular resistance following nifedipine was 23 percent at rest  p less than 0 0005  and 35 percent during exercise  p less than 0 0005   following diltiazem  it was 10 percent at rest  p less than 0 05  and 23 percent during exercise  p less than 0 025   following verapamil  it was 22 percent at rest  p less than 0 005  and 11 percent during exercise  p less than 0 025   the cardiac index rose significantly at rest and under exercise only after the administration of nifedipine   16 percent and  8 percent  resp   nifedipine caused the most distinctive peripheral vasodilation  the heart rate increased slightly following nifedipine and decreased slightly following diltiazem and verapamil  after long term therapy with nifedipine  13     5 months   the decrease in pulmonary artery pressure and pulmonary vascular resistance was no longer significant  in our opinion  the different hemodynamic action profiles will have consequences for the differential therapy in patients with copd and pulmonary hypertension  
class8	diagnostic value of nonfluoroscopic percutaneous lung needle aspiration in patients with pneumonia  in forty one patients  mean      sd  age 51     19 years  range  11 to 88 years  seven female and 34 male  with clinical signs and symptoms of pneumonia  we performed a nonfluoroscopic percutaneous lung needle  22 gauges  aspiration  plna  to investigate the diagnostic yield of this technique  all the patients were receiving antibiotics at the time of the study  and plna was performed either because of a lack of response to empiric antibiotic treatment or because of the severity of the pneumonia or the underlying condition of the patient  eight patients were mechanically ventilated  mv  due to acute respiratory failure  the plna was performed at bedside and without fluoroscopic guidance  twenty two microorganisms were identified by means of stains and or cultures of plna samples  sensitivity of plna was 43 percent  18 41   we detected three false positive cultures probably due to contamination from the skin area punctured  in the eight mv patients studied  the sensitivity of plna was 37 5 percent  and the microbiologic findings turned out to be crucial for the outcome of the patients  pneumothorax developed in three patients  7 percent  after plna  none of these three patients developed a pleural infection but two of them required thoracostomy drainage  none of the mv patients presented complications  our results showed that nonfluoroscopic plna is a technique with moderately good sensitivity and with a low rate of false positive cultures  8 percent  to diagnose pulmonary infections in patients with unresponsiveness to empiric antibiotic treatment or with severe pneumonia  further evaluation of its diagnostic value and complications in mv patients is needed  although our preliminary results suggest that plna can be an alternative technique to other methods for diagnosing pulmonary infections in patients receiving artificial ventilatory support  
class8	intravenous and oral corticosteroids for the prevention of relapse after treatment of decompensated copd  effect on patients with a history of multiple relapses to determine if a regimen of intravenous and oral corticosteroids reduces the relapse rate after treatment of decompensated copd in the ed  30 patients were studied  forty five visits in which intravenous and oral corticosteroids were given  t visits  were compared with an equal number of matched visits in which they were withheld  n visits   no differences were noted between t and n visits with respect to clinical findings  laboratory results and other forms of therapy  treatment with corticosteroids reduced the relapse rate within 24 h of discharge  at 48 h  the cumulative relapse rate for t visits  8 9 percent  was significantly lower than for n visits  33 3 percent  p   0 005   for patients with a history of multiple relapses  a regimen consisting of intravenous and oral corticosteroids reduces the risk of relapse after ed treatment of decompensated copd  
class8	predicting failure following shunting of pleural effusions  we placed 43 shunts in 34 patients in five years  twenty four had malignant effusions and ten had benign effusions  thirty one patients had unilateral shunts  three had bilateral shunts and six required revisions for shunt failure  two patients died after shunt placement from disease progression  of the nine patients who experienced poor results  one was noncompliant in operating the shunt and eight had occluded shunts  in the 30 patients  who were compliant and had adequate length of follow up  five had excellent results  12 had good results  and five had fair results  two of the patients with occluded shunts had good results after shunt revision  24 patients had some symptomatic relief with shunting  evaluation of factors including a history of prior abdominal surgery  performance status  and pleural fluid cell counts  differential  chemistries  and cytology revealed no significant differences between the patients who experienced shunt failure and those who had patent shunts  shunting of pleural effusions is well tolerated and has good success rates in properly selected patients  
class8	quality of life in elderly patients with chronic nonspecific lung disease seen in family practice  we studied the quality of life of elderly patients with chronic nonspecific lung disease  cnsld  in family practice  we also investigated the relationship between patients  somatic condition and their quality of life  seventy patients  aged 40 years or older  with a diagnosis or symptoms of cnsld completed the sickness impact profile  sip  and the list of daily activities  dal   pulmonary function  fev1  ivc  and respiratory symptoms were assessed  the results indicated that patients were more impaired in their physical and psychosocial functioning than healthy control subjects  most lung function parameters showed no correlation with the sip scores  the respiratory symptoms of wheezing and dyspnea were related to patients  quality of life  patients with chronic obstructive pulmonary disease  copd  were more restricted in their daily functioning than patients with asthma  since the relationship between patients  somatic condition and their quality of life is weak  we recommend comprehensive care that encompasses psychosocial as well as somatic interventions  
class8	acute pulmonary effects of aerosolized pentamidine  a randomized controlled study  toronto aerosolized pentamidine study  taps  group  from june 1988 to february 1989  we enrolled 36 patients with human immunodeficiency virus into a randomized double blind placebo controlled trial assessing the efficacy and toxicity of aerosolized pentamidine  ap  as secondary prophylaxis for pneumocystis carinii pneumonia  each patient underwent spirometric evaluations before and after aerosolized treatment  there was no significant difference in the results of baseline pulmonary function tests between the two groups  eleven patients  65 percent  in the ap group developed cough but only four demonstrated significant reduction in the forced expiratory flow rates after ap  four patients  21 percent  in the placebo group developed cough  but no significant change in the expiratory flow rates was noted  all bronchospastic episodes were self limited and symptomatically responded to remedial inhaled albuterol  salbutamol  treatment  we conclude that ap treatment is frequently associated with coughing attacks  65 percent   but the actual incidence of bronchospasm on spirometry is much lower  24 percent  and is generally quite mild  
class8	neutrophilia in bronchoalveolar lavage fluid of diffuse panbronchiolitis  the clinical and pathologic features of diffuse panbronchiolitis  dpb  have been well reported to date  although its pathogenesis remains unknown  in the present study  we performed bronchoalveolar lavage  bal  on three patients with biopsy specimen proven dpb and eight patients with highly probable dpb  six women and five men  one smoker and ten nonsmokers   nine patients with chronic bronchitis  all men  five smokers and four nonsmokers   and nine normal control subjects  six women and three men  all nonsmokers  to clarify the cell populations in the lower respiratory tract  neutrophils comprised 55 3     24 4 percent of recovered cells by bal in dpb patients but only 6 6     6 4 percent in chronic bronchitis patients  and 1 8     1 5 percent in normal control subjects  p less than 0 001  all comparisons   the dpb patients also exhibited a decreased percentage of alveolar macrophages  34 9     23 5 percent  compared with chronic bronchitis patients and normal control subjects  p less than 0 001  all comparisons   the percentage of lymphocytes of the recovered lavage cells in dpb patients did not differ from that in chronic bronchitis patients and normal control subjects  these results indicate that neutrophils play an important role in the pathogenesis of dpb  they also suggest that neutrophilia of bal recovered fluid is a common finding in diseases associated with bronchiolar inflammation despite some clinical and pathophysiologic differences  
class8	pulmonary lipid peroxidation in cigarette smokers and lung cancer patients  lipid peroxidation  lpo  was studied in lung tissues of patients with lung cancer  lc  n   37  or nonlung cancer  nlc  n   13  and its relationships with the smoking habits and the degree of airway obstruction were investigated  specimens of peripheral lung parenchyma  free of tumor tissue  were taken and the malondialdehyde  mda  content was measured in the s 12 fractions  airway obstruction was assessed by flow volume curves  and data were expressed as percentage of the predicted values  cigarettes smoked were expressed as pack years  the patients with lc and nlc did not differ by mda content  age  and number of pack years  on the contrary  fef75 85 and mef75 were significantly lower in lc than in nlc patients  p less than 0 05   the mda content was inversely correlated to number of days patients had refrained from smoking  r    0 66  p less than 0 001   the mda content was higher in recent smokers  ie  people smoking during the last 30 days before surgery  than in the other patients  0 136     0 007 vs 0 116     0 007 mumol g of tissue  p less than 0 05  and  by considering only recent smokers  mda content was higher in lc patients  0 144     0 008 mumol g of tissue  than in nlc patients  0 113     0 014 mmol g tissue  p   0 059   when patients were divided into  high mda  and  low mda  groups  mef75 was much lower in the high mda group  35 1     3 4 percent  than in the low mda group  55 1     8 1 percent   p less than 0 01   these results suggest the following   1  enhanced level of prooxidant state in the lungs is associated with recent cigarette smoking   2  lc patients may be more prone than respective nlc patients to oxidative stress   3  mda level and degree of small airway obstruction were associated and differed between lc and nlc patients even though these groups did not differ in the percentage of recent smokers  and  4  a common free radical mediated pathway may be active for both lc and small airway obstruction  
class8	three mixed venous saturation catheters in patients with circulatory shock and respiratory failure thirty one critically ill patients with acute respiratory failure and circulatory shock were divided into three groups  group 1 included 11 patients with an inserted mixed venous saturation  svo2  catheter using three reference wavelengths and characterized by one transmitting and one detecting fiberoptic filament  oximetrix opticath catheter   group 2 included eight patients with an inserted svo2 catheter using two reference wavelengths and characterized by one transmitting and one detecting fiberoptic filament   edwards sat one catheter   group 3 included 12 patients with an inserted svo2 catheter using two reference wavelengths and characterized by one transmitting and two detecting fiberoptic filaments  once calibration procedures were performed  svo2 measured by the catheter and by an hemoximeter osm 3  reference value  were compared following each therapeutic intervention  over a period of 1 5 to 6 hours during which the hematocrit value remained unchanged  119 measurements were obtained in group 1  91 in group 2 and 181 in group 3  the dispersion of svo2 values was much more pronounced with the two reference wavelength systems using either one or two detecting fiber optic filaments  and the correlation coefficient was significantly higher with the three reference wavelength system  r   0 970 for the oximetrix catheter vs r   0 855 for the edwards catheter and r   0 826 for the spectramed catheter  p less than 0 001   after 24 hours  the spontaneous drifts in the two reference wavelength systems  using either one or two detecting fiber optic filaments  expressed as the svo2 value measured by the catheter minus the reference svo2 value  were significantly higher than the spontaneous drift in the three reference wavelength system  9 3     7 percent for the edwards catheter and     6     4 1 percent for the spectramed catheter vs 3 3     3 1 percent for the oximetrix catheter  p less than 0 05   this study shows that a three wavelength system is more accurate than a two wavelength system for measuring acute changes in svo2  the addition of a second detecting fiber optic filament does not seem to improve the accuracy of the system when svo2 changes occur in conditions of stable hematocrit  
class8	lactate levels as predictors of the relationship between oxygen delivery and consumption in ards  we reviewed the changes in do2 and vo2 in 58 patients with ards after interventions which included fluid loading  blood transfusion  and peep  after a significant change in do2  patients with lactic acidosis  lactate level greater than 2 4 mmol l  exhibited significant corresponding changes in vo2  p less than 0 001   however  no change in vo2 was observed in patients without lactic acidosis  1 beta greater than 0 8   we conclude that a biphasic pattern of oxygen utilization in patients with ards emerges when subsets of patients with and without lactic acidosis are compared  lactic acidosis  a marker of anaerobic metabolism  may be a characteristic of patients with ards who exhibit changes in vo2 that are dependent on changes in do2  
class8	mechanical disruption of pulmonary emboli in dogs with a flexible rotating tip catheter  kensey catheter   pulmonary embolism was induced in 11 dogs by the injection of three  to four day old allogeneic blood clots  the clots were made radiopaque by soaking them in contrast material  the resulting clots were firm  3 to 4 cm long  and 1 cm in diameter  injection of the clots into the external jugular vein consistently produced occlusion of at least one of the lobar pulmonary arteries  in every instance in which the tip of the catheter could be positioned at the clot embolus  six dogs   the clots were readily fragmented with a number 8 french  2 67 mm od  flexible rotating tip catheter  kensey catheter  activated at 80 000 rpm  overall perfusion was shown by posttreatment angiograms to be markedly improved  these studies show that catheter tip fragmentation of pulmonary emboli with a kensey catheter has excellent potential for therapeutic application in patients with pulmonary embolism  
class8	relationship between blood plasma prostaglandin e2 and liver and lung metastases in colorectal cancer  the relationship of prostaglandin e2  of which a large amount is produced in various neoplasms  and hematogenous distant metastases was investigated in a total of 44 colorectal cancer patients because of its varied pathophysiologic potentials  the authors found significantly high levels of pge2 in local venous blood draining the carcinoma and in peripheral blood in cases with liver or lung metastasis  as well as a significantly large amount of pge2 production in the carcinoma tissue  the results suggest that increased local blood pge2 could enhance the metastasis formation  and increased peripheral blood pge2 may be useful in the detection of such metastasis in colorectal cancer  
class8	endoscopic palliative intubation of the esophagus invaded by lung cancer  thirty two patients with esophageal involvement by lung cancer were managed by endoscopic intubation  in 22 patients with extrinsic esophageal strictures  the success rate of intubation was 91   and 82  were discharged with their dysphagia relieved and esophageal patency restored  the mean survival rate was 4 4 months  in 10 patients with esophago bronchial fistulas  3 had the fistulous tract obliterated and lived a mean of 5 months  this low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor associated stenosis  the overall morbidity rate was 28 1   18 8  perforation  6 3  hemorrhage  and 3 1  tracheal obstruction   the overall mortality rate was 18 8   although complications were more frequent than in primary esophageal tumors  endoscopic intubation was the only way to palliate this desperate condition and provided 66 6  of patients with relief of symptoms  nutritional improvement  and a mean survival time of 4 5 months  
class8	pneumonia syndromes  a clinical approach in the elderly  important in the pathogenesis of pneumonia in the elderly patient are chronic diseases  including diabetes mellitus  coronary artery disease  congestive heart failure  chronic obstructive pulmonary disease  and cerebrovascular disease  also vital are the changes that take place in the immune system and mucociliary clearance mechanisms of the lung  the clinician should be aware of these risk factors  especially since the mortality rate of lower respiratory infections approaches 40  in these elderly patients  treatment guidelines are included  
class8	changes in self concept during pulmonary rehabilitation  part 1  the purpose of this two part study was to describe changes in self concept during and after a formal pulmonary rehabilitation program  a 20 item semantic meaning differential scale was administered to 37 patients with severe chronic obstructive pulmonary disease who were participating in a multidisciplinary pulmonary rehabilitation program  patients were asked to evaluate their past  present  and future selves on program admission  on program discharge  and 2 to 6 months after home discharge  mean total self concept score for the present self significantly increased between program admission and home discharge 3 weeks later  mean change 31 32     22 04  p less than 0 0001   no significant declines in self concept were found 2 to 6 months after home discharge  p   0 39   men showed a significantly higher change in total self concept score than women during the 3 week program  p   0 03   however  the men s change score dropped significantly after home discharge  p   0 02   suggesting a need for more intensive follow up care than with women  the self concept tool in this study provided an easy way to monitor subjective changes in psychologic status  
class8	changes in self concept during pulmonary rehabilitation  part 2  this two part study describes changes in self concept during pulmonary rehabilitation  a 20 item semantic meaning differential scale was administered to 37 patients with severe chronic obstructive pulmonary disease who were participating in a multidisciplinary pulmonary rehabilitation program  patients were asked to evaluate their past  present  and future self concepts on program admission  on program discharge  and 2 to 6 months after home discharge  in this part of the study item level quantitative data as well as qualitative data from the counseling session at program discharge are reported  the quantitative data documented detailed changes in self concept at various stages of pulmonary rehabilitation  counseling session results indicated that patient involvement in item level analysis greatly facilitates psychosocial intervention  findings from this study establish clinical indications for use of the self concept evaluation tool in adult patients with chronic obstructive pulmonary disease  use of this tool is recommended early in the rehabilitation process  
class8	ligation of the superficial femoral vein in prevention of pulmonary embolism  an old fashion procedure  from 1974 to 1988  interruption of the superficial femoral vein  sfv  was performed to prevent pulmonary embolism  pe  in 73 patients  the mean age of the patients was 62 years  phlebography showed thrombi in the following localizations  calf veins  67 3    superficial femoral or popliteal veins  56 6    common femoral veins  19 5   and iliac veins  2 7    a floating thrombus in the popliteal or femoral vein was the main indication for surgery in 97 3  of patients  pulmonary embolism had occurred in 76 7  and was associated with neoplasm in 13 7   ligation of the sfv was performed in 93 limbs and completed iliac or femoral thrombectomy in 32 3   the procedure was performed under locoregional anesthesia in 82 9  of the cases  hospital mortality was 1 4  and 3 year survival  considering only pe related deaths was 95 3     2 7   follow up was complete for all patients and averaged 3 0 years  for a 3 years pe free rate of 90 8     3 6   persistent symptoms included increased limb tenseness in 12 5  and mild ankle edema in 25   bilateral strain gauge plethysmography  sgp  was obtained in 65 limbs  the time necessary to obtain a 50  75 and 100  decrease in calf volume  respectively t1 2  t3 4 and tt  was calculated for the operated limb and compared with the untreated limbs used as controls  a prolongation of t1 2 from 2 5     0 3 sec in controls to 4 3     0 4 sec in the operated limb  p less than 0 01  was found  thus  our experience with ligation of the superficial femoral vein is favourable since long term ill effects have been minimal and strain gauge plethysmography  sgp  showed only mildly altered venous drainage  
class8	platelet derived growth factor in idiopathic pulmonary fibrosis  fibrosis is a complex process involving an inflammatory reaction  fibroblast proliferation  and abnormal accumulation of interstitial collagens  mononuclear cells are usually present in lung fibrosis  activated monocytes and macrophages in culture have been shown to produce several growth factors including platelet derived growth factor  pdgf   pdgf is a potent mitogen and chemoattractant for fibroblasts and smooth muscle cells and a stimulator of collagen synthesis  we have studied the expression of c sis pdgf 2 mrna in lung tissues derived from five patients with idiopathic pulmonary fibrosis  ipf  and from four control individuals without ipf  northern blot analysis of specimens obtained from four patients with ipf revealed the expression of the c sis pdgf 2 protooncogene  a control lung tissue without ipf did not express the c sis protooncogene  in situ hybridization extended these studies demonstrating the expression of the c sis mrna in the five specimens with ipf but not in the four control specimens without ipf  the expression of c sis mrna was localized primarily in the epithelial cells  invading alveolar macrophages also expressed c sis mrna  the expression of c sis mrna was accompanied by the expression of pdgf like proteins in lung specimens with ipf but not in control lung specimens  these findings demonstrate the in vivo expression of the c sis pdgf 2 protooncogene and the production of pdgf like proteins in the epithelial cells and macrophages of the fibrotic tissue  this localized and sustained production of pdgf like mitogen may constitute an important contributing factor in the abnormal fibroblast proliferation and collagen production  events associated with pulmonary fibrosis  
class8	itraconazole therapy in aspergillosis  study in 49 patients  itraconazole  200 to 400 mg once daily  was administered to 49 patients with different types of aspergillosis  pulmonary aspergilloma  14 patients   chronic necrotizing pulmonary aspergillosis  14   and invasive aspergillosis  21   itraconazole was prescribed alone or in combination or after treatment with amphotericin b and flucytosine  of 14 aspergilloma patients  2 were cured and 8 had symptomatic improvement  in chronic necrotizing pulmonary aspergillosis  7 of 14 patients were cured and 6 improved significantly  in invasive aspergillosis treatment failed in 6 patients and 15 were cured  itraconazole can be an alternative to amphotericin b in the treatment of invasive aspergillosis and chronic necrotizing pulmonary aspergillosis  in aspergilloma itraconazole may be useful in inoperable cases  
class8	repeated exposure of asthmatic airways to inhaled adenosine 5  monophosphate attenuates bronchoconstriction provoked by exercise  inhaled adenosine 5  monophosphate  amp  induces bronchoconstriction in subjects with asthma  probably caused by histamine release from airway mast cells  and repeated amp bronchial challenge leads to attenuation of the bronchoconstrictor response  since exercise induced bronchoconstriction may be mediated by hypertonic mast cell degranulation  we postulated that repeated amp bronchial challenge should reduce the response to subsequent exercise challenge  eight atopic subjects with asthma took part in an unblinded  randomized trial  on the control study day  a treadmill exercise test previously demonstrated to induce a greater than 20  fall in fev1 was performed  on the amp study day  three amp dose response bronchial challenges were performed at 1 hour intervals  each amp challenge was continued until either a provocative concentration causing a 20  fall in fev1 had been achieved  pc20  and the pc20 was calculated  or the maximum concentration of amp  400 mg ml  had been administered  after recovery of the fev1 from amp challenge  a treadmill exercise test identical to the test on the control study day was performed  on the amp study day  the geometric mean pc20 was 15 3  7 9 to 29 5  mg ml for the first test  and 28 2  10 7 to 77 4  mg ml for the third test  not significant   on the control study day  the mean maximum percentage fall in fev1 after exercise was 28 0      2 7   whereas on the amp study day  it was reduced to 13 0      4 3   p less than 0 01   a significant correlation was found between the change in responsiveness to amp induced by repeated challenge and the attenuation of the subsequent exercise response  p less than 0 05   
class8	therapeutic embolization  enhanced radiolabeled monitoring  radiolabeling of ivalon  polyvinyl alcohol sponge  particles permits localization of injected particles during embolization through the use of a portable gamma camera and provides a means to prevent potentially fatal complications such as pulmonary embolization  a more efficient technique of labeling ivalon particles with technetium 99m sulfur colloid was developed  an increase in labeling efficiency allowed more accurate determination of the distribution of injected ivalon particles  scanning electron microscopy demonstrated the stability of the ivalon particles during this new labeling process  two patients with arteriovenous malformations underwent therapeutic embolization with radiolabeled ivalon particles  gamma camera imaging of the lesion and chest was performed throughout the procedure  
class8	mr imaging of the bird s nest filter  the appearance of the bird s nest inferior vena cava filter on magnetic resonance  mr  images of 11 patients is described  no complication or symptomatic filter displacement was encountered as a result of mr imaging performed at 1 5 t  the filters created significant local artifact and distortion on mr images  however  diagnostic mr images of the pelvis  spine  and brain may still be obtained  
class8	intra abdominal palpation of a nasogastric tube in the stomach does not assure appropriate placement  improperly placed nasogastric  ng  tubes have been associated with considerable morbidity  the only reliable indicator of correct ng tube placement appears to be the aspiration of gastric contents  we have reported a case of major morbidity from an improperly placed ng tube that perforated the cervical esophagus  dissected the mediastinum  and terminated in the omental bursa  no gastric aspirate was obtained by suctioning of the tube  but correct placement was presumed based upon the surgeon s direct intraoperative palpation of the tip of the tube  failure to aspirate gastric contents should alert the practitioner to the possibility of improper ng tube placement  
class8	disseminated strongyloidiasis in aids and non aids immunocompromised hosts  diagnosis by sputum and bronchoalveolar lavage  in conclusion  disseminated strongyloidiasis is a fatal disease that commonly affects the lungs  the disease should be suspected in an immunocompromised host who came from an area endemic for s stercoralis even years before the onset of symptoms or in patients with unexplained gram negative bacteremia or meningitis  treatment should be started promptly and should be maintained for a long time  
class8	early tracheostomy for primary airway management in the surgical critical care setting  during a 12 month period  264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit  one hundred twenty patients  46   were disengaged from the ventilator  and 38 patients  14   died  of the remaining 106 patients  40   51 patients  group i  were to receive tracheostomy within 1 to 7 days  and 55 patients  group ii  underwent late  8 or more days after admission  tracheostomy  multiple variables in four categories  admission  operative  ventilatory  and outcome  were analyzed prospectively to define the impact that early tracheostomy had on duration of mechanical ventilation  intensive care stay  and hospital stay  morbidity and mortality rates of the procedures were assessed  early tracheostomy  in a homogeneous group of critically ill patients  is associated with a significant decrease in duration of mechanical ventilation  as well as shorter intensive care unit and hospital stays  compared with translaryngeal endotracheal intubation  there were no deaths attributable to tracheostomy  and overall morbidity of the procedures was 4   we conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation  furthermore  early tracheostomy shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation  
class8	trends in lung cancer  chronic obstructive lung disease  and emphysema death rates for england and wales 1941 85 and their relation to trends in cigarette smoking trends in smoking associated respiratory diseases in england and wales during 1941 85 have been studied  with careful attention to problems caused by changes in classification of cause of death  three diseases were selected for analysis  lung cancer  emphysema  and chronic obstructive lung disease  during 1971 85 deaths that would previously have been certified under chronic bronchitis have increasingly tended to be classified under chronic airways obstruction  the definition of chronic obstructive lung disease that was used includes both terms to avoid the artificial decline caused by consideration of chronic bronchitis in isolation  age specific rates for all three diseases show a pronounced cohort  period of birth  pattern  rates for men rising up to the rates for those born shortly after the turn of the century and then declining  and rates for women peaking in the cohort born 20 25 years later  for chronic obstructive lung disease  but not for lung cancer and emphysema  the cohort peak is superimposed on a sharply declining downward trend  in both sexes cohort patterns of cumulative cigarette consumption peak at a time broadly similar to those seen for the three diseases  trends in cigarette consumption  however  cannot explain the underlying steeply declining rate of chronic obstructive lung disease  nor can they fully explain the declining trends in lung cancer and emphysema rates in younger men and women  
class8	use of biological glue to control pulmonary air leaks  biological glue is a natural adhesive generated by the interaction between fibrinogen  pre glue  and thrombin to produce fibrin  the pre glue is prepared from a single donor  to avoid the problems of pooled plasma  and stored as cryoprecipitate  before being used it is thawed  dissolved in saline  and activated into an adhesive by the addition of topical thrombin  biological glue was used prophylactically to prevent air leaks from bronchial suture lines and raw lung surfaces after pulmonary resections in six patients  in addition two new methods of using biological glue have been developed for the control of persisting air leaks  in selective intrabronchial tamponade the glue is instilled into the bronchial tree through a flexible bronchoscope  and in therapeutic pleurodesis it is instilled into the pleural cavity through a chest drainage tube  the air leaks were resolved in all cases  seven procedures using selective intrabronchial tamponade were carried out in six patients  four were immediately successful but three were not and required further interventions  therapeutic pleurodesis alone was successfully carried out in one patient and as an adjunct to selective intrabronchial tamponade on two occasions  a thoracotomy was eventually needed in one of the seven patients  
class8	effects of inflammation and fibrosis on pulmonary function in diffuse lung fibrosis  to investigate the relation between lung function and inflammation and fibrosis in patients with diffuse lung fibrosis  a study was made of untreated patients without appreciable airway obstruction  14 patients with cryptogenic fibrosing alveolitis and seven with pneumoconiosis   quantitative assessment of inflammatory infiltration and fibrosis was carried out on open lung biopsy specimens and compared with lung volumes  carbon monoxide transfer factor  tlco   tlco corrected for alveolar volume  tlco va   and arterial blood gases at rest and during exercise  the degree of fibrosis and the degree of cellular infiltration were positively correlated  lung volumes and tlco were correlated with the grades of fibrosis and cellular infiltration of alveoli  arterial blood gases during exercise tended to correlate with both fibrosis and infiltration  p less than 0 06   in contrast  morphological data were not correlated with gas exchange at rest or with tlco va  it is concluded that  in untreated patients with diffuse lung fibrosis  lung volumes  tlco  and arterial blood gases during exercise reflect the lung lesions  and that the pulmonary function tests used cannot discriminate between fibrosis and infiltration of the lung by inflammatory cells  
class8	appropriate and inappropriate neuroendocrine products in pulmonary tumourlets  pulmonary tumourlets are focal aggregates of neuroendocrine cells that occur in the periphery of the lung and may be associated with chronic inflammation and scarring  six such lesions were seen in five lungs from a series of 35 pairs of lungs studied at necropsy  all were immunoreactive for neurone specific enolase  protein gene product 9 5  and a range of neuroendocrine products  of the peptides found in neuroendocrine cells in normal human lungs  gastrin releasing peptide was present in all tumourlets and calcitonin in all but one  none contained leucineenkephalin  of a series of peptide and protein hormones not present in the neuroendocrine cells of healthy human lungs  growth hormone was present in all six tumourlets and adrenocorticotrophin in two  identical patterns of peptide expression were displayed by neuroendocrine cells in the airway associated with the tumourlets in two cases  such cells were increased in number and abnormally clustered  aberrant expression of peptides might accompany the morphological changes in the pulmonary neuroendocrine cells seen in diseased lungs  their florid focal proliferation occasionally resulting in the formation of a tumourlet  
class8	plasma cross linked fibrin degradation products in pulmonary embolism  plasma concentrations of cross linked fibrin degradation products  a marker of intravascular thrombosis and fibrinolysis  were measured in 495 patients with suspected pulmonary embolism referred for ventilation perfusion lung scanning to determine whether concentrations are increased in pulmonary embolism and their potential use in diagnosis  lung scans were described as normal  n   66  or as showing a low  n   292   indeterminate  n   58   or high probability  n   79  of pulmonary embolism  there was a difference between the mean levels of cross linked fibrin degradation products in each scan category  normal scans  142 ng ml  low probability scans  295 ng ml  indeterminate probability scans  510 ng ml  high probability scans  952 ng ml  p less than 0 001   of the patients with high probability scans  96  had raised concentrations  explanations for discrepant low results include incorrect scan diagnosis  delay in blood sampling  and anticoagulation  of the patients with a low or indeterminate probability of pulmonary embolism  43  had increased concentrations of cross linked fibrin degradation products that could be attributed in most cases to another illness  owing to the wide range of values in each lung scan diagnostic category  raised concentrations of these fibrin degradation products cannot be used without reference to the patient s clinical state as a discriminatory test for pulmonary embolism  further evaluation of the significance of normal concentrations in excluding a diagnosis of pulmonary embolism appears to be warranted  
class8	external detection of pulmonary accumulation of indium 113m labelled transferrin in the guinea pig  accumulation of radioisotope labelled transferrin in the lungs of guinea pigs was determined with an external detection system  the method is based on the intravascular and extravascular distribution of indium 113m labelled transferrin compared with the intravascular distribution of technetium 99m labelled red blood cells  guinea pigs were given iloprost  a prostacyclin analogue and potent pulmonary vasodilator  and noradrenaline  a pulmonary vasoconstrictor  in an attempt to increase and decrease respectively the blood volume in the lungs  neither agent altered transferrin accumulation in the lung by comparison with a saline infusion  iloprost infused before and after oleic acid infusion reduced macro molecular leakage when compared with oleic acid alone  these data suggest that the double isotope method can distinguish between hydrostatic and injury induced pulmonary oedema  
class8	prostaglandin f2 alpha enhancement of capsaicin induced cough in man  modulation by beta 2 adrenergic and anticholinergic drugs  the effect of inhaled prostaglandin  pg  f2 alpha on the response to the inhaled tussive agent capsaicin was investigated in normal subjects  seven subjects inhaled three breaths of four doses of capsaicin  0 3  0 6  1 2  and 2 4 nmol  before and immediately after inhaling pgf2 alpha  0 1 mumol  or placebo  0 15m nacl  on separate days  the numbers of capsaicin induced coughs were greater after pgf2 alpha  mean 42 3 coughs  than after 0 15m sodium chloride  30 1   visual analogue scores  0 10 on a 10 cm continuous scale  showed that capsaicin was more irritant after pgf2 alpha than after saline  total respiratory resistance  rrs   measured by the forced oscillation technique  was unaltered throughout the study  a double blind  placebo controlled study of the effects of inhaled salbutamol  200 micrograms  0 6 mumol  and ipratropium bromide  40 micrograms  0 1 mumol  on cough induced by capsaicin  2 4 nmol  and by pgf2 alpha  0 1 mumol  and on pgf2 alpha augmented  capsaicin induced coughing was performed in seven subjects  neither drug had any effect on capsaicin induced coughing  salbutamol reduced coughing due to pgf2 alpha  mean 7 7 coughs after salbutamol  9 3 after placebo  but ipratropium bromide did not  mean 6 9 coughs after ipratropium bromide  6 6 after placebo   salbutamol also inhibited the augmentation of the capsaicin induced cough that followed inhalation of pgf2 alpha  mean augmentation 1 9 coughs after salbutamol  4 1 after placebo   whereas ipratropium bromide did not  augmentation 1 7 coughs after ipratropium bromide  2 7 after placebo   no changes in rrs were seen after pgf2 alpha or either drug  thus salbutamol reduces pgf2 alpha induced cough and the augmentation of capsaicin induced cough that follows pgf2 alpha  
class8	the hyperimmunoglobulinaemia e and recurrent infections syndrome in an adult  published erratum appears in thorax 1990 dec 45 12  984  a 27 year old white woman with a history of chronic eczema and episodes of serious infection of the chest  skin  and bone presented with acute respiratory failure  she was found to have a spontaneous right pneumothorax and a pneumatocele in the left upper lobe  despite a left upper lobectomy she was left with chronic respiratory failure  bullous lung disease  and bilateral bronchiectasis  the hyperimmunoglobulinaemia e and recurrent infections syndrome was diagnosed only in adult life  
class8	pulmonary disease following intravesical bcg treatment  bacillus calmette guerin  bcg  is an attenuated strain of mycobacterium bovis that has been used in the treatment of malignant disease for over 20 years and for the treatment of bladder cancer since 1976  major complications of this treatment are infrequent  we report two cases of systemic illness with pulmonary manifestations after treatment with intravesical bcg  
class8	use of a fenestrated silicone drain to stent a malignant tracheobronchial stenosis  an innovative use of a fenestrated silicone drainage tube as an endobronchial stent is reported  the patient had respiratory obstruction due to a carinal tumour and laser photoresection had failed to restore airway patency  
class8	bronchoalveolar lavage findings in a patient with the organic dust toxic syndrome  a previously healthy student developed the organic dust toxic syndrome after unloading a grain silo for one day  bronchoalveolar lavage seven days later showed a total cell count six times normal with 70  lymphocytes  this suggests that the previously described acute neutrophil influx into the alveolar spaces in this syndrome is rapidly replaced by a lymphocyte dominated infiltration  
class8	pleuropulmonary manifestations of hepatic amebiasis pleuropulmonary manifestations of hepatic amebiasis occurred in 30 patients  18  60   presented with at least 1 pulmonary complaint and 10  33   had multiple pulmonary symptoms  in 14 patients  47    abnormalities were found on examination of the chest  in 16 chest roentgenograms  53    there was at least 1 abnormality  right sided pleural effusion  9 patients  and elevated right hemidiaphragm  8 patients  were the most common  all patients were treated with metronidazole  flagyl  and had resolution of the amebic liver abscess and pulmonary disease  pleuropulmonary disease is a common complication of amebic liver abscess  the clinical presentation and chest roentgenograms are virtually diagnostic and obviate the need for invasive procedures to confirm the diagnosis  pleuropulmonary disease resolves with amebicidal treatment of the hepatic abscess  
class8	inhaler and spacer use in obstructive airway diseases  the role of inhaled aerosols in the treatment of obstructive airway diseases is increasing for both immediate bronchodilation and prophylactic anti inflammatory effects  inhaled aerosol agents are available in metered dose inhaler and nebulizer forms  maximum therapeutic benefit from metered dose inhalers is assured when the correct inhaler technique is used  spacer devices may be helpful in some patients  
class8	characterization of the morphonuclear features and dna ploidy of typical and atypical carcinoids and small cell carcinomas of the lung  the authors analyzed several cytomorphonuclear parameters related to chromatin distribution and dna ploidy in typical and atypical carcinoids and in small cell lung cancers  nuclear measurements and analysis were performed with a samba 200  titn  grenoble  france  cell image processor with software allowing the discrimination of parameters computed on cytospin preparations of feulgen stained nuclei extracted from deparaffinized tumor tissues  the authors  results indicate a significant increase in dna content  assessed by integrated optical density  iod   from typical carcinoids to small cell lung carcinomas  with atypical carcinoids showing an intermediate value  parameters related to hyperchromatism  short and long run length and variance of optical density  also characterize the atypical carcinoids as being intermediate between typical carcinoids and small cell lung cancers  the systematic measurement of these cytomorphonuclear parameters seems to define an objective  reproducible  scale  of differentiation that helps to define the atypical carcinoid and may be of value in establishing cytologic criteria for differential diagnosis  
class8	isolation of measles virus in primary rhesus monkey cells from a child with acute interstitial pneumonia who cytologically had giant cell pneumonia without a rash  the isolation of measles virus in primary rhesus monkey kidney cells  prmk  in patients with documented giant cell pneumonia who have presented without a rash is limited  the diagnosis usually is made by cytologic examination of nasal or bronchial secretions in which characteristic multinucleated giant cells with intranuclear and intracytoplasmic inclusion bodies are observed  the diagnosis of giant cell pneumonia has been associated with measles virus but not exclusively  canine distemper  herpes group viruses  and parainfluenza infections have been associated with these cells  in addition  vitamin a deficiency also has been cytologically associated with multinucleated giant cells  the authors describe the isolation of measles virus from bronchial washing and sputum in prmk cells at 4 days from an 11 year old child with acute interstitial pneumonia who was in remission for acute lymphocytic leukemia  classic cytopathologic effect  cpe  consisting of syncytial and hole formation on the prmk monolayer was apparent  in addition  a foamy appearance of the monolayer was noted in an otherwise clean lot of monkey cells  confirmatory testing with measles antibody of the infected areas of the monolayer by indirect immunofluorescence  ifa  was positive for measles antigen and negative for mumps  parainfluenza  types i  ii  and iii  and influenza a and b virus  serologic studies for measles antibody revealed an ifa igg titer of greater than 1 10 240  and an igm titer of 1 128  cytologic examination of the same bronchial fluid revealed the typical giant cells with characteristic inclusions associated with measles virus  because this disease usually is severe  and often fatal  prompt recognition of this virus is essential  not only to the patient  who can be treated with immunoglobulin and or antiviral therapy  but also to prevent the spread of the virus to other patients and medical personnel  these findings also support direct evidence for the etiologic role of measles virus in giant cell pneumonia that has been detected either histologically or cytologically and in tissue culture at autopsy  
class8	brake mechanics  asbestos  and disease risk  health risks posed by inhalable asbestos fibers are known to exist in a variety of industrial and nonindustrial settings  although early studies described an increased risk of asbestosis  lung cancer  and mesothelioma in asbestos industry workers  subsequent research revealed the existence of a potential asbestos related health hazard in nonasbestos industries such as the textile and railroad industries  brake mechanics and garage workers constitute a large work force with potential exposures to levels of asbestos capable of producing disease  unfortunately  the health risk faced by these workers has received little attention  this article briefly discusses currently available information on the asbestos health risks of workers in this setting  and highlights the need for further investigations of this occupational group  
class8	arterial oxygen desaturation during gastrointestinal endoscopy this prospective study evaluated the incidence and severity of arterial oxygen desaturation during gastrointestinal endoscopy  following pulmonary function testing  115 male patients underwent esophagogastroduodenoscopy  egd   colonoscopy  or colonoscopy followed by egd  with continuous recording of arterial oxygen saturation  sao2   most patients  80 115  70   showed arterial oxygen desaturation  greater than 4  decrease from baseline sao2   severe arterial oxygen desaturation  sao2 less than or equal to 85   reflecting hypoxemia  pao2 less than or equal to 50 mm hg  was noted in one third of patients overall  37 115  32    severe arterial oxygen desaturation occurred in 9 62 egd patients  15    23 46 colonoscopy patients  50    and 4 7 patients having colonoscopy followed by egd  57    arterial oxygen desaturation occurs frequently during gastrointestinal endoscopy and is often severe  these data support the concept that continuous monitoring of sao2 should be standard procedure during all gastrointestinal endoscopic procedures  
class8	treatment of wegener s granulomatosis with intermittent high dose intravenous cyclophosphamide purpose  concerns regarding the long term toxicity of daily cyclophosphamide  cp  therapy for the systemic vasculitides have led us to evaluate alternative approaches to treatment in an attempt to achieve comparable efficacy with less toxicity  this study sought to determine the efficacy  toxicity  and immunologic effects of glucocorticoids  gc  and intermittent high dose intravenous cp   pulse  cp  in the treatment of 14 patients with wegener s granulomatosis  wg   patients and methods  the diagnosis of active wg was supported by a typical clinical presentation and histopathologic findings of vasculitis  granulomatous inflammation  and tissue necrosis  gc treatment was initially provided on a daily basis and later tapered to an alternate day schedule if vasculitis remained inactive  pulse cp treatment was initially administered once a month for 6 months  if after 6 months remission had been attained and gc therapy had been discontinued  then pulse cp treatment was given at less frequent intervals thereafter  treatment and evaluation were provided for participants as inpatients in a clinical research center  national institutes of health   results  thirteen of 14 patients  93   initially experienced unequivocal improvement with pulse cp therapy  and seven of 14  50   achieved remission within 4 months  however  treatment was associated with significant toxicity in two patients and later relapses in nine patients  so that a total of 79  either failed to achieve sustained remission or were unable to continue therapy  three of 14  21   patients have achieved sustained remissions with the pulse cp protocol and one additional patient  who had a limited exacerbation of wg  continues to receive that therapy after 14 to 22 months  mean 17 months   conclusions  the use of pulse cp and gc therapy in 14 patients with wg was associated with a high initial response rate  however  failure to respond initially to treatment  to sustain improvement  or to tolerate continued treatment was noted in 79  of patients within a period of 1 to 22 months  these observations indicate that this particular pulse cp protocol does not achieve a high degree of lasting efficacy  
class8	pleuritis as a manifestation of reactivation tuberculosis  purpose  the purpose of this study was to determine the frequency with which tuberculous pleuritis is a manifestation of reactivation tuberculosis and to compare the clinical manifestations of reactivation tuberculous pleuritis with  classic  tuberculous pleuritis  in which chest roentgenograms reveal no parenchymal infiltrates  patients and methods  we evaluated the medical records of 59 patients in whom tuberculous pleuritis was confirmed by histologic findings or mycobacterial culture  twenty seven patients  46   had typical chest roentgenographic findings of reactivation tuberculosis  whereas 32  54   had classic tuberculous pleuritis  the clinical and laboratory features of these two groups were compared  results  symptoms were more prolonged and pleural fluid glucose and lactate dehydrogenase concentrations were more markedly abnormal in patients with reactivation pleuritis than in those with classic pleuritis  suggesting a more chronic inflammatory process in the former group  compared with patients with classic tuberculous pleuritis  those with reactivation pleuritis had a lower frequency of reactive tuberculin skin tests  61  versus 88   and granulomatous pleural inflammation  25  versus 72    but a higher bacillary burden  manifest by a higher frequency of positive sputum smears for acid fast bacilli  50  versus 0   and positive mycobacterial cultures from sputum  60  versus 23   and pleural fluid  91  versus 66    conclusions  in contrast to previous reports  tuberculous pleuritis was a manifestation of reactivation tuberculosis in 46   27 of 59  of patients  tuberculous pleuritis is a more chronic process in patients with reactivation disease than in those with classic pleuritis  the lower frequency of reactive tuberculin skin tests and granuloma formation  combined with the higher bacillary burden in patients with reactivation pleuritis  suggest that these patients mount a less effective immune response to mycobacterium tuberculosis infection than do patients with the classic form of tuberculous pleuritis  
class8	cardiorespiratory effects of endoscopic esophageal variceal sclerotherapy  endoscopic variceal sclerotherapy  evs  is an effective means of controlling variceal hemorrhage  which develops as a consequence of portal hypertension  while esophageal perforation  ulceration  strictures  and mediastinitis are potential complications associated with this procedure  it is not clear whether isolated pleuropulmonary events such as pleuritis  pneumonitis  and adult respiratory distress syndrome are causally related to the evs  endoscopy and sedation with the attendant risk of aspiration  particularly in the background of hepatic encephalopathy  may account for some of these events  recent controlled studies of respiratory function demonstrate that evs as such results in minor changes in gas exchange  lung volumes  and pulmonary and systemic hemodynamics  most pulmonary complications have been reported with the use of sodium morrhuate sclerosant  comparative studies among different sclerosants are necessary to evaluate relative safety  finally  there have been rare reports of myocardial ischemia and pericarditis reported in association with evs  but these are of a transient nature  chest symptoms  roentgenographic pleuropulmonary changes  pulmonary hemodynamics  and cardiac perturbations are transient and should not preclude offering evs to patients with variceal hemorrhage  
class8	viral bronchiolitis during early life induces increased numbers of bronchiolar mast cells and airway hyperresponsiveness  the objectives of this study were to determine the kinetics of sendai virus induced increases in bronchiolar mast cells and to determine whether virus induced increases in bronchiolar mast cells were associated with increased airway responsiveness to methacholine and with altered allergic inflammatory responses to antigen stimulation  mast cell density in intrapulmonary airways was measured in outbred cd  crl cdbr  rats by use of morphometric techniques at 7  15  30  60  and 90 days after viral or sham inoculation  density of bronchiolar mast cells was higher in virus inoculated rats than in control rats at 30  60  and 90 days after inoculation  p less than 0 01   but not at 7 or 15 days after inoculation  total pulmonary mast cell numbers were increased in virus inoculated rats at 30 days after inoculation  rats at 42 days after viral inoculation had over a threefold increase in sensitivity to the concentration of nebulized metbacholine that would stimulate a 50  increase in respiratory resistance  virus inoculated rats sensitized to ovalbumin had over a 10 fold increase  p less than 0 02  in pulmonary neutrophils that were recovered by bronchoalveolar lavage at 4 hours after ovalbumin aerosol challenge  virus inoculated rats at this time also had higher densities of neutrophils in bronchiolar walls than allergen exposed control rats  the results indicate that sendai virus induces increases in numbers of bronchiolar mast cells at times from 30 to 90 days after inoculation  and that mast cell increases are associated with airway hyperresponsiveness to methacholine and heightened allergic airway inflammatory reactions  
class8	intraluminal fibrosis induced unilaterally by lobar instillation of cdcl2 into the rat lung  lung injury induced by intratracheal instillation of cadmium chloride  cdcl2  into the rat lung may serve as a model of human interstitial lung disease  in this study  cdcl2 solutions were instilled through a lobar bronchus into the left lung of the rat  two doses  400 micrograms or 50 micrograms of cdcl2  each in 400 microliters of neutral saline  were used and the morphologic changes occurring during the first 7 days after a single exposure were documented by light and electron microscopy  with the higher dose  inflammatory cells appeared in the alveolar interstitium 1 day after cdcl2 administration  edema and thickening of the alveolar walls were evident  as were damaged type i epithelial cells and denuded basement membranes  fibrin was found in the air spaces  within 2 days  inflammatory cells were seen in large numbers and fibroblasts were observed passing through gaps in the alveolar basement membranes into the air spaces  by 4 and 7 days after cdcl2  various forms of intraluminal fibrosis  including intrabronchiolar budding  mural incorporation  and obliterative changes  were observed  the contralateral lungs had normal appearing architecture for all the time points investigated  in the lower dose exposure  gradients of alveolar damage were observed in which normal lung  interstitial fibrosis  and or intraluminal fibrosis were seen within treated lungs  in the mildly damaged regions  interstitial fibrosis predominated  while in the more severely damaged regions  mural incorporation of the convoluted basement membranes was observed  the pulmonary fibrosis that developed appeared to be similar to some human interstitial lung diseases and may offer a system in which to study the regulation of collagen deposition and fibrosis development in these pathologic conditions  
class8	neuromuscular effects of respiratory and metabolic acid base changes in vitro with and without nondepolarizing muscle relaxants  the effects of metabolic  bicarbonate   hco3   and respiratory  carbon dioxide  pco2  acid base changes on indirectly elicited twitch tension with and without nondepolarizing neuromuscular blocking agents were compared in a rat phrenic nerve hemidiaphragm preparation  ionized calcium  ca2   and magnesium  mg2   concentrations in the modified krebs  solution were measured and kept constant  likewise  twitch was altered when ph changes were produced by altering either pco2 or  hco3   decreasing ph either by increasing pco2 or by decreasing  hco3  significantly decreased  p less than 0 01  twitch  by 9 5     0 6  sem  n   8  and 10 6     1 5   respectively  increasing ph by decreasing pco2 or by increasing  hco3  significantly increased  p less than 0 01  twitch  by 5 6     0 9 and 7 9     0 6   respectively  after a partial depression of twitch by nondepolarizing neuromuscular blocking agents  the effects of pco2 and  hco3  changes were again assessed  decreasing ph by increasing pco2 or by decreasing  hco3  intensified d tubocurarine  dtc   28 2     1 6 and 32 0     2 9   respectively  and vecuronium  23 0     1 4 and 36 8     3 2   respectively  block  whereas it reversed metocurine  1 2     2 2  ns and 2 9     1 3   respectively  and pancuronium  8 3     1 5 and 11 5     3 0   respectively  block  conversely  increasing ph by decreasing pco2 or by increasing  hco3  antagonised dtc  12 8     2 2 and 13 6     1 8   respectively  and vecuronium  25 3     1 7 and 25 0     3 0   respectively  block  whereas it potentiated metocurine  4 2     0 6 and 8 0     1 1   respectively  and pancuronium  11 0     1 2 and 17 5     2 0   respectively  block  except where indicated  all changes in block described above were statistically significant  
class8	additive effect of albuterol and ipratropium bromide in the treatment of bronchospasm in children  inhaled albuterol  a   salbutamol  alone and albuterol plus ipratropium bromide  ib  were administered to 12 asthmatic children  following administration of a alone or in combination with ib  there was a significant increase in fev1 and fef  significant statistical difference in favor of the association a plus ib was observed at 120 and 240 minutes for fev1 and in the period 120  180  and 240 minutes for fef  the additive effect was present both in the large and small airways  the short lived additive effect of a plus ib suggests the opportunity to increase the frequency of drug administration in patients with severe bronchial obstruction  
class8	effects of albuterol and procaterol on exercise induced asthma  procaterol and albuterol  beta agonists  were studied using a placebo controlled  repeated exercise challenge design in order to assess their duration of effectiveness in both bronchodilation and in modifying exercise induced asthma  eia   fifty three subjects aged 12 to 50 years who had at least a 20  drop in fev1 during a screening exercise tolerance test were entered  subjects took two inhalations of procaterol  10 micrograms inhalation   albuterol  90 micrograms inhalation   or placebo  thirty minutes later they exercised on a treadmill at a workload sufficient to induce greater than or equal to 80  aerobic o2 consumption for six minutes  pulmonary function was measured before and serially for 30 minutes after exercise  the same exercise challenge was repeated three  six  and nine hours after drug administration  both procaterol and albuterol bronchodilated and modified eia at 30 minutes and three hours  mean drops in fev1 being 8 2 and 9 7  respectively at 30 minutes and 16 8 and 16 3  at three hours  this was compared with placebo falls of 30  and 26   at six hours the subjects  response was similar after both procaterol and albuterol  and fewer subjects had a 20  fall in fev1 than with placebo  although protection afforded by both beta agonists was substantially less than at three hours  both drugs were tolerated well  
class8	exercise induced biphasic responses and methacholine reactivity in asthma  biphasic  early and late  asthmatic responses to exercise occurred in seven of 43 children with reproducible exercise induced asthma  as biphasic allergen induced asthma is associated with a prolonged increase in nonspecific bronchial hyperreactivity  this effect was not sought in the 43 asthmatic children  there was no significant change in methacholine pd20 fev1 before and after exercise challenge  either in children who had early  or early and late  exercise responses  late reactions after allergen exposure are likely to be of considerable clinical significance in relation to the enhancement of bronchial responsiveness  it is reassuring that this is not the case for exercise challenge  as it would have major implications in relation to the recommendations that asthmatics should participate in normal activities and even in training programs  furthermore  it suggests that there are differences between the pathophysiology of asthma induced by exercise and that produced by allergens  
class8	oral gold therapy in steroid dependent asthma  nasal polyposis  and aspirin hypersensitivity  eight patients are described who fulfill the criteria for the triad of asthma  nasal polyposis  and aspirin hypersensitivity who have been treated with oral chrysotherapy from 7 to 17 months  patient diary and symptom scores reflect an overall improvement in global symptoms  monthly pulmonary assessment  spirometry  does not indicate a significant change  improvement or deterioration  but average daily oral prednisone requirements have decreased  one of eight patients experienced a minor side effect of treatment but did not require discontinuation of therapy  oral gold therapy may prove to be an alternative therapy in a select population of patients and permit a reduction or discontinuation of oral corticosteroid therapy  
class8	functional character and augmentation of lymphocytes in regional lymph nodes of patients with lung cancer  it appears that lymph node metastases are more frequent in lung cancer than in other cancers because of impaired defensive mechanisms in the regional lymph nodes  however  little is known about the immunologic function of regional lymph node lymphocytes  rlnl  in patients with lung cancer  we have studied the immunologic properties of rlnl in comparison with peripheral blood lymphocytes  pbl   we measured the natural killer  nk  cell activity of rlnl and pbl in patients with lung cancer and found that the nk activity was significantly more depressed in the rlnl than in the pbl  in contrast  interleukin 2  il 2  production was markedly higher in the rlnl than in the pbl  the cytotoxic effect of rlnl in nonmetastatic lymph nodes on target cells  such as k562 cells  or pc 3 and pc 10 cells  nk resistant  human lung cancer of adenocarcinoma and epidermoid carcinoma  respectively  was significantly enhanced by in vitro incubation with recombinant il 2  ril 2   furthermore  we clarified that both ril 2 and ok 432  which is a biologic response modifier and il 2 inducer as well  augmented the cytotoxicity of rlnl and that these effector cells were lymphokine activated killer  lak  cells  the depletion of lymphocyte subsets by pretreatment with specific monoclonal antibody showed that the lak activity in rlnl was mediated by cd3  and cd8  cells  whereas the lymphocyte subsets contributing the lak activity in pbl were cd3  and cd16  cells  it was concluded that a majority of the effector cells in rlnl were lak cells of the cytotoxic t cell population  
class8	doppler assessment of pulmonary hypertension induced by hypoxic breathing in subjects susceptible to high altitude pulmonary edema  to verify the abnormal pulmonary vascular response implicated in the pathogenesis of high altitude pulmonary edema  hape   we examined the hemodynamic responses to hypoxia in hape susceptible subjects  hape s  by means of both right heart catheterization and pulsed doppler echocardiography  the hape s were seven men and one woman with a history of hape  six healthy volunteers who had repeated experiences of mountain climbing without any history of altitude related problems served as control subjects  the hape s showed much greater increase in pulmonary vascular resistance  pvr  than did the control subjects  resulting in a much higher level of pulmonary arterial pressure  ppa  under acute hypoxia both of 15  o2 and 10  o2  we then evaluated the usefulness of pulsed doppler echocardiography in the prediction of pulmonary hypertension  acceleration time  act  and right ventricular ejection time  rvet  were measured from the flow velocity pattern in the right ventricular outflow tract  the ratio of act to rvet was correlated to invasively determined mean ppa  ppa  and pvr  the results were as follows   1  act rvet   0 52 to 0 0047  ppa   r    0 93  see   0 017  p less than 0 001  hape s    2  act rvet   0 55 to 0 0055  ppa   r    0 70  see   0 030  p less than 0 001  hape s    4  act rvet   0 52 to 0 00077  pvr   r    0 91  see   0 016  p less than 0 001  control subjects   we conclude that hape s have a constitutional abnormality in the pulmonary vascular response to hypoxia  which is a possible causative factor of hape  and that pulsed doppler echocardiography may be supportive to assess the pulmonary vascular pressor response in the hape s  
class8	endogenous opioids modulate the increase in ventilatory output and dyspnea during severe acute bronchoconstriction  the aim of this study was to evaluate whether endogenous opioids are involved in the regulation of breathing pattern and respiratory drive during bronchoconstriction induced by methacholine  mch   we studied six male asymptomatic asthmatics 18 to 35 yr of age  in a preliminary study we determined the concentration of mch causing a 60  fall in fev1  pc60 fev1   on two subsequent days  we measured breathing pattern  dyspnea sensation  borg scale   mouth occlusion pressure  p0 1   and fev1 before and 10 min after an intravenous injection of either naloxone  0 1 mg kg  or saline according to a randomized double blind crossover design  a mch concentration equal to the pc60 fev1 was then inhaled  and measurements were repeated 5 min later  neither placebo nor naloxone affected baseline breathing pattern  p0 1  and fev1  naloxone pretreatment did not influence airway response to mch  the mean percent fall in fev1 was 65 9     1 3 and 64 7     1 2   mean     1 se  on the placebo day and the naloxone day  respectively  after mch inhalation no significant changes in ve  vt  and breathing frequency occurred when patients received placebo  however  p0 1 increased from 1 48     0 17 to 3 43     0 70 cm h2o  p less than 0 05   and vt ti fell from 0 66     0 08 to 0 52     0 04 l s  p less than 0 05   naloxone pretreatment resulted in an increase in breathing frequency  from 18 2     1 7 to 22 8     2 6 breaths min  p less than 0 05  and vt ti  from 0 58     0 06 to 0 74     0 05 l s  p less than 0 05  after mch  
class8	the relationship between respiratory impairment and asbestos related pleural abnormality in an active work force with the general improvement in environmental controls in workplaces where asbestos is used  an increasing number of workers are seen who exhibit isolated pleural plaques  the question as to whether these are associated with respiratory impairment independently of parenchymal disease remains unresolved  the question was reinvestigated using quantitative gallium 67 lung scanning to take into account early parenchymal change not evident on the chest radiograph  we carried out a cross sectional study of 110 construction insulators all currently at work  overall  58 2  had pleural abnormality  52 5  pleural plaques only  and 5 5  diffuse pleural thickening as assessed from the pa chest radiograph  compared with those without  those with any pleural abnormality had a decrease in fev1 and fvc on average of 222 and 402 ml  p less than 0 05   and those with isolated pleural plaques  a decrease on average of 200 and 350 ml  p less than 0 05   after taking into account age  height  smoking status  and the presence of parenchymal abnormality as assessed by chest radiography and gallium uptake  the complaint of dyspnea with strenuous activities was also significantly related to the width and extent of chest wall pleural thickening  p less than 0 05   independently of parenchymal disease  this study suggests that the most common radiographic findings in asbestos exposed  isolated pleural plaques are associated with a significant reduction in fev1 and fvc  which cannot be attributed to the presence of radiographic and subradiographic pulmonary fibrosis  
class8	selective igg subclass deficiencies and antibody responses to pneumococcal capsular polysaccharide antigen in adult community acquired pneumonia  we measured the serum concentrations of igg subclasses in healthy subjects  n   26  and in patients with community acquired pneumonia  cap  on admission  n   38   at recovery  n   21   and 9 months after admission  n   19   then  in 8 of the control subjects and 15 of the patients  we measured igg subclasses and mean serum antibody concentrations of pneumococcal capsular polysaccharides before and 3 wk after immunization with a pneumococcal vaccine  compared to the control subjects  the serum concentration of the igg2 subclass was lower at admission in patients with cap of bacterial or unknown cause  p less than 0 005   concentrations of igg subclasses in patients did not differ between admission and recovery  or between admission and 9 months later  after vaccination  in both control subjects and patients  there was an increase in the concentrations of igg2 subclasses  p   0 01  and antipneumococcal antibodies  p less than 10  4    we show that serum igg2 concentration in patients with cap of bacterial or unknown cause is lower than in healthy subjects and remains lower for several months  after immunization with a pneumococcal vaccine  the increase in serum concentrations of igg subclasses and antipneumococcal antibodies in patients does not differ from those in control subjects  
class8	timing of corticosteroid treatment  effect of lung lymph dynamics in air injury in awake sheep  in paired experiments  we studied the effects of high dose methylprednisolone on the acute pulmonary injury caused by 4 h of venous air embolization in 19 chronically instrumented  unanesthetized sheep with lung lymph fistulas  we compared the effect of methylprednisolone  30 mg kg intravenous bolus  given before embolization  early  1 h  in the course of embolization  late  3 h  in the course of embolization  or after embolization  at the beginning of the recovery period   we measured pulmonary hemodynamics and lymph dynamics  in six sheep we also fixed lung tissue for semiquantitative histology  and in some we measured leukocyte concentrations in blood and in pulmonary lymph  methylprednisolone did not significantly affect pulmonary hemodynamics but it largely prevented lung injury when it was given before embolization  it also lessened the degree of lung injury when it was given during embolization  although this effect became less marked as treatment was delayed  methylprednisolone had no effect on lung injury when given after embolization was completed  4 h   we found fewer leukocytes attached to air emboli and fewer endothelial cell gaps in the lungs of sheep given methylprednisolone as prophylaxis  leukocyte counts were lower in lung lymph and higher in the circulating blood of methylprednisolone treated sheep  we conclude that methylprednisolone has a preventive effect on air embolism lung injury  such that its effect is greater when given earlier during the development of injury  
class8	central airway obstruction due to cytomegalovirus induced necrotizing tracheitis in a patient with aids  cytomegalovirus  cmv  infection in patients with the acquired immunodeficiency syndrome  aids  can present as either disseminated disease  pneumonitis  retinitis  gastroenteritis  neuropathy  or a subclinical infection  we report a patient whose initial manifestation of cmv infection was severe central airways obstruction due to necrotizing tracheitis  at bronchoscopy  the lesion appeared deeply ulcerated  distinctly different from previously described airway lesions in patients with aids  mucosal biopsies showed characteristic intranuclear and intracytoplasmic inclusions and cultures yielded only cmv  the patient responded partially to ganciclovir  steroids  and antibiotics against suspected anaerobic superinfection but died as a result of central nervous system disease believed due to toxoplasmosis or lymphoma  cmv infection of the upper airway should be considered in the patient with aids presenting with atypical cough or stridor and ulcerated endobronchial lesions  
class8	sarcoidosis complicated by hiv infection  three case reports and a review of the literature  we report three cases of sarcoidosis complicated by human immunodeficiency virus  hiv  infection and review four other isolated case reports in the literature  there is clinical overlap of both diseases  including symptoms  pulmonary function abnormalities  and lymphocyte function  bronchoalveolar lavage  bal  in these patients showed a lymphocytic alveolitis without pathogens  bal lymphocyte subset analysis showed markedly depressed cd4  cd8  ratios in three patients  these data were clinically useful for distinguishing the cd8  alveolitis associated with hiv infection from the cd4  alveolitis associated with sarcoidosis  three patients improved with corticosteroid therapy  two patients with bal documented cd8  alveolitis tolerated discontinuation of steroids  one patient s sarcoidosis improved without therapy concurrent with the diagnosis of kaposi s sarcoma  another patient developed sarcoidosis 1 yr after manifesting hiv positive serology  bal can be used to distinguish the lymphocytic alveolitis of sarcoidosis from that associated with hiv infection  patients with active sarcoidosis complicated by hiv infection can be effectively treated with corticosteroid therapy  
class8	ciliary motility in two patients with yellow nail syndrome and recurrent sinopulmonary infections  the yellow nail syndrome  yns  is described as a combination of yellow nails  chronic lymphedema  pleural effusions  and recurrent sinopulmonary infections  but all these features need not be present for the diagnosis  the mechanism that renders patients with this syndrome susceptible to respiratory infections is not known  to determine whether abnormal ciliary motility is a predisposing factor  in vitro ciliary beat frequency  cbf  was measured in two patients with yns and recurrent respiratory infections  in each case  the cbf was within normal limits  12 hz   these data suggest that abnormal ciliary motility is not a pathophysiologic mechanism of recurrent sinopulmonary infections in yns  
class8	manual ventilation bags as a source for bacterial colonization of intubated patients  a group of 14 intensive care unit  icu  patients were studied to determine if manual ventilation bags  mvb  could serve as a source of bacterial or fungal pathogens that could colonize the respiratory tract of intubated patients  a total of 51 cultures were simultaneously obtained of patient s sputum  the exterior mvb surface  mvb port  and mvb interior  postexhalation valve   pathogens colonizing or infecting the respiratory tract of intubated icu patients were frequently simultaneously present on the exterior surface of the mvb and inside the mvb port used to connect the mvb with the endotracheal tube  in addition  coagulase negative staphylococci and yeast were frequently present on the exterior surface of the mvb  the interior of the mvb was usually sterile  in three instances pathogens were isolated from the mvb before isolation from the patient s sputum  mvb may serve as a source for colonizing the respiratory tract of intubated icu patients and or the hands of medical personnel  the exterior surface and port of mvb should be cleaned of visible debris and disinfected at least once a day  
class8	differential roles of opioid receptors in respiration  respiratory disease  and opiate induced respiratory depression  in summary  these findings indicate the importance of designing future experiments that delineate between opioid and nonopioid forms of respiratory disease and dysfunction  and the need to identify means of diagnosing them in order to achieve successful recovery  apparently there is great diversity between animal species in terms of contributions of endogenous opioids to tonic control of ventilation  and future work should strive to identify which species is most appropriate as a model of human ventilatory control and disease  certain opioid receptor types appear to be linked to independent respiratory functions  for instance  mu receptors in the brain stem produce strong inhibitory actions on respiratory parameters  including rr  vt  ve  and co2 sensitivity  these effects have been observed in vivo and by electrophysiologic recordings in vitro  delta receptors may also exert some inhibitory effect on respiration  especially in the nts  in the cns  the ventral surfaces of the medulla and pons  especially the nts and na  seem to be important sites for opioid induced inhibition of respiration  whereas the spinal cord probably is not involved in opioid mediated ventilatory depression  kappa receptors appear to be devoid of respiratory depressant activity  whereas sigma receptors may stimulate some ventilatory parameters  morphine and similar pure mu agonists  such as fentanyl and oxymorphine  probably produce their analgesic and respiratory depressant effects through stimulation of mu receptors  mixed agonists antagonists that have mu antagonist  or partial agonist  activity plus kappa agonist and or sigma agonist activity show a ceiling effect for respiratory depression  future tests need to determine which opioid receptor may be responsible for the ceiling effect  in addition  the effects of mu  delta  kappa  and sigma selective agonists on hypoxic drive should also be determined  as a drug that stimulates hypoxic sensitivity in the face of hypercapnic depression may produce less overall respiratory depression due to counteractive effects  in the future  clinically optimal opiates should have more specificity of action than those available now  this may be achieved by creating drugs selective for single receptors or by creating drugs with desirable combinations of receptor selectivities  the combinations of mixed agonists antagonists with pure mu agonists currently in use today are promising  as they provide analgesia with reduced respiratory depression  in the early days of opiate research and development  combination drug regimens were thoroughly tested to determine the  ideal ratios  that would retain analgesic properties but not the other undesirable effects such as respiratory depression  196   abstract truncated at 400 words   
class8	lung lobe torsion following lobectomy  three cases of postoperative pulmonary lobe torsion were reported  two of three showed hemorrhagic infarctions  and as a result underwent rethoracotomies and removal of the affected lobes  from these experiences  we consider that computed tomography  ct  and bronchofiberscopic examinations are useful for the diagnosis of advanced torsion  
class8	clinical prediction rule for pulmonary infiltrates objective  to derive and validate a clinical rule for predicting pneumonic infiltrates in adult patients with acute respiratory illness  design  prevalence studies in three settings  setting  emergency departments of the university of illinois hospital at chicago  the university of nebraska medical center at omaha  and the medical college of virginia at richmond  patients  symptoms  signs  comorbidity data  and chest roentgenogram results were recorded for 1134 patients from illinois  the derivation set   150 patients from nebraska  and 152 patients from virginia  the validation sets   all patients presented to the emergency department and had a chest roentgenogram to evaluate fever or respiratory complaints  measurements and main results  within the training set  temperature greater than 37 8 degrees c  pulse greater than 100 beats min  rales  decreased breath sounds  and the absence of asthma were identified as significant predictors of radiographically proved pneumonia in a stepwise logistic regression model  p   0 001   the logistic rule discriminated patients with and without pneumonia in the training set with a receiver operating characteristic  roc  area of 0 82  in the validation sets  the rule discriminated pneumonia and nonpneumonia with roc areas of 0 82 and 0 76 after adjusting for differences in disease prevalence  p greater than 0 2 compared with the training set   the predicted probability of having pneumonia for patients with different clinical findings corresponded closely with the incidence of pneumonia among patients with such findings in the three settings  conclusions  among adults presenting with acute respiratory illness  a prediction rule based on clinical findings accurately discriminated patients with and without radiographic pneumonia  and was used in two other samples of patients without significant decrement in discriminatory ability  this rule can be used by physicians to develop more effective strategies for detecting pneumonia and for helping to determine the need for radiologic study among patients with acute respiratory disease  
class8	a clinical triad to diagnose paraneoplastic retinopathy  two elderly men developed photosensitivity and light induced glare  transient visual symptoms  and progressive visual loss several months before small cell carcinoma of the lung was discovered  both patients had impaired visual acuity and color vision  ring scotomas  and attenuated retinal arteriole caliber  electroretinography demonstrated abnormal cone and rod mediated responses  antiretinal antibodies were identified in their serum  their visual sensory function improved following therapy with immunosuppressive agents  the triad of photosensitivity  ring scotomatous visual field loss  and attenuated retinal arteriole caliber should alert one to a paraneoplastic disorder affecting the retina  
class8	latent sensitisation to respiratory syncytial virus during acute bronchiolitis and lung function after recovery  to determine whether latent sensitivity to respiratory syncytial virus antigen s  occurs after infection  27 infants with acute bronchiolitis were studied and compared with 15 hospital controls  blood was collected for whole blood challenge  and histamine release was measured by a high performance liquid chromatography technique with fluorometric detection  there was a significantly greater histamine release to respiratory syncytial virus antigen s  in those with bronchiolitis than in controls  expressed either in amount  median 154 nmol l compared with 104 nmol l  or percentage release  median 20  compared with 3    there was a significant difference between index and control groups in terms of individual histamine responses  these findings strongly suggest that infants develop latent sensitivity to respiratory syncytial virus antigen s  during the course of acute bronchiolitis  serial lung function tests were performed in 15 infants  all infants had abnormalities of lung function at some stage  but the small numbers of subjects precluded comparison between  sensitised  and  non sensitised  infants  further study is indicated to define the relation of latent sensitisation and subsequent bronchial hyper responsiveness after respiratory syncytial virus infection in infants  
class8	how curable is relapsed wilms  tumour  the united kingdom children s cancer study group  three hundred and eighty one children with wilms  tumour were treated on the united kingdom children s cancer study group wt1 study  1980 6   seventy one patients relapsed during or after treatment  which included surgery and chemotherapy  with irradiation depending on stage and histology  despite treatment with various combinations of chemotherapy  surgery  and radiotherapy there were only 17 survivors  for unfavourable histology  any stage  only two of 20 survive  we conclude that  after relapse  even for patients who have had localised disease and favourable histology  the  salvage  rate is little more than 50  and for all others the likelihood of cure is very small  three of 41 children who relapsed less than 12 months from diagnosis survive  compared with 14 of 30 who relapsed later  it is essential that even with this  good prognosis  tumour initial treatment is optimal and given by centres experienced in management of children s cancer  furthermore  there is a clear need for additional effective chemotherapeutic agents for relapsed patients  
class8	an unusual cause of thoracic mass  a previously well 10 year old boy presented with scoliosis  a mass in the chest wall  and a pleural effusion  chest radiography showed the triad of chronic consolidation  pleural effusion  and rib periostitis  investigations confirmed thoracic actinomycosis  tissue spread was evaluated by computed tomography  it was successfully treated with benzylpenicillin  which was later replaced by clindamycin  
class8	tumor necrosis factor alpha mediates acid aspiration induced systemic organ injury  acid aspiration induced systemic organ injury is mediated by the sequestration of activated neutrophils  pmn   in other settings cytokines have been shown to increase neutrophil endothelial adhesion  a requisite for injury  this study tests whether the systemic leukosequestration and permeability following localized aspiration is mediated by tumor necrosis factor  tnf  alpha induced synthesis of an adhesion protein  anesthetized rats underwent tracheostomy and insertion of a fine bore cannula into the anterior segment of the left lung  this was followed by the instillation of either 0 1 ml 0 1 n hci  n   18  or 0 1 ml saline in control rats  n   18   localized aspiration induced generalized pulmonary leukosequestration with 95 pmn 10 high power fields  hpf  in the aspirated lung and 46 pmn 10 hpf in the nonaspirated lung  higher than control values of 7 pmn 10 hpf and 5 pmn 10 hpf in saline  and nonsaline aspirated sides  respectively  p less than 0 05   the leukosequestration was associated with permeability edema shown by increased protein concentrations in bronchoalveolar lavage  bal  of 3900 micrograms ml in the aspirated and 2680 micrograms ml in the nonaspirated side  higher than saline with 482 micrograms ml and 411 micrograms ml  respectively  p less than 0 05   there was generalized pulmonary edema following aspiration measured by increase in wet to dry weight ratios  w d  of 6 6 in the aspirated and 5 1 in the nonaspirated lung  higher than control values of 3 5 and 3 4  respectively  p less than 0 05   localized aspiration led to systemic leukosequestration documented by increases in myeloperoxidase activity  units g tissue  of 2 2 and 1 7 in heart and kidney  higher than control values of 0 3 and 0 4  respectively  p less than 0 05   this event was associated with edema of these organs with w d ratios of 4 6 and 4 3  relative to control values of 3 0 and 3 4  p less than 0 05   treatment of animals  n   18  20 minutes after aspiration with anti tnf alpha antiserum  rabbit anti murine  but not normal rabbit serum  n   18  reduced lung leukosequestration in the aspirated and nonaspirated segments  61 and 32 pmn 10hpf   bal protein concentration  1490 and 840 micrograms ml   and w d ratio  4 3 and 3 7   all p less than 0 05   in the heart and kidney there were reductions in myeloperoxidase activity  0 7 and 0 6  and w d ratio  3 5 and 3 6   both p less than 0 05   treatment of rabbits  n   18  with the protein synthesis inhibitor cycloheximide  0 2 mg kg hr was as effective as tnf alpha antiserum in modifying aspiration injury  abstract truncated at 400 words   
class8	relief of tracheal compression by aortopexy  we have performed aortopexy in 12 children with tracheal compression  six infants had compression secondary to a vascular anomaly  group 1   and the other 6 had previous repair of esophageal atresia  group 2   eleven of the 12 children are alive after a mean follow up of 36 months  in group 1  1 patient died and 3 patients  50   experienced recurrent respiratory distress  five infants sustained a major postoperative complication  and the average postoperative hospital stay was 25 days  in group 2  however  aortopexy was uniformly successful  there were no deaths  no postoperative complications  and no cases of postoperative respiratory distress  and the mean postoperative hospital stay was only 10 days  for children with reflex apnea after repair of esophageal atresia  aortopexy is lifesaving and can be performed with minimal morbidity and mortality  great caution is indicated in children with tracheal compression from other causes  
class8	cor triatriatum  clinical presentation and surgical results in 12 patients  twelve patients with cor triatriatum have been seen at our institution since 1979  the clinical presentation  diagnostic evaluation  and surgical results are outlined in this retrospective review  operation is the treatment of choice for this rare congenital cardiac defect  one patient died 1 day before scheduled operation  and 2 patients died postoperatively  yielding a surgical mortality rate of 17  and an overall mortality rate of 25   resection of the obstructing atrial membrane was performed using hypothermic cardiopulmonary bypass in all cases  left atriotomy was performed in 6 patients  and right atriotomy was performed in 7  the two postoperative deaths occurred in patients who had serious associated cardiac defects  associated anomalies include atrial septal defect  persistent left superior vena cava  and partial anomalous pulmonary venous return  the postoperative course has been excellent in all 9 surviving patients  all remain asymptomatic  cor triatriatum is amenable to surgical repair with excellent results when diagnosed early and when not complicated by other severe cardiac anomalies  
class8	tracheal and main bronchial disruptions after blunt chest trauma  presentation and management tracheobronchial disruption is one of the less common injuries associated with blunt thoracic trauma  this injury can be life threatening  however  and failure to diagnose it early can lead to disastrous acute or delayed complications  nine cases of tracheobronchial disruption in the setting of nonpenetrating thoracic trauma were seen at four los angeles trauma centers between 1980 and 1987  mechanism of injury  presentation  diagnosis  and management of these patients were reviewed  disruptions involved the trachea in 3 patients  the right bronchus in 5 patients  and the left bronchus in 2 patients  tracheobronchial disruptions occurred in settings of high energy impact type injuries and were more likely to have associated injuries than they were to occur alone  common presenting signs included subcutaneous emphysema  dyspnea  sternal tenderness  and hemoptysis  radiographic findings were most commonly pneumothorax  pneumomediastinum  and clavicle or rib fractures  rigid bronchoscopy and fiberoptic bronchoscopy were both highly accurate methods for diagnosis but only in the hands of trained cardiothoracic surgeons  delay in diagnosis increased the likelihood of postoperative complications  
class8	complications after cardiac operations in patients with severe pulmonary impairment  the postoperative courses of 39 patients with severe lung disease  31 with obstructive disease and 8 restrictive  who underwent a cardiac operation were retrospectively reviewed  the stay in the intensive care unit of the study group was 7 9     10 3 days  mean     standard deviation  compared with 2 4     3 9 days for the control group  100 patients with less impaired pulmonary function   p less than 0 001   the study group also had a greater number of valve replacements than did the control group  p less than 0 01   patients with obstructive disease had more respiratory complications than did patients with restrictive disease  p less than 0 05   there were 21 cases of atelectasis  effusions were noted in 11 patients  ten patients had bronchospasm  bronchial secretions were a major problem in 6 patients  pneumonia developed in 4 patients  and pneumothorax occurred in 3 others  the two in hospital deaths were not directly related to pulmonary complications  our findings indicate that  1  patients with severe lung impairment generally do well after a cardiac operation but have more postoperative pulmonary complications than patients with less impairment   2  patients with restrictive pulmonary disease appear to fare better than those with obstructive disease   3  pulmonary function tests can alert the clinician to the possible risk of postoperative complications  but they cannot  by themselves  be used to exclude patients from operation  and  4  patients with severe pulmonary impairment facing valve replacement are at greater risk of pulmonary complications than patients having other types of cardiac surgical intervention  
class8	results in 104 patients undergoing bronchoplastic procedures for bronchial lesions  bronchoplastic procedures were used in 104 patients with various bronchial disorders  ten had benign lesions and 94  malignant tumors  the principal operative procedures were sleeve lobectomy and sleeve pneumonectomy for bronchogenic carcinoma  but 11 limited bronchial resections were performed in patients with benign lesions  minute bronchogenic carcinomas  and low grade malignant tumors  of the 94 patients with malignant tumors  79 underwent a bronchoplastic procedure without carinal resection  sleeve lobectomy in 75 and limited bronchial resection in 4   and there was one operative death  1 3    the overall 5 year survival rate for the patients with bronchogenic carcinoma in this group was 45  and that for patients undergoing curative resection  57   survival of patients in stages i  ii  and iiia was 79   55   and 30   respectively   a bronchoplastic procedure with carinal resection was performed in 15 patients  twelve in this group underwent sleeve pneumonectomy  there were two operative deaths  and 1 patient has survived for longer than 4 years  two patients with low grade malignant tumors underwent carinal resection without lung resection and are still alive  we believe that bronchoplasty is a safe and valuable procedure and that limited bronchial resection appears to be the procedure of choice for localized bronchial lesions  
class8	intraoperative bronchial aspiration of ruptured pulmonary hydatid cysts  ruptured pulmonary hydatid cysts are seen clinically and radiologically as persistent cavitary lesions of the lung  bronchi opening into the pericyst cavity allow for discharge of fluid matter but not the escape of solid remnants of the collapsed parasite  operative manipulation of the involved lung in the course of surgical management of chronic ruptured pulmonary hydatids can force fragments of the laminated membrane or small daughter cysts into the bronchial tree  such extruded solid fragments lodge in bronchi of the same or opposite lung with resulting acute obstruction of airways  intraoperative bronchial aspiration of hydatid material was seen in 7 patients with ruptured hydatid cysts of the lung  either primary or secondary to transdiaphragmatic extension of liver hydatids  the first clinical sign can be unexplained difficulty in ventilation  effective management consists of prompt exposure of the stem bronchus on the operative side  with bronchotomy for suction retrieval of escaped solid fragments of the parasite  
class8	swan ganz catheter induced massive hemoptysis and pulmonary artery false aneurysm  swan ganz catheter induced massive hemoptysis and later pulmonary artery false aneurysm occurred in a patient with prosthetic mitral regurgitation  this patient was successfully managed by double lumen endotracheal intubation  control of pulmonary hypertension  reversal of anticoagulation  mitral valve re replacement  and transcatheter embolization  the pertinent literature is reviewed  
class8	resection of the superior vena cava for primary lung cancer  5 years  survival  we describe a patient with squamous cell carcinoma of the right lung that required a resection of the superior vena cava combined with a tracheal sleeve pneumonectomy  the superior vena cava was totally replaced with a polytetrafluoroethylene graft with 115 minutes cross clamping of the superior vena cava  the patient remains healthy and the polytetrafluoroethylene graft remains patent 5 years 4 months after operation  
class8	spontaneous pneumothorax in patients with acquired immunodeficiency syndrome treated with prophylactic aerosolized pentamidine  spontaneous pneumothorax is a known complication of pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome  to evaluate the possible pathogenesis and natural history of pneumothorax in patients receiving aerosolized pentamidine prophylaxis  we retrospectively reviewed 327 outpatients positive for human immunodeficiency virus receiving aerosolized pentamidine  there were 12 spontaneous pneumothoraces in this group of patients  seventy five percent of patients with pneumothorax had roentgenographic evidence of fibrocystic lung parenchyma and clinical evidence of active pneumocystis pneumonia  the majority  83   required chest tube evacuation  there was a 50  mortality rate associated with this complication  these findings suggest that spontaneous pneumothorax in patients treated with aerosolized pentamidine most commonly represents a prophylaxis failure associated with a high mortality rate  
class8	acute renal failure due to ciprofloxacin  acute renal failure developed in three patients within a few days of starting ciprofloxacin hydrochloride therapy  an allergic interstitial nephritis was suggested by fever and eosinophiluria in one patient and by erythema multiforme in another  a kidney biopsy specimen confirmed this diagnosis in one patient  renal function improved shortly after withdrawal of the drug in all three patients  literature survey revealed an additional three patients with a similar complication  allergic manifestations  such as fever or rash  were a feature in most reported cases  in view of this potential complication  renal function should be closely monitored in patients receiving ciprofloxacin therapy  especially if other potentially nephrotoxic drugs are prescribed concomitantly  
class8	mucinous cystadenoma of the lung  a report of two cases with immunohistochemical and ultrastructural analysis  we describe two patients who presented with solitary pulmonary masses that consisted of unilocular cysts lined by columnar mucinous epithelium  the cysts contained copious mucus  the epithelial lining of the cysts showed foci of stratification and papillary infolding  histologically identical lesions have previously been termed unusual mucous cysts or mucinous cystadenomas  we believe that these tumors are true neoplasms differentiating toward the respiratory epithelial mucous cell  they should be distinguished from a variety of pulmonary neoplasms including bronchoalveolar carcinoma  bronchial mucous gland adenoma  mucoepidermoid carcinoma  and metastatic adenocarcinoma  
class8	pulmonary arteriolar muscularization in coal workers  pneumoconiosis and its correlation with right ventricular hypertrophy  the relationship between the thickness of the walls of small pulmonary arteries  the medial wall thickness as a percentage of external diameter  percentage of medial thickness  in coal miners and control subjects were studied using morphometric techniques and correlated with the degree of right ventricular hypertrophy  severity of coal workers  pneumoconiosis  emphysema  and other chronic lung diseases  pulmonary arteries less than 100 microns in external diameter were identified and the external diameter  medial thickness  and intimal thickness were quantitatively measured in the lung tissues of 57 coal miners and 15 control subjects with and without other chronic lung diseases  coal workers  pneumoconiosis  emphysema  and right ventricular hypertrophy were assessed uniformly in all cases  the arterial wall thickness correlated with right ventricular hypertrophy  progressive massive fibrosis  and other chronic lung diseases  severity of emphysema also showed a weak correlation  although the functional significance of these findings is not known  we conclude that the muscularization of pulmonary arterioles provides a structural basis for the development of right ventricular hypertrophy in coal miners  
class8	pulmonary blastoma with malignant melanoma component  pulmonary blastomas are rare primary tumors that consist of tubular or glandular structures embedded in an undifferentiated mesenchymal stroma  focal cartilage  bone  and skeletal muscle as well as squamous differentiation have been described in these tumors  we report a unique case of a pulmonary blastoma showing a malignant melanoma component  immunohistochemical stains for s100 protein and hmb 45 were positive in the areas of melanocytic differentiation  
class8	strapless oral nasal interface for positive pressure ventilation  a custom fabricated strapless oral nasal interface  soni  is described  it was used in the long term administration of intermittent positive pressure ventilation  ippv  by 18 patients with paralytic or restrictive pulmonary insufficiency  this interface is an acrylic shell which is firmly fixed to an orthodontic bite plate  it is designed to form a seal over the nose and mouth for the entry of ippv  eight patients were ventilator dependent 24 hours a day  the ten patients who required only nocturnal aid had improvement in daytime arterial blood gases  although nine of these patients could manage less than 15 minutes of unassisted breathing  free time  supine  all slept supine on soni ippv  the 13 patients who underwent sleep monitoring maintained a mean oxygen saturation of 95 3      1 7  and acceptable end tidal pco2  30 to 45 mmhg   these 13 patients have used soni ippv for an average of 22 months  range   3 to 63 months   impediments to successful long term use of a soni include the presence of a hyperactive gag reflex or stimulation of excessive oral secretions  when combined with mouth ippv  glossopharyngeal breathing  the intermittent abdominal pressure ventilator  or the cuirass ventilator for daytime use  soni ippv is an option for the patient who prefers total ventilatory support by noninvasive means  
class8	selection factors resulting in improved survival after surgical resection of tumors metastatic to the lungs  from 1973 through 1987  a total of 140 patients underwent 184 operations for removal of metastatic tumors to the lungs  the number of lesions removed ranged form one to 30  of the patients  44  had solitary lesions  overall 3 year survival was 62 6   and 5 year survival was 48 2   in all primary tumors except melanoma and breast cancer  3 year survival was greater than 50  and 5 year survival was greater than 40   with rare exceptions  the operation of choice for unilateral lesions was ipsilateral thoracotomy  and for bilateral lesions it was median sternotomy  adequate conservative resection was the rule  there were three pneumonectomies  25 lobectomies  71 single wedge resections  38 multiple unilateral wedge resections  and 47 bilateral wedge resections  there were no postoperative hospital deaths  cox covariate analysis demonstrated improved survival in patients whose largest lesion was less than 1 5 cm in diameter and with disease free interval longer than 1 year  but survival was not related to number of lesions or age of patient  an aggressive surgical approach is justified in patients with most primary tumors and a limited number of lung metastases less than 1 5 cm in diameter  resection of metastases from melanoma and breast cancer should be accomplished after other sites of metastatic disease have been ruled out by the most stringent criteria  
class8	metastatic carcinoma to the retina  clinicopathologic findings in two cases  two cases of metastatic carcinoma to the neuroretina are reported  one patient had an oat cell carcinoma of the lung that was metastatic to the brain and retina  this was confirmed postmortem  the other patient had metastatic breast carcinoma with seeding of tumor cells into the vitreous from a focus of retinal embolism  the diagnosis was confirmed from a vitrectomy specimen  
class8	critical volume for pulmonary acid aspiration  reappraisal in a primate model  we have studied  in the monkey  the critical volume for the production of severe pneumonitis following pulmonary aspiration of gastric contents  aspiration of 0 4 ml kg 1 and 0 6 ml kg 1 at ph1 produced mild to moderate clinical and radiological changes  but no deaths  aspiration of 0 8 ml kg 1 and 1 0 ml kg 1 at ph1 was associated with an increasingly severe pneumonitis  at 1 0 ml kg 1  50  of the animals died  a mortality rate considerably less than that reported previously in animal studies  if these results were to be extrapolated to humans  the critical volume for severe aspiration could be increased from 25 ml to 50 ml  0 8 ml kg 1   considerably reducing the percentage of patients perceived to be  at risk   
class8	effect of different rates of infusion of propofol for induction of anaesthesia in elderly patients  the effect of changing the rate of infusion of propofol for induction of anaesthesia was studied in 60 elderly patients  propofol was administered at 300  600 or 1200 ml h 1 until loss of consciousness  as judged by loss of verbal contact with the patient  had been achieved  the duration of induction was significantly longer  p less than 0 001  with the slower infusion rates  104  68 and 51 s   but the total dose used was significantly less  p less than 0 001  in these patients  1 2  1 6 and 2 5 mg kg 1  respectively   the decrease in systolic and diastolic arterial pressure was significantly less in the 300 ml h 1 group at the end of induction and immediately after induction  p less than 0 01   the incidence of apnoea was also significantly less in the slower infusion group  
class8	foam cuffed tracheal tubes  clinical and laboratory assessment  the efficiency of a foam cuffed tracheal tube has been studied in protecting the pulmonary tree from aspiration of oropharyngeal and gastric contents  following instillation of methylene blue dye above the cuff  subsequent fibreoptic bronchoscopy revealed no instance of dye staining of the tracheal mucosa  a  bench  study was undertaken subsequently to estimate the likely pressure that the cuff would exert on the tracheal mucosa as a result of elastic recoil properties of the foam  the results suggested that  under normal clinical conditions  the pressure is not likely to exceed a value at which impairment of the mucosal blood supply would occur  
class8	wegener s granulomatosis presenting during first trimester of pregnancy  we describe a case of wegener s granulomatosis in a lady who presented acutely with pulmonary haemorrhage  fever and breathlessness during her early pregnancy  she responded well to aggressive medical treatment  
class8	variations in urethral and bladder pressure during stress episodes in healthy women  pressure variations in the urethra and bladder during stress episodes and their time separations were investigated in 30 healthy female volunteers  the pressure was measured by means of a double microtip transducer catheter with the distal sensor in the bladder and the proximal sensor at the bladder neck  the mid urethra and the distal urethra  in advance of the pressure spike during cough a pressure rise was demonstrated in the bladder and at all 3 sites of measurement in the urethra  the urethral pressure increments preceding and following the pressure spike were statistically significantly higher in the mid urethra than the corresponding bladder pressures  this active urethral pressure generation in the mid urethra and distal urethra was initiated 200 ms before the bladder pressure began to rise  the pressure in the urethral high pressure zone was higher than the bladder pressure in all cases  passive pressure transmission to the urethral high pressure zone can take place only insignificantly due to a continuous higher pressure inside the urethra than in the bladder and due to the location of the high pressure zone in the demarcation of the abdominal cavity  it was concluded that the urethral pressure rise in the high pressure zone during stress episodes is mainly generated actively by intra  and or peri urethral structures  
class8	surgery in patients on long term steroid therapy  a tentative model for risk assessment  increased morbidity after operation has been associated with long term steroid therapy  to determine the correlation between steroid therapy and such morbidity  the perioperative course of 55 steroid treated patients was reviewed  27 had bronchopulmonary disorders  group p  and 28 had non pulmonary diseases  group np   there were six  11 per cent  deaths  of which three were steroid related  among the 13 non lethal postoperative complications  eight were considered to be steroid related in group p and one in group np  the duration of steroid therapy was for a median of 24 months  range 1 408 months  in group p and for a median of 6 months  range 1 240 months  in group np  p less than 0 01   in contrast  the daily dose of hydrocortisone or equivalent before operation was significantly lower in group p  with a median of 0 51 mg kg 1 day 1  range 0 20 2 56 mg kg 1 day 1  than in group np  with a median of 1 20 mg kg 1 day 1  range 0 23 7 38 mg kg 1 day 1   p less than 0 01   in conclusion  bronchopulmonary disorders requiring a long duration of steroid therapy are associated with a higher risk of steroid related complications after surgery  a convenient mathematical model is proposed which may allow a preoperative assessment of surgical risk  using steroid dose and duration of treatment  
class8	heterogenous amplification of myc family oncogenes in small cell lung carcinoma  one hundred forty two foci of small cell lung carcinoma  sclc  from 47 patients were examined for amplification of myc family oncogenes  c myc  n myc  and l myc   by dot blot hybridization using formalin fixed and paraffin embedded materials which were resected surgically or obtained at autopsy  some selected patients were also examined by in situ hybridization  amplification of myc family genes was detected in 11 patients  23 4    c myc in one  n myc in five  and l myc in five   two of the 11 patients  one with n myc and one with l myc  had heterogenously amplified clones  in the patient with n myc amplification  amplification was detected in metastatic tumors in the pancreas  lung  and pleura  but not in the liver and lymph node metastases  in the primary tumor  areas with and without n myc amplification were seen  in the patient with l myc amplification  although amplification was not detected in the surgically resected primary lesion  mediastinal lymph node metastatic lesions obtained at autopsy showed l myc gene amplification  these two cases  together with previously reported evidence  suggest that myc gene amplification plays an important role in malignant progression  rather than development  of sclc  in stage iii and iv groups  patients with over ten fold myc gene amplification were suggested to survive for a shorter time than patients without such amplification  p   0 06   
class8	identification of somatostatin receptors in human small cell lung carcinoma  biopsy specimens obtained from eight patients with lung cancer were tested for content of somatostatin receptors by autoradiography  somatostatin receptors were detected in two of three patients with small cell lung cancer  sclc  but in none of five patients with non small cell lung cancer  nsclc  including adenocarcinoma  two   squamous cell carcinoma  two   and bronchoalveolar carcinoma  one   in those with sclc  specific somatostatin receptor binding was evidenced only in tumor foci and not in surrounding stroma or normal lung parenchyma  further tissue characterization by immunoperoxidase staining with the pancytokeratin monoclonal antibody  mab lu 5  revealed labeling to all of the nsclc but to none of the sclc specimen  selective immunoreactivity was detected in both the sclc and the nsclc specimen to chromogranin and neuron specific enolase  nse  whereas none of the specimen had detectable immunostaining to somatostatin  bombesin  serotonin  adrenocorticotropic hormone  neurofilament  calcitonin  and synaptophysin  the identification of somatostatin receptors in primary human lung cancer may have a bearing on the biology of this disease and perhaps on the clinical application of somatostatin analogues in patients with sclc  
class8	nasal lymphoma  a retrospective analysis of 60 cases  sixty cases of nasal lymphomas were reviewed  there were 42 men and 18 women  the median age was 49 years  the histologic types were low grade in four cases  intermediate grade in 33  high grade in seven  and unclassifiable in 16  thirteen cases had features of polymorphic reticulosis  the immunophenotype was available in 18 cases and a majority of 67  of them were t cell  forty one of them  68   had clinically localized  stage i and ii  disease which often spread locally to neighboring tissues and they presented predominantly with nasal symptoms  nasal lymphoma appeared to carry a poor prognosis  although our patients with clinically localized disease had significantly better prognosis than those with advanced disease  the 5 year survival of stage i and ii patients was only 55   chemotherapy did not appear to be more effective than radiotherapy alone in preventing relapses but the patient number was too small to allow a firm conclusion to be made  patients with advanced disease had even poorer prognosis with a 5 year survival of only 17   innovative therapy has to be developed for these patients  
class8	chemotherapy related hemolytic uremic syndrome after the treatment of head and neck cancer  a case report  a 62 year old woman who was being treated for squamous cell carcinoma of the head and neck developed a chemotherapy related hemolytic uremic syndrome during the second cycle of neoadjuvant chemotherapy consisting of cisplatin  bleomycin  and methotrexate  though the syndrome was suspected early  attempts at reversing the hematologic and renal abnormalities were unsuccessful  at postmortem examination  the characteristic microvascular lesions of the hemolytic uremic syndrome were found in the kidneys  
class8	primary carcinoma of the upper urinary tract  effect of primary and secondary therapy on survival  the pathologic material and medical records of 76 patients with primary upper urinary tract carcinomas were reviewed to identify the role of grade and stage in predicting survival  to determine any differences in survival between ureteral and renal pelvic carcinoma  to understand the role of local therapy in low grade  low stage tumors  and to establish the usefulness of adjuvant therapies in metastatic disease  kaplan meier survival curves with cox mantel analysis for statistical significance revealed both grade and stage to be excellent predictors of survival  no differences in survival were noted between renal pelvic and ureteral carcinomas for equivalent stage tumors  for low grade  low stage tumors  although there was an increased risk of local recurrence with local therapy  there were no differences in survival between patients treated with local therapy or radical surgery  finally  cisplatin based chemotherapy seemed to improve survival in patients with metastatic disease  
class8	thromboembolism  a complication of weekly chemotherapy in the treatment of non hodgkin s lymphoma  in a retrospective survey of 85 patients who received chemotherapy as treatment for non hodgkin s lymphomas  the authors found that clinically apparent thromboembolic disorders occurred in four of 11 patients receiving weekly chemotherapy  and in none of 74 patients who were treated on less intensive schedules  suggesting that intensive weekly chemotherapy is thrombogenic  the possible mechanisms of this effect are discussed  
class8	unusual case of pacemaker lead migration  pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts  we report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism  while being treated with intravenous cefuroxamine  the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent left pulmonary embolism  
class8	left ventricular ejection fraction may not be useful as an end point of thrombolytic therapy comparative trials  in the era of comparative and adjunctive trials in reperfusion therapy  the need to develop alternative end points for mortality reduction is clear  left ventricular ejection fraction  which has been commonly used as a surrogate  is problematic due to missing values  technically inadequate studies  and lack of correlation with mortality results in controlled reperfusion trials performed to date  in this paper  we present a composite clinical end point that includes  in order  severity of adverse outcome death  hemorrhagic stroke  nonhemorrhagic stroke  poor ejection fraction  less than 30    reinfarction  heart failure  and pulmonary edema  such a composite index may be useful to detect true therapeutic benefit in reperfusion trials without necessitating greater than 20 30 000 patient enrollment  
class8	peak flow nasal patency indices and self assessment in septoplasty  the present study evaluates the results of septoplasty monitored by the objective peak flow nasal patency indices and the subjective patient self assessment scores of nasal obstruction  mini wright peak flow meters were used  the peak flow nasal patency index was defined as the ratio between nasal and oral peak flow rates  uni and bi lateral  as well as ex and in spiratory  indices were calculated  both peak ex and in spiratory flow nasal patency indices were significantly increased 1 and 6 months post operatively  indicating improved nasal patency  the most marked post operative increase of the nasal patency indices was seen for the preoperatively worst airway and the total airway  a weak significant positive correlation was found between the peak flow nasal patency indices and the patient mean self assessment scores of the uni and bi lateral nasal obstruction  the change of the peak flow nasal patency indices measured 6 months post operatively correlated well with the patient overall assessment of the operative changes of the total nasal patency  the method was found quick and easy to handle in monitoring the effect of functional septoplasty and is recommended as an alternative to rhinomanometry  
class8	trimming of the inferior turbinates  a prospective long term study  the aim of this study was to determine whether the initial benefits of radical trimming and anterior trimming of the inferior turbinates on nasal airflow persisted in the long term  radical trimming significantly reduced nasal resistance at 2 months following operation  n   12   p less than 0 005   there was no significant change in nasal resistance over the next 20 months  symptom scores for nasal obstruction also showed a significant reduction  n   16   p less than 0 005   at 2 months  and did not change significantly over the next 20 months  radical trimming of the inferior turbinates is a highly effective operation in patients with hypertrophy of the inferior turbinates with few initial complications  however  further analysis of the data revealed that up to 20  of patients lose the initial subjective benefit of relief of nasal obstruction within 2 years of follow up  late onset crusting occurs in some patients though this is not directly attributable to an increase in nasal airflow  this study also concludes that anterior trimming of the inferior turbinates cannot be recommended as a form of treatment  
class8	chest infection following head and neck surgery  a pilot study  this paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery  the overall rate of chest infection was 11   but was 20  in those patients having a tracheotomy  no infection developed in patients with an intact airway  other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake  we recommend that prophylactic antibiotics be continued for at least 48 h in patients requiring a tracheotomy as part of their head and neck surgery  this is against the trend of shorter antibiotic regimens recommended for prevention of wound infections  
class8	acute respiratory failure  pregnancy entails many unique physiologic changes that make the management of ards both challenging and unique  most of these women are young and in excellent health before their acute injury  and their survival should exceed that of the general population who develop ards  we advocate aggressive management of the suspected lung injury including early intubation and the institution of invasive hemodynamic monitoring  this approach ensures the most thorough assessment of the extent of the initial injury and allows rapid assessment of therapeutic maneuvers and their subsequent adjustment  our goal is to reverse the initial insult early while avoiding further iatrogenic injury  optimal management of the maternal fetal pair requires the cooperation of an obstetrician well versed in cardiopulmonary physiology and physicians skilled in intensive care medicine  
class8	mechanical measures in the prophylaxis of postoperative thromboembolism in total knee arthroplasty  total knee arthroplasty patients are at high risk for deep venous thrombosis and pulmonary embolism  prophylaxis against deep venous thrombosis and pulmonary embolism in these patients seems mandatory  pharmacologic agents such as dextran 40  aspirin  and warfarin are effective but may be associated with significant complications such as drug reaction  bleeding  hematoma  and hemarthrosis  heparin was not effective and was associated with significant bleeding complications  mechanical methods such as continuous passive motion and sequential pneumatic compression stockings were without complications and seemed equal to or more effective than pharmacologic agents  adding warfarin to mechanical methods did not seem to augment the antithromboembolic effect of the mechanical methods  
class8	does alternate day cloprednol therapy prevent bone loss  a longitudinal double blind  controlled clinical study  osteoporosis is a serious side effect of systemic treatment with steroids  cloprednol  a synthetic glucocorticoid with an anti inflammatory potency twice that of prednisone  causes less calcium and nitrogen excretion than does prednisone in equipotent doses  therefore a double blind study was undertaken comparing the effects of alternate day cloprednol and prednisone therapy on bone mineral density in 39 patients  cloprendol  13 men and 8 women aged 48 5     2 8 years  prednisone  9 men and 9 women aged 49 7     1 7 years  with lung diseases  ten patients with asthma  9 men and 1 woman aged 37 8     3 7 years  inhaling daily beclomethasone served as control subjects  trabecular and total bone density of the distal tibia and radius was determined quarterly during 1 year with a special purpose computed tomographic system  initial mean trabecular bone density of the patients receiving cloprednol and prednisone was 17  below normal  after a treatment period of 1 year  we found a loss of radial trabecular bone density  mean     sem  of 1 33      0 49  in the cloprednol group and 2 38      0 69  in the prednisone group  in postmenopausal women  prednisone but not cloprednol therapy caused significant  p less than 0 01  trabecular bone loss  5 29      0 99  versus 0 70      0 65    the control group lost 0 91      0 79   loss of cortical bone was insignificant in all three groups  in post menopausal women  1 year of alternate day cloprednol therapy was associated with significantly less bone loss than was prednisone therapy in equipotent dosages  
class8	community acquired pneumonia  evidence of functional inactivation of alpha 1 proteinase inhibitor  quantitative and qualitative elastase inhibitory capacity  eic  alpha 1 proteinase inhibitor  alpha 1 pi  was measured in pulmonary arterial and systemic arterial blood of patients with community acquired pneumonia  cap   eleven patients with uncomplicated cap were compared with 16 patients with fulminating pneumonia requiring intensive care management  an appropriate increase in quantitative alpha 1 pi was demonstrated in all patients  a significant functional inactivation of alpha 1 pi was demonstrated in the icu treated patients that was not apparent in the uncomplicated cap patients  p less than  01   this low eic returned to normal 4 wk after hospital discharge in all survivors  a significant  p less than  02  difference in eic between the pulmonary arterial and systemic arterial blood was found in the nonsurvivors on admission  which suggests that alpha 1 pi is inactivated in the lungs of patients with fulminating cap  the present data demonstrate that alpha 1 pi is functionally inactivated in patients with fulminating cap  this low serum functional alpha 1 pi may result in proteolytic lung damage and an unfavorable outcome  
class8	tracheostomy in children with guillain barre syndrome during the 10 yr period beginning january 1979  59 infants and children with guillain barre syndrome  gbs  were admitted to our hospital  tracheostomies were performed in 15 patients and their records were reviewed  fourteen patients were recalled for assessment of pulmonary function and respiratory muscle strength  rms   the median duration of assisted ventilation  including endotracheal  et  intubation  was 21 days and the median duration of tracheostomy was 39 days  only two patients were discharged with the tracheostomy in situ  all patients were successfully decannulated at the first attempt  no tracheostomy related complications or symptoms were reported apart from croup in two patients  on review  lung volumes and maximal inspiratory and expiratory flows were normal  there was no evidence of tracheal stenosis or significant tracheomalacia  rms tests were normal  in this hospital  tracheostomy is a safe  well tolerated procedure in the management of infants and children with gbs who need long term ventilation  there were no deaths and all patients returned to their normal school or were gainfully employed after their illness  although 12 patients had mild persistent weakness of at least foot dorsiflexion  
class8	prevention of nosocomial lung infection in ventilated patients  use of an antimicrobial pharyngeal nonabsorbable paste  a comparative  prospective study was made of the incidence of infection in the lower airway  purulent tracheobronchitis and pneumonia  in long term patients who were mechanically ventilated due to respiratory failure of noninfectious origin  twenty eight patients were randomly allocated into a study group  a  n   13  in which a nonabsorbable paste containing 2  tobramycin  2  amphotericin b  and 2  polymyxin e was administered locally to decontaminate the oropharynx  and a control group  b  n   15  in which a paste without antibiotics was also applied to the oropharynx  we studied the effectiveness of the prophylactic technique in decontaminating the oropharynx and trachea of organisms potentially pathogenic for the respiratory system  decontamination was successful in ten of 13 patients in group a vs  one of 15 patients in group b  p less than  001   the results demonstrated a lower rate of infection in the lower respiratory tract in the study group  three patients with tracheobronchitis and no pneumonias  than in the control group  three patients with tracheobronchitis and 11 with pneumonia   the difference between both being highly significant  p less than  001   two  15   patients in group b developed sepsis of pulmonary origin  none of the patients on prophylactic treatment developed this complication  although the overall mortality was similar in both groups  group a  30  vs  group b  33    we believe that infection contributed to a great extent to the death of two of five patients in group b  we conclude that nosocomial pneumonia  which is a frequent complication in critically ill patients on mechanical ventilation  could be prevented by local application of nonabsorbable antibiotics to the oropharynx  
class8	iatrogenic illness in pediatric critical care  iatrogenic illness may be an important determinant of the need for pediatric intensive care  we prospectively evaluated consecutive admissions to a pediatric icu  picu  over two time periods totaling 6 months  twenty five  4 6   admissions were necessitated by iatrogenic illnesses  drug induced conditions accounted for eight  32   of the iatrogenic patients  and complications of medical surgical acts accounted for 17  68    diagnoses included six respiratory failures due to seizure medications  six chronic upper airway complications of neonatal intensive care  four posttonsillectomy and postadenoidectomy complications  two chronic postcardiac surgery complications  two cardiac catheterization complications  and five miscellaneous conditions  one  3 7   patient with iatrogenic illness died  as a group  patients with iatrogenic illness were at a risk of dying similar to other patients  we conclude that iatrogenic illness is a significant cause of picu admission  
class8	high frequency oscillation during simulated altitude exposure  ventilatory requirements using high frequency oscillation  hfo  during simulated altitude exposure were investigated in control dogs and animals with oleic acid induced lung injury  fio2 values of 0 21 and 1 0 were supplied by bias flow to the normal and injured dogs  respectively  after a control period  animals were exposed to a simulated altitude of 8 000 ft  barometric pressure 564 torr   followed by a second control period at ground level  both experimental groups had similar values of paco2 at ground level and during exposure to reduced barometric pressure  the tidal volume necessary to maintain eucapnia was higher in oleic acid injured animals compared with the control group  cardiac output and functional residual capacity were lower  the alveolar arterial oxygen difference was substantially larger in the oleic acid group  adequate gas exchange can be maintained with hfo during exposure to altitude provided that ventilation and inspired po2 are not reduced below normobaric levels  
class8	undiagnosed tuberculosis in patients with human immunodeficiency virus infection we describe the clinical features of 11 patients with human immunodeficiency virus infection in whom tuberculosis was undiagnosed and untreated prior to death  most patients  9 of 11  had pulmonary complaints and 8 of 11 had roentgenographic findings suggestive of tuberculosis  hilar or mediastinal adenopathy  pleural effusion  apical infiltrate or miliary pattern   despite these findings  tuberculin skin tests were not performed in any of the patients  acid fast smears of sputum were obtained in three cases and bronchoscopy performed in only four  reflecting the low index of suspicion for tuberculosis  pneumocystis carinii pneumonia was the presumptive diagnosis in nine cases but was confirmed in only one case  autopsy revealed tuberculosis as the cause of death in four patients  of the seven patients who did not undergo autopsy  disseminated tuberculosis  manifest by mycobacteremia  was the only life threatening illness identified and probably contributed to death  increased awareness of the clinical and roentgenographic features of tuberculosis in hiv infected patients  combined with more intensive use of acid fast smears and tuberculin skin testing  are necessary in order to decrease mortality from this treatable complication of hiv infection  
class8	pulmonary manifestations of disseminated cryptococcosis in patients with aids  forty eight patients with disseminated cryptococcosis and aids were retrospectively studied to define the pulmonary manifestations  cryptococcus neoformans  cn  was first isolated from a pulmonary site in 12 patients  disseminated disease was subsequently documented in all these patients  symptoms and roentgenographic manifestations  normal  nodular circumscribed infiltrates  pleural effusions  lobar consolidation  were diverse  interstitial infiltrates predicted the presence of another opportunistic lung infection besides cryptococcosis in five patients  three untreated and two treated patients   infectious causes other than cryptococcosis were established by culture and clinical course in five of the ten patients who developed chest roentgenographic abnormalities during amphotericin b therapy  endobronchial abnormalities were identified in four patients at bronchoscopy  bronchoalveolar lavage  9 9  and pleural fluid  3 3  cultures were sensitive tests for detection of pulmonary involvement with cn  
class8	mortality from pulmonary embolism in the united states  1962 to 1984  to examine the effect of advances in the prevention of and therapy for pe  we reviewed mortality for pe in the united states from 1962 to 1984  age adjusted pe mortality increased by 67 to 100 percent between 1962 and 1974 for white and non white men and women  from 1975 to 1984  these rates declined by 20 to 28 percent  non white pe mortality was greater than white pe mortality  men had a greater risk of pe death than women  age specific patterns  more than 40 years of age  of pe mortality followed those of the age adjusted death rates  with increases noted in all groups between 1962 and 1974 and declines during the 1975 1984 period  these patterns might reflect improved ascertainment of cases and better prevention of disease  the magnitude of the rates suggests that the list of indications for prophylactic anticoagulation should be re examined for possible expansion  
class8	exercise performance of polycythemic chronic obstructive pulmonary disease patients  effect of phlebotomies  the purpose of this study was to determine the effects of phlebotomy on the exercise tolerance and right and left ventricular ejection fraction of polycythemic patients with chronic obstructive pulmonary disease  ten patients with copd  mean fev1   1 32     0 55 l  and polycythemia  mean hct   62     3 percent  were studied before and after their hematocrits had been reduced to approximately 50 percent  post phlebotomy the maximal oxygen consumption increased from 1 09     0 34 l min to 1 26     0 43 l min  p less than 0 05  and the maximum workload increased from 56 5     32 6 watts to 74 5     23 4 watts  p less than 0 05   the increase in the exercise tolerance appeared to be primarily due to an increased cardiac output at emax  there was no relationship between the increases in the upright exercise capacity and changes in the supine ejection fractions of the right or left ventricular either at rest or during exercise  
class8	quality of well being before and after antibiotic treatment of pulmonary exacerbation in patients with cystic fibrosis  general quality of life has only recently been measured with an objective tool in patients with cystic fibrosis  cf   and there have been no reported attempts to document changes in patients  overall well being over time  as patients deteriorate or respond to intervention  we applied the quality of well being scale  qwb  in 28 patients with cf before and after a two week course of oral ciprofloxacin used to treat pulmonary exacerbations  there were significant correlations between changes in qwb and various pulmonary function test results  qwb vs fev1  r   0 4  p less than 0 03  qwb vs fvc  r   0 5  p less than 0 01  and qwb vs sao2  r   0 4  p less than 0 05  thus  the qwb can track changes in general well being in cf patients over a brief time and detect changes associated with pulmonary exacerbation and its treatment  
class8	subpleural mononuclear cell infiltration  significance in the differential diagnosis of pleuritis showing nonspecific histologic findings  to determine if patients who had lymphocyte rich pleural effusion and a pleural biopsy without any specific findings could be histopathologically differentiated between those with tuberculous and nontuberculous pleuritis  we histologically re evaluated the pleural biopsies of all patients whose pleural effusion was predominant with lymphocytes and contained no malignant cells  a total of 40 patients with a nonspecific histologic findings of pleural biopsy specimen were categorized based on their ultimate diagnosis as having tuberculous  n   15   carcinomatous  n   10  or nontuberculous  benign pleuritis  n   15   the pleural biopsy specimen of patients with nontuberculous  benign pleuritis frequently showed a band like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate  10 out of 15 patients   while the same finding was infrequent in those with tuberculous pleuritis  0 out of 15  p   0 0001  and pleuritis associated with carcinoma  three out of 10  p   0 082   based on these results  the presence of band like infiltration of mononuclear cells in the subpleural adipose tissue with minimal pleural inflammatory infiltrate in pleural biopsy specimens of patients with lymphocyte rich pleural effusion suggests that the pleuritis is nontuberculous in its nature  
class8	bronchial cartilage alterations in lung transplantation  changes in the hyaline cartilage of the proximal bronchial tree were investigated in a group of combined heart lung and double lung recipients with and without ob  ossification  calcification and fibrovascular ingrowth into the normally avascular hyaline bronchial cartilage were observed in almost all patients and were independent of small or large airway inflammation  alterations in the integrity of hyaline cartilage have been produced by others in animals by ligation of the blood supply  finding similar changes in airway cartilage of all transplanted lungs argues that there is relatively poor perfusion to the proximal air conducting passage  such a mechanism may contribute to the development of ob  bronchiectasis and a predilection for infections following pulmonary transplantation  
class8	hypothyroidism and pleural effusions  serous effusions have been thought to be an unusual complication of hypothyroidism and most commonly have been associated with ascites  pericardial fluid and heart failure  pleural fluid as an isolated finding in hypothyroidism is apparently rare and complete analysis of these hypothyroid associated pleural effusions has not been described  to determine the frequency  chemical characteristics and clinical associations of hypothyroidism and pleural effusions  the medical records of 128 patients with hypothyroidism  defined by an increased serum tsh concentration  were reviewed  the majority of effusions in patients with hypothyroidism were due to other diseases  effusions solely due to hypothyroidism appeared to be a real entity  these effusions were borderline between exudates and transudates and showed little evidence of inflammation  
class8	hyperresponsiveness of the extrathoracic airway in patients with captopril induced cough it has been suggested that cough from captopril may originate from an increased sensitivity of receptors in the extrathoracic airway  ea   to explore this hypothesis  we assessed the responsiveness of ea and bronchi and the cough sensitivity to inhaled histamine in nine hypertensive patients with captopril induced cough  group 1  during treatment and one month after withdrawal of the drug treatment  nine patients who were asymptomatic while receiving captopril  group 2  and nine patients receiving no current treatment  group 3  served as controls  the ea responsiveness was assessed by using the maximal midinspiratory flow  mif50  as an arbitrary index of ea constriction and was expressed as the histamine concentration causing a 25 percent decrease in mif50  pc25mif50   pc15fev1 was the index of bronchial responsiveness and pccough  dose causing five or more coughs  was that of cough sensitivity  airway hyperresponsiveness  ea hr or bhr  was diagnosed when pc25mif50 or pc15fev1 were 8 mg ml or lower  patients with captopril cough  as compared with controls  had significantly lower values of pc25mif50  pc15fev1  and pccough  ea hr and bhr were found  respectively  in seven and three of these patients and in none of the control subjects  in all the patients of group 1  cough and ea hr resolved after withdrawal of captopril treatment  while bhr persisted in one  pc25mif50  pc15fev1  and pccough were all significantly improved  our findings suggest that cough during captopril therapy may originate from receptors in the ea  
class8	the entrainment of low frequency breathing periodicity  it has been predicted by mathematical models of the respiratory control system that the delay between the lung and the respiratory controller may determine the cycle time found in periodic breathing  we examined cycle time of periodic breathing and circulation time in 11 patients known to have circulation delay due to heart failure  we did not find a significant relationship between the amount of periodic breathing and circulation delay  but found a very high correlation between circulation delay and the cycle time of periodic breathing  r2   0 825  p   0 0001   
class8	bronchoalveolar lavage in liquid paraffin pneumonitis  we evaluated cells and lipids recovered in the bronchoalveolar lavage fluid from seven patients with liquid paraffin pneumonitis  for each patient  the balf was whitish with oil droplets on the surface  alveolar macrophages contained numerous  large vacuoles that did not react with may grunwald giemsa  papanicolaou  or periodic acid schiff but were stained in black with sudan b  orange with sudan iii and red with oil red o  liquid paraffin was identified on thin layer chromatography of balf extracted lipids as a very hydrophobic compound migrating on the solvent front as control liquid paraffin  this abnormal spot was definitely identified as liquid paraffin by infrared spectroscopy and gas liquid chromatography for the first patient  the number and percentage of ams were largely decreased in the balf of each patient  whereas the number of neutrophils  eosinophils and lymphocytes was increased  these findings suggest that this cell mediated inflammatory response plays a role in the development of interstitial fibrosis at late stages of liquid paraffin pneumonitis  
class8	feasibility of intraoperative cytodiagnosis of lung cancer  of 354 thoracotomies  114 cases involved intraoperative cytopathologic evaluation  the study included 86 men and 28 women  and 184 specimens were examined  smears were taken from the lung lesion or lymph node and the chest wall or bronchial stump by imprint or needle aspiration  intraoperative evaluations were compared with histologic findings  in 85 cases not diagnosed as malignant preoperatively  malignancy was confirmed in 97 6 percent of cases and histologic type in 71 8 percent  in the 28 cases diagnosed as malignant preoperatively  there was only one false negative  the most important finding during thoracotomy is whether a lesion is malignant or not  the time required to obtain a pathologic diagnosis also is important  we are able to obtain the results of a cytologic diagnosis within 10 min  cytologic diagnosis of malignancy during thoractomy may be a feasible and convenient method of diagnosis  especially where malignancy is suspected  
class8	concentration of tumor associated trypsin inhibitor  tati  in pleural effusions  we measured the concentration of tumor associated trypsin inhibitor  tati  in plasma and pleural fluid of 84 patients with pleural effusions of various causes  we observed elevated  greater than 30 micrograms l  tati levels in pleural fluid in 45 percent of patients with pleural effusion associated with malignant disease and in 15 percent of patients with benign disease  similar results were obtained for tati in plasma  the concentration of tati in pleural fluid closely parallelled that in plasma  in patients with renal insufficiency and in patients with biliary obstruction  the tati levels were elevated both in plasma and pleural fluid  a positive correlation was seen between the concentration of tati and the activity of alkaline phosphatase in plasma  the results show that simultaneous determination of tati in plasma and pleural fluid improves the diagnosis of cancer only marginally  our results also support the hypothesis that elevated tati levels may reflect an acute phase reaction caused by inflammatory disease or tissue destruction associated with cancer not only in inflammatory conditions  but also in malignant disease where the tumor itself is not producing tati  
class8	neural respiratory drive and neuromuscular coupling in patients with chronic obstructive pulmonary disease  copd   in 15 spontaneously breathing patients with chronic obstructive pulmonary disease  copd  divided into two groups  one with normocapnia  a  and one with chronic hypercapnia  b   we evaluated the maximal voluntary inspiratory muscle strength  mip   the pattern of breathing  the mouth occlusion pressure  po 1   the neural respiratory drive  nrd   assessed by surface electromyographic  emg  activity of the diaphragm  emgd  and emg activity of intercostal muscles  emgint   and the chest wall neuromuscular coupling  assessed in terms of po 1 emgd ratio  compared with an age matched normal control group  both a and b groups exhibited lower mip  significantly greater emgd and emgint  and lower po 1 emgd ratio  however  a similar pattern  along with a rapid and shallow breathing  differentiated group b from group a  in group b we found a significant direct relationship between po 1 emgd ratio and mip  and an inverse relationship between paco2 and po 1 emgd ratio  these data seem to indicate the following   1  emg is a more precise method than po 1 in assessing the magnitude of the nrd   2  nrd is increased in these patients  and  3  clinical manifestations probably associated with inspiratory muscle fatigue  marked decrease in muscle strength  rapid and shallow breathing  and alveolar hypoventilation  may be accompanied by a greater nrd and a more marked derangement in chest wall neuromuscular coupling in copd  
class8	determinants of cell type in patients with cancer of the lungs  in order to evaluate the determinants of cell type in patients with primary lung cancer  we compared smoking characteristics in 1 939 patients  1 474 men and 465 women   patients with squamous cell carcinomas  adenocarcinomas  or small cell carcinomas were eligible  this study did not consider smoking as a risk factor for lung cancer  as all subjects had a confirmed diagnosis  we were interested in smoking history and the pattern of smoking among those whose risk was 100 percent  among these patients  we confirmed that a larger subset of nonsmoking individuals developed adenocarcinomas than squamous cell or small cell carcinomas  however  the duration and intensity of cigarette smoking  as measured by pack years  were not determinants of tumor cell type in male patients  small cell carcinomas in women were more strongly associated with cigarette smoking than either squamous cell carcinomas or adenocarcinomas  more than 3 500 different substances have been measured in tobacco smoke  including tumor initiators  promoters  and those involved in tumor progression  these data confirm the hypothesis that factors other than cigarette smoking are more likely to be involved in the initiation of adenocarcinomas than other cell types  endogenous and exogenous factors related to gender may be more important than the duration or intensity of cigarette smoking  
class8	real and pseudo late asthmatic reactions after submaximal exercise challenge in patients with bronchial asthma  a new definition for late asthmatic responses after exercise challenge  the late asthmatic reaction after exercise challenge remains a controversial issue  in this study  21 patients recorded peak expiratory flow rate  pefr  on two control days without performing exercise  there was no difference between both control days when pefr at 1 h was compared with baseline pefr and when pefr at 4 to 13 hours was compared with baseline pefr  after analyzing variation coefficients of baseline pefr on a control day and exercise day  pefr was not allowed to differ more than 15 3 percent in the same patient when comparing exercise day and control day for the late fall in pefr in the study  in 17 of 81 patients  a late asthmatic reaction after exercise challenge was present when pefr fall was greater than or equal to 20 percent compared with baseline pefr value  in eight of the 17 patients  a real late asthmatic reaction to exercise challenge was present with a pefr fall greater than or equal to 20 percent on at least three successive time points and who had a pefr fall greater than or equal to 20 percent compared with corresponding clocktime on a control day  the late asthmatic reaction to exercise challenge is characterized not as a nonspecific epiphenomenon  but as a fall in pefr of greater than or equal to 20 percent compared with baseline pefr value and with corresponding clocktime on a control day on at least three successive time points  graphic illustration of airway responses following exercises may facilitate the detection of a late asthmatic response  
class8	permeability pulmonary edema following lung resection  the etiology of edema associated with pulmonary resection was investigated in five patients during the immediate postoperative period  three patients received pneumonectomy while two patients had one lobe resected  all patients suffered from severe respiratory distress and had x ray evidence of diffuse interstitial pulmonary edema within 12 hours of surgery  hemodynamic data were obtained with radial and pulmonary artery catheters  edema fluid was obtained along with blood samples for simultaneous determination of protein and albumin content  all patients studied had normal or high cardiac output  normal cardiac filling pressures  and edema fluid protein to serum protein ratio of 0 6 or greater suggestive of permeability changes contributing to edema fluid accumulation  calculated shunt fraction exceeded 25 percent in all patients  pulmonary edema has been noted in patients following pulmonary resection in the early postoperative period  in patients reviewed here  two factors appeared to be significant  first is an increase in pulmonary capillary pressure associated with passage of a normal to high cardiac output in a reduced volume pulmonary vascular bed  the second factor  as demonstrated by protein content in the edema fluid  is injury to the alveolar capillary membrane  
class8	hemoptysis in a 49 year old man  an unusual presentation of a sporadic disease  although amebiasis is prevalent in tropical and subtropical areas  it occurs sporadically in the united states  pleuropulmonary involvement is seen in about 20 percent of the patients with amebic liver abscesses  we describe a patient with pleuropulmonary amebiasis who complained of hemoptysis but had no gastrointestinal symptoms  this rather unusual presentation caused a considerable delay in securing the diagnosis  
class8	rounded atelectasis complicated by obstructive pneumonia and pulmonary arterial thrombosis  published erratum appears in chest 1991 jun 99 6  1556  a patient with a history of asbestos exposure developed rounded atelectasis  the mass was associated with local bronchial obstruction  obstructive pneumonia and arterial thrombosis  autopsy demonstrated marked pleural thickening and radiographically inapparent asbestosis  this is the first reported case in which seemingly benign rounded atelectasis not only increased morbidity  but also contributed to mortality through airway obstruction and local arterial thrombosis  
class8	dialysis induced respiratory acidosis  the inability to increase alveolar ventilation can lead to co2 retention and acute respiratory acidosis in patients with ventilatory limitation  in this case  a young woman receiving maximum ventilatory support was unable to excrete excess co2  associated with increasing dianeal concentrations of peritoneal dialysis  since the patient s lung disease had necessitated a large amount of ventilatory support  the patient was unable to increase ve appropriately to handle excess co2  peritoneal dialysate was an additional source of carbohydrates  peritoneal dialysate is an additional carbohydrate source that may result in hypercapnia and respiratory acidosis in patients with respiratory compromise  to our knowledge  this is the first case report in an adult which demonstrates that peritoneal dialysis with high glucose loads produced an acute respiratory acidosis that was reversed by decreasing the glucose concentrations in the dialysate  excess co2 production should be considered with respiratory disorders associated with dialysis  
class8	occult fatal pulmonary embolism with disseminated intravascular coagulation  an unusual case masquerading as miliary tuberculosis  we report a fatal case of occult pulmonary embolism complicating bronchogenic carcinoma which presented with rapidly progressive pulmonary miliary shadows and respiratory failure  a clotting profile abnormality compatible with disseminated intravascular coagulation was noted  postmortem examination showed extensive clots occluding the major pulmonary vessels and areas of pulmonary infarcts  histologic examination revealed fibrin deposition in the microvasculature compatible with dic  cases of pulmonary embolism with dic have previously been reported  but this is the first case with pathologic confirmation  thus  unusual presentation with diffuse lung shadow and dic should not deter the clinician from correct diagnosis so that appropriate treatment can be promptly started  
class8	pulmonary malignant angioendotheliomatosis  presentation with fever and syndrome of inappropriate antidiuretic hormone  a 64 year old man presented with protracted fever  hyponatremia  and mononeuritis multiplex  inappropriate antidiuretic hormone secretion was established  the absence of pulmonary infiltrates precluded any lung biopsy  autopsy revealed malignant angioendotheliomatosis involving multiple organs including the alveolar septa and pulmonary vasculature  an early diagnosis of mae in the setting of fever and siadh may be possible via transbronchial biopsy  
class8	utility of angiograms in patients with catamenial hemoptysis  pulmonary endometriosis is the likely cause in patients with hemoptysis during menses  while we describe two cases of catamenial hemoptysis  which were localized with chest ct scanning  angiograms revealed normal appearance  we suggest that angiograms may have little value in the evaluation of patients with pulmonary endometriosis  
class8	kyphoscoliosis and respiratory failure  a patient treated with assisted ventilation for 27 years  a 62 year old woman had had kyphoscoliosis since age 12 years  respiratory failure developed at age 35 years following a respiratory infection  a tracheostomy was done and she required assisted ventilation using a respiratory  bird   many attempts at weaning her from the ventilator were unsuccessful  she has remained dependent on assisted ventilation for more than 27 years but has had a relatively comfortable and meaningful life  in 1983  a left pleuroscopy was done related to recurrent pneumothorax and numerous small bullae were seen on the lung surface  recent investigation using computed tomographic scanning has shown patchy areas of emphysema in both lungs  emphysema is not a feature of kyphoscoliosis and it is suggested that intermittent positive pressure applied to the lung over long duration may cause the lung destruction of emphysema  
class8	use of nd yag laser in endobronchial kaposi s sarcoma  an unusual case of endobronchial kaposi s sarcoma causing right middle and lower lobe atelectasis is reported  the lesion was successfully removed with nd yag laser photoresection  
class8	the malignancy sarcoidosis syndrome  in a retrospective review of six patients with malignancy preceding sarcoidosis  we found four cases of malignant lymphoproliferative disease  ld  and one case each of ovarian cancer and breast cancer  the median interval from onset or relapse of malignancy to sarcoidosis was nine months  of the four patients with ld  sarcoidosis appeared within six months of termination of chemotherapy for three of the patients and 15 months after allogeneic bone marrow transplantation for the fourth patient  at the time of diagnosis of sarcoidosis  there was no clinical or pathologic evidence of malignancy in the chest  we conclude that in contradistinction to the previously described syndrome of sarcoidosis preceding ld  there exists a syndrome of sarcoidosis following malignancy with or without chemotherapy  
class8	septic pulmonary emboli  a rare cause of bilateral pneumothorax in drug abusers  an intravenous drug abuser presented with bilateral pneumothorax  this is a previously unreported  to our knowledge  complication of septic pulmonary emboli secondary to right sided endocarditis  this possibility must be considered in the differential diagnosis of pneumothorax in drug addicts  
class8	retroperitoneal air after routine hemorrhoidectomy  report of a case  retroperitoneal air as a complication after routine hemorrhoidectomy has not been reported in the literature  this occurred recently after hemorrhoidectomy in a 34 year old patient receiving glucocorticoid therapy for rheumatoid arthritis  adverse steroidal effects of wound healing have been well documented  it is believed that steroid induced tissue changes contributed to the development of this unique complication  
class8	a randomized controlled evaluation of a psychosocial intervention in adults with chronic lung disease  the effect of a stress management program on morbidity and psychosocial and physical function in patients with chronic lung disease was assessed  adults attending either a va pulmonary clinic or university hospital pulmonary rehabilitation clinic who met criteria for obstructive or restrictive pulmonary disease were randomly assigned to receive the intervention or to a control group  the intervention was provided by a nurse and included one to three teaching sessions  reading material  audiotapes  and telephone follow up  the program focused on stress management techniques such as cognitive restructuring  progressive relaxation  breathing exercises  and visual imagery  the 45 experimental subjects were similar to the 49 controls with respect to baseline characteristics  experimental and control subjects had similar rates of mortality  hospital days  bed disability days  restricted activity days  and physician visits during the 12 month follow up  there were no differences between the two groups in physical or psychosocial function at six months or in levels of stressful life changes  social supports  and self esteem at six and 12 months  intervention recipients had better function at 12 months  suggesting a possible benefit of the intervention  
class8	effects of supplemental oxygen administration in an infant with pulmonary artery hypertension  in patients with pulmonary disease  pulmonary artery hypertension often occurs as a result of pulmonary artery vasoconstriction  primarily from hypoxia and alveolar hypotension  in this report we describe the hemodynamic effects of breathing supplemental oxygen in a child with bronchopulmonary dysplasia and pulmonary artery hypertension  these hemodynamic effects include an improvement in oxygenation  an increase in systemic vascular resistance  and a decrease in the pulmonary vascular resistance  as a direct result of these changes in vascular resistances  alterations of heart rate  cardiac index  stroke volume  aortic pressure  oxygen consumption  and pulmonary artery pressure have been shown to occur  oxygen is widely used to treat many physiologic conditions  however  during the administration of supplemental oxygen  rarely do we recognize the hemodynamic changes associated with its use  these hemodynamic effects must be clearly understood and appreciated before oxygen administration in any clinical situation  
class8	trapped lung syndrome after cardiac surgery  a potentially preventable complication of pleural injury  a case of trapped lung syndrome after coronary artery bypass grafting  cabg  is presented  a significant pleural injury occurred during the bypass operation resulting in intrapleural hemorrhage  pleural fibrosis  and trapped lung syndrome  the physicians caring for the patient when she was first seen with the trapped lung syndrome were unaware of the potential relationship between the two prior bypass surgeries to this pulmonary complication  recognition of the potential for pleural injury to occur after cardiac operations is important and may allow for earlier diagnosis and institution of appropriate therapeutic interventions  early recognition and treatment with pleural fluid drainage and reexpansion of the collapsed lung may help prevent this potentially serious pleuropulmonary complication from occurring  in addition  the presentation of this pleuropulmonary complication may be delayed after the cardiac surgery  making early diagnosis more problematic  
class8	hydraulic conductivity of canine parietal pleura in vivo  the hydraulic conductivity  lp  of the parietal pleura was measured in vivo in spontaneously breathing anesthetized dogs in either the supine  n   8  or the prone  n   7  position and in an excised portion of the chest wall in which the pleura and its adjacent tissue were intact  n   3   a capsule was glued to the exposed parietal pleura after the intercostal muscles were removed  the capsule was filled with either autologous plasma or isotonic saline  transpleural fluid flow  v  was measured at several transpleural hydrostatic pressures  delta p  from the rate of meniscus movement within a graduated pipette connected to the capsule  delta p was defined as the measured difference between capsule and pleural liquid pressures  the lp of the parietal pleura was calculated from the slope of the line relating v to delta p by use of linear regression analysis  lp in vivo averaged 1 36 x 10  3      0 45 x 10  3   sd  ml h 1 cmh2o 1 cm 2  regardless of whether the capsule was filled with plasma or saline and irrespective of body position  this value was not significantly different from that measured in the excised chest wall preparation  1 43 x 10  3      1 1 x 10  3  ml h 1 cmh2o 1 cm 2   the parietal pleura offers little resistance to transpleural protein movement  because there was no observed difference between plasma and saline  we conclude that because the lp for intact parietal pleura and extrapleural interstitium is approximately 100 times smaller than that previously measured in isolated stripped pleural preparations  removal of parietal pleural results in a damaged preparation  
class8	lung overexpansion increases pulmonary microvascular protein permeability in young lambs  to study the effects of inflation pressure and tidal volume  vt  on protein permeability in the neonatal pulmonary microcirculation  we measured lung vascular pressures  blood flow  lymph flow  ql   and concentrations of protein in lymph  l  and plasma  p  of 22 chronically catheterized lambs that received mechanical ventilation at various peak inflation pressures  pip  and vt  nine lambs were ventilated initially with a pip of 19     1 cmh2o and a vt of 10     1 ml kg for 2 4 h  base line   after which we overexpanded their lungs with a pip of 58     3 cmh2o and a vt of 48     4 ml kg for 4 8 h  ql increased from 2 1     0 4 to 13 9     5 0 ml h  l p did not change  but the ratio of albumin to globulin in lymph relative to the same ratio in plasma decreased  indicating altered protein sieving in the pulmonary microcirculation  seven other lambs were mechanically ventilated for 2 4 h at a pip of 34     1 cmh2o and a vt of 23     2 ml kg  base line   after which their chest and abdomen were bound so that pip increased to 54     1 cmh2o for 4 6 h without a change in vt  ql decreased on average from 2 8     0 6 to 1 9     0 3 ml h  p   0 08   and l p was unchanged  
class8	late phase bronchial vascular responses in allergic sheep  sheep were classified on the basis of their airway response to ascaris suum antigen aerosols as allergic or nonsensitive  allergic sheep were classed as acute or dual responders  acute responders had only an immediate increase in mean airflow resistance after antigen  whereas dual responders had an immediate and late phase  6 8 h after antigen challenge  increase in mean airflow resistance  nonsensitive sheep had minimal airway responses to antigen  less than 30  increase from base line   the sheep were anesthetized 2 wk later and  after a left thoracotomy  were challenged with antigen to determine bronchial vascular responses  bronchial artery blood flow was measured with an electromagnetic flow probe  airway responses to antigen aerosol challenge were similar in the anesthetized and conscious animals  the mean fall in bronchial vascular resistance  bvr  immediately after antigen challenge was similar in acute and dual responders  41     7 and 47     9  of base line  respectively   in dual responders  late phase airway responses were preceded by a significant increase from base line in qbr and a fall in bronchovascular resistance  bvr   the mean fall in bvr 6 8 h after antigen challenge in documented dual responders was significantly different from bronchial vascular responses in acute responders  59     3 vs  89     10   respectively   sheep without airway responses to a  suum had no significant changes in bronchial hemodynamics or airways mechanics  late phase associated changes in bvr are a specific response to antigen challenge and may be a sensitive index of mediators being released  
class8	urinary n tau methylimidazole acetic acid excretion in respiratory disease  n tau methylimidazole acetic acid  n tau miaa  is the principal urinary metabolite of histamine  the basal urinary excretion rate of n tau miaa was determined as 0 117     0 008  se  mg h  with a renal clearance for n tau miaa of 273     27 ml min implying active secretion  after subpharmacological infusion of histamine  50 ng kg 1 min 1 over 2 h  in five volunteers that increased plasma histamine from 0 28     0 04 to 0 71     0 15 ng ml  urinary excretion of n tau miaa over 8 h was increased by less than 17  compared with a control saline infusion  urinary n tau miaa excretion in normal controls  273     14 micrograms mmol creatinine  was similar to that observed in patients with severe acute asthma  253     22 micrograms mmol   antigen induced bronchoconstriction  269     21 micrograms mmol   seasonal allergic rhinitis  304     31 micrograms mmol   and clinically stable bronchiectasis  270     22 micrograms mmol   in contrast  large increases in metabolite excretion  greater than 7 000 micrograms mmol creatinine  were observed in a patient with systemic mastocytosis where very high plasma histamine levels were recorded  greater than 500 ng ml  and marked systemic hemodynamic effects occurred  we conclude that urinary n tau miaa will only be increased in pathologies where sustained hyperhistaminemia occurs and that increased local histamine production in the lung or the upper airway does not cause a measurable change in the basal urinary excretion of this metabolite  
class8	an unusual late complication following surgical repair of tetralogy of fallot  a case is presented of extrusion of right ventricular outflow tract patch material through a mediastino cutaneous fistula occurring five years after repair of tetralogy of fallot  the focus of the mediastinal infection was an infected epicardial pacemaker electrode placed at the time of initial surgery  subsequent echocardiographic studies showed minimal right ventricular outflow tract or pulmonary arterial dilatation  and  with no further surgery  the child is well after two and a half years follow up  
class8	parathyroid hormone like peptide in normal and neoplastic human endocrine tissues  pth like peptide  plp  is produced by tumors commonly associated with hypercalcemia as well as nonneoplastic tissues and several endocrine glands and tumors  to characterize the distribution of plp in human endocrine tissues and tumors  we localized plp in formalin fixed paraffin embedded material using the avidin biotin peroxidase technique with polyclonal antisera  among peptide hormone producing tissues  plp was identified in nontumorous adenohypophysis and pituitary adenomas  medullary thyroid carcinomas  normal  hyperplastic  and adenomatous parathyroids  adrenal medulla and pheochromocytomas  normal pancreatic islets  and endocrine tumors of pancreas  gut  and lung  including small cell carcinomas  in other endocrine tissues plp was identified in nontumorous thyroid follicular epithelium  colloid nodules  and follicular neoplasms  normal adrenal cortex  adrenocortical adenomas  and carcinomas  nontumorous testicular leydig cells  normal ovarian granulosa and thecal cells  an ovarian thecoma and a granulosa cell tumor  placental trophoblast  and decidua  these results demonstrate that plp is localized in many normal and neoplastic endocrine cells  including those not known to influence extracellular calcium homeostasis  the presence of plp in a variety of endocrine tissues suggests that it may play a local physiological role in the growth or function of endocrine cells  
class8	thyroiditis as the presenting manifestation of disseminated extrapulmonary pneumocystis carinii infection  a 38 yr old male with acquired immunodeficiency syndrome developed neck pain in association with mild hyperthyroidism and a diffusely enlarged thyroid gland  radioactive iodine scanning was consistent with thyroiditis  and biopsy of the thyroid demonstrated the presence of pneumocystis carinii in thyroid tissue  treatment with pentamidine followed by trimethoprim sulfamethoxazole led to rapid normalization of thyroid size in association with the development of hypothyroidism  this case illustrates the natural history of pneumocystis carinii thyroiditis and suggests that thyroid disease be added to the spectrum of human immunodeficiency virus associated endocrine dysfunction  
class8	importance of sampling method in dna analysis of lung cancer  lung carcinomas are characterised by considerable histological variation within the tumour  the possible effects of this morphological heterogeneity on the estimation of tumour ploidy were investigated  multiple tissue blocks were systematically taken from 20 lung tumours and analysed by flow cytometry  the routine  archival paraffin wax embedded diagnostic blocks from these cases were also analysed  nineteen  95   of the tumours were shown to contain aneuploid stemlines by systematic sampling  but if only one of these systematic tissue blocks had been taken from each case the incidence of dna aneuploidy could have been as low as 45   only 15  75   tumours were aneuploid when all the routine archival blocks were analysed  but by specifically selecting tumour areas from the archival material the accuracy of this method was increased to 90   it is concluded that tumour sampling methods are of primary importance in assessing the dna content of lung tumours  routine paraffin wax embedded archival tissue provides a suitable source of material for this purpose  provided that  turnover  selection is carried out  
class8	life threatening hemorrhage after placement of an endosseous implant  report of case this article reports an unusual but dangerous complication of implant surgery  minimal perforations of the lingual plate and inferior border of the mandible had been considered previously to be benign occurrences  this report demonstrates the importance of managing acute airway problems resulting from perforations  
class8	role of nasal allergy in chronic maxillary sinusitis  diagnostic value of nasal challenge with allergen  the role of nasal allergy in chronic maxillary sinusitis without an air fluid level was studied in 37 patients  seventy three nasal provocation tests with various inhalant allergens were performed in 37 patients by means of rhinomanometry  and maxillary sinus radiographs were performed before and repeatedly after the allergen challenge  forty one positive nasal responses  nrs  occurred in 29 patients  13 were immediate only  18 were late only  and 10 nrs were dual responses  of these responses  32 demonstrated radiographic changes  primarily an increase in mucosal edema and or opacification  these responses were accompanied by increased pressure in the maxillary sinuses  acute headache  and sometimes otalgia  eight patients did not develop any nrs  however  increased thickening of the mucosal membrane of the maxillary sinuses  accompanied by subjective symptoms  was recorded in three of these nonresponders  these results demonstrate the role of nasal allergy in some patients with chronic maxillary sinusitis  which may affect the diagnostic and therapeutic approaches to this disorder  
class8	a placebo controlled trial of immunotherapy with two extracts of dermatophagoides pteronyssinus in allergic rhinitis  comparing clinical outcome with changes in antigen specific ige  igg  and igg subclasses  a double blind  placebo controlled trial of immunotherapy was conducted in patients with dermatophagoides pteronyssinus rhinitis  thirty patients received an extract with a high content of der p i  pharmalgen   20 received a conventional mite extract  allpyral   and 30 patients received histamine chloride  placebo   specific igg and subclasses were measured before and after 3 and 12 months of treatment by ria and or elisa  and specific ige by rast  clinical outcome was assessed by skin prick tests  nasal challenge  visual analogue  and diary card symptom and drug scores  from these findings  a clinical index was derived  an igg response occurred only in the pharmalgen treated group  d  pter igg and igg1 increased by 3 months  p less than 0 05  and then plateaued to 12 months  p less than 0 05   igg4 levels increased throughout treatment  p less than 0 05 and p less than 0 01   as did the igg ige ratio  a subclass switch from igg1 to igg4 occurred  d  pter ige rose at 3 months  p less than 0 05   clinical improvement occurred at 3 and 12 months in the pharmalgen treated group only  pretreatment levels of ige  igg1  or igg4 did not predict clinical outcome  our findings are compatible with the hypothesis that igg subclasses may modulate antigen ige interactions  although the antibody response to this potent extract need not be causally related to improvement  
class8	different prevalence and degree of nonspecific bronchial hyperreactivity between seasonal and perennial rhinitis  from the patients observed at our respiratory allergology service  we selected patients with rhinitis only  without any past or present respiratory symptoms  for our study  all these patients had normal pulmonary function  were administered carbachol or methacholine bronchial challenges  and had one or more skin reactions to perennial or seasonal allergens  patients were allocated to three groups  group a  patients with seasonal rhinitis who were administered nonspecific challenges out of season  group b  patients with seasonal rhinitis tested during the season  and group c  patients with perennial rhinitis  the three groups were divided into subgroups according to the duration in years of rhinitis and to the degree of nonspecific bronchial responsiveness  the distribution into four groups of reactivity  arbitrarily defined as normal and mildly  moderately  and severely increased reactivity  was as follows  group a  124  21  30  22  group b  75  15  7  and 21  and group c  69  17  39  and 72  respectively  the patients of group c  perennial rhinitis  demonstrated a distribution significantly  p less than 0 001  different from subjects with seasonal rhinitis  both group a and group b  our results are consistent with the hypothesis that perennial rhinitis is much more important than seasonal rhinitis as a risk factor for developing nonspecific bronchial hyperresponsiveness  
class8	neuropeptides and nasal secretion  recent research has disclosed that neurotransmitters and neuropeptides released within the autonomic nervous system exert homeostatic control of nasal secretion  although cholinergic and adrenergic influences have long been thought to be the predominant mechanisms  the nonadrenergic  noncholinergic responses may have more suitable  longer lasting effects  peptides from sensory nerves  such as calcitonin gene related peptide  substance p  and neurokinin a  may participate in axon response mediated vasodilation and plasma extravasation  substance p and gastrin releasing peptide may induce glandular secretion  defensive responses to local mucosal injury may be amplified by axon response  which initiates these vascular and glandular reactions  cholinergic effects are primarily responsible for mediating parasympathetic reflexes  but vasoactive intestinal peptide may regulate acetylcholine release  augment glandular secretory responses  and have a vasodilatory effect  in the sympathetic nervous system  neuropeptide y probably functions as a long acting vasoconstrictor  integration of sympathetic and parasympathetic influence may regulate the normal nasal cycle  and sensory and parasympathetic defensive reflexes may respond to epithelial and mast cell stimulation  it is possible  then  that the pathophysiology of vasomotor rhinitis involves an exaggeration of these neural influences  
class8	the role of histamine in allergic rhinitis  studies using nasal provocation followed by nasal lavage have demonstrated that histamine plays an important role in the mediation of allergic rhinitis but not of rhinovirus infection  the response to antigen challenge is often biphasic  during the early response  increases in histamine levels appear to be associated with activation of mast cells  in a subset of persons who exhibit an additional late response  however  the rise in histamine is concomitant with an increase in the number of basophils  further evidence of the role of histamine in allergic rhinitis has emerged from nasal provocation experiments involving pretreatment with a variety of drugs known to antagonize or affect release of histamine  nasal provocation with histamine causes sneezing  itching  rhinorrhea  and nasal congestion  most h1 antihistamines have been found to inhibit sneezing and to lessen the increase in vascular permeability  but they do not affect histamine release  the h1 antihistamine terfenadine  however  inhibits histamine release during the early response  effects on late response remain unknown  prednisone decreases histamine levels during the late  but not the early  response  one week pretreatment with topical steroids  on the other hand  affects both the early and the late response  
class8	platelet activating factor  and leukotriene b4 induced release of lactoferrin from blood neutrophils of atopic and nonatopic individuals  we found increased accumulation of neutrophils and their components  lactoferrin  lf  and elastase  as well as platelet activating factor  paf  and leukotriene b4  ltb4  at sites of ongoing human allergic reactions  to determine whether paf or ltb4  could be the stimulus for in vivo lf release  blood neutrophils of 17 subjects were incubated with paf  ltb4  or the phorbol ester  phorbol myristate acetate  pma   and the released lf  elisa assay  was compared with spontaneous release  significantly increased lf release was induced by paf  10  5  to 10  8  mol l  p less than 0 002   ltb4  10  7  to 10  8  mol l  p less than 0 004   and pma  0 05 micrograms ml  in a dose dependent reaction  cytochalasin was not required for lf secretion but did enhance such responses  paf induced lf secretion was inhibited by the specific paf antagonist  bn 52063  more lf was released from neutrophils of atopic than from nonatopic subjects in response to paf  10  6  mol l  4 2 micrograms ml     0 2 versus 2 6 micrograms ml     0 2  p less than 0 001  but not to ltb4  pma  or buffer  p  not significant   we conclude that  1  paf and ltb4 released in vivo could stimulate local neutrophils to release lf with possible pathogenic effects and  2  neutrophils of atopic subjects are more responsive to paf than neutrophils of nonatopic subjects in this regard  
class8	immediate skin test reactivity to food and drug administration approved standardized extracts  in an effort to determine whether recently introduced food and drug administration approved standardized extracts produce clinically appropriate responses in a population  200 subjects were skin prick tested  spt   thirteen extracts  10 pollens  two house dust  hd  mites and cat  were tested in three groups of subjects  50 with a history of asthma or allergic rhinitis  al   50 without asthma or perennial or seasonal allergic rhinitis but with a positive immediate family history for these conditions  fal   and 100 subjects without a personal or family history for these conditions  nal   an spt mean wheal diameter greater than or equal to 3 mm was considered positive  ninety percent  95  confidence interval  ci   82  to 98   of al subjects had at least one positive spt  forty six percent of fal subjects  95  ci  30  to 58   and 29  of nal subjects  95  ci  20  to 38   had at least one positive spt  more fal than nal subjects had at least one spt  p less than 0 05   and fal subjects had more positive spts than nal subjects  p less than 0 05   further supporting the genetic regulation of allergen specific ige production  of the five al subjects with no spt wheal greater than or equal to 3 mm  three subjects were available for intradermal tests  thirteen nonstandardized allergens similar to allergens used for spt were applied intradermally in each of these three subjects and were all negative  compared with history  an spt wheal greater than or equal to 3 mm to cat produced a sensitivity of 0 90  a specificity of 0 90  and diagnostic accuracy of 0 90  tenfold dilutions of pollens and cat reduced sensitivity without significantly improving specificity  
class8	increased bronchial hyperresponsiveness after inhaling salbutamol during 1 year is not caused by subsensitization to salbutamol  recently  it was suggested that long term administration of an inhaled beta 2 agonist might increase bronchial hyperresponsiveness  bhr  to histamine  possibly as a consequence of subsensitization to the inhaled beta 2 agonist  to test this hypothesis  we studied two groups of patients with asthma or with chronic obstructive pulmonary disease  an experimental group of 15 patients  inhaling 400 micrograms of salbutamol four times daily during 1 year and subsequently 40 micrograms of ipratropium bromide four times daily for 6 months  and a control group  consisting of 22 patients with the opposite treatment regimen  the bhr  the response in fev1 to cumulative doses of salbutamol  and the number of beta 2 adrenoceptors and antagonist affinity of these receptors on circulating lymphocytes were assessed at the start of the study and at 6 month intervals for 1 1 2 years  the bhr increased significantly  p   0 001  during the year salbutamol was inhaled and returned to about the value at the start of the study after inhaling ipratropium bromide for 6 months  no change occurred in the bronchodilating responses to cumulative doses of salbutamol  nor was any change observed in the number and the affinity of beta 2 adrenoceptors on lymphocytes  it was concluded that long term use of salbutamol caused a small but significant increase in bhr  the increase in bhr was not caused by subsensitization of beta 2 adrenoceptors to salbutamol  
class8	measurement of histamine in nasal lavage fluid  comparison of a glass fiber based fluorometric method with two radioimmunoassays  the determination of histamine in nasal secretions and nasal lavage fluid may be of importance to monitor activation of histamine containing cells in the nasal cavity  however  such studies have been besieged by controversy  specifically to findings of changes in histamine levels in relation to allergenic stimulation  this controversy may be due to the specificity and accuracy of the various methods used to determine histamine in the nasal fluid  we have therefore applied and compared three new methods to determine histamine in nasal lavage fluids obtained before and after allergen challenge in normal subjects and patients with allergic rhinitis  we used a fluorometric glass fiber based histamine method  fhr  and two rias  i and ii  the fhr  detection limit  7 0 nmol  and the ria ii  detection limit  0 2 nmol  are specific for histamine itself  whereas the ria i  detection limit  18 0 nmol  measures mainly methylhistamine and cross reacts to some extent with histamine  the histamine levels in the nasal lavage fluids from the nasal challenges demonstrated histamine values between 100 and 2000 nmol l of histamine with significantly higher levels in the postallergen challenges for the allergic subjects as compared to the normal control subjects  the fhr correlated well with the ria i and ria ii methods with correlation coefficients of 0 77 to 0 88  p less than 0 001   respectively  however  the ria i  methylhistamine antibody  always demonstrated absolute histamine values 5  to 20  of values measured by the ria ii  at the level of cross reactivity to histamine   
class8	down regulation in hypersensitivity pneumonitis  levels of soluble interleukin 2 receptor  sol il 2r  in the bronchoalveolar lavage fluid  balf  of pigeon breeders with hypersensitivity pneumonitis were compared with balf levels in asymptomatic pigeon breeders who had been exposed to pigeon allergens for an equivalent length of time  no mean difference in sol il 2r levels was detected when these levels were expressed per milliliter balf  epithelial lining fluid  or per t lymphocyte  in sarcoidosis  the availability of sol il 2r per t cell was significantly higher for the group with inactive sarcoidosis compared with the group with active sarcoidosis  the results do not support the hypothesis that down regulation  in subjects exposed to allergens causing hypersensitivity pneumonitis  is a function of cell free sol il 2r levels in balf  in the dynamic situation  however  the hypothesis appears tenable  
class8	developmental expression of plasminogen activator inhibitor type 1 by human alveolar macrophages  possible role in lung injury  urokinase activity is regulated by the specific endogenous plasminogen activator inhibitors type 1  pai 1  and type 2  pai 2   one of these inhibitors  pai 1  has been directly implicated in connective tissue metabolism by virtue of its ability to bind extracellular matrix proteins  because the normal lung is relatively rich in urokinase and abnormalities in urokinase activity have been associated with fibrotic lung diseases  we have explored the possibility of local production of pai 1 and pai 2 in human lung  reverse transcription and subsequent amplification by the polymerase chain reaction of total lung rna revealed pai 1 mrna in each of three normal samples and in two specimens from patients with the adult respiratory distress syndrome  ards   in situ hybridizations of lung biopsy specimens from a patient with ards with crna probes to pai 1 and pai 2 indicated that alveolar macrophages express pai 1 mrna during the acute injury phase  subsequent reverse transcription and pcr amplification of normal human monocyte and alveolar macrophage mrna revealed that neither cell type expressed mrna for urokinase inhibitors  however  after 24 h stimulation with endotoxin in vitro  monocytes were strongly positive for pai 2 but negative for pai 1 mrna whereas  under the same conditions  alveolar macrophages exhibited mrna for both pai 1 and pai 2  metabolic labeling of endotoxin stimulated alveolar macrophages with 35s methionine followed by immunoprecipitation with pai 1 and pai 2 antibodies revealed that macrophages synthesized both pai 1 and pai 2  as judged by immunoprecipitation and functional studies  pai 2 was found to be the major intracellular pa inhibitor whereas pai 1 was found to predominate outside the cell  thus  mononuclear phagocytes exhibit a developmental potential for pai 1 expression  the release of pai 1 by stimulated macrophages  as observed in the setting of ards  may be one mechanism by which these cells promote connective tissue accumulation  
class8	a randomized controlled trial of glucocorticoid prophylaxis against experimental rhinovirus infection  the effects of combined intranasal and systemic glucocorticoid steroids on the local inflammatory response  and symptoms due to experimental rhinovirus infection were studied in 45 adults randomized to prophylaxis with either placebo or steroids  intranasal beclomethasone  168 micrograms twice a day  was begun 4 days before viral challenge and continued 5 days after challenge  oral prednisone  30 mg twice daily  was given for 3 days beginning 1 day before challenge  during the first 48 h after viral inoculation  nasal obstruction  nasal mucus weights  and kinin concentrations in nasal lavages were lower in steroid recipients  but subsequent increases in these variables in the steroid group resulted in no significant cumulative differences between treatment groups  these data suggest that steroid prophylaxis may suppress nasal inflammation and cold symptoms during the first 2 days in experimental rhinovirus colds  
class8	pneumococcal anticapsular antibodies in patients with chronic cardiovascular and obstructive lung disease in the netherlands  differences in pneumococcal anticapsular antibody concentrations were assessed among patients with various chronic disorders and among young  25 35 years of age  and older adults  55 65 years   antibody concentrations were determined by elisa  using the whole 23 valent pneumococcal polysaccharide vaccine as antigen  no differences in mean or distribution of serum antibody concentrations were found among young adults  either healthy or asthmatic  or among older adults  healthy or with chronic obstructive pulmonary or chronic cardiovascular disease   each group included individuals with low antibody levels  therefore  the enhanced susceptibility to pneumococcal infections reported for some groups at risk  that is  elderly individuals and patients with chronic obstructive pulmonary or chronic cardiovascular disease  cannot be attributed solely to low anticapsular antibody concentrations  
class8	adverse effects of aspirin  acetaminophen  and ibuprofen on immune function  viral shedding  and clinical status in rhinovirus infected volunteers  a double blind  placebo controlled trial was conducted to study the effects of over the counter analgesic antipyretic medications on virus shedding  immune response  and clinical status in the common cold  sixty healthy volunteers were challenged intranasally with rhinovirus type 2 and randomized to one of four treatment arms  aspirin  acetaminophen  ibuprofen  or placebo  fifty six volunteers were successfully infected and shed virus on at least 4 days after challenge  virus shedding  antibody levels  clinical symptoms and signs  and blood leukocyte levels were carefully monitored  use of aspirin and acetaminophen was associated with suppression of serum neutralizing antibody response  p less than  05 vs  placebo  and increased nasal symptoms and signs  p less than  05 vs  placebo   a concomitant rise in circulating monocytes suggested that the suppression of antibody response may be mediated through drug effects on monocytes and or mononuclear phagocytes  there were no significant differences in viral shedding among the four groups  but a trend toward longer duration of virus shedding was observed in the aspirin and acetaminophen groups  
class8	transmission of chlamydia pneumoniae in young children in a japanese family  chlamydia pneumoniae strain twar was isolated from the respiratory tract of a 5 year old girl suffering from pneumonia  the igm and igg antibody titers to twar were 1 32 and 1 128  respectively  cultures and serology for other common bacterial and viral respiratory pathogens were negative  although she was treated with 35 mg kg day rokitamycin  twar was repeatedly isolated after treatment  her 3 year old sister developed acute bronchitis  and twar was isolated from her nasopharynx  she was treated with 43 mg kg day erythromycin with prompt improvement  and twar was not isolated after treatment  although her mother  grandmother  and 8 month old sister suffered from respiratory illness during these periods  twar was not isolated from them  the repeated isolations from the index patient suggest that infection was transmitted from sister to sister  this case represents the first reported isolation of twar from young children in the same household and the first from japan  
class8	pilot trial of selective decontamination for prevention of bacterial infection in an intensive care unit  selective decontamination of the oropharynx and gastrointestinal tract with nonabsorbable antimicrobials and sucralfate  a stress ulcer prophylactic that maintains the normal gastric acid bacterial barrier  were compared for prevention of pneumonia in a cardiac surgery intensive care unit  over 8 months  51 patients received selective decontamination and 56 received sucralfate  the selective decontamination regimen included polymyxin  gentamicin  and nystatin given as an oral paste and as a solution  patients also received standard antacid or histamine2 blocker stress ulcer prophylaxis  patients in the selective decontamination group had significantly less colonization of the oropharynx and stomach by gram negative bacilli  12  vs  55   p less than  001   significantly fewer infections due to gram negative bacilli  6  vs  20   p    02   and fewer infections overall  12  vs  27   p    04   there was one episode of pneumonia in the selective decontamination group and five in the sucralfate group  mortality and length of stay did not differ between the groups  but those receiving selective decontamination had less than one third as many days of systemic antibiotic therapy with no increase in colonization or infection with resistant gram negative bacilli  thus  selective decontamination appeared to reduce both extrapulmonary and pulmonary infections  
class8	lipid peroxidation and expression of copper zinc and manganese superoxide dismutase in lungs of premature infants with hyaline membrane disease and bronchopulmonary dysplasia  the putative involvement of reactive oxygen species in the etiology of lung damage in infants receiving mechanical ventilation has been examined by comparing the levels of peroxidation and expression of the antioxidant enzymes  cuzn and mn superoxide dismutase  in lungs from control and affected infants as well as from fetuses and infants who died postnatally after term delivery  mean levels      sd  of lung peroxidation  determined with a thiobarbituric acid method  were similar in affected and control premature neonates and in fetal subjects  1 87     1 26  1 92     2 07  and 1 19     1 36 nmol mg protein  respectively   expression of cuzn and mn superoxide dismutases was also similar in these subjects and in the patients who died postnatally  thus activity measurements and immunoblotting studies showed continuous expression of these enzymes throughout development with no apparent change in protein levels or size  immunohistochemical examination of lung tissue showed expression of cuzn and mn superoxide dismutases in epithelial  smooth muscle  endothelial  and some mesenchyme components  in patients with bronchopulmonary dysplasia  alveolar walls were thickened by an excess of fibrous tissue and terminal air spaces were lined mainly by type ii pneumatocytes  all structures  including abnormal fibrous components  were positive for both cuzn and mn superoxide dismutase  our data show that  unlike some experimental animals  expression of at least these antioxidant enzymes in human infants born prematurely is similar to that in adults  and indicate that such infants are better adapted for life in an oxygen containing environment than previously suspected  
class8	effect of fasting on the lung glutathione redox cycle in air  and oxygen exposed mice  beneficial effects of sugar  fasting increases susceptibility to hyperoxic lung damage in mice  at least in part  by decreasing lung glutathione level  to determine whether fasting alters other components of the glutathione redox cycle  and whether a diet of sugar alone reverses fasting s effects  normally fed  sugar fed  and fasted mice were exposed to room air or 100  oxygen for up to 4 days  in air exposed mice  fasting decreased glutathione peroxidase  gp  and glutathione reductase  gr  activities 15  to 20  on days 3 and 4  p less than 0 01  and glutathione level 25  to 30  on days 2 to 4  p less than 0 05   when corrected for protein concentration  gp and gr values were similar to those in the fed mice  but glutathione levels remained lower on days 2 and 3  p less than 0 05   oxidized glutathione  gssg  was unchanged  but the ratio of gssg to total glutathione  reduced glutathione plus gssg  increased on day 2  p less than 0 05   in oxygen exposed fed mice  gp increased 62  and gr increased 39  on day 4  p less than 0 05   the time when the lung injury was most severe  glutathione increased 30  on days 3 and 4  p less than 0 05   and gssg increased threefold and eightfold on days 3 and 4  p less than 0 01   oxygen exposed fasted mice were all dead by day 3  versus no deaths in the fed mice   failed to increase gr and total glutathione in response to the oxidant stress  and increased gp and gssg on day 3 to the same extent as the fed mice did on day 4  
class8	role of endoscopy in diagnosing scleroma in its uncommon sites  eighty cases suffering from rhinoscleroma were studied  suspected cases were examined by sinoscopy  nasopharyngoscopy and bronchoscopy for detection of secondary involvement in these sites  antroscleroma  salpingoscleroma and tracheo bronchoscleroma have been found in a relatively high percentage of cases  the role of endoscopy in early diagnosis  initial symptomatic treatment and follow up cases is discussed  
class8	smoking cessation in chronic reinke s oedema  in evaluating the long term results of surgical treatment of reinke s oedema  there has been found to be a high incidence of recurrence  the recurrence rate is significantly lower amongst those patients who gave up smoking after treatment  a group of patients with chronic reinke s oedema were followed for six months  maximum efforts were made to help the patients to stop smoking  twenty nine patients entered the study  but only eight of them  28 per cent  refrained from smoking  all were women  39 70 years  and all experienced reduced discomfort  although none of the voices were restored to normal  diffuse laryngitis disappeared completely  but the oedema did not disappear entirely in any patient  before treatment of chronic reinke s oedema patients must be well advised and informed  and if surgery is decided upon  they must be urged most strongly to stop smoking  if they wish to enhance the possibility of satisfactory long term results  
class8	epistaxis as an unusual presentation of an antrochoanal polyp  antrochoanal polyps rarely present with severe epistaxis  we present the case of a young male patient who presented in such a manner  thus leading to the suspicion of an angiofibroma as the underlying pathology  the radiological investigations  treatment and pathological features are discussed  
class8	a  silent  intracranial complication of frontal sinusitis  intracranial complications of frontal sinusitis  although rare today  do still develop despite widespread use of antibiotics  we report a case which demonstrates how silently a frontal lobe abscess may present with subtle changes in mood and behaviour  with no focal neurological signs  diagnosis and management are discussed and a brief review of the incidence of intracranial complications of frontal sinusitis  mode of spread  clinical presentation  investigations  treatment and bacteriology is presented  
class8	infectious mononucleosis complicated by lingual tonsillitis  although upper airway obstruction and superimposed infection are well known complications of infectious mononucleosis  lingual tonsillitis in this context has not been mentioned in the literature  we describe a case of acute bacterial lingual tonsillitis with airway obstruction complicating infectious mononucleosis  the role of the base of tongue region in the pathophysiology of infectious mononucleosis is discussed  
class8	acute upper airway obstruction following teflon injection of a vocal cord  the value of nebulized adrenaline and a helium oxygen mixture in its management a 67 year old man presented with a 45 year history of a week voice  this was result of polio which had left him with a right vocal cord palsy  the patient underwent a teflon injection of the right vocal cord under general anaesthesia to improve the quality of his voice  in the immediate post operative period  he suffered acute upper airway obstruction  the problem of acute upper airway obstruction following teflon injection is considered and its management with nebulized adrenaline and a helium oxygen mixture is discussed  
class8	multiple primary malignancies in patients with malignant tumours of the nasal cavities and paranasal sinuses  the incidence of multiple primary malignancies  mpm  was analysed in 1297 patients with malignant tumours of the nasal cavities and paranasal sinuses  the patients were followed for a minimum of six years or until death  the incidence of mpm was 3 4 per cent  44 1297  which is lower in patients with malignant tumours of other regions in the upper aerodigestive tract  five of the 44 patients had second malignancies within previously irradiated areas  there was a difference between the proportion of histologies occurring in irradiated tissues compared with the overall 1297 patients  this finding suggests that radiotherapy may induce a second cancer  
class8	inter arytenoid glottic bar following intubation  inter arytenoid glottic bar is a rare complication of prolonged endotracheal intubation  we present two such cases and their treatment  the aetiology of this complication is multifactorial and involves local factors  local trauma  movement of the endotracheal tube within the larynx  infection  and anatomical influences  together with systemic factors such as in our two cases  the relative importance of these factors is discussed  a comment is also made on the use of a pre operative topogram and the importance of an ent assessment in patients with airway problems following prolonged intubation  
class8	lambert eaton syndrome  autonomic neuropathy and inappropriate antidiuretic hormone secretion in a patient with small cell carcinoma of the lung  a patient with small cell carcinoma of the lung developed asymptomatic autonomic neuropathy  inappropriate antidiuretic hormone  adh  secretion and lambert eaton myasthenic syndrome  the autonomic neuropathy and inappropriate adh secretion were present at the time of diagnosis of the tumour  following chemotherapy these resolved  but 5 months later the patient developed lambert eaton syndrome which responded to 3 4 diaminopyridine  this sequence of changes appears to be unique  
class8	treatment of small cell lung cancer with an alternating chemotherapy regimen given at weekly intervals  a southwest oncology group pilot study  we designed an intensive  weekly treatment regimen for patients with small cell lung cancer  sclc  using six of the most active chemotherapeutic agents for this disease  doxorubicin  dox   cyclophosphamide  ctx   vincristine  vcr   etoposide  vp 16   cisplatin  cddp   and methotrexate  mtx    the goal of this program was to gain rapid  repetitive exposure to multiple  active drugs  treatment was administered weekly for a total of 16 weeks  seventy six sclc patients  limited disease  34  extensive disease  42  were treated  the overall complete plus partial response rate was 82   complete response rates of 47  and 38  were observed in patients with limited  ld  and extensive disease  ed   respectively  the median survivals for patients with ld and ed were 16 6 and 11 4 months  respectively  toxicities were tolerable and were primarily hematologic  twenty six patients had one or more transient life threatening toxicities  but only one patient developed a fatal toxicity  eighty four percent of the patients received 80  or greater of the intended protocol dosages over the entire 16 week treatment period  we conclude that this intensive  short duration treatment regimen is at least as good as other  standard  regimens  and we are encouraged aged by the complete response rate and median survival in patients with ed sclc  
class8	the relative value of conventional staging procedures for developing prognostic models in extensive stage small cell lung cancer  published prognostic models for small cell lung cancer  sclc  have either combined limited  and extensive stage patients or have not included standard anatomic staging information to assess the relative value of the knowledge of specific sites and number of sites of metastases in predicting survival in extensive stage disease  we studied 136 extensive stage patients in whom traditional staging procedures were performed and in whom other previously demonstrated significant pretreatment variables were determined  using the cox proportional hazards model  when all data were included  three variables were significant  performance status  ps   p    0001   number of sites of metastases  p    0010   and age  p    0029   a prognostic algorithm was developed using these variables  which divided the patients into three distinct groups  when the anatomic staging data were omitted  the serum albumin  p    0313  was the only variable in addition to ps  p    0001  and age  p    0064  that was significant  an alternative algorithm using these three variables was nearly as predictive as the original  therefore  in extensive stage patients  reasonable pretreatment prognostic information can be obtained without using the number or specific sites of metastases as variables once the presence of distant metastases has been demonstrated  
class8	cerebral venous oxygen content as a measure of brain energy metabolism with increased intracranial pressure and hyperventilation  in order to test the hypothesis that the cerebral arteriovenous oxygen difference  avdo2  and venous oxygen content  vo2  could be used to monitor brain energy metabolism in the setting of increased intracranial pressure  icp   12 cats were studied with 31p magnetic resonance spectroscopy  six cats were subjected to intracranial hypertension by cisternal infusion of saline  energy failure occurred at an average avdo2 of 8 4     3 2 vol       standard deviation   range 4 7 to 14 7 vol    the vo2 at the point of metabolic failure averaged 1 45     0 6 vol  and extended over a narrower range  1 0 to 2 9 vol    in an additional six cats  icp was raised to the threshold of metabolic failure and hyperventilation was then instituted  pco2 10 to 18 torr   five of the six cats experienced a drop in vo2 with hyperventilation  in two of these animals  hyperventilation resulted in a vo2 of 1 1 vol  or less and in metabolic failure as evidenced by a fall in phosphocreatine  it is concluded that a vo2 of less than 2 vol  is correlated with brain ischemia and that the safety of hyperventilation in the setting of increased icp can be monitored by the use of vo2  
class8	administered dose and tumor dose of bleomycin labeled with cobalt 57 in mice and men  tumor concentrations of the chemotherapeutic drug  bleomycin  labeled with cobalt 57  co bleo  were compared in mouse tumor models and in human lung tumors using quantitative single photon emission computed tomography  drug concentrations in histologically similar human tumors showed marked variability for the same injected dose  id   small cell carcinomas showed concentrations between 1 09 and 8 85  id cc x 10  3  while non small cell lung tumors showed a concentration variation between 0 36 and 6 75  id cc x 10  3   in contrast to the situation in human tumors  uptake in mouse tumors showed only slight variability in animals with the same tumor model  emt 6 tumors in mice showed at 6 hr significantly higher uptake of co bleo  p less than 0 001  and significantly higher tumor to lung ratio  p less than 0 001  when compared to murine fibrosarcomas  the emt 6 tumors in contrast to the fibrosarcomas responded to bleomycin treatment in a dose dependent manner  the results indicate that while in mice the tumor dose closely follows the administered dose  in humans  the tumor dose and the tumor to lung ratio in the individual patient cannot be predicted from the administered dose  
class8	imaging of tumor in patients with indium 111 labeled biotin and streptavidin conjugated antibodies  preliminary communication tumor localization in patients has been achieved through the in vivo use of streptavidin and biotin  in these preliminary studies  the monoclonal antibody hmfg1 was conjugated with streptavidin and 1 mg was administered intravenously to each of 10 patients with documented squamous cell carcinoma of the lung  two to 3 days later  111in labeled biotin was also administered intravenously  no evidence of toxicity was observed  background radioactivity levels were reduced in liver  1  id at 24 hr  and kidneys  2   and in all other normal tissues and blood  images of lung tumor were obtained in as little as 2 hr following administration of labeled biotin  in eight patients  tumor was detected with labeled biotin alone without the previous administration of streptavidin conjugated antibody but in three of these patients  the images were improved with the prior administration of conjugated antibody  these results suggest that this approach may improve the tumor to normal tissue radioactivity ratios in radioimmunotargeting  
class8	pedunculated soft tissue mass on the alveolar gingiva  clinical conference  a case of peripheral ameloblastoma  a rare intraoral neoplasm  has been presented  the lesion appears most commonly as a mass on the mandibular lingual gingiva of patients in their fifth and sixth decades of life  the peripheral ameloblastoma does not share the aggressive nature of the intraosseous variant  the lesion has been overtreated in the past and warrants only a local supraperiosteal excision  
class8	early ribavirin treatment of respiratory syncytial viral infection in high risk children  a 3 year prospective  blinded  multicenter study was done to assess the efficacy of early ribavirin intervention in mild respiratory syncytial virus illness in children with bronchopulmonary dysplasia or with congenital heart disease  a cohort of 178 children younger than 36 months of age with bronchopulmonary dysplasia or congenital heart disease were followed  forty seven infants whose respiratory syncytial virus infection resulted in mild symptoms of less than or equal to 72 hours  duration received ribavirin  n   20  or water placebo aerosol  n   27  either in a hospital or at home  outcome measures included respiratory and analog score  room air oxygen  saturation  and oxygen flow needed to maintain saturation at greater than or equal to 91   no difference in age  gender  family size  passive smoking  baseline oxygen saturations in room air  or duration of symptoms before treatment was found between groups  after 3 days of therapy  ribavirin produced a greater rate of improvement of analog scores  p   less than or equal to 0 001   lower oxygen requirements  p   0 01   and higher oxygen saturation  p   0 01   respiratory scores and total hospital days did not differ significantly between the groups  treatment failure occurred in 2 of 20 children  10   in the ribavirin group versus 5 of 27 children  18   in the placebo group  a nonsignificant difference  no child required assisted ventilation or had an adverse reaction  we conclude that early ribavirin therapy may help to reduce morbidity from respiratory syncytial virus infection in high risk young children  
class8	prediction of postoperative clinical course by autologous tumor killing activity in lung cancer patients  fifty patients with primary localized lung cancer were tested at the time of surgery for the ability of their lymphocytes to kill autologous  freshly isolated tumor cells  and the assay was evaluated for prognostic significance  peripheral blood lymphocytes of 27 patients  54   demonstrated significant autologous tumor killing activity in 6 hour 51cr release assays  twenty three of the 27 patients with autologous tumor killing activity remained tumor free and survived more than 5 years after curative surgery  while all 23 who were negative for autologous tumor killing activity relapsed by 18 months after surgery and died within 42 months after surgery  the differences in survival curves for the two groups were highly significant  p less than  00003   autologous tumor killing activity was not correlated with natural killer  nk  cell activity against k562 human myeloid leukemia cells or proliferation of lymphocytes stimulated with autologous  freshly isolated tumor cells in mixed culture  there were no differences in total survival between patients with positive results and those with negative results in tests of nk cell activity and autologous mixed lymphocyte tumor culture reaction  these results indicate that autologous tumor killing activity is a meaningful prognostic indicator and provide evidence for immunological control of tumor growth and metastasis  according to our preliminary data  it is unlikely that lung cancer patients who remain tumor free after 60 months of follow up will develop recurrence or die from the disease  we are conducting a study to determine whether induction of autologous tumor killing activity before surgery  by treatment with biological response modifiers can improve the clinical outcome in patients who do not naturally have this potential  
class8	auto peep in the multisystem injured patient  an elusive complication  auto peep  a peep   unrecognized alveolar positive and expiratory pressure during mechanical ventilation  is an acknowledged hazard in patients with chronic obstructive lung disease  we evaluated 50 consecutive trauma patients for the presence of a peep and its effect on hemodynamic stability  injury severity scores  iss  were 8 to 41  21     1   revised trauma scores  rts  ranged from 2 0 to 7 8  6 2     0 2   mode of ventilation was assist control  inspiratory flow rates were 40 to 120 l m  78     2   a peep  determined in the non assisting patient by occluding the expiratory port at end exhalation  was present in 28 patients  56   and ranged from 1 to 12 cm h2o  5 3     0 4 cm h2o   data segregated by a peep versus no a peep were as follows  mean     sem    table  see text   p less than 0 05  ve   minute ventilation  paw   mean airway pressure  upon reversal of a peep in the eight patients with levels greater than 5 cm h2o  mean blood pressure rose from 90     17 to 102     22 mm hg and central venous pressure fell from 13     5 to 7     5 mm hg  a peep was successfully treated in these eight patients by increasing peak flows  minimizing ve requirements and selective use of bronchodilators  in sum  the hypermetabolic ventilated trauma patient should be monitored routinely for this common phenomenon which may have profound cardiopulmonary effects in the setting of acute resuscitation  
class8	effect of endotoxin and a burn injury on lung and liver lipid peroxidation and catalase activity  both endotoxin and a burn alone produce oxidant induced tissue lipid peroxidation  the endotoxin response is due in large part to hydrogen peroxide  the combination of endotoxin after a burn results in an increased liver  but not lung  oxidant injury  our purpose was to determine whether the burn oxidant injury inactivated endogenous liver tissue catalase  thereby amplifying a subsequent h2o2 insult  twenty six adult sheep were studied  twelve sheep had a 15  tbs burn  tissue catalase activity  measured in lung and liver 3 days postburn  was significantly decreased from a control of 3 58     1 8 and 193     63  respectively  to 1 72     0 63 and 148     33 k sec 1  0 5 gram tissue  the addition of endotoxin 3 days postburn resulted in an increase in liver malondialdehyde  mda  a measure of lipid peroxidation  from a control of 110     80 to 450     54 nmol gram tissue  this value was significantly greater than the 210     80 nmol gram tissue seen after endotoxin alone  lung tissue mda with burn and endotoxin was 65     8 compared to 42     7 for control and 80     6 nmol gram for endotoxin alone  we conclude that a decrease in liver catalase activity occurs after a burn  the decrease corresponds to an accentuated oxidant induced lipid peroxidation after an added endotoxin insult where h2o2 is known to be an etiologic agent  the catalase activity also decreases in postburn lung  but accentuated lung damage was not seen  indicating a variable tissue response from the burn induced decrease in antioxidant activity  
class8	effect of chronic respiratory acidosis on urinary calcium excretion in the dog  it is currently believed that the two chronic acidemic disorders exert disparate effects on urinary calcium excretion  chronic metabolic acidosis induces consistent hypercalciuria  but no appreciable change or even a decrease in calcium excretion is reported to attend chronic respiratory acidosis  whereas the effect of metabolic acidosis is well documented  little work has been carried out in chronic hypercapnia  in fact  most of the studies on chronic respiratory acidosis were short in duration  had employed only mild hypercapnia  or had failed to control carefully the prevailing metabolic conditions  we have carried out balance observations in nine dogs exposed to a 10  co2 atmosphere in an environmental chamber for a period of two weeks  chronic respiratory acidosis led to a significant increase in urinary calcium excretion from a mean control value of 0 4     0 1 mmol day to 0 6     0 1 mmol day during both week 1 and 2 of hypercapnia  p less than 0 05   hypercalciuria occurred even though filtered load of calcium fell  mean fractional excretion of calcium increased significantly during each week of hypercapnia averaging 0 60     0 12  during control  1 05     0 13  during week 1  and 1 26     0 17  during week 2 of hypercapnic exposure  p less than 0 05   there were no changes in plasma levels of immunoreactive parathyroid hormone or 1 25 dihydroxyvitamin d3  these findings suggest that chronic respiratory acidosis  just like chronic metabolic acidosis  augments urinary calcium excretion by a direct depressive effect on the tubular reabsorption of calcium  
class8	diagnosis of malignant cardiac disease by endomyocardial biopsy among oncology patients  endomyocardial biopsy has been used primarily for the evaluation of anthracycline cardiotoxicity  in addition  however  endomyocardial biopsy may be useful for the detection of malignant cardiac neoplasms  between 1982 and 1989  metastatic involvement of the heart was diagnosed by endomyocardial biopsy in seven patients at our institution  all except one of these patients were older than 50 years of age and had dyspnea as an initial symptom  and all had a known malignant lesion  results of endomyocardial biopsy confirmed cardiac involvement by a hematologic malignant lesion in four patients and metastatic melanoma in two patients  in one patient  who had a history of breast cancer and lymphoma  a metastatic neoplasm of uncertain differentiation was observed  myocyte damage was evident in endomyocardial biopsy specimens from two of the four patients with hematologic malignant disease  endomyocardial biopsy was performed to confirm the possibility of metastatic involvement in five patients  in the other two  endomyocardial biopsy was performed to determine whether anthracycline cardiotoxicity was present  and metastatic involvement was unanticipated  
class8	value of antigen detection in predicting invasive pulmonary aspergillosis two elisas were used to detect serum and urinary aspergillus antigen in 121 patients who were profoundly neutropenic after leukaemia therapy or bone marrow transplantation  the presence of antigen correctly predicted development of invasive pulmonary aspergillosis  ipa  in 16 patients  in 2 other cases antigen appeared after the clinical diagnosis had been made  while in only 1 case was antigen not detected  in 11 of 13 episodes of clinically suspected fungal infection antigen was detected before clinical diagnosis was made  by contrast  antigen was detected in only 1 of 90 patients who had no evidence of ipa  both elisas gave positive and negative predictive values for ipa of greater than 95   demonstrating the value of antigen detection in early diagnosis of aspergillus infection and the assay s ability to predict subsequent development of ipa  we conclude that neutropenic patients should be screened for aspergillus antigen  and propose that initial detection of fungal antigen justifies commencement of empirical antifungal therapy  such an approach should improve the survival of patients who are at risk of developing this usually fatal infection  
class8	angioedema from angiotensin converting enzyme inhibitors  a cause of upper airway obstruction  angiotensin converting enzyme  ace  inhibitors have several side effects of concern to the otolaryngologist  angioedema is a rare  but potentially lethal adverse effect when associated with upper airway obstruction  four cases of ace inhibitor induced angioedema  three with significant upper airway obstruction  are reported  angioedema secondary to ace inhibition appears to be mechanism based  the probable link is the potentiation of bradykinin  which results in vasodilation  increased vascular permeability  and angioedema  since angioedema can progress to upper airway obstruction  otolaryngologists must be aware of this association  the differential diagnosis and treatment of this adverse effect is discussed  as well as a review of ace inhibitors and other causes of angioedema  
class8	computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis  in this study  the computed tomography scans of 100 patients with chronic hyperplastic rhinosinusitis were reviewed to establish a clinical staging system  fourteen percent of the patients were classified as stage i  single focus disease   36  as stage ii  multifocal disease responsive to conservative therapy   32  as stage iii  diffuse disease partially responsive to medication   and 16  as stage iv  diffuse disease associated with bony changes and poorly responsive to conservative treatment   the incidence of recurrent or persistent disease ranged from 13  for stage ii to 30  for stage iv  stage i and iii patients had 13  and 18  recurrence rates  respectively  computed tomography staging is shown to be useful in outlining operative strategies and is a reliable prognosticator of the disease process  
class8	esthesioneuroblastoma  surgical treatment without radiation  this study compares the treatment of two groups of patients diagnosed with esthesioneuroblastoma limited to the nasal cavity without evidence of cribriform plate erosion  five patients were treated with radiation and extracranial excision  and eight patients were treated by craniofacial resection only  the incidences of local recurrence were 60  and 12   respectively  the paper also presents a new staging classification for these tumors  
class8	flexible nd yag laser palliation of obstructive tracheal metastatic malignancies  flexible nd yag endoscopic laser surgery may become an effective new modality for palliation in patients with obstructive endotracheal metastatic malignancies  we report the results of the treatment of two patients with severely obstructing intraluminal tracheal metastatic melanoma and medullary thyroid carcinoma  using the neodymium yag laser via the flexible fiberoptic bronchoscope  both patients complained of significant dyspnea  orthopnea  cough  and hemoptysis and were not candidates for rigid bronchoscopy because of underlying medical contraindications and anatomical problems  multiple treatment sessions were used with treatment intervals of 1 to 2 weeks  all treatments were performed in the operating room under sedation  without intubation  with topical lidocaine and standard superior laryngeal nerve block  successful relief of airway obstruction with complete regression of the endotracheal masses was achieved and no recurrences were seen after 9 months  follow up  flexible nd yag laser bronchoscopy offered an alternative for the relief of obstructing endotracheal or bronchial malignancies in patients in whom the rigid bronchoscope could not be passed  it seemed to prolong survival in selected cases  and provided definite improvement in quality of life  
class8	an in vivo canine model for testing treatment effects in laryngeal hyperadduction disorders  adductor spastic dysphonia is a voice disorder characterized by a strained  squeezed  effortful voice produced by true and false cord hyperadduction  an in vivo canine model has been developed to simulate hyperadduction of the true cords  using this model  the thyroarytenoid muscle was found to have a greater effect on intraglottic and subglottic pressure than cricothyroid muscle contraction  the intraglottic and subglottic pressure was reduced after simulated recurrent laryngeal paralysis  this model can be used in future studies to compare laryngeal treatment modalities for disorders that have a component of vocal cord hyperadduction  such as spastic dysphonia  
class8	pancreaticopleural fistula  report of 7 patients and review of the literature  pancreaticopleural fistula is an uncommon clinical condition  its presentation is often confusing because of the paucity of clues suggestive of pancreatic disease and the preponderance of pulmonary symptoms and signs  most patients are alcoholics but only one half will have a clinical history of previous pancreatitis  pleural effusions are large  recurrent  and highly exudative in nature  many patients go through extensive pulmonary evaluation before the pancreas is identified as the site of primary pathology  an elevated serum amylase may be the first clue to the diagnosis  however  the key to the diagnosis is a dramatically elevated pleural fluid amylase  effusions in association with acute pancreatitis  esophageal perforation  and thoracic malignancy are important to consider in the differential diagnosis of an elevated pleural fluid amylase but are usually easy to exclude  computed tomography is excellent in defining pancreatic abnormalities and should be the first abdominal imaging study in suspected cases  endoscopic retrograde cholangiopancreatography  ercp  is used as a diagnostic tool only in confusing cases  although no systematic study evaluates medical versus surgical therapy  we recommend an initial 2 to 4 week trial of medical therapy  including allowance of no oral intake  total parenteral nutrition  chest tube thoracostomy  and possibly a regimen of somatostatin or its analogs  the major complication in these patients is superinfection  which results in significant morbidity and mortality  failure of medical therapy should be considered failure of pleural effusion s  to clear  recurrence after reinstatement of oral intake  or superinfection  for those patients who fail to benefit from medical therapy  surgery is indicated  
class8	disseminated histoplasmosis in the acquired immune deficiency syndrome  clinical findings  diagnosis and treatment  and review of the literature  histoplasmosis is a serious opportunistic infection in patients with aids  often representing the first manifestation of the syndrome  most infections occurring within the endemic region are caused by exogenous exposure  while those occurring in nonendemic areas may represent endogenous reactivation of latent foci of infection or exogenous exposure to microfoci located within those nonendemic regions  however  prospective investigations are needed to prove the mode of acquisition  the infection usually begins in the lungs even though the chest roentgenogram may be normal  clinical findings are nonspecific  most patients present with symptoms of fever and weight loss of at least 1 month s duration  when untreated  many cases eventually develop severe clinical manifestations resembling septicemia  chest roentgenograms  when abnormal  show interstitial or reticulonodular infiltrates  many cases have been initially misdiagnosed as disseminated mycobacterial infection or pneumocystis carinii pneumonia  patients are often concurrently infected with other opportunistic pathogens  supporting the need for a careful search for co infections  useful diagnostic tests include serologic tests for anti h  capsulatum antibodies and hpa  silver stains of tissue sections or body fluids  and cultures using fungal media from blood  bone marrow  bronchoalveolar lavage fluid  and other tissues or body fluids suspected to be infected on clinical grounds  treatment with amphotericin b is highly effective  reversing the clinical manifestations of infection in at least 80  of cases  however  nearly all patients relapse within 1 year after completing courses of amphotericin b of 35 mg kg or more  supporting the use of maintenance treatment to prevent recurrence  relapse rates are lower  9 to 19   in patients receiving maintenance therapy with amphotericin b given at doses of about 50 mg weekly or biweekly than with ketoconazole  50 60    but controlled trials comparing different maintenance regimens have not been conducted  until results of such trials become available  our current approach is to administer an induction phase of 15 mg kg of amphotericin b given over 4 to 6 weeks  followed by maintenance therapy with 50 to 100 mg of amphotericin b given once or twice weekly  or biweekly  if results of a prospective national institutes of allergy and infectious disease study of itraconazole maintenance therapy document its effectiveness  alternatives to amphotericin b may be reasonable  
class8	coccidioidomycosis during human immunodeficiency virus infection  a review of 77 patients  through a retrospective review  we identified 77 previously unreported cases of coccidioidomycosis during hiv infection  patients were classified into 1 of 6 categories based on their primary clinical presentation  20 had focal pulmonary disease  group 1   31 had diffuse pulmonary disease  group 2   4 had cutaneous coccidioidomycosis  group 3   9 had meningitis  group 4   7 had extrathoracic lymph node or liver involvement  group 5   and 6 has positive coccidioidal serology without a clinical focus of infection  group 6   coccidioidal serologies were positive on initial testing in 83  of the patients in whom such serologic testing was performed  sera from 39  of patients were positive for tp antibodies while 74  had cf antibodies  eleven of 12 seronegative patients had pulmonary disease  group 1 or 2   serologic results of other patients sent to a single reference laboratory were similar  with 26  positive for immunodiffusion tp antibodies and 79  positive for immunodiffusion cf antibodies  for the 77 patients in this study  the cd4 lymphocyte count was below 0 250 x 10 9  cells l in 46 of the 55 patients who had this test performed  and a low cd4 count was significantly associated with mortality  p less than 0 01   at the time of follow up  32 of the 77 patients  42   had died  there were significantly more deaths in those with diffuse pulmonary disease  group 2  than in other groups  p less than 0 001   amphotericin b  ketoconazole  fluconazole  and itraconazole were all used as antifungal therapies  outcome could not be related to the therapy used  of note  3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions  
class8	corticosteroids as adjunctive therapy for severe pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome  a double blind  placebo controlled trial  background  preliminary reports suggest that patients with the acquired immunodeficiency syndrome  aids  and pneumocystis carinii pneumonia may benefit from the addition of corticosteroid treatment to antibiotic therapy  methods  we conducted a double blind  placebo controlled trial to assess the efficacy of adjunctive corticosteroids in patients with aids and severe p  carinii pneumonia  patients with marked abnormalities in gas exchange who had been treated with antibiotics for less than 72 hours were randomly assigned to receive either methylprednisolone  40 mg  or placebo every 6 hours for 7 days  in addition to treatment for 21 days with trimethoprim sulfamethoxazole  the primary outcome measures were survival until hospital discharge and the development of respiratory failure  results  twenty three patients were enrolled in the study  there were no significant differences in base line clinical or laboratory measures between the two treatment groups  of 12 patients treated with corticosteroids  9  75 percent  survived until hospital discharge  as compared with only 2 of 11 placebo recipients  18 percent   p less than 0 008   respiratory failure developed in nine placebo recipients  as compared with only three patients treated with corticosteroids  p less than 0 008   no patient required the interruption or discontinuation of corticosteroid or antibiotic treatment because of toxicity or a complicating event  because of the marked difference in survival  it was deemed unethical to continue the trial  and the study was terminated  conclusions  early adjunctive corticosteroid therapy can improve survival and decrease the occurrence of respiratory failure in patients with aids and severe p  carinii pneumonia  
class8	a controlled trial of early adjunctive treatment with corticosteroids for pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome  california collaborative treatment group  background  pneumocystis carinii pneumonia remains a common cause of serious morbidity and mortality in patients with the acquired immunodeficiency syndrome  aids   the extensive lung injury that accompanies pneumocystis associated respiratory failure and the reports of clinical benefit from the use of adjunctive corticosteroids provided the rationale for this prospective multicenter trial  methods  a total of 333 patients with aids and pneumocystis pneumonia received standard treatment and were randomly assigned to receive either corticosteroids  beginning with the equivalent of 40 mg of prednisone twice daily  or no additional therapy  the primary end points in this unblinded trial were the occurrence of respiratory failure  hypoxemia ratio  partial pressure of arterial oxygen divided by fraction of inspired oxygen  less than 75  intubation  or death   death  and dose limiting toxicity of the initial standard therapy  results  of the patients with confirmed or presumed pneumocystis pneumonia  n   225 and n   26  respectively   those assigned to treatment with corticosteroids had a lower cumulative risk at 31 days of respiratory failure  0 14 vs  0 30  p   0 004  and of death  0 11 vs  0 23  p   0 009   as well as a lower risk of death within 84 days  0 16 vs  0 26  p   0 026   the frequency of dose limiting toxicity of the standard therapy was similar in the two treatment groups  intention to treat analyses of the entire cohort confirmed these findings  clinical benefit could not be demonstrated  however  for patients with mild disease  hypoxemia ratio  greater than 350   equivalent to a partial pressure of oxygen greater than 75 torr on room air  the patients assigned to corticosteroid treatment had an excess of localized herpetic lesions  26 percent vs  15 percent  p   0 04  but not of other infections or of neoplasms  conclusions  early adjunctive treatment with corticosteroids reduces the risks of respiratory failure and death in patients with aids and moderate to severe pneumocystis pneumonia  because the adverse effects are few  corticosteroids should be included as part of the initial treatment for persons with aids who have moderate to severe pneumocystis pneumonia  
class8	identification of the primary gene defect at the cytochrome p450 cyp2d locus  the mammalian cytochrome p450 dependent monooxygenase system is involved in the metabolism of drugs and chemical carcinogens  the role of these enzymes in toxicological response is exemplified by an autosomal recessive polymorphism at the cytochrome p450 cyp2d6 debrisoquine hydroxylase locus which results in the severely compromised metabolism of at least 25 drugs  and which in some cases can lead to life threatening side effects  in addition  this polymorphism  which affects 8 10  of the caucasian population  has been associated with altered susceptibility to lung and bladder cancer  here we report the identification of the primary mutation responsible for this metabolic defect and the development of a simple dna based genetic assay to allow both the identification of most individuals at risk of drug side effects and clarification of the conflicting reports on the association of this polymorphism with cancer susceptibility  
class8	subdural hematoma associated with metastatic neoplasms  two cases of subdural hematoma  one acute and the other chronic  associated with cancer metastatic to the dura are reported  various mechanisms of the association of hematomas with cancer are reviewed  
class8	aspiration in bilateral stroke patients  seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations  34  48 6   aspirated  patients with aspiration were more likely to have posterior circulation strokes  abnormal cough  abnormal gag  and dysphonia  however  patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough  an abnormal gag reflex  or both  the prediction of patients at risk for aspiration was not improved by additional clinical information  ie  presence of dysphonia or bilateral neurologic signs   
class8	central neurogenic hyperventilation  pharmacologic intervention with morphine sulfate and correlative analysis of respiratory  sleep  and ocular motor dysfunction  central neurogenic hyperventilation  cnh   for which there is no effective therapy  can eventually result in respiratory fatigue and death  this report describes a patient with cnh due to a brainstem anaplastic astrocytoma who also exhibited disturbances of sleep and ocular motor function  the cnh responded clinically to morphine sulfate and methadone  analysis of ventilatory response to co2 before and after morphine demonstrated a depression of ventilatory response  49 to 53  of baseline  and occlusion pressure response  35 to 50  of baseline  to co2  with a requirement for high doses of naloxone  10 mg iv  to reverse the effect  polysomnography revealed sustained hyperventilation  elevated o2 saturation  and low end tidal co2 throughout all stages of non rapid eye movement  nrem  sleep  and absence of rapid eye movement  rem  sleep  ocular motor evaluation disclosed absence of horizontal and reflexive saccades with compensatory head thrusts  correlation of the clinical and physiologic data with the mri abnormalities suggested that the lesion responsible for cnh in this patient might reside in the medial tegmental parapontine reticular formation  since recurrent episodes of hyperventilation responded in a sustained fashion to iv and oral opiates  this treatment may warrant consideration in other patients with cnh  
class8	serologic evidence of subclinical pertussis in immunized children  incidental to a vaccine study involving 783 immunized children conducted at two study sites  inner city children had significantly higher geometric mean pertussis agglutinin titers compared with suburban children just before the fourth dose of diphtheria tetanus whole cell pertussis vaccine  47 vs  25  p less than 0 001   higher titers in the inner city were correlated with residence in census tracts where cases of pertussis were reported  three hundred thirty two children in a placebo arm of the study who were clinically observed and had paired serum samples taken during a 2  to 4 month period were analyzed for evidence of natural bordetella infection  twelve  11   inner city children and three  1 3   suburban children had spontaneous 4 fold or greater rises in at least two different pertussis antibodies measured  agglutinin  antitoxin or enzyme linked immunosorbent assay for igg to pertussis toxin  igg and iga to filamentous hemagglutinin   eighty percent of these children had iga to filamentous hemagglutinin  nine of 12 inner city children with serologic evidence of pertussis lived within 6 blocks of a case of pertussis reported within 1 month of the observed antibody rise in study subjects  none had a household member with pertussis and none had symptomatic disease  
class8	current epidemiology of pertussis in japan  since the introduction of whole cell pertussis vaccine into general use as part of the routine immunization in 1947 under the preventive immunization law  a steady decrease in reported cases of pertussis was noted until 1974  at that time the number of reported cases reached an all time low and no deaths caused by pertussis were reported  the vaccine  diphtheria tetanus whole cell pertussis vaccine  had been given to infants 12 weeks old or older in a 0 5 ml dose by deep subcutaneous injection  three doses were given at intervals of 3 to 8 weeks and the fourth dose  booster  was given 12 to 18 months after the third dose  the immunization was completed with those four doses  because whole cell vaccine appeared to be associated with severe neurologic illnesses  it was temporarily suspended in 1975  the vaccine was resumed soon thereafter but the age of administration was raised to 24 to 48 months  under these circumstances acceptance rates of pertussis occurred  reaching a peak in 1979  although whole cell vaccine was used even after temporary suspension  it was considered to be unacceptable by the public  as a result the acellular pertussis vaccine was developed and has totally replaced whole cell vaccine since 1981  a steady decrease in reported cases of pertussis as well as the number of deaths has been noted since 1979 in accordance with increase in vaccine acceptance rates  the national surveillance system begun in 1981 demonstrated also a steady decrease in the incidence of pertussis during the past 9 years  
class8	thrombocytosis after pneumonia with empyema and other bacterial infections in children  thrombocytosis is seen in association with many conditions  including infectious diseases  we studied thrombocytosis after severe bacterial infections  particularly pneumonia with empyema in children  a systematic survey of the phenomenon was conducted  twenty seven children admitted for pneumonia with empyema were studied  thrombocytosis  platelet counts greater than 500 x 10 3  microliters  was present in 92 5   platelet counts reached their maximum at 15 1     3 7 days  range  7 to 25  and declined to normal after 3 weeks of illness  compared with a healthy control group  significant thrombocytosis  but of lower incidence  was also noted in children with lobar pneumonia without pleural effusion  bacterial meningitis and osteomyelitis  platelet functions were examined in seven of the children but no abnormalities were observed  bone marrow aspiration of three children with pneumonia and empyema showed megakaryocytic hyperplasia  we found no correlation between thrombocytosis  neutrophilia  fever  the clinical course  complications  prognosis or treatment  neither thromboembolic nor hemorrhagic phenomena were observed  
class8	immunoglobulin g subclass deficiency and predisposition to infection in down s syndrome  serum immunoglobulins and igg subclasses were measured in 26 children with down s syndrome using an enzyme linked immunosorbent assay and monoclonal antibodies  eighteen  69   of the children had increased susceptibility to infection  none of the children had deficiencies of total igg and igm  and only one had an iga deficiency  igg4 deficiency was diagnosed in 14  54   children  one child had a deficiency of igg2  there were no children with deficiencies of either igg1 or igg3  there was a significant correlation between igg subclass deficiency and predisposition to infection  p less than 0 05   ninety percent of the patients with severe infections had low igg4 whereas only 25  of those with no infections had low concentrations of igg4  these results suggest that it is important to screen patients with down s syndrome who have frequent systemic or respiratory infections for igg subclass deficiencies because this may not be apparent from the assay of total igg  
class8	study design considerations for ribavirin  efficacy studies  five placebo controlled double blind studies  each including approximately 30 subjects  have addressed the question of the effect of aerosolized ribavirin on the course of rsv lower respiratory infection in infancy  the fact that each was able to establish a beneficial effect despite the small number of subjects studied is convincing evidence that such an effect exists  the studies from rochester using oximetry and an analog illness severity scale indicate that this effect is both statistically significant and clinically relevant  these tools are reliable and easily applicable measures for multicenter studies when illness severity is selected as an outcome measure  characteristics that should be taken into consideration when assigning experimental groups include age  sex  a history of prematurity or underlying conditions and arterial oxygen saturation  future studies will address additional questions about the efficacy of ribavirin  such as its role in critically ill children  the economic benefits of its use in terms of duration of hospitalization  the usefulness of early treatment of rsv disease in high risk infants  and the impact of treatment on long term consequences of rsv infection  these studies may require outcome variables and subject selection strategies different from those used in earlier studies  
class8	transbronchial biopsies in children after heart lung transplantation  sixty transbronchial biopsies have been performed in eight children after heart lung transplantation  the selection of fiber optic bronchoscope or a small  4 mm  30 cm  rigid bronchoscope was made according to the size of endotracheal tube required at surgery  if the endotracheal tube was size 7 5 or greater  a fiber optic bronchoscope was used  whereas if the endotracheal tube size was below 7  a rigid bronchoscope was used  for the diagnosis of lung rejection  the histology of biopsies revealed a sensitivity of 91  and specificity of 69   similar to the result in adults   the histology also distinguished lung infection from rejection  complications included three pneumothoraces and two clinically significant episodes of hemorrhage  one of which led to a cardiorespiratory arrest  which may have been caused by hypoxia  as a result  arterial oxygen saturation is now monitored during the procedure using a pulse oximeter  
class8	dexamethasone effects on the hospital course of infants with bronchopulmonary dysplasia who are dependent on artificial ventilation  a randomized double blind placebo controlled trial was conducted to evaluate the effects of enterally administered dexamethasone on the hospital course of infants with bronchopulmonary dysplasia  a total of 23 infants with a birth weight less than 1500 g who were dependent on artificial ventilation 3 to 4 weeks of age received dexamethasone  n   12  or saline placebo  n   11   dexamethasone  0 5 mg kg per day  was given in tapering doses for 7 days followed by hydrocortisone  8 mg kg per day  which was progressively reduced for a total of 17 days of therapy  infants who received dexamethasone required less oxygen on days 8 and 17  p less than  05  and were more likely to extubate 8 days after therapy than infants in the control group  respectively 8 12 vs 3 11 infants  p less than  05  p    12 after yates correction   the use of dexamethasone significantly shortened median duration of mechanical ventilation  4 vs 22 days  p less than  05  but had no effect on length of oxygen therapy  hospitalization  home oxygen therapy  occurrence and severity of retinopathy of prematurity  rate of growth  and mortality  no significant complications resulted from dexamethasone therapy  measurements of plasma dexamethasone levels confirmed the absorption of drug from the gastrointestinal tract  23 7 ng ml in dexamethasone vs 4 6 ng ml in the control group  p less than  05   dexamethasone administration resulted in short term improvements in pulmonary function but did not ameliorate the hospital course of infants with bronchopulmonary dysplasia  
class8	predicting risk for bronchopulmonary dysplasia  selection criteria for clinical trials early identification of neonates in whom bronchopulmonary dysplasia is most likely to develop permits appropriate enrollment into clinical trials testing early intervention therapies for the prevention or treatment of bronchopulmonary dysplasia  analysis of 160 neonatal intensive care unit survivors to 28 days revealed that supplemental oxygen requirement at 28 days could be predicted by a logistic regression including  1  birth weight  gestational age  5 minute apgar score  and peak inspiratory pressure at 12 hours for 12 hour old neonates and  2  birth weight  gestational age  peak inspiratory pressure at 12 hours  and mean airway pressure at 10 days for 10 day old neonates  these two regression analyses were applied prospectively to three new data sets totaling 238 neonates to test their predictive ability  neonates were classified into low   moderate   or high risk groups on the basis of their predicted probability of requiring oxygen supplementation at 28 days  low   probability of less than 25   moderate   probability of 25  to 75   and high   probability greater than 75   although these populations were demographically distinct from the original group  the regression analyses performed well  the regression analysis for 12 hours of age classified 125 neonates at low risk of whom 9  required supplemental oxygen at 28 days  and the regression analysis for 10 days classified 141 neonates at low risk of whom 7  required supplemental oxygen  the 12 hour regression analysis classified 80 neonates at moderate risk of whom 33  required supplemental oxygen at 28 days and the 10 day regression analysis classified 49 neonates at moderate risk of whom 24  required supplemental oxygen  
class8	surfactant replacement therapy with a single postventilatory dose of a reconstituted bovine surfactant in preterm neonates with respiratory distress syndrome  final analysis of a multicenter  double blind  randomized trial and comparison with similar trials  the surfactant ta study group  the effects of a single dose of surfactant ta were assessed in premature neonates  birth weight 750 to 1749 g  with respiratory distress syndrome  rds  in a multicenter  double blind  randomized clinical trial  only neonates with surfactant deficiency and without ultrasonographic evidence of intracranial hemorrhage greater than or equal to grade ii were enrolled  fifty four patients received surfactant  100 mg of phospholipid per kilogram of body weight  and 46 patients received an air placebo within 8 hours of life  treatment with this surfactant resulted in a significant reduction in the severity of rds with a concomitant increase in the proportion of neonates with mild disease  the frequency of pulmonary interstitial emphysema and of pneumothorax was significantly lower in treated neonates compared with control neonates  2  vs 26   p    0008  and 7  vs 39   p    0004  respectively   the frequency of intracranial hemorrhage was significantly lower in the surfactant group compared with the control group  20  vs 54   p    0008  and was also reduced for the smallest neonates in the surfactant group  13  vs 73   p    00008   when categorized according to severity of intracranial hemorrhage and severity of bronchopulmonary dysplasia  the surfactant group was at a significant advantage  adjusted cochran mantel haenszel x2   10 72  p less than  001 and x2   4 43  p    036  respectively   the proportion of neonates surviving without intracranial hemorrhage and or bronchopulmonary dysplasia was 63  in the surfactant group vs 26  in the control group  p    0004   as for the smallest neonates  it was 58  in the surfactant group vs 4  in the control group  p    0002   there were no differences between the groups with respect to the frequency of patent ductus arteriosus  46  vs 37    pulmonary hemorrhage  6  vs 7    necrotizing enterocolitis  0  vs 2    sepsis  4  vs 2    retinopathy of prematurity  13  vs 22    or death  15  vs 22    it is concluded that treatment with the single dose surfactant regimen used in this study reduces the severity of respiratory distress during the 48 hours after treatment and decreases the major pulmonary morbidity and intracranial hemorrhage in premature neonates with rds  further studies are needed to determine whether  1  treatment at birth or as soon as after rds is diagnosed and  2  the use of multiple dose of this surfactant would result in any additional benefits  
class8	pulmonary and acid base assessment  with increased technology  increased patient longevity  and burgeoning health care knowledge  pulmonary assessment of clients has become more complex  and nurses are now challenged to develop more comprehensive skills  these include a more focused patient history on selected clients as well as careful inspection  palpation  percussion  and auscultation  additional techniques such as voice sounds provide the nurse with even more assessment data  an understanding of common pathologic pulmonary problems and their corresponding assessment findings as well as knowledge about acid base imbalances will result in more effective professional nursing care  
class8	dyspnea  a multidimensional model of dyspnea that includes sensation  perception  distress  response  and reporting components is presented  assessment tools currently available are evaluated as are recent research findings for pharmacologic  oxygen  physical  and psychologic treatments  this article concludes by suggesting a role for the nurse in dyspnea amelioration  
class8	let s stop the comeback of tuberculosis  best drug regimens for prevention and treatment  tuberculosis has been on the increase in recent years  so physicians need to be aware of it once again  very effective drugs are available to treat the disease  pharmacokinetics  dosing schedule  and adverse reactions of each anti tuberculous agent need to be considered  a short  6 month  course of therapy is now recommended  isoniazid  rifampin  rifadin  rimactane   and pyrazinamide are given for the initial 2 months  followed by isoniazid and rifampin for 4 months  if drug resistance is a factor  a fourth drug is added to the initial regimen  and therapy may have to be extended  chemoprophylaxis with isoniazid is very important to reduce the incidence of tuberculosis  it should be given to all high risk persons  
class8	viral pneumonias  a diagnostic and therapeutic challenge  viral pneumonias are both a diagnostic and a therapeutic challenge for primary care physicians  the illness should be suspected when an upper respiratory tract infection progresses to include dyspnea and cyanosis  rapid diagnostic tests are now available to detect most of the viruses that cause pneumonias  fortunately  viral pneumonias usually resolve without specific antiviral therapy  however  ribavirin is indicated for respiratory syncytial virus pneumonia in children and ganciclovir sodium  cytovene  for cytomegalovirus pneumonia in immunocompromised patients  acyclovir  zovirax  is indicated for pneumonias due to herpes simplex virus and varicella zoster virus infections  a high index of suspicion for bacterial superinfections is essential to reduce the risk of death from this complication  
class8	breathing exercises for the medical patient  the art and the science  the art of breathing exercises can be traced to the late 1800s  in the past 10 years  the increased demand for treatment for respiratory muscle failure of dysfunction has resulted in numerous studies evaluating methods of treatment or training  this article provides an overview of research and practice  focused on treating the medical patient experiencing dyspnea or loss of respiratory muscle strength and endurance  
class8	chronic obstructive pulmonary disease  chronic obstructive pulmonary disease is indeed a multifaceted illness  the obstructive picture is the result of multiple pathologic processes  the most common cause is cigarette smoking  the key to decreasing the incidence of this disease is education to prevent people from starting to smoke and to educate those who do smoke to stop  the therapeutic management involves numerous medications  oxygen  and physiotherapy  unfortunately  the pharmacologic management remains largely empiric with sympathomimetics  anticholinergics  methylxanthines  and corticosteroids  these agents  especially methylxanthines and corticosteroids  are not without considerable toxicity  therefore  embarking on a pharmacologic plan requires weighing the risk to benefit ratio carefully and having a comprehensive plan to assess subjectively and objectively the efficacy and toxicity of the chosen therapy  
class8	pharmacotherapy of asthma and allergic rhinitis  it has become easier to treat and control the symptoms of asthma  while the treatment of allergies remains directed toward the prevention and blockade of histamine induced symptoms  this article details treatment options  including beta 2 selective sympathomimetic agonists  methods of delivery  theophylline  cromolyn  corticosteroids  antihistamines  decongestants  and intranasal steroids  
class8	bacterial tracheitis  report of eight new cases and review  bacterial tracheitis  previously referred to as nondiphtheritic laryngitis with marked exudate  was commonly discussed in pediatric textbooks before 1940  it seemed to disappear as a clinical entity after that time  but it has been recorded with increasing frequency in the pediatric literature since 1979  we describe eight new cases and review 110 previously described cases  the clinical course consists of a prodromal upper respiratory illness with stridor  fever  and a variable degree of respiratory distress  unlike patients with croup  patients with bacterial tracheitis do not respond to aerosolized racemic epinephrine  most patients require endotracheal intubation  some require tracheostomy  reported complications include pneumonia  pneumothorax  formation of pseudomembranes  toxic shock syndrome  and cardiopulmonary arrest  bacterial tracheitis is a secondary bacterial infection following a primary viral respiratory infection  the most common preceding viral infection is parainfluenza  staphylococcus aureus and haemophilus influenzae are the predominant causes of bacterial tracheitis  secondary bacterial infection may occur as a result of tracheal mucosal injury or impairment of normal phagocytic function due to viral infection  
class8	acute respiratory disease in spain  seven years of experience the clinical and epidemiologic features of viral and nonviral pathogens involved in acute respiratory diseases are described in the context of cases of infection  especially atypical pneumonia and bronchiolitis  studied at the centro nacional de microbiologia  virologia e immunologia sanitarias in madrid during a 7 year period  1979 1986   these etiologies were demonstrated in 1 637  36 2   of 4 521 cases  among viruses  respiratory syncytial virus most frequently infected children  influenza virus showed the same pattern of circulation as in other european countries  of nonviral agents  mycoplasma pneumoniae and c  burnetii were most often involved in lower respiratory tract infections  with a variable predominance in patients of different ages  a high proportion of cases of m  pneumoniae infection occurred in infants and children aged less than 1 year  and most of these cases occurred during spring and summer  the majority of q fever cases  including those observed in two outbreaks  occurred in the northern region  
class8	resolution of lung abscess due to pseudomonas aeruginosa with oral ciprofloxacin  case report  a case of lung abscess due to pseudomonas aeruginosa is presented that did not resolve with the use of conventional antipseudomonal antibiotics  including tobramycin with ticarcillin clavulanate and ceftazidime with gentamicin and ticarcillin clavulanate  oral ciprofloxacin was administered for 12 weeks  and the infection was resolved  no resistance occurred  and there was no recurrence of abscess within 18 months following therapy  
class8	pulmonary and disseminated infection due to mycobacterium kansasii  a decade of experience  fifty five patients with mycobacterium kansasii isolates  47 pulmonary and eight disseminated  were identified at a large texas hospital from 1975 to 1985  the mean age of patients was 60 years  and there was a slight male predominance  isolation of m  kansasii usually represented disease  the great majority of patients with pulmonary infection due to m  kansasii had underlying pulmonary diseases  and 70  had nonpulmonary predisposing factors  m  kansasii pulmonary disease clinically and radiographically resembled pulmonary tuberculosis  disseminated m  kansasii infection occurred in severely immunocompromised patients  who frequently had pulmonary predispositions as well  disseminated infection most of ten involved the lung  reticuloendothelial system  bone  joint  and skin and presented with signs and symptoms related to these organs  despite only moderate in vitro susceptibility of m  kansasii to routine antituberculous drugs  most patients responded to rifampin containing regimens  the prognosis of patients with m  kansasii disease was determined primarily by their underlying diseases  
class8	early treatment with acyclovir for varicella pneumonia in otherwise healthy adults  retrospective controlled study and review  the effect of early acyclovir therapy on the course of varicella pneumonia in previously healthy adults was assessed  medical records from five university affiliated medical centers were retrospectively reviewed  included were all immunocompetent adults with a clinical diagnosis of primary varicella  a chest radiograph consistent with varicella pneumonia  and an arterial blood gas measurement indicating significant hypoxia  of the 38 patients who met the study criteria  11 had had a course of intravenous acyclovir initiated within the first 36 hours of hospitalization  the mean time from admission to initiation of therapy in this early treatment group was 9 6 hours  the group that received early acyclovir treatment had a lower mean temperature beginning on the fifth day of hospitalization  37 0 degrees c vs  37 7 degrees c  p    011  and a lower mean respiratory rate beginning on the sixth day of hospitalization  21 vs  28 respirations per minute  p    004   early acyclovir therapy also resulted in a significant improvement in oxygenation beginning on the sixth day of hospitalization in patients with follow up arterial blood gas measurements  p    035   thus  early institution of acyclovir therapy is associated with reduction in fever and tachypnea and improvement in oxygenation in otherwise healthy adults with varicella pneumonia  
class8	pneumonia due to legionella micdadei in bone marrow transplant recipients  legionella micdadei has previously been described as a cause of nosocomial pneumonia  particularly in kidney transplant recipients  cell mediated immunity is the principal host defense against this pathogen  a common clinical scenario in the immunocompromised host is that of septic pulmonary embolus  but asymptomatic infections have also been reported  the organism is weakly acid fast in clinical specimens but loses this property when grown on solid media  we report two cases of l  micdadei pneumonia  differing markedly in clinical severity and outcome  in bone marrow transplant recipients  additionally  we note the growth of the organism in liquid culture media with preservation of its acid fast property  
class8	virologic and pathogenetic aspects of cytomegalovirus infection  cytomegalovirus  cmv  is a ubiquitous agent that rarely causes disease in immunocompetent humans but is an important cause of morbidity and mortality in the immunocompromised  a number of host and viral factors are associated with pathology following cmv infection  cmv can be found at many sites in the body but only causes disease at some of these and then only in certain patient populations  in some situations the mechanism underlying disease is direct viral replication  but in others  particularly cmv pneumonitis in allogeneic transplant recipients  an immunopathologic basis is strongly implicated  an important factor in the pathogenesis of infection and the expression of symptomatic disease is the source of cmv infection whether it arises from an exogenous source or is due to reactivation of latent endogenous virus  exogenous infection can occur in previously seronegative individuals or in those with prior exposure to the virus  in renal transplant recipients both types of exogenous infection have been associated with disease  another factor that affects the interaction between cmv and its host is the modulating effect of the virus on the host immune response  the mechanism of which remains unknown  
class8	cytomegalovirus infections after allogeneic bone marrow transplantation  cytomegalovirus  cmv  infection occurs in approximately 50  of all recipients of allogeneic bone marrow transplants and is seen more frequently in cmv seropositive patients than in cmv seronegative patients  sources of infection include reactivation of latent endogenous virus  blood products from cmv seropositive blood donors  and the use of marrow from a cmv seropositive donor for a cmv seronegative recipient  the most common and severe clinical syndrome associated with cmv infection in allogeneic transplant recipients is interstitial pneumonia  which occurs in approximately 15  of patients  risk factors for cmv pneumonia include old age  conditioning with total body irradiation  and severe graft vs  host disease  the rapid diagnosis of cmv pneumonia has been facilitated by immunochemical staining of bronchoalveolar lavage fluid or by centrifugation of cell cultures with cmv monoclonal antibodies  the treatment of cmv pneumonia remains problematic  but therapy with a combination of intravenous immune globulin  ivig  plus ganciclovir has resulted in survival rates substantially better than those achieved in previous trials of antiviral therapy  in cmv seronegative patients  cmv infection and pneumonia can be prevented or modified by the use of cmv seronegative blood products and ivig  ivig may also have the additional benefits of preventing other infectious complications and graft vs  host disease in patients receiving cmv seronegative blood products  for cmv seropositive patients  effective prophylaxis for cmv reactivation and pneumonia has not yet been established  but a clinical trial of prophylactic ganciclovir is now under way  
class8	cytomegalovirus infections in bone marrow transplant recipients given intensive cytoreductive therapy  cytomegalovirus  cmv  infections were studied in 785 bone marrow transplant recipients given intensive cytoreductive therapy  cmv excretion occurred in 24   viremia in 9   seroconversion in 40   and overall active infection in 47   cmv disease was much less common  retinitis  enteritis  and pneumonitis occurred in only one  five  less than 1    and 55  7   of the patients  respectively  allograft recipients were more likely to develop cmv disease than were autograft patients  p    0001  despite comparable rates of active cmv infection  cmv disease was rare after primary infection in both autograft and allograft recipients  0 and 1   respectively   in contrast  cmv disease occurred in 16  of seropositive allograft recipients  among allograft recipients  risk factors for cmv pneumonitis were seropositivity  age greater than 10 years  and acute graft vs  host disease  while the use of cyclosporine as prophylaxis against graft vs  host disease was protective  although active infection rates did not decrease  the rates of cmv pneumonitis in allograft recipients during successive years declined significantly  p less than  001   
class8	successful strategy for prevention of cytomegalovirus interstitial pneumonia after human leukocyte antigen identical bone marrow transplantation  cytomegalovirus  cmv  interstitial pneumonia is a frequent and often fatal complication of allogeneic bone marrow transplantation  because therapy for cmv pneumonia was  until recently  largely ineffective  prophylactic methods were explored  this study shows that the strategy of using cmv seronegative blood products for seronegative patients with seronegative donors or weekly administration of intravenous immunoglobulin for all other patients reduced the attack rate of cmv pneumonia  the results of this study are put into the perspective of previously published data  
class8	complications of extracorporeal membrane oxygenation in neonates  in cases of severe respiratory failure  cardiopulmonary bypass has been used as support until cardiac and pulmonary recovery occurs  we report the wilford hall usaf medical center experience with extracorporeal membrane oxygenation  ecmo  and its associated complications  from july 1985 to march 1989  57 neonates were placed on membrane oxygenators  the overall survival was 79   technical complications encountered included catheter related problems  mechanical complications of the pump apparatus  and hemorrhage  hemorrhagic complications were the most frequent and devastating complications encountered  intracranial hemorrhage accounted for six deaths associated with bypass  extracorporeal membrane oxygenation is successful in significantly improving survival of neonates whose predicted mortality approaches 100  with conventional treatment  the rate of infant mortality using the membrane oxygenator is not affected by technical complications related to catheter position  mechanical problems with the circuit  or hemorrhage  excluding intracranial hemorrhage  the major cause of death of infants receiving extracorporeal membrane oxygenation is the underlying disease process leading to cardiopulmonary failure  
class8	analysis of the two team approach to anterior spinal fusion  an anterior approach to the spine via a thoracoabdominal incision offers the surgeon many advantages  the major vascular structures are visualized  stabilization of a long segment of the spine is strong  and recovery is speedy  nevertheless  this is a major operation and one with potential morbidity and mortality  at children s hospital of new orleans  the pediatric surgery and pediatric orthopedic surgery services work together to reduce these risks and in so doing maintain an acceptable morbidity  with this two team approach  we operated on the spines of 39 patients between 1978 and 1988  the most common indications for operation included idiopathic scoliosis  neuromuscular disease  and congenital abnormalities  a thoracoabdominal approach was used in 32 patients  a thoracic approach in four patients  and an abdominal approach in three patients  twenty nine patients experienced 65 complications  45 of these complications were respiratory in nature  there were no postoperative deaths  factors unrelated to the incidence of postoperative complications included age  volume of crystalloid infused during operation  volume of blood replacement  and length of anesthesia  
class8	pneumocystis carinii pneumonia manifested as a hilar mass and cavitary lesion  an atypical presentation in a patient receiving aerosolized pentamidine prophylaxis  a case of pneumocystis carinii pneumonia  pcp  in a patient with aids was manifested radiographically as a hilar mass and cavitary lesion  the patient had been receiving aerosolized pentamidine as prophylaxis against pcp  nonuniform deposition of aerosolized pentamidine was probably responsible for this atypical radiographic appearance of pcp  
class8	pleuropulmonary tularemia  successful treatment with erythromycin  a 64 year old man had community acquired pneumonia that was retrospectively diagnosed as pleuropulmonary tularemia  he was successfully treated with erythromycin  we review the case and briefly discuss the literature on this point  
class8	the contributions of john b  murphy to thoracic surgery  john b  murphy was a prominent surgeon who lived in chicago from the 1880s until his death in 1916  during his career  he was associated with both rush presbyterian and northwestern medical schools  he was responsible for popularizing the use of an artificial pneumothorax as an effective adjunct in the treatment of pulmonary tuberculosis  this modality was not  however  his original concept  in addition to all of the fields of general surgery  murphy undertook the management of empyema and lesions of the chest wall and also performed thoracoplasty procedures  although he had done several thoracotomy procedures in his laboratory  he rarely undertook this operation in a clinical setting  drop ether anesthesia was used for all surgical procedures  murphy did not use closed water seal drainage of the chest  his oration on thoracic surgery  given at the annual meeting of the ama  in 1898  was an excellent monograph on the subject and undoubtedly contributed to the increased interest and progress in this field of surgery  murphy was a wise surgeon  an able technician and a scholarly teacher  the high regard in which he was held by his contemporaries is best expressed by the remark of william mayo      he was the surgical genius of our generation   
class8	radiologic staging of chest in testicular seminoma  we investigated the usefulness of chest x ray  cxr   conventional planar tomography  tom   and computerized axial tomography  cat  in evaluating patients with stages i and ii testicular seminoma  all patients had a cxr  and 22 patients had either tom or cat as part of initial staging  no occult pulmonary or mediastinal nodal disease was found during initial staging  and none of the patients manifested recurrence of tumor in these sites as a first event  review of the literature corroborates our finding of a very small thoracic failure rate in early stage seminoma  routine use of cat or tom is not indicated in staging these patients  
class8	nasolaryngoscopy for family physicians  nasolaryngoscopy is easy to learn and safe and convenient to perform  it is readily accepted by patients and is a rich source of clinical information  the flexible nasolaryngoscope allows the physician to directly observe the anatomy of the nasal passages  pharynx and larynx  the procedure is helpful for identifying the etiology of chronic nasal complaints and hoarseness  other possible indications for nasolaryngoscopy include suspected nasal foreign body  recurrent nasal or pharyngeal bleeding  and epiglottitis  with the use of this instrument  treatment of otolaryngologic conditions may be more specific  thereby reducing unnecessary referral or delay in treatment  
class8	hiv disease  a review for the family physician  part ii  secondary infections  malignancy and experimental therapy  the first part of this two part article included recommendations for the initial evaluation of patients suspected of having hiv infection  the centers for disease control s classification scheme for hiv disease and current recommendations for the use of zidovudine  in this second part  secondary infections and malignancy are reviewed  and various experimental therapies are briefly discussed  
class8	effects of common illnesses on infants  energy intakes from breast milk and other foods during longitudinal community based studies in huascar  lima   peru  to assess the effects of common infections on dietary intake  131 peruvian infants were observed longitudinally  home surveillance for illness symptoms was completed thrice weekly  and food and breast milk consumption was measured during 1615 full day observations  mean      sd  energy intakes on symptom free days were 557     128 kcal d  92 4     26 5 kcal kg 1 d 1  for infants aged less than 181 d and 638     193 kcal d  77 7     25 7 kcal kg 1 d 1  for infants aged greater than 180 d  statistical models controlling for infant age  season of the year  and individual showed significant 5 6  decreases in total energy intake during diarrhea or fever  there were no changes with illness in the frequency of breast feeding  total suckling time  or amount of breast milk energy consumed  by contrast  energy intake from non breast milk sources decreased by 20 30  during diarrhea and fever  and the small decrements in total energy consumption during illness were explained entirely by reduced consumption of non breast milk foods  
class8	inflammatory myofibroblastic tumor  plasma cell granuloma   clinicopathologic study of 20 cases with immunohistochemical and ultrastructural observations  twenty cases of inflammatory myofibroblastic tumor  imt  were studied  19 involved the lung and 1 the esophagus only  the patients  ages ranged from 3 to 72 years  there were 9 males and 11 females  involvement of a bronchus was seen in one case and of mediastinal structures in four  chest pain and dyspnea were common symptoms  eight patients were asymptomatic  seven patients underwent lobectomy  12 local excision  and 1 biopsy alone  the lesions were nonencapsulated and ranged from 1 2 to 15 cm  various proportions of plasma cells  histiocytes  and spindle cells were observed  the latter corresponded ultrastructurally to fibroblasts and myofibroblasts  were immunoreactive for vimentin and actin and focally for desmin  and were negative for epithelial markers  plasma cells were polyclonal for light chains  one patient had two recurrences  and in one case a large pleural imt was found eight years after the excision of a similar lesion in the lung  all patients with follow up  ten  were well as long as ten years after the diagnosis  average  3 7 years   
class8	survey of histologic specimens of human cancer for human papillomavirus types 6 11 16 18 by filter in situ hybridization  histologic specimens  317  of genital and nongenital cancers and normal tissue were analyzed for the presence of the dna of human papillomavirus  hpv  6  11  16  and 18 by filter in situ hybridization performed on paraffin embedded  formalin fixed tissue  histofish   hpv dna was found in 73 of 172  42   anogenital lesions and 17 of 116  15   nonanogenital carcinomas  no hpv dna was found in normal mouse skin  five samples   human autopsy liver  two samples   or kidney  eight samples   or in carcinomas of the breast  three samples   bladder  five samples   or colon  nine samples   of the nongenital tumors  hpv dna was found in the carcinomas of the lung  2 of 5   anus  7 of 18   esophagus  9 of 39   buccal cavity  1 of 5   and larynx  5 of 50   hpv dna was also detected in 2 of 11 histologically normal specimens of the cervix and 1 of 3 human skin lesions  the detection of hpv dna in carcinomas of the lung  larynx  and esophagus as well as in the anogenital region confirms recent suggestions that hpv types 6  11  16  and 18 have a wider association with different types of cancer than previously believed  the study also shows that histofish is a useful method for detecting hpv dna in histologic specimens  
class8	childhood deaths from toy balloons  we describe four children who died of suffocation by rubber balloons in canada between 1983 and 1988  in the united states  at least 121 children have died in a similar manner in the 15 years between 1973 and 1988 according to a report by the us consumer product safety commission  although the highest mortality occurred among infants  30  25   of the 121 deaths occurred in children 6 years of age or older  balloons account for 43  of the approximately 15 childhood deaths related to children s products that are documented each year by the consumer product safety commission  toy rubber balloons are thus the leading cause of pediatric choking deaths from children s products  preventive efforts should be directed toward a ban on this type of balloon and the development of safer alternatives  meanwhile  public information campaigns should alert parents  physicians  and policymakers to the dangers of toy rubber balloons  
class8	use of intrapleural streptokinase in the treatment of thoracic empyema  the incidence of pleural effusions in bacterial pneumonia may exceed 40   a factor that may be related to increased morbidity and mortality  options in the treatment of complicated pleural effusions or empyema  when unresponsive to closed tube drainage  include repositioning of the indwelling tube thoracostomy or insertion of additional chest tubes  instillation of intrapleural streptokinase  and surgical intervention  the authors describe the course of three patients wherein the use of intrapleural streptokinase was efficacious in effecting prompt drainage of previously inadequately evacuated empyema  thus eliminating the necessity for further invasive intervention  
class8	pulmonary disease in aids patients  pulmonary disease remains a major complication of the human immunodeficiency virus  hiv   over the past decade several changes in the pattern of disease have occurred  pneumocystis carinii pneumonia  pcp  remains the most common opportunistic pathogen in aids patients  though its incidence on bronchoscopy has declined and empiric therapy often occurs without a specific diagnosis  changes in the management of patients with pcp have included different dosages and routes of administration for chemotherapy  improved overall survival  and a recent increase in the number of patients surviving episodes of respiratory failure  in addition  infection with mycobacteria tuberculosis  m tb   has emerged as a major public health problem  the pattern of m tb  is distinct from non immunocompromised patients though response to therapy usually occurs  
class8	ultrastructural localization of proteinase 3  the target antigen of anti cytoplasmic antibodies circulating in wegener s granulomatosis  to investigate the distribution of proteinase 3  the target antigen of anti cytoplasmic antibodies  acpa or c anca   within the organelles of resting normal human polymorphonuclear leukocytes and monocytes  the authors used immunocytochemical techniques on thin frozen sections  to obtain valuable tools for immunolabeling  two murine monoclonal antibodies  mabs  directed against the acpa antigen were produced  in neutrophils  the authors observed immunogold label for the acpa antigen  predominantly in myeloperoxidase positive azurophil granules  and in smaller amounts on the plasma membrane  in monocytes  the acpa antigen could be detected in small granules  which occasionally also contained myeloperoxidase  and rare labeling was found on the monocyte membrane  the finding that the acpa antigen is expressed on the plasma membrane of neutrophils and monocytes  thereby becoming accessible to circulating autoantibodies  supports the supposition that acpa are not only markers of disease activity  but also are involved in the pathogenesis of wegener s granulomatosis  
class8	inhibition of angiogenesis and tumor growth in the brain  suppression of endothelial cell turnover by penicillamine and the depletion of copper  an angiogenic cofactor  microvascular proliferation  a hallmark of malignant brain tumors  represents an attractive target of anticancer research  especially because of the quiescent nonproliferative endothelium of the normal brain  cerebral neoplasms sequester copper  a trace metal that modulates angiogenesis  using a rabbit brain tumor model  normocupremic animals developed large vascularized vx2 carcinomas  by contrast  small  circumscribed  relatively avascular tumors were found in the brains of rabbits copper depleted by diet and penicillamine treatment  cdpt   the cdpt rabbits showed a significant decrease in serum copper  copper staining of tumor cell nuclei  microvascular density  the tumor volume  endothelial cell turnover  and an increase in the vascular permeability  breakdown of the blood brain barrier   as well as peritumoral brain edema  in non tumor bearing animals  cdpt did not alter the vascular permeability or the brain water content  cdpt also inhibited the intracerebral growth of the 9l gliosarcoma in f 344 rats  with a similar increase of the peritumoral vascular permeability and the brain water content  cdpt failed to inhibit tumor growth and the vascularization of the vx2 carcinoma in the thigh muscle or the metastases to the lung  findings that may reflect regional differences in the responsiveness of the endothelium  the distribution of copper  or the activity of cuproenzymes  metabolic and pharmacologic withdrawal of copper suppresses intracerebral tumor angiogenesis  angiosuppression is a novel biologic response modifier for the in situ control of tumor growth in the brain  
class8	prevalence of chronic bronchitis among us hispanics from the hispanic health and nutrition examination survey  1982 84  in the hispanic health and nutrition examination survey  hhanes   puerto ricans had a higher age adjusted prevalence of self reported chronic bronchitis  2 9 percent  95  ci   2 2  3 6  than mexican americans  1 7 percent  95  ci   1 3  2 1  or cubans  1 7 percent  95  ci   0 9  2 5   the prevalence of chronic bronchitis was at least 2 times higher in smokers as compared to nonsmokers among puerto ricans and cubans  but not for mexican americans  
class8	admissions to the intensive care unit after complications of anaesthetic techniques over 10 years  2  the second 5 years compared with the first 5 years there was a 19  increase in general anaesthetics  a 171  increase in local and  or  sedation techniques and a 9  increase in obstetric epidurals with no increase in anaesthetic staffing  in this second 5 year period  46 patients were admitted to the intensive care unit as a result of a complication of an anaesthetic technique  these patients represented 1 in 2371 anaesthetic techniques carried out in the district compared with the previous 5 years where the incidence was 1 in 1543  seven patients died  15 2    the complication was considered to be wholly or partially avoidable in 14 instances  30 4    four of these subjects died  
class8	treatment of atelectasis of upper lung lobes  selective bronchial suctioning with j shaped catheter tip and guide mark  we developed a technique for blind bronchial suction using a curved tip catheter with a guide mark  for the treatment of atelectasis of the lower and middle lobes of the lung  suction of the upper lobe bronchi could not be performed because of the combination of the peculiar anatomy of the upper lobe bronchi with catheter design  we treated successfully two cases of atelectasis of the right upper lobes using a rusch metras bronchography catheter with a guide mark which is not readily available  therefore we devised a j shape tipped catheter with a guide mark  we have successfully treated 13 episodes of atelectasis of the right upper lobe in 10 patients and one episode in the left upper lobe in one patient with this new catheter  
class8	laryngeal oedema from a neck haematoma  a complication of internal jugular vein cannulation  laryngeal oedema occurred after formation of a neck haematoma after attempted internal jugular vein cannulation  this resulted in complete respiratory obstruction and respiratory arrest and it was impossible to ventilate her lungs manually or intubate her trachea  oxygenation of the patient was only possible using transtracheal ventilation  
class8	effects of famotidine and cimetidine on plasma levels of epidurally administered lignocaine  the effects of two h2 receptor antagonists  famotidine and cimetidine  on the plasma levels of epidurally administered lignocaine were studied  group a  n   20  received famotidine 20 mg orally the night before surgery and 20 mg intramuscularly 60 minutes before induction of anaesthesia  group b  n   15  received cimetidine 200 mg orally the night before the surgery and 400 mg orally 60 minutes before the anaesthetic induction  group c  n   20  received neither famotidine nor cimetidine and served as controls  twelve millilitres of 2 0  lignocaine with adrenaline 1 200 000 was injected into the epidural space in all patients  after the establishment of general anaesthesia with nitrous oxide  oxygen  and enflurane  0 3 0 5    the patients who received cimetidine showed significantly higher plasma concentrations of lignocaine compared with either group a or group c at all investigation times  p less than 0 01   the mean peak plasma concentrations were 2 4  sem 0 1   3 2  sem 0 2  and 2 3  sem 0 1  micrograms ml in group a  b  and c  respectively  this study suggests that famotidine is preferable to cimetidine for control of gastric acidity before the use of lignocaine as the epidural anaesthetic  
class8	acid aspiration prophylaxis in 288 obstetric anaesthetic departments in the united kingdom  the choice of drugs for acid aspiration prophylaxis in 288 obstetric anaesthetic departments in the united kingdom was determined by questionnaire  the results are compared with a similar survey of anaesthetic departments 5 years ago  the prescription of sodium citrate and the h2 receptor antagonist ranitidine has superseded that of mist  magnesium trisilicate  
class8	emergency tracheal intubation in the postanesthesia care unit  physician error or patient disease  inadequate airway maintenance has been a major factor in perioperative morbidity  to determine the incidence and etiology of emergency tracheal intubations in the postanesthesia care unit  pacu   we retrospectively reviewed 13 593 consecutive admissions to our pacu from october 1986 through october 1988  twenty six patients  26 13 593   0 19   required the insertion of an endotracheal tube while in the pacu  seventy seven percent  20 26  of the intubations occurred within 1 h of extubation and or admission to the pacu  intubation was more common at the extremes of age  54  of those intubated were more than 60 yr old  p   0 003   19  were less than 3 yr old  p less than 0 05   twenty three percent of the intubated patients had undergone otolaryngologic procedures  p   0 008   interestingly  73  of the intubations occurred during the months of january through june  p   0 016   median pacu admission scores were lower for the intubated group  p less than 0 001   there was no association between intubation and gender  p   0 74   anesthetic technique  p   0 41   or anesthetic agent  p   0 49   of the 26 intubations  18  69   were considered to be directly related to anesthetic management  despite the extremely low incidence of emergency tracheal intubation in a heterogeneous group of patients admitted to our pacu  preventable anesthesia related etiologic factors including excessive sedative or anesthetic effect  inappropriate fluid management  persistent muscle relaxant effect  and upper airway obstruction contributed to the majority of these intubations  
class8	local and global function of the right ventricle in a canine model of pulmonary microembolism and oleic acid edema  influence of ventilation with peep  right ventricular  rv  dysfunction may occur due to increased rv afterload and  hence  might also contribute to the decrease in cardiac output following institution of peep in patients with adult respiratory distress syndrome  ards   to test this hypothesis  the authors examined the influence of peep on local and global rv function in 12 anesthetized dogs with experimental ards  eards  induced by pulmonary microembolization with glass beads and oleic acid  local rv function was analyzed in the rv inflow tract  rvit  and rv outflow tract  rvot  by assessing both diastolic segment length  systolic segment shortening  and segment work  sonomicrometry   global rv contractility was quantified by measuring maximum rate of pressure rise  drvp dtmax  and maximum velocity of contractile element shortening  vmax   in eards  despite a fivefold increase in pulmonary vascular resistance  there was no change in cardiac index  ci   global rv contractility  rvit and rvot work  and rvit shortening  whereas rvot shortening decreased from 12 4 to 7 4   p less than 0 01   diastolic segment length increased in rvit  p less than 0 05  but not in rvot  peep of 10 cmh2o did not alter global rv contractility  rvit and rvot shortening  and rvit work but reduced rvot work   35   p less than 0 01  and ci   11   p less than 0 001   cardiac index further decreased during peep of 20 cmh2o   38   p less than 0 001   while global rv contractility remained intact despite decreased rvit and rvot shortening   32  and  69   p less than 0 05  and work   26  and  59   p less than 0 01  in the presence of reduced fiber preload in both regions  from these findings  it was concluded that 1  the decreased ci during mechanical ventilation with peep at constant right ventricular end diastolic pressure  rvedp  is not caused by depressed global rv contractility in dogs with eards and a normal myocardium prior to insult  decreased diastolic segment length and segment shortening during peep suggest that 2  peep reduces stroke volume by the starling mechanism rather than by ischemia of the rv free wall  finally  regionally incongruent changes of fiber preload indicate that 3  local differences in rv wall compliance are likely to occur subsequent to eards and peep  
class8	manual translaryngeal jet ventilation and the risk of aspiration in a canine model  study objectives  manual translaryngeal jet ventilation  tljv  is a safe and effective method of maintaining normal ventilation in apneic subjects  little data exist on the amount of airway protection afforded with this technique of airway management  we sought to evaluate the risk of aspiration during manual tljv  setting  data were collected in a laboratory animal model  design  a prospective  nonrandomized  controlled trial was performed  participants  seventeen adult apneic mongrel dogs were enrolled  interventions  intratracheal gastrograffin was instilled and radiographic changes assessed during ventilation using a 0 to 3 scale  none to severe   thirty six trials were performed  with equal numbers at both 30 degrees and 45 degrees head elevation  the three groups studied were animals without airway protection  control   animals with a cuffed endotracheal tube  tube   and animals with a percutaneous tljv cannula and a 50 psi oxygen source ventilated at a rate of 20 breaths per minute  jet   measurements and main results  significantly less radiographic evidence of aspiration was noted in the jet and tube groups at 30 degrees and 45 degrees compared with control animals  p    002 each   at 45 degrees head elevation a trend toward increased aspiration scores in the jet group compared with the tube group  p    065  was observed  conclusion  in our model  manual tljv at 20 breaths per minute and an i e ratio of 1 2 provided protection from aspiration comparable to that observed with a cuffed endotracheal tube at 30 degrees head elevation  at 45 degrees elevation  this protection was diminished  
class8	prehospital administration of inhaled metaproterenol  study objectives  we conducted a study of the prehospital use of inhaled metaproterenol  design  setting  type of participants  and interventions  advanced life support  als  providers were trained with a standardized curriculum to identify patients likely to benefit from prehospital inhaled metaproterenol administration  unit doses of metaproterenol were used in a small volume nebulizer  we prospectively included 122 patients in an initial study  71 men  age  63     19 years  to evaluate the safety and effectiveness of metaproterenol in the field  and 150 patients  including the original 122  in an additional study to evaluate patient selection criteria  measurements and main results  the treatments resulted in an increase in peak flows  a decrease in respiratory rates  and no change in heart rates  in 62  of patients  the increase in peak flow exceeded 15   wheezing improved in 59  of the patients  worsened in 4   and did not change in the remainder  air entry by auscultation improved subjectively in 59  of patients  mild tremor occurred in 8  of patients  moderate tremor occurred in 1   and no tremor occurred in the remainder  significant dysrhythmias did not occur  conclusions  als providers correctly identified patients for this therapy  no technical problems were encountered in the field with this treatment approach  we conclude that als providers can be taught to identify patients likely to benefit from inhaled metaproterenol  that inhaled metaproterenol can be administered in the field  and that metaproterenol is both safe and effective when used in the prehospital setting  
class8	atypical presentation of pulmonary embolism  today we have discussed an interesting patient with an atypical presentation of pulmonary embolism  we have outlined a suggested algorithm to aid in the diagnosis and management of this disease  references 8 through 24 in the reference section are suggested readings that offer further insight into the diagnosis and management of this entity  
class8	characterization of distal bronchial microflora during acute exacerbation of chronic bronchitis  use of the protected specimen brush technique in 54 mechanically ventilated patients  to obtain accurate information on distal bronchial microflora during acute exacerbation in patients with chronic bronchitis  we prospectively studied 54 such patients who had been receiving mechanical ventilation because of hypercapnic respiratory failure  fiberoptic bronchoscopy using a protected specimen brush  psb  was performed on each patient within the first 24 h after admission  cultures of protected brush specimens demonstrated no growth in 27 patients  50    with the exception of fever  38 2     0 8 versus 37 7     0 6 degrees c  p less than 0 05   the initial severity of the episode of exacerbation was similar in patients with and without infection  a total of 44 organisms were isolated in the 27 patients with positive cultures  the predominant pathogens were hemophilus spp  and streptococcus spp   involved in 74  of cases   but other organisms were isolated in 12 of 27 patients  mortality rates  duration of mechanical ventilation  and duration of hospitalization were not significantly different between patients with bronchial microflora treated with appropriate antimicrobial therapy  n   27  and patients without bronchial microflora either receiving empirical antibiotic therapy  n   18  or not  n   9   these data suggest that distal bronchial infection due to the usual pathogens  as far as shown by protected specimen brush cultures  may not be the sole or even the predominant cause of acute exacerbation of chronic bronchitis in patients requiring mechanical ventilation  
class8	distinguishable types of dyspnea in patients with shortness of breath  dyspnea frequently accompanies a variety of cardiopulmonary abnormalities  although dyspnea is often considered a single sensation  alternatively it may encompass multiple sensations that are not well explained by a single physiologic mechanism  to investigate whether breathlessness experienced by patients represents more than one sensation  we studied 53 patients with one of the following seven conditions  pulmonary vascular disease  neuromuscular and chest wall disease  congestive heart failure  pregnancy  interstitial lung disease  asthma  and chronic obstructive pulmonary disease  patients were asked to choose descriptions of their sensation s  of breathlessness from a dyspnea questionnaire listing 19 descriptors  cluster analysis was used to identify natural groupings among the chosen descriptors  we found that patients could distinguish different sensations of breathlessness  in addition  we found an association between certain groups of descriptors and specific conditions producing dyspnea  these findings concur with those in an earlier study in normal volunteers in whom dyspnea was induced by various stimuli  we conclude that different types of dyspnea exist in patients with a variety of cardiopulmonary abnormalities  furthermore  different mechanisms may mediate these various sensations  
class8	a family study of the variability of pulmonary function in alpha 1 antitrypsin deficiency  quantitative phenotypes  a group of 52 alpha 1 antitrypsin deficient individuals of phenotype pi z and 117 of their relatives underwent a protocol including pulmonary function testing  completion of a questionnaire  and blood donation  our population permitted a minimum frequency estimate  7 x 10  4   for pi null alleles  five quantitative phenotypes were measured  including fev1  fef25 75  total serum alpha 1at  oxidized serum alpha 1at  and total serum ige  we found that  1  total alpha 1at levels were higher in pi z subjects with lung function impairment  fev1 less than or equal to 65  of predicted  than in pi z subjects who were not impaired   2  pi z subjects with lung function impairment had elevated serum levels of oxidized alpha 1at  and  3  ige levels were relatively elevated in first degree pi mz relatives of impaired pi z subjects  moreover  fev1 tended to be relatively reduced in heterozygous parents of impaired pi z subjects  suggesting that a subset of pi mz individuals are at risk for development of lung disease because of familial factors  these results represent an initial step toward the development of intermediate phenotypes that will be predictive of a severe course in alpha 1at deficiency  they suggest that  in addition to cigarette smoking  atopic predisposition and undetermined familial factors may be important codeterminants of lung disease progression  
class8	pulmonary denervation in humans  effects on dyspnea and ventilatory pattern during exercise  the role of the pulmonary autonomic nerves in the mediation of respiratory sensation is unclear  pulmonary neurogenic mechanisms may contribute to dyspnea either directly or indirectly via an influence on the pattern of ventilation  using human heart lung transplantation as a model of pulmonary denervation  we studied the ventilatory response  respiratory drive  p0 1   and sensation of breathlessness  modified borg scale  during maximal incremental bicycle exercise  the subjects were four female heart lung transplant recipients 3 to 9 months post transplant and 10 age matched control subjects  the ventilatory response to increasing co2 output  vco2  was higher  p less than 0 001  in transplant recipients than in control subjects  such that ventilation at peak exercise was similar in the two groups despite a lower peak vco2 in transplant recipients  the ratio of tidal volume to inspiratory capacity increased with increasing ventilation in a similar fashion in both groups  although the respiratory rate increased more quickly in transplant recipients  it was similar at peak ventilation in the two groups  ventilatory timing and duty cycle at half peak and peak ventilation were similar in transplant recipients and control subjects  dyspnea ratings were not different between the two groups at similar levels of ventilation  dyspnea as a function of p0 1 was also similar in transplant and control groups  these results indicate that pulmonary neurogenic mechanisms play a role in determining the level  but not the pattern  of ventilation during exercise  furthermore  these pathways do not appear to contribute significantly to the perception of breathlessness in normal humans  
class8	the role of mucous glycoproteins in the rheologic properties of cystic fibrosis sputum  cystic fibrosis  cf  is characterized by excessive amounts of thick and tenacious mucous secretions that obstruct organ ducts and passages  in the respiratory tract this is associated with chronic infection resulting in the hypersecretion of purulent sputum  which the patient finds difficult to clear  we have studied the rheologic properties of purulent sputum from six patients with cf and five patients with chronic bronchitis to assess whether cf is associated with increased sputum viscoelasticity  in addition  we have isolated the major rheologic determinants  mucous glycoproteins  from cf and chronic bronchitis sputa and  using a magnetic microrheometer  investigated the possibility that the altered properties of mucus in cf are associated with abnormalities in these glycoproteins  creep compliance analysis indicated that the cf sputa possessed raised levels of both elasticity  p less than 0 01  and viscosity  p less than 0 01   these increases in both rheologic parameters were found to be associated with increases in the dna content  p less than 0 01  and dry weight  p less than 0 05   mucous glycoproteins were isolated from cf and chronic bronchitis sputum samples by gel filtration on sepharose cl4b  followed by concentration to form 8  wt wt gels  in the absence of other sputum components  no abnormality in the rheologic properties of cf mucin gels could be detected  however  when dna was added  the cf gels responded with increases in both elasticity and viscosity of as much as 30   p less than 0 05   an effect not observed in the chronic bronchitis gels  these results suggest that a subtle abnormality may exist in cf mucous glycoproteins and that this could have a role in the altered physical properties of mucous secretions in cf  
class8	frequency and clinical implications of monoclonal antibody detection of tumor associated antigens in serum of patients with lung cancer  we previously showed that a panel of monoclonal antibodies  mab   5e8  5c7  and 1f10  that detect serum tumor associated antigens  taa  could distinguish patients with lung cancer from those without to a highly significant degree  however  among patients with lung cancer  the frequency and clinical importance of serum taa expression were not established  therefore  we analyzed the serum and initial clinical characteristics of 52 philadelphia va patients with newly diagnosed lung cancer seen over a 13 month period  a modified semiquantitative elisa was employed to determine mab reactivity  our cohort was characterized by a mean age of 65     9 year  sd  and mean karnovsky score of 74     10  marked weight loss was present in 28 subjects  and 39 presented with either stage iii or iv disease  the panel detected taas in 38 of 52 cases  sensitivity 73   95  cl  60 83    including 13 of 22 squamous cell  9 of 12 adenocarcinoma  10 of 11 undifferentiated  and 6 of 7 small cell carcinomas  no significant differences were found between the reactive and nonreactive patients in terms of age  stage at presentation  histologic subtype  performance status  or weight loss  however  1f10 and 5c7 were each associated with a greater risk of early death by cox proportional hazard analysis  p   0 017 and 0 006  respectively  even when other prognostic variables are accounted for  we conclude that specific serum taa can be detected in the majority of lung cancer patients with all major histologic subtypes in a cohort with advanced tumors and poor prognostic indices  
class8	determination of serum concentrations of type iii procollagen peptide in mechanically ventilated patients  pronounced augmented concentrations in the adult respiratory distress syndrome  type iii procollagen peptide  pcp  is a byproduct of type iii collagen synthesis and a potential marker of collagen secretion  in chronic diffuse interstitial lung diseases  elevated pcp concentrations have been found in serum as well as in bronchoalveolar lavage fluid  it has been proposed that pcp is a marker of early  active stages of fibrosis  as severe fibrosis is a frequent complication in adult respiratory distress syndrome  ards   we investigated pcp in patients with ards and compared the results with those from patients requiring mechanical ventilation because of heart failure and after neurosurgical and surgical interventions  and those from spontaneously breathing patients  including healthy volunteers and patients with pneumonia  liver cirrhosis  and renal failure  pcp concentrations in patients with ards were extremely elevated compared with those in control subjects  p less than 0 001  and correlated positively with fio2  r   0 71  p less than 0 01   these results support the pathophysiologic concept of early fibrogenesis in ards  as preventing pulmonary fibrosis in ards is essential in improving survival rate  we believe pcp can be a valuable diagnostic tool in ards  
class8	effect of pentoxifylline on hemodynamics  alveolar fluid reabsorption  and pulmonary edema in a model of acute lung injury  we investigated the effect of pentoxifylline  ptx  on the development of pulmonary edema in a model of adult respiratory distress syndrome in rabbits  lung injury was induced by repeated saline lavages in adult rabbits weighing 2 5 to 3 5 kg  rabbits pretreated with ptx  20 mg kg bolus followed by 20 mg kg h infusion  developed significantly lower amounts of lung edema 4 h after saline lavage  extravascular lung water to dry weight ratio  w d   6 9     0 6 sd versus 8 9     0 5 in control animals   ptx produced a 25  increase in cardiac output  but there were no differences between treated and untreated groups in calculated pulmonary vascular resistance or microvascular pressure  to determine whether ptx could have lowered pulmonary venous resistance and thus lowered effective microvascular pressure for fluid filtration  we directly measured pulmonary artery and left atrial pressures  and measured by micropuncture the pressure in 20 to 40 microns subpleural venules in four open chested rabbits 3 to 4 h after lavage  venous resistance was low  venous pressure drop 0 9     0 1 mm hg  and was unchanged by ptx infusion  to determine if ptx decreased lung water by accelerating active alveolar fluid reabsorption  a single 60 ml aliquot of saline was instilled into the lungs of normal rabbits treated with saline or ptx  both groups had a similar decrease in lung water content 1 and 4 h later  our data indicate that ptx reduces edema formation in rabbits after saline lavage  not by lowering microvascular pressures for fluid filtration or by acceleration alveolar fluid reabsorption  but possibly by its anti inflammatory effect on neutrophil function  
class8	persistent lower respiratory tract inflammation associated with interstitial lung disease in patients with tropical pulmonary eosinophilia following conventional treatment with diethylcarbamazine  tropical pulmonary eosinophilia  tpe  presents as an acute syndrome with dyspnea  fluffy infiltrates  and rounded opacities on the chest radiograph  reduced lung function  marked eosinophilia in the blood and lower respiratory tract  and high titers of specific ige and igg antifilarial antibodies  the standard therapy for tpe is a 3 wk course of diethylcarbamazine  dec  following which there is almost always a marked improvement in all parameters  however  clinical observations suggest that the disease can persist despite dec therapy and lead to chronic dyspnea with restrictive lung impairment  to evaluate the concept that dec therapy is not completely  curative  for tpe  but rather leaves most individuals with a mild  chronic form of tpe defined by persistent inflammation of the lower respiratory tract  we evaluated 23 individuals an average of 12     2 months following a standard 3 wk course of diethylcarbamazine for acute tpe  in the majority there were mild  persistent symptoms referrable to the lung  chest x ray abnormalities  blood eosinophilia  and elevated serum ige and filarial specific igg  on the average  lung function was consistent with the presence of chronic  mild interstitial lung disease  when the inflammatory cells from the lower respiratory tract were examined  there was a persistent eosinophilic alveolitis  tpe post dec 1769     376 eosinophils microliters epithelial lining fluid  normal subjects 256     38  p less than 0 02   evaluation of the lower respiratory tract inflammatory cells recovered from the tpe post dec treated individuals demonstrated spontaneous release of exaggerated amounts of o2   and h2o2 compared to normal subjects  p less than 0 05  both comparisons   
class8	the penetration of aminoglycosides into the alveolar lining fluid of rats  the effect of airway inflammation  the concentration time profile of gentamicin and tobramycin in the alveolar lining fluid  alf  of rats was determined after intravenous bolus injection using bronchoalveolar lavage  bal   bal can be used for evaluating the penetration of both aminoglycosides into the alf if highly sensitive detection methods are used  and an endogenous marker  urea  can be applied to avoid the unpredictable dilutional effect of the lavage procedure  the concentration of gentamicin and tobramycin in alf reached a peak after 5 and 10 min  respectively  and remained high when plasma concentrations were declining  suggesting an accumulation reservoir in the lung acini  the ratio of the auc of the concentration time profile in alf and plasma was 0 67 and 0 45 for gentamicin and tobramycin  respectively  the penetration of both aminoglycosides into the alf was significantly higher after induction of airway inflammation by inhalation of endotoxin  the ratio of the auc in alf and plasma in the endotoxin exposed animals was 0 76 and 0 55 for gentamicin and tobramycin  respectively  the ratio of the auc of the concentration time profile of gentamicin in alf to that of tobramycin was 1 27 without inflammation and 1 44 after endotoxin exposure  thus  both with and without inflammation  gentamicin penetrates better into the alf than does tobramycin  
class8	bronchodilator response to ipratropium bromide in infants with bronchopulmonary dysplasia  although the muscarinic antagonist ipratropium bromide is used clinically as a bronchodilator in infants ventilated because of bronchopulmonary dysplasia  bpd   no studies have compared the response or efficacy of different dosages or its effectiveness in combination with beta adrenergic agonists  we measured the response of respiratory system mechanics in 10 ventilated infants  25     2 days of age  to 75  125  and 175 micrograms ipratropium bromide  ib   125 micrograms ib plus 0 04 mg salbutamol  sal   175 micrograms ib plus 0 04 mg sal  and saline vehicle  delivered via nebulizer into the ventilator circuit  respiratory system resistance  rrs  and compliance  crs  were measured by the passive flow volume technique  rrs and crs were measured before and at 1 to 2 h and at 4 h after delivery of the five drug dosages or saline  all six studies were completed within a 72 h period  saline had no significant effect on mechanics  significant responses to ipratropium alone were seen only after 175 micrograms where rrs decreased 20     3   sem   p less than 0 05  at 1 to 2 h and 16     5   p less than 0 05  at 4 h  after 125 micrograms ib   sal and 175 micrograms ib   sal  rrs was significantly decreased both at 1 to 2 h and at 4 h  and crs was significantly increased 20     6  and 20     4   respectively  at 1 to 2 h  the greatest decrease in rrs  26     6   was seen 1 to 2 h after 175 micrograms ib   salbutamol  
class8	formoterol  a new inhaled beta 2 adrenergic agonist  has a longer blocking effect than albuterol on hyperventilation induced bronchoconstriction  the duration of effect of inhaled formoterol  24 micrograms  was compared with that of a placebo and that of inhaled albuterol  200 micrograms  in 12 adult asthmatic subjects who underwent hyperventilation tests with cold dry air   20 degrees c  on 4 study days  on the control day  they were subjected to four hyperventilation tests to ensure functional stability  on the 3 remaining days  after a first hyperventilation test  they inhaled placebo  albuterol  or formoterol in randomized  double blind fashion  the hyperventilation test was repeated 1  4  and 8 h and  if the blocking effect was still present  12 and 24 h after the drug had been administered  the dose of hyperventilation of cold air causing a 20  fall in fev1  pd20  was interpolated on the dose response curve  the magnitude of the blocking effect at each time interval on each study day was assessed by comparing the changes in pd20 from baseline with the within day variability of pd20  standardized change in pd20   the acute bronchodilator effect was not significantly different as assessed 15 min  21     14  for albuterol and 18     18  for formoterol  and 1 h  20     13  for albuterol and 18     17  for formoterol  after administering the medication  the duration of the blocking effect  defined as the return to 2 sd from the standardized change in pd20  was significantly more prolonged for formoterol  8 0     3 4 h  than for albuterol  3 0     1 7 h   t   4 2  p less than 0 0001   
class8	respiratory health effects of the indoor environment in a population of dutch children  the effect of indoor exposure to nitrogen dioxide on respiratory health was studied over a period of 2 yr in a population of nonsmoking dutch children 6 to 12 yr of age  lung function was measured at the schools  and information on respiratory symptoms was collected from a self administered questionnaire completed by the parents of the children  nitrogen dioxide was measured in the homes of all children with palmes  diffusion tubes  in addition  information on smoking and dampness in the home was collected by questionnaire  there was no relationship between exposure to nitrogen dioxide in the home and respiratory symptoms  respiratory symptoms were found to be associated with exposure to tobacco smoke and home dampness  there was a weak  negative association between maximal midexpiratory flow  mmef  and exposure to nitrogen dioxide  fev1  peak expiratory flow  and mmef were all negatively associated with exposure to tobacco smoke  home dampness was not associated with pulmonary function  lung function growth  measured over a period of 2 yr  was not consistently associated with any of the indoor exposure variables  the development of respiratory symptoms over time was not associated with indoor exposure to nitrogen dioxide  there was a significant association between exposure to environmental tobacco smoke in the home and the development of wheeze  there was also a significant association between home dampness and the development of cough  
class8	pulmonary fibrosis in aluminum oxide workers  investigation of nine workers  with pathologic examination and microanalysis in three of them  epidemiologic surveys have indicated an excess of nonmalignant respiratory disease in workers exposed to aluminum oxide  al2o3  during abrasives production  however  clinical  roentgenographic  histologic  and microanalytic description of these workers are lacking  this is a report of nine al2o3 exposed workers with abnormal chest roentgenograms  profusion greater than or equal to 1 0  ilo uc  from a plant engaged in the production of al2o3 abrasives from alundum ore  mean duration of exposure was 25 yr  and time since first exposure was 28 yr  in a subgroup of three  the severity of symptoms  reduction in the forced vital capacity  67  predicted  and diffusing capacity  51  predicted   and progressive roentgenographic changes  profusion greater than or equal to 2 2  prompted open lung biopsy  lung tissue was analyzed by scanning electron microscopy and electron microprobe analysis  in each of the three biopsies  interstitial fibrosis with honeycombing was seen on routine section  in one biopsy  silica and asbestos fiber counts were at the low end of the range seen with silicosis and asbestosis  however  the absence of asbestos bodies and silicotic nodules suggested that the fibrosis was due to another cause  metals occurred in amounts several orders of magnitude above background  and the majority was aluminum as al2o3 and aluminum alloys  the findings in these nine workers suggests a common exposure as the possible cause  the nonspecific pathologic findings  absence of asbestos bodies and silicotic nodules  and the striking number of aluminum containing particles suggest that al2o3 is that common exposure  the possibility of  mixed dust  fibrosis should also be considered  
class8	computerized tomography in the evaluation of allergic bronchopulmonary aspergillosis  allergic bronchopulmonary aspergillosis  abpa  is a destructive disease of the lung characteristically associated with central bronchiectasis  this study was designed to determine if high resolution computerized tomography  ct  could be used to define bronchiectasis in patients with suspected disease  sixteen patients with asthma were studied  all demonstrated immediate cutaneous reactivity to common aeroallergens including aspergillus fumigatus  eight patients had clinical and immunologic evidence of abpa  six to 12 high resolution ct sections  1 5 mm  were obtained at 1  to 2 cm intervals from the aortic knob to the dome of the diaphragm  all radiographs were evaluated separately by two readers in a blinded fashion and graded as to the presence and type of bronchial dilatation and bronchial wall thickening  bronchial dilatation was seen in 41  of lung lobes in the abpa group compared to 15  in the non abpa asthmatic control group  upper lobe involvement and bronchial wall thickening was common to both groups  the presence of bronchiectasis in the control group may indicate that asthma is a more destructive lung disease than is currently appreciated  high resolution ct of the chest has been shown in previous studies to have a sensitivity and specificity approaching that of bronchography  and the current findings support its use in the detection of bronchiectasis in patients with asthma suspected of having abpa  
class8	pulmonary histiocytosis x with mediastinal lymph node involvement  in this report  we describe a patient with the classic histology of pulmonary histiocytosis x  who had bilateral reticulonodular densities and mediastinal lymph node involvement  the diagnosis was confirmed by the use of electron microscopy and immunohistochemical markers  ps100  hla dr  and cd1   which allowed us to recognize the lymph node infiltration of x histiocytes  an association of mediastinal lymph node enlargement with pulmonary histiocytosis x has been reported but it has never been histologically documented  
class8	flexible bronchoscopic removal of radioccult polyurethane foam  with pneumonitis in a hyperventilated lobe  an intellectually delayed adult ingested and aspirated a large quantity of polyurethane foam  developing acute respiratory failure in association with partial airway obstruction  the foam was identified by flexible bronchoscopy and successfully removed from the bronchus intermedius and left mainstem bronchus with a retrieval basket  this facilitated normalization of blood gases and eventual recovery  however  the unobstructed right upper lobe became infiltrated radiographically  presumably resulting from regional hyperinflation and or occult focal aspiration  
class8	colobronchial fistula  a rare complication of crohn s colitis  a 29 yr old white woman presented with chronic pneumonia in the left lower lobe and with left pleural effusion  she was known to have inflammatory bowel disease  but she was asymptomatic under maintenance treatment with 5 asa  she received numerous antibiotic regimens according to susceptibility testing of microorganisms cultured from sputum and bronchial lavage and on an empiric basis was also given antituberculosis treatment  but there was no clinical improvement or change in the chest radiographic findings  sputum was repeatedly examined and yielded  among other organisms  clostridium inocuum  enterobacter  klebsiella pneumoniae  proteus mirabilis  and staphylococcus aureus  on one microscopic examination of sputum  the presence of feculent material was suspected  a subsequent gastrografin enema revealed a cologastric and colobronchial fistula between the splenic flexture of the colon and the greater curve of the stomach and the bronchial system  segmental resection of the colon and resection of the lower lobe of the left lung were performed  histologic findings of the resected colon were consistent with crohn s disease  after a long period of postoperative recovery  the patient returned to good general health and well being  to our knowledge  a colobronchial fistula caused by crohn s colitis has not been previously reported  
class8	the rise of tuberculosis in america before 1820  bills of mortality  newspaper and gazette articles  journals  and other records with specific references to  consumption    phthisis   and other terms for tuberculosis were reviewed to determine the occurrence and importance of tuberculosis in the american colonies before 1820  review of these sources indicates a marked increase in the proportional mortality from tuberculosis in the united states in the 18th century   consumption  may have been the leading cause of death in adult american colonists  
class8	six month isoniazid rifampin treatment for pulmonary tuberculosis in children  one hundred and seventeen children with pulmonary tuberculosis underwent treatment with a 6 month daily regimen of rifampin  15 mg kg day  and isoniazid  10 mg kg day   the criteria for the diagnosis of pulmonary tuberculosis were  1  clinical symptoms and signs in 93 children  79     2  history of direct contact with an adult with tuberculosis in 106 children  91     3  tuberculin reaction of 5 mm or more  without previous bacillus calmette guerin  bcg   in 45 children  38     4  suggestive radiologic alterations in all patients  and  5  positive bacteriology or histology in four patients  3    the treatment was completed by 97 children  83    the mean weight gain during therapy was 2 145 g  there was an excellent clinicoradiologic response to the treatment  and improvement in chest roentgenograms was observed in all patients at the end of therapy  no relapses occurred among the patients followed for an average of 21 4 months  this study indicates that the treatment of primary pulmonary tuberculosis in children with a combination of rifampin and isoniazid daily for 6 months is efficacious and does not result in any relapse  
class8	tumor cell lines established in vitro  an independent prognostic factor for survival in non small cell lung cancer  objective  to determine the relation between in vitro establishment of tumor cell lines and survival in patients with non small cell lung cancer  design  cohort study  setting  single institution tertiary care center  patients  one hundred twenty three consecutive patients with non small cell lung cancer from whom a viable tumor specimen could be obtained  intervention  tumor tissue was removed at the time of entry into a therapeutic protocol  the tumor tissue was processed in the laboratory for attempted cell line establishment  patients classified as potentially curable  stages i  ii  and iiia  were treated with surgical resection  radiation therapy  or a combination  patients suitable for palliative therapy only  stages iiib and iv  were treated with radiation therapy with or without chemotherapy  chemotherapy was based on in vitro drug sensitivity when available  cell line establishment was correlated to clinical outcome  measurements and main results  univariate analysis of survival was done using the log rank test  multivariate analysis was done by cox modeling step up and step down techniques  cell lines were established from the tumor specimens of 25 patients  20    those patients experienced a median survival of 7 months compared with 18 months in patients from whom cell lines could not be established  p less than 0 001   in the 61 patients with potentially curable disease  8 patients  13   with cell lines established had a median survival of 8 months compared with 32 months for those without cell lines established  p   0 001   in the 62 palliative group patients  the median survival of the 17 patients  27   from whom tumor cell lines were established was 5 months compared with 7 months for those without cell lines  p   0 15   multivariate analysis in both groups showed cell line establishment to be a significant indicator of prognosis  p less than 0 0001 for curable group  p less than 0 01 for palliative group   conclusion  in vitro tumor growth is related to decreased patient survival  which in turn reflects the biologic aggressiveness of cancers giving rise to these tumor cell lines  
class8	systems architecture for quantification of dynamic myoelectric and kinematic activity of the human vocal tract  this paper describes a systems architecture useful for scientific investigations that require the acquisition and analysis of multiple  time synchronous signals in large volume  the architecture has recently been developed by this group to enhance our capability to research and quantify central nervous system function in the production of normal and pathologic speech  the architecture utilizes modern advances in desktop microcomputers and has been designed so that vocal motor control laboratories  or similar settings  with modest funding can more fully participate in comprehensive investigations of speech production  research experiments organized with this architecture may involve many more subjects and measures than previously possible without significant increases in time and personnel resources  this paper will demonstrate the technique and practicality of this architecture as it is being used to successfully guide research to map hierarchic central nervous system regions of involvement in two speech disorders  spasmodic dysphonia and stuttering  the architecture has broad usefulness to many areas of otolaryngology and health science  
class8	peak inspiratory pressure requirements in infants born weighing less than 750 g  the possibility that peak inspiratory pressure requirements or the arterial alveolar oxygen ratio can predict the clinical outcome in infants weighing less than 750 g at birth was explored in a consecutive series  nine of 10 infants  90   with a peak inspiratory pressure requirement of more than 18 cm h2o at 48 hours or more than 16 cm h2o at 72 hours from age subsequently died later of respiratory causes  defined as death after 72 hours of pulmonary interstitial emphysema  bronchopulmonary dysplasia  or cor pulmonale   twenty of 21 remaining infants  95   survived until discharge  using these data a 95th centile for peak inspiratory pressure requirement during the first 72 hours of life was constructed  the potential value of this centile in predicting later death of respiratory causes was examined in a separate series  twelve of 15 infants  80   whose peak inspiratory pressure requirements remained below the 95th centile  or were not ventilated  n   6   survived  in contrast  11 of 12  92   infants whose requirements crossed the 95th centile died later of respiratory causes  the infants who died had more radiological changes and higher mean arterial carbon dioxide pressure than survivors suggesting that the severity of the initial lung disease rather than the way that ventilation was managed determined prognosis  peak inspiratory pressure requirement was more useful than arterial alveolar oxygen ratio in clearly distinguishing between survivors and infants who died later of respiratory causes  
class8	thoracoplasty  current application to the infected pleural space thoracoplasty  once commonly used in the management of cavitary pulmonary disease  continues to find application in the obliteration of infected pleural spaces  this study reports a series of 13 patients receiving thoracoplasty between 1976 and 1989  five patients had chronic apical empyema spaces without prior resection of lung tissue  two of the empyemas were due to tuberculosis  two were due to atypical mycobacteria  and one was due to postpneumonic empyema  all patients had extensive destruction of upper lobe tissue  eight patients had undergone prior pulmonary resection  3 had persistent infected spaces in the early postoperative period  3 had development of empyemas and bronchopleural fistulas late  5 to 19 years  after pulmonary resection  and 2 had postpneumonectomy empyema  all patients had rigid cavity walls preventing space obliteration by rib removal alone and required concomitant resection of the thickened pleura and intercostal muscle tissues  bronchopleural fistulas were present in 11 patients and were closed with adjacent nonintercostal muscle  all patients survived and had successful obliteration of the infected spaces with acceptable physiological and cosmetic results  we conclude that thoracoplasty remains a useful procedure in the management of the infected pleural space in select patients  
class8	strategy for lymphadenectomy in lung cancer three centimeters or less in diameter we have surgically treated 221 patients with a primary lung cancer 3 0 cm or less in diameter  there were 8 patients with a tumor 1 0 cm or less in diameter  group a   84 with a tumor 1 1 to 2 0 cm in diameter  group b   and 129 with a tumor 2 1 to 3 0 cm in diameter  group c   the incidence of n0  n1  and n2 disease was 100   0   and 0   respectively  for patients in group a  83   5   and 12  in group b  and 62   12   and 25  in group c  n0 versus n2  p less than 0 01   for the 63 patients with regional lymph node involvement   skipping  metastasis was present in 28 6   the 5 year survival rate was 80  for group a  74  for group b  and 51  for group c  group b versus group c  p less than 0 01   of the 121 patients who underwent complete resection and were followed up for 5 years  41  had recurrence  8  with local recurrence and 33  with distant metastasis  therefore  it is important to do as complete a resection as possible together with mediastinal lymphadenectomy  efforts to detect systemic spread should be made at the time of preoperative evaluation  even when the lung tumor is small  
class8	prognostic determinants in extracorporeal membrane oxygenation for respiratory failure in newborns  extracorporeal membrane oxygenation  ecmo  is becoming an accepted therapeutic modality for newborn respiratory failure  but there is little information available regarding the prognostic determinants with this technique  one hundred thirty five newborns treated with ecmo over a 4 year period were critically analyzed with regard to the influence that birth weight  gestational age  age at initiation of ecmo  best blood gases before ecmo  number of hours on ecmo  renal failure  intracerebral hemorrhage  and long distance air transport had on survival  infants with meconium aspiration and those undergoing long distance transfer showed significant differences in blood gases before ecmo  with survivors having more normal ph and carbon dioxide tension values  intracerebral hemorrhage and renal failure that developed during ecmo were grave prognostic signs  with few survivors in either group  these data show that ability to ventilate patients before ecmo  giving normal carbon dioxide tension and ph values  is an important prognostic sign in infants with meconium aspiration and undergoing long distance transfer for ecmo  whereas renal failure and intracerebral hemorrhage are usually lethal complications of ecmo  each center performing ecmo should continually reevaluate this invasive technique and its results and complications  
class8	surgical management of pulmonary metastatic leiomyosarcoma with gross endobronchial extension  metastatic leiomyosarcoma occasionally is seen with gross endobronchial extension without invasion of the bronchial wall  these patients have major airway obstruction and partial or total atelectasis of the lung  precise bronchoscopic assessment coupled with intraoperative bronchotomy allows the surgeon to determine the origin of the tumor and to save uninvolved pulmonary parenchyma  our experience with 4 such patients illustrates the possibility of saving lung tissue despite total bronchial obstruction  
class8	giant chest wall tumor resulting from tissue reaction to foreign bodies  three patients are reported in whom chest wall tumors developed 19 to 28 years after thoracoplasty and increased in size with time  the tumors could be removed operatively with good results  all tumors were composed of hematoma and necrotic material  and in all cases they revealed foreign bodies microscopically  diagnosis and possible etiological factors are discussed  
class8	thoracoscopic treatment of spontaneous pneumothorax using carbon dioxide laser  in an effort to improve the success rate of the previously described thoracoscopic electrocautery ablation technique of spontaneous pneumothorax  the carbon dioxide laser was evaluated in 12 patients  the recurrent  5 patients  or persistent  7 patients  spontaneous pneumothoraces were caused by rupture of  1  blebs in 6 patients   2  intrapulmonary apical type ii bullae in 3 patients  and  3  diffuse bullous emphysema  type iii  in 3  the air leaks were successfully sealed in all but 1 patient with ruptured type ii bulla  surgical specimen from this single failure suggested that the entire inner lining of the bullae must be thermocoagulated  this technical modification led to successful outcome in 2 subsequent cases  with the use of carbon dioxide laser  it was possible to treat not only small blebs but all types of bullae causing spontaneous pneumothorax  laser thoracoscopy is effective and safe in treating spontaneous pneumothorax  
class8	pulmonary resection combined with cardiac operations  surgical management of patients with concomitant critical cardiac disease and resectable lung lesions is controversial  during a 7 year period  1982 to 1988   21 patients underwent combined cardiac and pulmonary operations  patients had cardiac symptoms only  the lung lesions were found on preoperative chest roentgenograms  the pathological diagnosis was established in only 2 of the patients before operation  all underwent concurrent pulmonary resection during cardiac operations requiring extracorporeal circulation  the pulmonary operations included 17 wedge resections and four lobectomies  the final diagnoses in 8 patients with stage i non small cell lung cancer included epidermoid carcinoma  4   adenocarcinoma  3   and bronchoalveolar carcinoma  1   postoperatively  1 patient required a permanent pacemaker and 1 patient died  the actuarial survival at 5 years for all patients who underwent combined procedures was 95   the 5 year survival for the 8 patients with lung cancer was 88  compared with 100  for those with benign pulmonary pathology  p   0 172   this experience suggests that combining pulmonary resection with cardiac operations is safe and offers a favorable prognosis to a select group of patients  
class8	tracheal reconstruction with polytetrafluoroethylene graft in dogs  use of prosthetic materials for long segment tracheal reconstruction has been limited owing to infection  graft migration  ingrowth of fibrous tissue  and stenosis  polytetrafluoroethylene  ptfe  is flexible and porous  and it may resist infection more than previously used materials  we evaluated ptfe for use in long segment tracheal reconstruction  a 5 cm segment of trachea was resected in 9 dogs and replaced with a 20 mm reinforced ptfe graft using 4 0 vicryl sutures  in 2 control dogs  one tracheal arch was resected and a primary anastomosis was performed  the animals were followed up with weekly bronchoscopy and endoscopic photography  euthanasia was performed at 16 weeks or when signs of respiratory distress developed  at postmorten examination  the anastomoses were examined grossly and with light and scanning electron microscopy  in all 9 dogs that underwent tracheal replacement with ptfe  granulation tissue developed at the anastomoses resulting in airway obstruction after 3 to 8 weeks  no epithelial growth occurred over the graft between the anastomoses  the control animals did well  we conclude that granulation tissue formation at the anastomosis and the lack of respiratory epithelial ingrowth across the graft makes ptfe unsuitable for long segment tracheal reconstruction  
class8	long term results of operation for non small cell lung cancer in the elderly  we surgically treated 185 patients with non small cell lung cancer who were 70 years old or older  the operative mortality rate was 3   and the 5 year survival rate was 48   the mortality and prognosis were similar to those in younger patients  the number of elderly patients who smoked heavily or who had ventilatory defects was high  but the incidence of pneumonectomy was low  there were no differences based on age in regard to histological type  tnm classification  and curability  pulmonary complications occurred in 21  of the elderly patients and were correlated with preoperative pulmonary function and smoking habits  when the elderly are to undergo elective pulmonary resection for lung cancer  the preoperative evaluation of pulmonary function should be thorough  and both preoperative and postoperative physical therapy should be given  if postoperative pulmonary function is predicted to be less than 0 8 l m2 of vital capacity and 0 6 l m2 of forced expiratory volume in 1 second  a limited resection or nonsurgical therapy should be considered  
class8	pleuropulmonary morbidity  internal thoracic artery versus saphenous vein graft  although use of the internal thoracic artery  ita  for coronary artery bypass grafting results in superior graft patency and improved patient survival  our initial clinical observations suggested an increased incidence of pleuropulmonary morbidity with its use  one hundred consecutive patients with left ita grafts were studied prospectively and compared with a consecutive retrospective group of 100 patients undergoing coronary artery bypass grafting with saphenous vein grafts only  preoperative  postoperative day  pod  2  pod 6  and postoperative week 8 chest roentgenograms were analyzed for atelectasis and effusion  postoperative left lower lobe atelectasis was common in both groups on both pod 2  saphenous vein  43   versus ita  53   not significant  and pod 6  saphenous vein  40   versus ita  41   not significant   there was a significantly higher incidence of pleural effusion on pod 6 in the ita group  84  versus 47   p less than 0 05  but most of these were small  there was more chest tube drainage  1 413 versus 1 028 ml  p less than 0 01  and a greater need for secondary thoracostomy or thoracentesis  4  versus 0   in the ita group  the left pleural space was opened in 67 of the 100 ita patients but pleurotomy did not appear to influence postoperative morbidity  we conclude that use of the internal thoracic artery for coronary artery bypass grafting results in a small but significant increase in pleuropulmonary morbidity  
class8	management of aortobronchial fistula with graft replacement and omentopexy  massive hemoptysis due to a recurrent aortobronchial fistula after repair of a thoracic aortic aneurysm developed in a 64 year old woman  the infected aortic tissue was resected and replaced with an in situ dacron graft covered by omentum  the patient is alive and well 15 months later  
class8	congenital tracheoesophageal fistula associated with carcinoma of the lung in an adult  a rare case of adult congenital h type tracheoesophageal fistula was diagnosed  subsequently  at operation  large cell  undifferentiated carcinoma of the right middle lobe with extension to the right lobe and adherence to the diaphragm was documented  the diagnosis  surgical intervention  and 4 year follow up are presented  
class8	bronchial anomaly of the right upper lobe  this case report presents a rare anomaly of right upper lobe bronchial anatomy  during routine right upper lobe resection for carcinoma  a common right upper and middle lobe bronchus was found  the resection was completed as a right upper and middle bilobectomy  knowledge of this uncommon variant was beneficial in performing the pulmonary resection  a review of the literature is presented  
class8	left recurrent laryngeal nerve paralysis  an unusual presentation of histoplasmosis  a case of histoplasmosis seen as left recurrent laryngeal nerve paralysis in a 49 year old man is described  the patient had roentgenographic findings of a solitary  noncalcified left upper lobe mass and mediastinal adenopathy  tissue diagnosis of histoplasmosis was obtained using a thoracotomy  allowing institution of appropriate treatment  
class8	job s syndrome  a rare cause of recurrent lung abscess in childhood  a clinical syndrome characterized by recurrent staphylococcal infection of the skin and respiratory tract from birth was described in 1966 and referred to as job s syndrome  marked hyperimmunoglobulinemia e was later found to be associated with this syndrome  this article describes a case of job s syndrome as a cause of recurrent lung abscess during childhood necessitating lung resection  
class8	lower extremity weakness as the initial manifestation of lung cancer  published erratum appears in arch phys med rehabil 1991 jan 72 1  61  a 55 year old woman had progressive lower extremity weakness  she had an 80 pack per year history of cigarette smoking  electromyographic findings were consistent with the lambert eaton myasthenic syndrome  despite a normal chest x ray  normal laboratory studies  and negative bronchoscopy  investigation for lung cancer was pursued  the final thoracotomy and pathology reports indicated a diagnosis of oat cell carcinoma  after treatment with chemotherapy and radiation therapy  clinical and electrophysiologic findings have resolved  two years after diagnosis  the patient remains in good health without evidence of recurrence  
class8	diffusing capacity of the lung and nifedipine in systemic sclerosis  lung involvement in systemic sclerosis may be due in part to a functional abnormality of the pulmonary vasculature  to investigate the possible role of a pulmonary vasospastic process in this disorder  21 non smoking patients who had no evidence of cardiac disease or pulmonary hypertension were evaluated with pulmonary function tests prior to administration of nifedipine  30 minutes after a single oral dose of nifedipine  20 mg   and after 4 weeks of treatment with nifedipine  10 mg 3 times daily   treatment with nifedipine did not significantly change any of the pulmonary function values  except for the carbon monoxide diffusing capacity  dlco   the linear trend between the individual dlco values at baseline and their changes immediately following the initial 20 mg dose of nifedipine  r    0 603  p   0 02  and after 4 weeks of treatment  r    0 636  p   0 01  showed that the lower the dlco value at baseline  the greater the improvement caused by nifedipine  these findings support the hypothesis of a potentially reversible pulmonary vasospasm in systemic sclerosis and suggest that nifedipine may be useful in the treatment of lung disease in these patients  however  further studies are needed  
class8	leiomyosarcoma of the sinonasal tract  a clinicopathologic study of nine cases  the clinicopathologic features of nine cases of sinonasal tract leiomyosarcoma  sntl  referred to the armed forces institute of pathology  washington  dc  during the period from 1970 through 1988 are described  this report represents the largest study to date on sntl  and our results are compared with the 21 previously reported cases of sntl  of the nine cases described  patients ranged in age from 22 to 86 years  mean  55 years   the most frequent clinical presentation was nasal obstruction unilaterally  the neoplasms were limited solely to the nasal cavity in four cases  44   and involved both the nasal cavity and paranasal sinuses in the remaining five cases  light microscopic  immunocytochemical  and ultrastructural features served to characterize these tumors as malignant neoplasms of smooth muscle origin  in contrast with previous studies  immunocytochemistry was employed to differentiate sntl from other spindle cell malignancies of the region  using newly available monoclonal antibodies to smooth muscle antigens  treatment was surgical  radiotherapy or chemotherapy did not appear to affect the progression of the disease  furthermore  no relationship was found between the aggressiveness of sntl and morphologic parameters  eg  mitotic count and tumor size   instead  prognosis was dependent on the distribution of disease at presentation  of all 30 patients with sntl described to date  10 had the neoplasm confined solely to the nasal cavity  the 10 neoplasms did not recur  we conclude that sntl may best be regarded as a locally aggressive neoplasm with only limited metastatic potential and that it could be curable by complete surgical excision  
class8	metastasizing pleomorphic adenoma of the nasal septum  pleomorphic adenoma is the most common benign tumor of glandular tissue occurring in the head and neck region  there have been several reports of metastasis of this benign appearing tumor from the salivary glands to distant sites  suggesting hematogenous spread and implantation  although occurrence of pleomorphic adenoma on the nasal septum has been described  to our knowledge this is the first reported case of recurrent septal pleomorphic adenoma with histologically benign tissue in an enlarged metastatic ipsilateral submandibular lymph node  suggesting lymphatic spread  the literature concerning the subject is reviewed  wide septal excision and modified neck dissection is the recommended treatment  
class8	glucocorticoids inhibit neurogenic plasma extravasation and prevent virus potentiated extravasation in the rat trachea  capsaicin increases the permeability of blood vessels in the rat tracheal mucosa through a mechanism involving the release of tachykinins from sensory nerves  this capsaicin induced increase in vascular permeability is potentiated by viral infections of the respiratory tract  the present study was done to determine whether this  neurogenic plasma extravasation  can be inhibited by glucocorticoids  to learn the time course of this inhibition  and to determine whether glucocorticoids can prevent the potentiating effect of viral respiratory infections on neurogenic plasma extravasation  groups of pathogen free f344 rats were treated with dexamethasone for 2 or 8 h  4 mg kg i p   or 48 or 120 h  0 5 4 mg kg per d i p    another group of rats was treated with dexamethasone for 120 h following the intranasal inoculation of sendai virus  the magnitude of plasma extravasation produced by capsaicin or substance p was assessed after this treatment by using monastral blue pigment and evans blue dye as intravascular tracers  we found that dexamethasone reduced  in a dose dependent fashion  the magnitude of plasma extravasation produced in the rat trachea by capsaicin and substance p  significant inhibition was produced by a dose of dexamethasone as small as 0 5 mg kg i p  the effect of dexamethasone had a latency of several hours and reached a maximum after 2 d of treatment  furthermore  dexamethasone prevented the potentiation of neurogenic plasma extravasation usually present after 5 d of sendai virus respiratory infection  
class8	transforming growth factor beta activity in sheep lung lymph during the development of pulmonary hypertension  chronic pulmonary hypertension is associated with extensive structural remodeling of the pulmonary arterial bed  the structural changes in the arterial walls include increased production of extracellular matrix components and smooth muscle cell hypertrophy  changes that have been similarly induced by transforming growth factor beta  tgf beta  in culture  in the present study  experiments were performed to determine whether tgf beta is present in sheep lung lymph  and whether tgf beta levels were altered in an animal model of chronic pulmonary hypertension induced by continuous air embolization  several standard biological assays for tgf beta activity were used for these determinations including soft agar assays  inhibition of epithelial cell proliferation  and a tgf beta specific radioreceptor assay  in each case  control lung lymph contained high concentrations of tgf beta  100 ng ml  which required transient acidification for detection  samples of lung lymph from hypertensive sheep showed a transient and early two  to threefold increase in concentrations of latent tgf beta  this activity could be partially blocked by tgf beta antibodies  these studies indicate that sheep lung lymph contains tgf beta and that the level of tgf beta increases early during the development of pulmonary hypertension  thus  tgf beta may contribute to the development of the structural changes in the pulmonary arteries that occur during the onset of chronic pulmonary hypertension  
class8	avoiding a wrapped endotracheal tube in laser laryngeal surgery  experiences with apneic anesthesia and metal laser flex endotracheal tubes  ninety one laser laryngeal procedures using the apneic technique of anesthesia were performed in 28 patients between 2 months and 64 years of age  seventy two procedures  79   were performed on children and 19 on adults  there were no complications  eight laser laryngoscopies were performed using a new metal laser flex endotracheal tube  obstruction of the endotracheal tube with a mucous plug occurred in one case  the apneic technique described in this paper provides a laser operative field free of an endotracheal tube  virtually eliminating the danger of a laser fire  it is a relatively safe and effective means of performing laser laryngeal surgery  in addition  the laser flex endotracheal tube appears to be an acceptable alternative to a metallic tape wrapped endotracheal tube  
class8	a palmar dermatosis linked to occult carcinoma of the upper thorax  head and neck  bazex s syndrome and tripe palm  an unusual  persistent  corregated to honeycombed thickening of the palms accompanied by tenderness around the fingernails was found to be a cutaneous marker for internal malignancy  this combination of signs and symptoms has been reported under two clinical entities  bazex s syndrome and tripe palm  this paraneoplastic syndrome is of interest to head and neck surgeons due to the location of the primary tumor  the site of metastatic disease  and the ability to cure the cutaneous disease by surgical removal of the primary tumor  in our patient  a squamous cell carcinoma of the lung not detectable on chest x ray presented as a cervical mass accompanied by cutaneous changes on the palms and fingernails  recognition of the relationship of the dermatologic changes to malignancy of a specific body region eventually led to the detection of the primary tumor  the characteristics of these paraneoplastic syndromes were reviewed in this report  
class8	trends in lung cancer incidence and mortality  united states  1980 1987  published erratum appears in mmwr morb mortal wkly rep 1990 dec 14 39 49  906  lung cancer is the most common fatal malignant neoplasm in the united states  based on current smoking patterns  the substantial public health burden of smoking related lung cancer will continue during the next several decades  this report describes trends in lung cancer incidence from 1980 through 1986 and lung cancer mortality from 1980 through 1987  
class8	bronchoscopy in critically ill patients  when is it appropriate  fiberoptic bronchoscopy is a valuable diagnostic and therapeutic tool for use in carefully selected patients with serious pulmonary disease  the authors review the benefits and risks of fiberoptic bronchoscopy and discuss the essentials of nursing care before  during  and after the procedure  
class8	emergent signs of cancer  recognizing them early in the office or er  primary care physicians have a crucial role in recognition of potentially emergent conditions in patients with known or suspected cancer  this task presents a significant challenge because the initial manifestations of these conditions are usually nonspecific  in most cases  therapy is far more effective when diagnosis is made at the earliest possible point  thus  physicians should become familiar with conditions commonly seen in cancer patients  such as superior vena cava syndrome  malignant pericardial effusion  spinal epidural metastasis  and altered mentation from brain metastases  metabolic encephalopathy  or hypoglycemia  
class8	surgical treatment for secondary retracted nose  this surgical technique is presented to correct nasal tip retraction  which is frequently associated with other surgical sequelae that can be corrected simultaneously  it is based on the use of a shield  an anchor  or half an anchor of otocartilage  with one or two posterior supports that are sutured together forming a small l and are fixed to the bed to project the nasal tip and  if necessary  to correct the unilateral or bilateral alar collapse  
class8	small cell lung cancer  staging with mr imaging  small cell lung cancer is an aggressive neoplasm  metastases are detected in two thirds of patients at diagnosis with use of conventional staging  which includes bilateral bone marrow biopsy  bone scintigraphy  and computed tomography  ct  of the head and abdomen  in 25 patients  small cell lung cancer was staged prospectively with both conventional staging and a magnetic resonance  mr  imaging protocol that included 1 5 t mr imaging of the pelvis  abdomen  spine  and brain  according to conventional staging  14 patients had extensive disease and 11 patients had limited disease  according to staging with mr  19 patients had extensive disease and six had limited disease  all metastatic disease sites seen with conventional staging were identified on mr images  mr images showed additional metastatic involvement in bone  four patients  and liver  three patients  not detected at conventional staging  a low attenuation hepatic lesion on a ct scan was identified as a hemangioma on mr images  these preliminary data suggest that small cell lung cancer may be accurately staged with use of a single mr imaging study  
class8	small nodular lesions in the lung periphery  new approach to diagnosis with ct  to evaluate relationships between lesions in the lung periphery and surrounding structures  particularly vessels and bronchi  axial multiplanar reconstruction  ampr  computed tomography  ct  was used to study 26 patients who underwent surgical resection of pulmonary nodules less than 3 cm in diameter  findings at ampr ct  conventional ct  and digital radiographic tomography were compared with findings obtained at evaluation of the resected specimen with regard to the ability to display the relationships between vessels  bronchi  and lesions  ampr ct was significantly superior to conventional ct and digital radiographic tomography in detecting involvement of pulmonary vessels  p less than  001   involvement of pulmonary veins was seen in all lung cancers  whereas such involvement was seen in only one of eight nonneoplastic lesions  thus  involvement of pulmonary veins is strongly suggestive of malignancy  ampr ct permits three dimensional visualization and morphologic assessment of pulmonary nodules  
class8	search and nonsearch protocols for radiographic consultation  six radiologists  acting as radiograph reviewers  used two different consultation protocols to differentiate among 292 ambiguous chest radiographic findings  120 simulated nodules and 172 normal findings  previous readers  false positive reports of nodules   the nonsearch protocol identified each finding  by film location   and reviewers rated the likelihood of each finding s being a pulmonary nodule  the search protocol asked reviewers to report and rate all locations regarded as possible nodules on each radiograph and assigned a default negative rating to any unreported finding  nodule or normal structure   receiver operating characteristic analyses demonstrated a significantly higher accuracy for each reviewer s search protocol discriminations between these nodules and ambiguous normal findings  this superiority of search result suggests that radiologists  second opinions about suspected lesions might be more accurate when consultants follow a search protocol  independently reviewing radiographs without prior knowledge of the specific findings that concerned the primary radiograph readers  
class8	potential usefulness of an artificial neural network for differential diagnosis of interstitial lung diseases  pilot study  an artificial neural network approach was applied to the differential diagnosis of interstitial lung diseases  the neural network was designed to distinguish between nine types of interstitial lung diseases on the basis of 20 items of clinical and radiographic information  a data base for training and testing the neural network was created with 10 hypothetical cases for each of the nine diseases  the performance of the neural network was evaluated by means of receiver operating characteristic analysis  the decision performance of the neural network was high  it was comparable to that of chest radiologists and superior to that of senior radiology residents  the preliminary results strongly suggest that the neural network approach has potential utility in the computer aided differential diagnosis of interstitial lung diseases  
class8	pulmonary masses  contrast enhancement  radiographic studies to discriminate benign from malignant pulmonary masses have previously focused on the morphologic and  more recently  the computed tomographic  ct  attenuation characteristics of the lung mass  experience with the use of an intravenously administered iodinated contrast medium in examining the enhancement properties of lung masses was reviewed  distinctive differences in the vascularity  pathophysiologic features  and pharmacodynamics of malignant versus benign pulmonary masses were identified  forty five patients with peripheral pulmonary masses were examined  enhancement was evaluated by means of optical density values measured on trispiral tomograms of the lung masses before and after bolus injection of contrast medium  results suggest that contrast enhancement of pulmonary masses can be measured on sectional images and that this may become a feasible diagnostic method in the detection of lung cancer  ct offers a simplified technique that is now being explored by the authors  
class8	diagnosis and treatment of pneumonia in the surgical intensive care unit  published erratum appears in surg gynecol obstet 1991 apr 172 4  324  it is often difficult to detect the onset of parenchymal pulmonary infection  pneumonia  in a surgical intensive care unit  sicu  setting  clinical and laboratory parameters that usually indicate the presence of pneumonia  such as fever  elevated white blood cell count and abnormal sputum culture  may also be present in patients with nonpneumonic infection  prompt diagnosis is particularly important for patients in sicu because the mortality rate associated with pneumonia in these patients may be as high as 50 per cent  in the sicu setting  pneumonia is best diagnosed using well defined roentgenologic criteria  treatment should consist of a broad spectrum antibiotic regimen to which all sputum pathogens are sensitive  such a regimen significantly reduces the mortality rate for patients with pneumonia in an sicu setting  aztreonam has been found to be as effective against susceptible gram negative bacilli as traditional agents  such as the aminoglycosides  and to have a significantly milder side effect profile  
class8	aqueductal  pencil  glioma presenting as neurogenic pulmonary edema  a case report  a case of neurogenic pulmonary edema due to hydrocephalus  without initial neurological deficit  is described  computed tomography demonstrated a ring enhancing lesion in the tectum of the mesencephalon obstructing the aqueduct of sylvius  the lesion  on autopsy  was a rare mesencephalic glioma described in the literature as a  pencil glioma  of the aqueduct  
class8	amiodarone  a postmarketing evaluation of monitoring for drug induced toxicity  amiodarone  an antiarrhythmic drug with predominantly class iii effects  has demonstrated serious adverse drug reactions and interactions  the departments of pharmacy and cardiology retrospectively evaluated the monitoring parameters at this institution  criteria based on current literature were developed  twenty six patients were administered amiodarone  qualifying for entry into the audit  of these patients  seven were excluded because their medical records were unavailable or incomplete  the 19 eligible patients were hospitalized during initiation of therapy and followed in the outpatient cardiology clinic  the collected data extracted from the medical charts were compared with the following elements of the criteria selected  baseline evaluation prior to the start of therapy  monitoring for signs of pulmonary  hepatic  thyroid  cardiac  ophthalmologic  neurologic  and dermatologic toxicity  and evaluation of potential drug interactions with digoxin and warfarin type anticoagulants  the percentage of criteria elements appropriately monitored on each patient ranged from 82 to 100 percent  with an average of 91 percent  the most frequently overlooked parameters were warning the patient of a possible photosensitivity reaction  decreasing the digoxin dose if the patient was concurrently taking amiodarone  and performing a slit lamp examination every six months  frequent examination of the patient s total organ system and laboratory tests  in addition to patient education  are essential to safe monitoring of amiodarone therapy  
class8	ability of calcium entry blockade by felodipine to disclose different pathogenetic mechanisms behind hyperventilation induced myocardial ischemia in men  to verify that myocardial ischemia occurring during either the overbreathing or recovery phase of the hyperventilation test is based on different pathogenetic mechanisms  2 consecutive series of patients  selected on the basis of their response to a run in hyperventilation test  were studied  group i comprised 15 patients who developed st segment depression early during overbreathing  whereas group ii consisted of 12 patients showing st segment depression late during the recovery phase  a single oral dose of felodipine 10 mg or of placebo was administered on 2 consecutive days according to a randomized  double blind  crossover design  and the hyperventilation test was repeated  on both days of the study  3 to 5 hours after drug intake  in group i  st segment depression occurred after placebo in all patients during overbreathing  with an increase in rate pressure product  from 112     31 at baseline to 168     55 mm hg x beats min 100 at the onset of st segment depression  p less than 0 01   after felodipine  13 patients continued to show st segment depression during overbreathing  together with an increase in rate pressure product  from 107     24 at baseline to 158     46 mm hg x beats min 100 at the onset of electrocardiographic changes  p less than 0 01   in group ii  all 12 patients showed st segment depression during recovery after placebo  with a rate pressure product comparable to baseline conditions  112     35 at baseline vs 102     27 mm hg x beats min 100 at the onset of st segment depression  difference not significant   after felodipine  no patient developed st segment depression or chest pain  
class8	angiocentric lymphoma with histologic features of neoplastic angioendotheliomatosis presenting with predominant respiratory and hematologic manifestations  report of a case and review of the literature neoplastic angioendotheliomatosis  nae  is a rare fatal disease characterized by widespread intravascular proliferations of neoplastic mononuclear cells  clinically  dermatologic and bizarre neurologic manifestations usually predominate  the origin of the neoplastic cells remains still undetermined  the authors report a patient with nae peculiar with respect to the following points   1  the patient predominantly manifested respiratory symptoms and hematologic findings and lacked cutaneous or neurologic manifestations  and  2  immunohistochemical and molecular genetic studies showed the b cell nature of the neoplastic cells  although previous cases with predominant respiratory or hematologic manifestations were reported to be of endothelial origin  despite the rarity  this type of nae or angiocentric lymphoma should be recognized because it is easily confused with other disorders  particularly vasculitis or thrombotic thrombocytopenic purpura  
class8	midfacial hypoplasia associated with long term intubation for bronchopulmonary dysplasia  six preterm infants with bronchopulmonary dysplasia were nasotracheally intubated for 68 to 243 days  gestational age at birth ranged from 24 to 35 weeks  endotracheal tube size was changed to account for growth and varied from 2 5 to 4 0 mm  these infants developed features of midfacial hypoplasia  namely  depressed nasal bridge  small tipped nose  long philtrum  underdeveloped malar areas  and carplike mouth  these features have not been associated with long term intubation in premature infants  we suggest that features of prolonged nasotracheal intubation  such as direct compression by the tube and the method of tube fixation  decreased air flow through the developing nares and sinuses and reduced faciomuscular activity  resulting in the observed midfacial hypoplasia  the degree to which growth corrects these deformations is unknown  
class8	cardiogenic hepatorenal syndrome  a variant of hepatorenal syndrome occurring in patients with chronic congestive heart failure following an episode of cardiogenic pulmonary edema  and in the absence of hypotension  is described  this was observed in 13 patients during an eleven year period  the clinical picture is characterized by hepatic injury and functional renal impairment  increase of serum glutamic oxaloacetic transaminase levels as high as 2100 iu  prolongation of prothrombin time  elevation of serum bilirubin  creatinine  blood urea nitrogen  and potassium levels  decrease in urinary sodium excretion  and a normal urinary sediment are the salient laboratory abnormalities of this entity  treated with conventional medication  the patients  course was fatal in 4 cases  when the splanchnic vasodilator dopamine was added to the patients  management  5 of 9 patients recovered  cardiogenic hepatorenal syndrome is a severe but potentially reversible complication of heart failure  the apparently beneficial effect of low dose dopamine needs further evaluation  
class8	lymphangiomyomatosis  newer concepts in pathogenesis and management  case reports  lymphangiomyomatosis was first reported more than forty years ago  although its incidence is rare  its occurrence is being increasingly recognized and has been the subject of a growing number of cases reports in recent years  this study adds 2 more cases to the file  both cases involved young women with the characteristic symptoms of dyspnea  cough  abdominal discomfort and swelling  chest pain  and hemoptysis  with abundant formation of refractory chylous  serous ascites  although the progression of the disease differed in each case  pulmonary function was affected in a similar way by the presence of obstructive and restrictive defects and a decrease in diffusing capacity  underlying abnormalities were dilated lymphatics  thickened lymphatic walls  and muscular proliferation of leiomyomatous origin  leading to bronchial restriction  the authors point to the subtlety required in arriving at a differentiated diagnosis of lymphangiomyomatosis lymphangioleiomyomatosis and the difference between the two conditions  they also make particular recommendations in respect to the importance of preliminary hormone receptor tests and to the wisdom to be exercised in ligating a main lymphatic duct in the chest to control the formation of ascites  pneumothorax  a frequent manifestation of lymphangiomyomatosis  is found to be the result of chronic air trapping due to a combination of narrowing of conducting airways and disruption of normal lung parenchyma  
class8	masqueraders in clinical allergy  laryngeal dysfunction causing dyspnea  published erratum appears in ann allergy 1991 jan 66 1  22  the allergist may be called upon to evaluate patients with dyspnea that is labeled  refractory asthma   in some patients  the site of origin of their dyspnea is the larynx  the diagnosis of laryngeal disorders requires a thorough understanding of the normal function of the laryngeal anatomy and physiology  some patients with asthma may have a component of their airway obstruction in the larynx and large airways  paradoxical vocal cord motion occurs when the true vocal cords approximate during inspiration  and although severe subjective dyspnea may occur  in most cases there is no evidence of hypoxia  hemoglobin desaturation  or an abnormality of the arterial alveolar oxygen gradient  provocative tests with methacholine are negative in this group of patients  patients with pvcm are usually female and may have an affiliation with the medical profession  many have psychologic difficulties  and the foundation of treatment is speech therapy and psychotherapy if indicated  other disorders that may produce dyspnea from laryngeal dysfunction include meige syndrome  abductor spastic dysphonia  and laryngospasm  recognition of these disorders will expedite timely  accurate diagnosis and treatment  
class8	mast cell heterogeneity in chronic idiopathic urticaria  patients with chronic urticaria are more sensitive to codeine skin testing than other allergic individuals  nonlesional skin in most patients with chronic urticaria was found to contain increased numbers of both total and atypical mast cells  the presence of increased mast cell density was found to correlate with the degree of clinical  dermatographism  and functional  codeine skin test  skin sensitivity  
class8	the association of selected cancers with service in the us military in vietnam  iii  hodgkin s disease  nasal cancer  nasopharyngeal cancer  and primary liver cancer  the selected cancers cooperative study group as part of a series of investigations into the health of vietnam veterans  we conducted case control studies involving 310 men with hodgkin s disease  48 with nasal carcinoma  80 with nasopharyngeal carcinoma  130 with primary liver cancer  and 1776 controls between 1984 and 1988  all men born between 1929 and 1953 and diagnosed in an area covered by eight cancer registries were considered eligible as cases  controls were recruited by random digit dialing  whereas the study had excellent power  96   to detect a twofold increase in risk for hodgkin s disease among vietnam veterans  its ability to detect a similarly elevated risk in the other cancers was limited  ranging from 38   nasal carcinoma  to 75   primary liver cancer   analyses showed that risks among vietnam veterans relative to other men were 1 1  hodgkin s disease   0 7  nasal carcinoma   0 5  nasopharyngeal carcinoma   and 1 2  primary liver cancer   none of these relative risks was significantly different from 1 0  similar results were obtained if vietnam veterans were compared with  1  other veterans or  2  men who never served in the military  an examination of several attributes of military service in vietnam  eg  branch  duration of service  and other characteristics that may have been associated with the use of agent orange  failed to identify any groups of veterans who were at increased risk for hodgkin s disease  small numbers limited further analyses of nasal  nasopharyngeal  and liver cancer  these results provide no evidence that  15 to 25 years following service in vietnam  the risk of these malignant neoplasms is higher among veterans  
class8	decision analysis  public health policy  and isoniazid chemoprophylaxis for young adult tuberculin skin reactors  as part of a plan to eliminate tuberculosis in america  tuberculin skin testing was advised for all us citizens  with isoniazid chemopreventive therapy administered to appropriate positive reactors  implementation of this plan  however  may be limited by concerns over which skin test reactors should receive isoniazid therapy  recent decision analyses suggest that  contrary to american thoracic society guidelines  asymptomatic skin test reactors under age 35 years with normal chest roentgenograms and no predisposing conditions to tuberculosis reactivation will not benefit from isoniazid chemopreventive therapy  repeated analysis of these studies reveals that calculated life expectancy depends on estimates of the probability of certain chance outcomes  if the isoniazid related hepatitis case fatality rate is below 1   isoniazid chemopreventive therapy appears to be beneficial  a literature review suggests that this rate is indeed this low  if the tuberculosis case fatality rate is above 6 7   also supported by the literature  the advantages of isoniazid therapy are further increased  this repeated analysis should reassure physicians that isoniazid chemoprophylaxis for tuberculin skin test reactors is beneficial to the individual and consonant with public health policies  
class8	clindamycin vs penicillin for anaerobic lung infections  high rate of penicillin failures associated with penicillin resistant bacteroides melaninogenicus  thirty seven adult patients with anaerobic lung infections  27 lung abscesses and 10 necrotizing pneumonias  were submitted to transthoracic needle aspiration and or bronchoscopic specimen brush cultures before therapy and thereafter in all cases considered to be failures  patients were randomly assigned to receive either clindamycin  600 mg intravenously every 6 hours  or penicillin g  2 million u every 4 hours for no less than 8 days  until clinical and radiological improvement became apparent  treatment was continued orally with clindamycin  300 mg every 6 hours  or penicillin v  750 mg every 6 hours  until completing a minimum of 4 weeks  ten of the 47 anaerobes initially isolated from the lung  nine bacteroides melaninogenicus and one bacteroides capillosus  were resistant to penicillin  but none were resistant to clindamycin  five of the nine patients harboring these penicillin resistant bacteroides received penicillin  and all failed to respond to therapy  overall  eight of the 18 patients in the penicillin group and one of 19 in the clindamycin group failed to respond to therapy  these drugs were equally well tolerated in both groups  the presence of penicillin resistant bacteroides is a frequent cause of penicillin failure in patients with anaerobic lung infections  in this setting  clindamycin appears to be the current therapy of choice for initial treatment  
class8	spectrum of invasive haemophilus influenzae type b disease in adults  a prospective nationwide surveillance of invasive haemophilus influenzae type b disease among adults  greater than or equal to 16 years old  was conducted in finland during 1985 through 1988  thirty one cases were identified  annual incidence  0 22 100 000   of these infections  71  occurred in patients with severe underlying conditions  the overall case fatality rate was 26   septicemia  13 patients  and pneumonia  seven patients  were the most common clinical manifestations of h influenzae type b infection  the others were epiglottitis  six patients   meningitis  three patients   and arthritis  two patients   epiglottitis occurred in significantly younger patients  all of whom were women and four of whom were previously healthy  subtyping of the h influenzae type b isolates according to the major outer membrane protein subtype  biotype  and lipopolysaccharide serotype showed that patterns that were uncommon  14   among children were more common  27   in the adults  
class8	barotrauma associated with high frequency jet ventilation for hypoxic salvage  most reports describe reduction in proximal airway pressures with high frequency jet ventilation  this led us to speculate that high frequency jet ventilation might reduce barotrauma by providing alveolar ventilation at lower airway pressures  we describe a group of patients in whom a high incidence of barotrauma was observed after institution of high frequency jet ventilation despite reduction in measured airway pressures  fifteen hypoxic patients who could not be treated with conventional ventilation and who had no roentgenographic evidence of barotrauma were entered into the study  airway pressures were measured during conventional ventilation and at 2 and 24 hours after high frequency jet ventilation  despite significant reduction in peak inspiratory and mean airway pressures  pneumothorax developed in seven of the 15 patients  an average of 21 hours after initiation of high frequency jet ventilation  five patients had bilateral pneumothorax and three developed tension pneumothorax  despite reductions in proximal airway pressures  barotrauma is a significant potential complication of high frequency jet ventilation in patients with noncompliant lungs  we currently place bilateral prophylactic thoracostomy tubes in patients with adult respiratory distress syndrome prior to initiation of high frequency jet ventilation  
class8	visualization of acute pulmonary emboli by transesophageal echocardiography  this report describes a patient who became hypoxic and hypotensive while awaiting cardiac surgery  an urgent transesophageal echocardiogram in the operating room showed a mass at the junction of the main and right pulmonary arteries consistent with thrombus  the thrombus was removed surgically  and the patient then had a successful aortic valve replacement  transesophageal echocardiography is therefore useful in the evaluation of the critically ill patient  
class8	combined modality therapy for locally advanced non small cell lung carcinoma  multi modality treatment consisting of cisplatin  vp 16  and 5 fluorouracil chemotherapy given concomitantly with external beam radiation was used to treat 64 patients with locally advanced stage iii non small cell lung carcinoma  this regimen was used in a preoperative fashion for four cycles in patients considered surgically resectable and with curative intent for six cycles in the remainder of patients  the clinical response rate for the entire group was 84  and the overall local control rate was 74   the median survival was 13 months with a median follow up for live patients of 19 months  the actuarial 3 year survival and disease free survival rates were 30  and 23   respectively  histologic complete response was 39  and appeared to predict for survival  the 3 year actuarial survival and disease free survival rates for 23 resected patients were 69  and 45   respectively  with the complete histologic responders having a disease free survival of 78   the pattern of first recurrence did not appear to differ by histology or presence of lymph nodes in this subset of patients  the actuarial 3 year survival and disease free survival rates for inoperable patients receiving six cycles of treatment were 18  and 23   respectively  the local control was 67  with the majority of these patients having stage iiib disease  the mountain international staging system appeared to predict for operability  local recurrence  and survival  this concomitant treatment regimen is feasible  with the major toxicities being leukopenia  nausea  and vomiting  
class8	angiocentric immunoproliferative lesion t cell non hodgkin s lymphoma and the acquired immune deficiency syndrome  a case report and review of the literature  the lesions known as lymphocytic vasculitis  polymorphic reticulosis  midline malignant reticulosis  lethal midline granuloma   lymphomatoid granulomatosis  and angiocentric lymphoma form what have been collectively termed the angiocentric immunoproliferative lesions  ail   because of recent reports demonstrating clonal rearrangements of the t cell receptor in these lesions  the ail are now thought to represent a continuous spectrum of post thymic t cell non hodgkin s lymphoma  nhl   nhl associated with the acquired immune deficiency syndrome  aids  represents intermediate or high grade b cell malignancies in hiv infected patients that may be etiologically related to the epstein barr virus  ebv   there have been reports of ebv associated t cell nhl  ail  and large granular lymphocyte  lgl  proliferations  as well as hiv associated t cell neoplasia  lgl t cell proliferations  and ail  we describe a case of polymorphic reticulosis  lethal midline granuloma  arising in an hiv infected individual  who later progressed to aids  and review the literature on hiv associated and ebv associated t cell neoplasia  lgl t cell proliferations  and ail  the etiology of this ail t cell nhl  especially in relation to ebv and hiv  is discussed  
class8	chylothorax after posterior spinal instrumentation and fusion  chylothorax occurred in a 16 year old girl after posterior spinal fusion and instrumentation for idiopathic scoliosis  nonoperative management  including chest tube drainage for 26 days and total parenteral nutrition  successfully treated this unusual complication after a posterior spinal fusion  
class8	swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes  eleven patients were tested for swallowing dysfunction after prolonged orotracheal intubation  ten had a tracheostomy tube  mean duration of orotracheal intubation was 19 9 days  mean age 65 yr  and no patient had a concomitant neurologic deficit  all patients had a modified barium swallow with videofluoroscopy  all patients had at least one defect of 11 defects characterized  there was a mean of six defects patient  the most common defects were delayed triggering of the swallow response  present in all patients  and pharyngeal pooling of contrast material  n   9   follow up videofluoroscopy was performed in five patients  all had improved  with mean defects decreasing from 6 1 to 2 8 patient  with one exception  no patient had any defect that was worse than mild in severity  we concluded that prolonged orotracheal intubation with or without tracheostomy may cause prolonged and severe swallowing dysfunction  the deficits improve with time  the presence of a gag reflex does not confer protection against aspiration of pharyngeal contrast  
class8	does prematurity alter the course of respiratory syncytial virus infection  we compared previously healthy prematurely born infants with full term infants hospitalized with respiratory syncytial virus  rsv  infection to evaluate the role of prematurity on the clinical course of the illness  during a 5 yr period  1984 to 1989   484 previously healthy patients were admitted to the hospital with rsv infection  no differences were found in the presenting symptoms of respiratory distress  cough  fever or shock  although the premature group was more likely to present with apnea  p less than  001   chest roentgenograms revealed that premature infants had a higher incidence of atelectasis infiltrate and hyperinflation  p less than  05   premature infants had longer hospital stays as well as a higher physiologic stability index and therapeutic intervention score  p less than  001   they were also more likely to receive supplemental oxygen  icu admission  mechanical ventilation  and nothing by mouth status  p less than  001   we conclude that premature birth increases the risk of more severe and prolonged rsv disease  
class8	respiratory response and pharmacokinetics of intravenous salbutamol in infants with bronchopulmonary dysplasia  the effects of iv salbutamol on respiratory mechanics were studied in six infants with bronchopulmonary dysplasia  salbutamol was infused at a dose of 30 micrograms kg over 30 min in five infants  a sixth infant received 66 7 micrograms kg over 4 min  salbutamol caused improvement in total respiratory system compliance and in airflow resistance  there was no correlation between salbutamol serum concentration and pulmonary function  elimination half time appears to be dictated in these infants more by the distribution volume  vd  than by clearance  cl   the area under concentration time curve of salbutamol correlated inversely to the change in heart rate  hr   there was a significant positive correlation between vd and percent hr change  these data provide evidence that preterm infants have measurable activity of bronchiolar beta 2 receptor responsive to salbutamol  
class8	incidence of colonization  nosocomial pneumonia  and mortality in critically ill patients using a trach care closed suction system versus an open suction system  prospective  randomized study  eighty four intubated  mechanically ventilated patients were prospectively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received endotracheal suctioning by an  open  suction method vs   closed  suction  trach care closed suction system  method  results show that closed suctioning is associated with a significant  67  vs  39  p less than  02  increase in colonization compared with open suctioning  however  difference in the incidence of nosocomial pneumonia was not significantly  26  vs  29   different between closed and open suctioning  differences in severity of illness  acute physiology and chronic health evaluation ii and therapeutic intervention scoring system   age  sex  presence of ng tubes  use of h2 antagonists or antacids  use of antibiotics  and history of smoking were all nonsignificant  survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed suctioning patients vs  open suctioned patients  p less than  03   this study shows that suctioning performed via the trach care closed suction system increases the incidence of colonization but not the incidence of nosocomial pneumonia  and may actually decrease mortality when compared with open suction systems  
class8	pentoxifylline attenuates edema formation in proteolytic enzyme induced lung injury  ex vivo canine lung lobes were exposed to a pancreatic proteolytic enzyme  chymotrypsin  alone or chymotrypsin after pretreatment with a continuous infusion with pentoxifylline  the lobes exposed to chymotrypsin gained 133 g  while the pentoxifylline treated lobes gained only 65 g  p less than  05  over the 3 h experimental period  these results suggest that pentoxifylline significantly attenuates the lung weight gain associated with chymotrypsin  
class8	continuous  in vivo pulmonary venous admixture from fiberoptically measured hemoglobin saturations  in six anesthetized swine  pulmonary venous admixture  qsp qt  was calculated by four methods  a  qsp qt 1  fiberoptically measured arterial and mixed venous hgb saturation  sao2 and svo2   pao2 and pvo2 derived from saturations  b  qsp qt 2  fiberoptically measured sao2 and svo2  pao2 and pvo2 measured by blood gas analysis  c  qsp qt 3  pao2 and pvo2 measured by blood gas analysis  sao2 and svo2 derived from tensions  d  qsp qt 4  sao2 and svo2 measured by bench oximetry  pao2 and pvo2 derived from saturations  input from the fiberoptic catheters was fed into a computer programmed to calculate qsp qt 1 every 20 sec  fifty eight of these values were compared with simultaneously calculated qsp qt 2  3  and 4  there was no difference between fiberoptic and derived sao2 or fiberoptic and cooximetric svo2  correlations and slopes for qsp qt 1 with qsp qt 2  3  and 4 were significant  p less than  05   comparing mean differences  qsp qt 1 was significantly different only from qsp qt 3  p less than  01   we conclude that dual oximetry reliably tracks qsp qt  
class8	prototype volume controlled resuscitator for neonates and infants  twenty five infants receiving assisted ventilation in an icu were manually ventilated for 5 min periods using either a new prototype volume controlled resuscitator  vcr  or a standard self inflating resuscitator  sir   variables monitored during these 5 min periods included heart rate  respiratory rate  mean arterial pressure  mean airway pressure  paw   end tidal co2  petco2   pulse oximetry oxygen saturation  pao2  and paco2  significant differences in posttrial values for the following variables were  a  petco2  31 2     9 1 vs  25 6     8 2 torr  p less than  001   b  paco2  38 0     4 9 vs  33 2     6 7 torr  p less than  01   and c  ph  7 4     0 6 vs  7 5     0 1  p less than  04  at comparable paw  9 5     7 6 vs  8 0     6 0  ns   eighty four percent  21 25  of infants in the vcr group had normal paco2 values  35 to 45 torr  while only 44   11 25  in the sir group achieved normocarbia  p less than  001   measurements of the highest  pmax  and lowest  pmin  inspiratory pressure  cm h2o  in 15 patients demonstrated marked variation in pmax with the sir  differences in pmax  sir minus vcr  were significant  10 8     3 7  p less than  02  but not in pmin  0 5     3 5  ns   our study demonstrates that ventilation with the vcr resulted in less hyperventilation with minimal pressure variability as compared with the sir  further studies in the neonate are warranted  
class8	utility of fiberoptic bronchoscopy in nonresolving pneumonia although fiberoptic bronchoscopy  fob  has been traditionally used to evaluate nonresolving pneumonia  its efficacy is unknown  we  therefore  reviewed fob in 35 consecutive patients who had  1  a roentgenographic infiltrate   2  cough   3  either temperature greater than 38 1 degrees c  leukocytosis  sputum production   4  symptoms present for at least ten days  and antibiotic therapy for at least one week  known lung cancer and aids were excluded  fiberoptic bronchoscopy was diagnostic in 86 percent  12 14  in whom a specific cause was found  no patient had endobronchial cancer  two patients with nondiagnostic fob and persistent systemic symptoms had open lung biopsy specimens showing wegener s granulomatosis and bronchiolitis obliterans with organizing pneumonia  boop   twenty one patients with nondiagnostic fob had no final diagnoses other than community acquired pneumonia  we conclude that fob is extremely useful in finding a specific diagnosis for a nonresolving pneumonia when a specific diagnosis can be made  fiberoptic bronchoscopy was most likely to yield a specific diagnosis in nonsmoking patients with multilobar infiltrates of long duration and could have been avoided in older  smoking  or otherwise compromised patients with lobar or segmental infiltrates with no decrease in diagnostic yield in our series  
class8	acute lobar atelectasis  a comparison of two chest physiotherapy regimens  fourteen cases of acute lobar atelectasis were alternately allocated to one of two chest physiotherapy regimens for treatment  treatment in group 1 comprised positioning  vibrations  hyperinflation  and suction  and in group 2  treatment consisted of hyperinflation and suction alone  treatment in either group was given hourly for six hours  patients in group 1 had a significantly higher mean percentage resolution of their atelectasis  mean value  60 1 percent   as seen on chest roentgenogram  after one treatment intervention than patients in group 2  mean value  7 6 percent  p less than  006   after the intensive six hour treatment period  the difference between the groups was marginally statistically significant  still favoring group 1 over group 2  p less than  055   follow up roentgenograms at 24 and 48 hours revealed no significant difference between the treatment groups  p greater than  10 and greater than  20  respectively   these results suggest that  at least initially in the course of acute lobar atelectasis  positioning and vibrations add to the efficacy of a treatment of hyperinflation and suction alone  
class8	diagnostic value of maximal exercise tidal volume  though breathing pattern is frequently analyzed during clinical exercise testing  there is little information regarding its usefulness in the differential diagnosis of impaired exercise tolerance  this study tested the hypothesis that differences in peak tidal volume during exercise between patients with different cardiorespiratory diseases are related largely to differences in severity of respiratory mechanical impairment  vital capacity   not to differences in disease state  patients with chronic obstructive pulmonary disease  restrictive lung disease  bronchial asthma  and heart disease  mitral valve disease or left ventricular dysfunction  were studied  subjects selected had one and only one of the above diagnoses  all subjects performed maximal  symptom limited  incremental exercise on a cycle ergometer  multiple linear regression of all subjects  n   30  in all four groups showed a significant correlation between vtmax and vc  vtmax   0 55  vc  0 09 l  r   0 827  p less than 0 0001   the vtmax vc  x 100  was  mean     sd  44     15  54     11  56     11  and 54     12 for the copd  rld  ba and hd patients respectively  there was no significant difference between any of the groups  we concluded that differences in vtmax between different patients are related largely to differences in vc  ie  differences in severity of respiratory mechanical impairment   not to differences in disease state  measurement of vtmax or the vtmax vc ratio has little value in the differential diagnosis of exertional dyspnea  
class8	systemic hypertension in sleep apnea syndrome  relationship with sleep architecture and breathing abnormalities  to examine the possible relationship between systemic ht and sas we compared 21 hypertensive  ht   and 29 normotensive  ht   patients for morphologic characteristics  sleep disturbances and respiratory events monitored during a full night polysomnography  there was no significant difference between ht  and ht  patients with respect to age  weight  bmi  sleep stage distribution and disorganization  apnea hypopnea index  number of episodes per hour of sleep  and duration  minutes per hour of sleep  nor o2 saturation indices  mean nocturnal and minimum o2 saturation  we conclude therefore that ht in sas patients is not directly related to morphologic characteristics  sleep disturbances and breathing abnormalities  
class8	atypical presentations of pneumocystis carinii pneumonia in patients receiving inhaled pentamidine prophylaxis  inhaled pentamidine is used commonly to prevent pneumocystis carinii pneumonia  pcp  in patients with advanced human immunodeficiency virus infection  case reports indicate that pcp can recur in patients who receive inhaled pentamidine and that clinical features may be atypical  to determine the magnitude of this problem  we reviewed retrospectively the medical records of patients with proven pcp during a 30 month period at two hospitals  four  31 percent  of 13 patients with previous pcp who received inhaled pentamidine prophylaxis had recurrent p carinii infection  including one patient with widely metastatic extrapulmonary disease  chest roentgenographic findings included cavities  pneumothoraces  bilateral and upper lobe interstitial infiltrates  and pleural effusion  false negative bronchoalveolar lavage and induced sputum examinations were frequent  we conclude that recurrent pcp in patients maintained on a regimen of inhaled pentamidine prophylaxis occurs frequently  causes chest roentgenographic abnormalities other than interstitial infiltrates  and may be difficult to diagnose  clinicians who choose to use this effective and convenient mode of prophylaxis should be aware of the problems attendant to its use  
class8	rapid diagnosis of lung cancer from palpable metastases by needle thrust  this study encourages the use of percutaneous fnb to diagnose and stage advanced lung cancer in patients with palpable metastases in supraclavicular lymph nodes or soft tissues  percutaneous fnb of metastases is much easier to learn than transthoracic needle aspiration  the superficial target is anchored and sampled with multiple passes using a short needle grasped directly in the fingers  it is fast  accurate  economical and nearly free of risk and pain  the technique saves time and money because it is the only procedure needed by many patients with palpable disease in stage iiib and iv  bronchoscopy  transthoracic needle aspiration and open surgical biopsy thus can be avoided in most patients with palpable metastases  prompt diagnosis by fnb of metastases speeds palliation for patients with urgent need  tumor cell type from fnb correlated with cytologic findings from sputum samples  bronchoscopy specimens and autopsy results  
class8	elevated prostaglandin e2 levels in bronchoalveolar lavage fluid of patients with bronchogenic carcinoma  understanding local pulmonary immunoregulatory mechanism s  in patients with carcinoma of the lung is an important step towards the development of innovative methods of treatment  prostaglandin e2 plays an integral role in immunoregulation  therefore  we evaluated pge2 concentrations in balf from 18 patients with bronchogenic carcinoma  compared to that from six patients with pulmonary diseases other than carcinoma and ten normal smokers of similar age  the level of pge2 in patients with lung carcinoma  158 1     88 7 pg ml  was significantly  p less than 0 001  higher than the other two groups  16 2     6 9 and 4 4     3 4 pg ml   levels of pge2 also varied among patients with carcinoma of different cell types  patients with sqca had significantly  p less than 0 001  higher levels of pge2  242 7     29 4 pg ml  than patients with adca or scca  82 3     27 9 and 66 3     15 2 pg ml  respectively   furthermore  there was a marked difference in pge2 concentration between carcinomatous lung and clinically noninvolved lung in patients with sqca and adca  further study is warranted to determine the interactions between pge2 and other cytokines  interleukin 1  il 2  and tumor necrosis factor   as well as the activity of cytolytic lymphocytes  lak cells  in the lungs of patients with bronchogenic carcinoma  
class8	pulmonary vascular steal in chronic thromboembolic pulmonary hypertension  after pulmonary thromboendarterectomy  performed for relief of chronic thromboembolic pulmonary hypertension  perfusion lung scans have frequently disclosed new perfusion defects in segments served by undissected pulmonary arteries  our hypotheses were that these new postoperative defects occurred with great frequency and did not represent postoperative vessel occlusion  we retrospectively reviewed the preoperative and postoperative perfusion scans of 33 consecutive patients undergoing pulmonary thromboendarterectomy  new postoperative perfusion defects were noted in 23 of 33 patients  the incidence of new defects was increased tenfold in segments that had  1  normal preoperative angiographic findings   2  normal preoperative radionuclide perfusion  and  3  not been entered at the time of surgery  postoperative angiograms  available in 15 of 33 patients  documented the nonembolic  nonocclusive nature of the new perfusion scan defects  the most plausible alternate explanation for this previously undescribed finding is a redistribution of pulmonary arterial resistance induced by the thromboendarterectomy  namely  a pulmonary vascular  steal    
class8	pathologic dependence of oxygen consumption on oxygen delivery in acute respiratory failure secondary to aids related pneumocystis carinii pneumonia  oxygen consumption is pathologically dependent on oxygen delivery in ards and sepsis  we asked whether oxygen consumption is dependent on oxygen delivery in severe acute respiratory failure secondary to aids related pcp  in five patients who had aids related pcp  diffuse bilateral pulmonary infiltrates  no evidence of bacterial infection  and acute respiratory failure requiring mechanical ventilation with arterial oxygen tensions less than 75 mm hg while breathing at least 50 percent oxygen  and peep greater than 10 cm h2o  we determined oxygen delivery and consumption by calculation from thermodilution cardiac output and arterial and mixed venous oxygen contents  oxygen delivery was increased using transfusion of two units of packed red blood cells over one hour  oxygen delivery increased 22 percent  638     204 to 778     201 ml min m2  p less than or equal to 0 006   oxygen consumption increased 11 percent  134     34 to 149     29 ml min m2  p less than or equal to 0 02   the oxygen extraction ratio did not change  we conclude that similar to ards and sepsis  oxygen consumption may be pathologically dependent on oxygen delivery in patients who have severe acute respiratory failure secondary to aids related pcp  
class8	prostacyclin but not phentolamine increases oxygen consumption and skin microvascular blood flow in patients with sepsis and respiratory failure  inadequate tissue oxygenation may occur in critically ill patients with sepsis despite an apparently adequate o2 transport  qo2   and this may contribute to the development of an o2 debt and also to multiple organ failure  it has been shown that increasing qo2 by infusing a vasodilator may reveal this o2 debt in septic patients  to investigate whether the site of action of vasodilators may be of importance in unmasking such an o2 debt  we administered prostacyclin  a prostaglandin with a preferential effect on the microcirculation  and phentolamine  an arteriolar vasodilator  in 11 patients studied during the first 48 hours after the onset of sepsis  and compared their effect on whole body oxygen consumption  vo2  and skin microvascular blood flow  the results demonstrated that increasing qo2 by prostacyclin but not by phentolamine significantly increases vo2 in critically ill patients with sepsis  the site of action of vasodilators may therefore play an important role in their ability to unmask an o2 debt  
class8	selection and evaluation of recipients for heart lung and lung transplantation  heart lung and lung transplantation is being successfully performed with increasing frequency in patients with end stage cardiopulmonary and pulmonary disease  transplantation must now be considered as a therapeutic option in selected patients  and physicians are required to understand the principles involved for determining suitable candidates and operative procedures of choice  indications  contraindications  and choice of operation with respect to underlying disease are discussed herein  as are methods of evaluation and appropriate timing for transplantation  special considerations regarding specific patient populations are also addressed  in properly selected patients  heart lung and lung transplantation provide a viable therapeutic option in those with end stage disease who are unresponsive to conventional management  
class8	pneumothorax following cytotoxic chemotherapy in malignant lymphoma  pneumothorax occurring as a complication of the antitumor effect of cytotoxic chemotherapy has been reported in occasional cases of a variety of tumors  its occurrence in malignant lymphoma has not been reported heretofore  in this report  we describe two cases of this complication in patients with malignant lymphoma and discuss the possible pathophysiologic mechanisms involved  because pulmonary involvement with the tumor was found in both cases  pneumothorax could be attributed to the anti tumor effect of cytotoxic agents on underlying lung involvement in patients with malignant lymphoma  
class8	tracheal stenosis and failure to wean from mechanical ventilation due to herpetic tracheitis  a 64 year old man with chronic obstructive pulmonary disease presented with pneumococcal pneumonia that progressed to respiratory failure within one week  requiring mechanical ventilation  despite a low minute ventilation and clear chest roentgenogram  multiple weaning attempts failed  bronchoscopy revealed significant narrowing of the distal trachea with erythema  edema  and ulceration of the mucosa  cytology of tracheal washings was consistent with herpes simplex virus  and the patient was successfully extubated following treatment with intravenous acyclovir  bronchoscopy following acyclovir therapy demonstrated resolution of the inflammation and narrowing  herpetic tracheitis is a rarely recognized reversible cause of tracheal stenosis  especially in a nonimmunocompromised patient  it should be suspected in patients without an obvious cause of failure to wean from mechanical ventilation  and can be successfully treated with acyclovir  
class8	septic pulmonary embolism complicating a central venous catheter  bacteremia is a recognized complication in patients with indwelling central venous catheters  more recently pulmonary embolism in such patients has also been described  despite abundant clinical experience with these devices  to our knowledge  septic pulmonary embolism has not been reported in adult patients  this case illustrates such a complication  
class8	adult respiratory distress syndrome due to blastomycosis during pregnancy  a 23 year old healthy woman in her third trimester of pregnancy developed adult respiratory distress syndrome secondary to blastomyces dermatitides  pregnancy related immunosuppression was believed to be responsible for the fungal infection  following emergency delivery of the infant and a full course of amphotericin b therapy  the patient made an uneventful recovery  although the fetal and maternal sides of the placenta demonstrated fungal spores  the child remained healthy  to our knowledge  this is the first report of blastomycosis associated adult respiratory distress syndrome occurring during pregnancy  
class8	phrenomediastinal echinococcosis  a patient with the rare presentation of posterior mediastinal echinococcosis is reported  magnetic resonance imaging  mr  demonstrated the extension of a primary retroperitoneal cyst into the posterior mediastinum which was subsequently confirmed surgically to be of echinococcal origin  such a case of phrenomediastinal echinococcosis has been described only once before in literature  
class8	pneumomediastinum  pneumothorax and subcutaneous emphysema following the measurement of maximal expiratory pressure in a normal subject  mediastinal and subcutaneous emphysema have been reported as a consequence of deliberate manipulations of the breathing pattern producing a valsalva like maneuver in healthy subjects  we present a case of pneumomediastinum  pneumothorax and subcutaneous emphysema occurring in a normal volunteer after repeated measurements of the pemax  
class8	ear involvement in the yellow nail syndrome  recognized features of the yellow nail syndrome include yellow nails  lymphedema  and pleural effusions  we report a patient with the additional feature of keratosis obturans  which may be a manifestation of this syndrome in the external ear  
class8	bilious pleural effusion following liver biopsy  pleural effusions in patients with chronic liver disease are common and usually are of little consequence  bilious pleural effusion can occur following percutaneous biopsy or cholangiography procedures if the pleura is traversed  this report emphasizes the role of biliary tract obstruction in the development of a bilious effusion and the importance of biliary tract decompression in treatment  we discuss the laboratory evidence supporting the diagnosis of bilious effusion and review the reported experience with this complication  
class8	acute bronchitis  general practitioners  views regarding diagnosis and treatment  a survey was conducted among 800 dutch general practitioners to establish their views on the diagnosis and treatment of bronchitis and related disorders with reference to 12 theoretical patients  the answers of the 467 respondents  response rate 60   showed no clear relationship between signs and symptoms of the patients and the diagnosis made  in the authors  opinion the diagnosis of pneumonia was made too often  the decision whether or not to prescribe an antibiotic for a coughing patient was based in part on the diagnosis made  but in part it was also made on the basis of the signs and symptoms  irrespective of the diagnosis  the authors have the impression that general practitioners tend to prescribe antibiotics too quickly to coughing patients  there is a need for guidelines for diagnosis and treatment of patients with acute bronchitis and related conditions  
class8	enteric neuronal autoantibodies in pseudoobstruction with small cell lung carcinoma  severe gastrointestinal dysmotility is a newly recognized paraneoplastic syndrome that occurs with small cell lung carcinoma  thirty four patients with small cell carcinoma  of whom 5 had chronic intestinal pseudoobstruction and 29 had no digestive symptoms  were studied serologically  four of the 5 patients with gut dysmotility had immunoglobulin g antibodies reactive with neurons of the myenteric and submucosal plexuses of jejunum and stomach in an indirect immunofluorescence assay  antibodies of this type were not found in any of the 29 patients who had no gut dysmotility  nor were they found in patients with chronic idiopathic intestinal pseudoobstruction  n   8   ovarian cancer  n   20   or epilepsy  n   4  or in normal subjects  n   9   in 4 of the patients with paraneoplastic pseudoobstruction  antibodies in highly diluted serum  1 4000 1 8000  bound selectively to nuclei and cytoplasm of neuronal elements in the gut  this novel autoantibody activity suggests that intestinal pseudoobstruction occurring in patients with small cell carcinoma may have an autoimmune basis  from a clinical standpoint  serological testing offers a simple means for determining which patients with gut dysmotility syndromes may have associated small cell carcinoma  thereby enabling earlier diagnosis and treatment of the tumor  
class8	segmental vascular resistance in postobstructive pulmonary vasculopathy  chronic unilateral pulmonary arterial ligation has been touted as a model of arteriopathy resulting in a tremendous increase in anastomotic bronchial flow  qbr  via collaterals  to investigate its effects on the pulmonary vasculature  we ligated the left main pulmonary artery of seven dogs and 120 days later pump perfused their left lower lobes  lll  via a cannula in the pulmonary artery at pulmonary arterial flow  qpa  of 250 ml min  we measured qbr  330 ml min  and compared lll with control contralateral right lower lobes  rll  and three lll from normal dogs  pressure flow  p q  curves were obtained by varying qpa  with arterial and venous occlusion we measured total  arterial  venous  and middle segment resistances under baseline conditions  after serotonin and histamine  either with or without qpa and with antegrade and retrograde qbr  light microscopy was done postmortem  the slope of the p q curve was 33 4 mmhg l 1 min in the ligated lobes compared with 15 9 in the controls  attributable by the occlusion technique mainly to a rise in arterial resistance  22 4 mmhg l 1 min compared with 7 4 in the controls  with a small rise in venous resistance  this was explained by significant arterial medial muscle thickening and some loss of lll volume  the arterial segment was markedly hypersensitive to serotonin  and the venous segment was mildly hypersensitive to histamine compared with controls  the occlusion data also enabled us to model the point of entry of the bronchial circulation into the pulmonary circuit at the precapillary level and to calculate bronchial vascular resistance  we conclude that postobstructive vasculopathy substantially raises pulmonary vascular resistance  mainly upstream from the site of entry of the bronchial circulation  the role of the latter may be to keep it from rising excessively in the segments it perfuses  i e   the middle and venous ones  
class8	altered function of pulmonary surfactant in fatty acid lung injury  to determine whether acute fatty acid lung injury impairs pulmonary surfactant function  we studied anesthetized ventilated rabbits given oleic acid  55 mg kg iv  n   11  or an equivalent volume of saline  n   8   measurements of pulmonary mechanics indicated a decrease in dynamic compliance within 5 min of injury and a decrease in lung volume that was disproportionately large at low pressures  consistent with diminished surfactant activity in vivo  bronchoalveolar lavage fluid obtained 1 h after injury had significantly increased erythrocytes and total leukocytes  largely polymorphonuclear cells  the phospholipid content and composition of the cell free fraction had only minor changes from those of controls  but the protein content was increased 35 fold  measurements of lavage surface activity in vitro showed an increase in average minimum surface tension from 1 3     0 4  se  dyn cm in controls to 20 2     3 9 dyn cm in injured animals  the alterations in static pressure volume curves and decrease in lavage surface activity suggest a severe alteration of surfactant function in this form of lung injury that occurs despite the presence of normal amounts of surfactant phospholipids  
class8	pulmonary blood volume and edema in postpneumonectomy lung growth in rats  after pneumonectomy in young animals  the contralateral lung undergoes compensatory growth and generally attains the same weight and air space volume as both lungs in age matched controls  in this study  we determined the contribution of lung edema and increased blood volume to the weight gain in rats  three weeks after pneumonectomy  n   18  or sham pneumonectomy  n   17   the pulmonary blood volume and the extravascular water and albumin were evaluated by use of 51cr labeled erythrocytes and 125i labeled albumin  the air space volume  blood free lung weights  and dna and protein content were also compared  the data show that the total pulmonary blood volumes and the blood volume per gram of blood free dry lung were similar in pneumonectomized and age matched sham controls  the total extravascular albumin and the extravascular albumin per gram of blood free dry lung were also similar as well as the extravascular lung water  wet to dry weight ratios  dna and protein content  and air space volumes  these data indicate that the increased weight of the postpneumonectomy lung was due to cellular and stromal proliferation  the blood volume and interstitial fluid increased in proportion to the increase in lung parenchyma  neither vascular congestion nor increased extravascular protein and water contributed to the observed weight gain  
class8	physiology of aging related to outcome in the adult respiratory distress syndrome  thirty nine patients with adult respiratory distress syndrome  ards  were enrolled in a study to identify potential age related changes in organ system function that may help explain the apparent association between age and poor outcome in these patients  criteria for enrollment included an arterial po2 to inspired o2 concentration ratio less than or equal to 200 in a clinical setting consistent with ards  patients were excluded if they were less than 18 yr old  had clinical manifestations of congestive heart failure  were seropositive for the human immunodeficiency virus  or had stage ii metastatic lung cancer  patients were divided into two groups  those less than 60 yr old  mean 42     3 yr  n   17  and those greater than or equal to 60 yr old  73     2 yr  n   16   a group of six patients was analyzed as a separate subset based on a body temperature less than or equal to 97 5 degrees f at enrollment  hypothermic patients  73     4 yr old   sepsis was present in 67  of the nonhypothermic patients and in all the hypothermic patients  mortality rates were 12  in the patients less than 60 yr and 69  in the nonhypothermic patients greater than or equal to 60 yr  all the hypothermic patients died  sequential data obtained over 6 days were compared within and between groups  the following results were obtained  1  the ratio of arterial po2 to inspired o2 fraction was greater and the positive end expiratory pressure used was significantly less in the patients greater than or equal to 60 yr old compared with the younger group  
class8	congenital midline nasal masses  diagnosis and management  congenital midline nasal masses  cmnms  are rare lesions most commonly caused by dermoids  hemangiomas  nasal gliomas or encephaloceles  we report a case of nasal glioma and discuss the embryologic development  evaluation  and management of such cmnms  
class8	effects of prostaglandin e1 on platelet attenuation of oxidant induced edema in isolated rabbit lungs  numerous studies suggest that platelets may contribute to preservation of normal endothelial cell permeability in models of lung injury  we have previously shown that washed human platelets prevent xanthine oxidase induced edema in the isolated perfused lung and that protective mechanisms depend on the platelet glutathione redox cycle  it is uncertain  however  whether platelets preserve endothelial function by reducing toxic oxygen metabolites or by aggregating and releasing endothelial cell supportive factors an activity that may require the glutathione redox cycle  in this study  we present data demonstrating that platelet prevention of oxidant lung injury occurs independent of platelet aggregation and release  isolated rabbit lungs perfused with a cell free medium were instilled with purine  2 mmol l  and xanthine oxidase  0 003 u ml  to generate oxidant lung edema  the infusion of washed human platelets  1 x 10 10  cells  prevented lung edema formation as measured by lung weight gain  wet to dry lung weight ratios  and lung histology  incubation of platelets with prostaglandin e1  pge1   a potent inhibitor of platelet aggregation and release  did not inhibit platelet attenuation of lung edema  additionally  with the instillation of pge1 into the perfusate to further inhibit platelet aggregation  no prevention of lung protection by pge1 treated platelets was seen when these results were compared with those from studies in which lungs were infused with xanthine oxidase and pge1  aggregometry studies documented that the inhibitory effect of pge1 on platelet aggregation persisted for up to 60 minutes  which was the duration of the isolated lung protocol  we conclude that platelet aggregation and release of platelet factors is not required for platelet attenuation of oxidant lung edema  
class8	the effect of rifampicin on rhinoscleroma  an electron microscopic study  twenty five cases suffering from rhinoscleroma were divided into two groups  the first group consisted of 15 patients treated with rifampicin systemically  the other group consisted of 10 patients treated locally with rifampicin in the form of ointment  electron microscopic study of the pathological changes in the lesions showed that rifampicin is highly effective both systemically and locally in the treatment of rhinoscleroma  
class8	radiological diagnosis of aspirated foreign bodies in children  review of 343 cases  in our series of 400 chinese children with foreign body aspiration  fba   343 cases were evaluated by fluoroscopy and or plain chest x rays before endoscopic removal of the foreign bodies  the majority of the foreign bodies  fbs  were organic  378 400  94 5 per cent   the results showed that mainstem bronchial foreign bodies were diagnosed correctly in 68 per cent of cases compared with 65 per cent correct diagnoses with segmental bronchial foreign bodies  but only 22 per cent correct diagnoses with tracheal  and 0 per cent correct diagnosis in those with laryngeal foreign bodies  eighty per cent  32 40  of the children with laryngotracheal fbs had normal x ray findings  whereas 67 7 per cent  205 303  of the children with bronchial fbs had abnormal chest x ray findings  the most common positive radiological signs in the children with tracheobronchial fbs were obstructive emphysema  131 213  62 per cent  and mediastinal shift  117 213  55 per cent   the incidence of major complications was related not only to the size of the foreign body and its location but also the duration since aspiration  the most common types of bronchial obstructions by airway fbs are discussed  
class8	chronic sinusitis and the yellow nail syndrome  diagnosing syndromes that include chronic sinusitis can expedite the management of both conditions  yellow nail syndrome is usually described as the combination of yellow nails  lymphoedema and often respiratory manifestations such as chronic sinusitis  bronchiectasis and pleural effusions  the pathology responsible for the syndrome is believed to be lymphatic hypoplasia  diagnosis of yellow nail syndrome is clinical not requiring any specialized tests  in the two cases described  the respiratory tract manifestations required the most active investigation and management  the significance of this syndrome to the otolaryngologist is discussed  
class8	rigid spine syndrome with respiratory failure  the pathogenesis and therapy of respiratory failure in the rigid spine syndrome are discussed in two cases who improved with respiratory assistance  in both cases  the partial pressures of oxygen and carbon dioxide were reversed in arterial blood gas analysis and  vc was less than 30   remission from respiratory failure has been obtained by the use of a ventilator during the night  the cause of the respiratory failure in both cases was severe restrictive respiratory dysfunction due to extreme flattening of the chest and fixation of the thorax during respiration as a result of contracture of costovertebral joints  all the previously reported cases of the rigid spine syndrome with respiratory failure died  appropriate use of the ventilator can improve the prognosis  
class8	high frequency oscillatory ventilation compared with conventional intermittent mechanical ventilation in the treatment of respiratory failure in preterm infants  neurodevelopmental status at 16 to 24 months of postterm age  the hifi study group  the high frequency intervention trial was a 10 center randomized clinical trial to test the efficacy and safety of high frequency oscillatory ventilation  hfo  in the treatment of neonates weighing 750 to 2000 gm  327 infants were assigned to hfo and 346 to conventional intermittent mechanical ventilation  imv   survival and lung morbidity rates were the same in the two groups  bayley psychometric evaluations and cns examination were performed at 16 to 24 months of postterm age in 77  of the survivors  185 hfo and 201 imv   there was no difference in growth or respiratory status at follow up  cerebral palsy was diagnosed in 19  10   hfo treated infants and 23  11   imv treated infants  there was no difference in severity between the two groups  a significantly higher incidence of hydrocephalus  12  vs 6   was present in the hfo group  p less than 0 05   bayley index scores greater than 83 were scored in 57  of hfo treated infants compared with 66  of imv treated infants  the proportion of children at follow up with a normal neuro developmental status  i e   bayley score greater than 83 and no major cns defect  was significantly less in the hfo than in the imv group  54 vs 65   p less than 0 05   both treatment groups showed a strong association between the presence of grade 3 or 4 intraventricular hemorrhage and the development of major cns or cognitive defects  no significant long term beneficial or deleterious effects were demonstrated in the use of hfo versus imv for the treatment of respiratory failure in low birth weight premature infants  except that there were slightly more neurologic deficits in the hfo group related to the higher proportion of survivors with major intraventricular hemorrhage  
class8	improved outcome at 28 days of age for very low birth weight infants treated with a single dose of a synthetic surfactant two identical double blind  controlled  randomized trials were initiated to determine whether the administration of a single 5 ml kg dose of a synthetic surfactant  exosurf neonatal   soon after the delivery of infants with birth weights 700 to 1350 gm  would improve rates of survival without bronchopulmonary dysplasia  both trials were terminated before enrolling their planned sample sizes because of the availability of exosurf under the provisions of a treatment investigational new drug program  we report the combined results of these trials  study infants were stratified according to birth weight and gender before random assignment to a treatment regimen  one hundred ninety two infants received exosurf and 193 received an air placebo  the study groups were similar when a variety of demographic features describing the mothers  their pregnancies  the circumstances of the births  and the infants were compared  exosurf treated infants required significantly less oxygen and respiratory support during the first 3 days of life in comparison with the air treated infants  fewer infants in the exosurf group had pulmonary interstitial emphysema  26 vs 13  p   0 028   in the exosurf group  there was a significant reduction in the combined outcome  neonatal death or survival with bronchopulmonary dysplasia  57 vs 39  p   0 042   and there was a significant increase in rates of survival without this disease  128 vs 137  p   0 042   there were no differences between treatment groups in the incidences of a variety of complications of prematurity  including apnea  patent ductus arteriosus  intraventricular hemorrhage  and necrotizing enterocolitis  we conclude that improvements in respiratory physiology after a single prophylactic dose of exosurf result in an increased likelihood of neonatal survival without bronchopulmonary dysplasia  
class8	effect of extracorporeal membrane oxygenation on survival of infants with congenital diaphragmatic hernia  to determine the effect of extracorporeal membrane oxygenation  ecmo  on the survival of infants with congenital diaphragmatic hernia  we undertook a retrospective review of 31 infants with congenital diaphragmatic hernia treated at children s national medical center  infants were categorized by means of the bohn quadrant analysis to determine the impact of ecmo on infants with congenital diaphragmatic hernia and a  poor prognosis   all infants assigned to the bohn 100  mortality quadrant required ecmo  the survival rate in this group was 86   6 7  when assessed preoperatively and 67   6 9  when assessed postoperatively  comparison of the change occurring in ventilation index and arterial carbon dioxide pressure demonstrated that after repair the clinical condition of 48  of infants deteriorated  40  improved  and 12  remained unchanged  of the 12 infants whose condition was worse after surgery  11 eventually required ecmo  our review demonstrates that ecmo improved survival significantly in infants with congenital diaphragmatic hernia who had a  poor prognosis  by the criteria of bohn et al  we recommend consideration of ecmo for all infants with congenital diaphragmatic hernia for whom maximal medical therapy has failed  
class8	national survey of the pattern of care for carcinoma of the lung  a national survey of the patterns of care for carcinoma of the lung sponsored by the commission on cancer of the american college of surgeons has documented continuing changes in epidemiology  treatment  and outcome  the project consisted of a long term study of 15 219 patients whose diagnosis was made in 1981 and a short term study of 19 074 patients whose diagnosis was made in 1986  the male female incidence ratios have continued to decrease and the decrease has moved into the older age groups  although the percentage of adenocarcinoma is increasing at the expense of squamous carcinoma  the latter is still the most prevalent histologic type  the accuracy of percutaneous needle biopsy and transbronchial biopsy of lung nodules reported from this group of 941 hospitals was high and equal to that reported by single institutions  the percentage of patients having a resection did not increase from 1981 to 1986  but for smaller lesions a move was apparent toward more lung sparing resections  little change has occurred in the use of adjuvant radiotherapy  particularly in stage iii disease  where approximately 50  of the patients received postoperative irradiation  an improvement in the overall 5 year survival when compared with surveillance  epidemiology  and end results data was noted  whether this is a true improvement in survival or is the result of selection because of an unrecognized change in the pattern of care for patients with a carcinoma of the lung is unknown  
class8	carcinosarcoma and spindle cell carcinoma of the lung  clinicopathologic and immunohistochemical studies  we examined pulmonary carcinomas with prominent sarcoma like lesions both clinicopathologically and immunohistochemically  grossly  two tumors had predominantly endobronchial growths  four bulky parenchymal growths  and two endobronchial  parenchymally mixed growths  in these eight patients  six tumors were completely resected  one patient was given irradiation only  and one patient died in the early postoperative period  on the basis of specific differentiation of the sarcoma like lesions  the tumors were separated into three groups  two with  true  sarcoma differentiated into soft tissues such as striated muscle or osteoid tissue  three with a fibromatous sarcoma resembling atypical pseudosarcomatous stroma  and three with spindle cell carcinoma with evidence of epithelial differentiation  the prognosis was poor  and tumors with specific differentiation into rhabdomyosarcoma  chondrosarcoma  or spindle cell carcinoma progressed more rapidly than did those with a fibromatous sarcoma  because the fibromatous sarcoma like lesions were found to relate to a longer survival time for the patients  we wish to emphasize that a distinction of sarcomatous components should be made with regard to assessing the prognosis of pulmonary carcinoma with sarcoma like lesions  
class8	utility of frozen section evaluation of lymph nodes in the staging of bronchogenic carcinoma at mediastinoscopy and thoracotomy  we conducted a retrospective analysis of the utility of frozen section diagnoses in determining lymph node status at mediastinoscopy in 122 consecutive patients with bronchogenic carcinoma  thirty five of 122 patients had one or more lymph nodes with frozen section evaluation positive for metastatic carcinoma  subsequent nodal sections not in the original frozen section study revealed metastatic carcinoma in two additional patients  the false negative rate was 1 6   sensitivity was 94 6   predictive value of negative frozen section evaluation results was 97 7   because there were no false positive frozen section results  specificity and predictive value for positive results of frozen section evaluation were 100   the statuses of individual lymph nodes from these 122 patients were also evaluated  six hundred twenty lymph nodes were sampled from the mediastinum at mediastinoscopy  frozen sections in 47 lymph nodes were positive  subsequent nodal sections not in the original frozen sections examination revealed metastatic carcinoma in four additional lymph nodes  the false negative rate was 0 6   sensitivity was 92 2   predictive value of negative results from frozen section evaluation was 99 3   because there were no false positive frozen section results  specificity and predictive value for positive results of frozen section examination were 100   we conclude that frozen section evaluation of lymph nodes at mediastinoscopy reliably indicates lymph node status  thus enabling the physician to decide whether to proceed to thoracotomy  thus staging of the carcinoma and definitive surgery can be accomplished during a single anesthetic procedure  combining mediastinoscopy and thoracotomy with frozen section diagnostic control also reduces both the length and cost of hospitalization  
class8	primary osteosarcoma of the lung  report of two cases and review of the literature  two cases of primary osteosarcoma of the lung are presented  in one case  the radiologic  clinical  and cytologic findings led to a preoperative diagnosis of undifferentiated carcinoma of the lung  in the second case  a lung nodule was discovered during postchemotherapy follow up in a patient with lymphoma  fine needle aspiration in the second case showed lymphoma  and further chemotherapy was instituted  however  persistent growth of the nodule prompted a resection  microscopic examination of the resected tumors in both cases revealed histologic features of high grade osteosarcoma  flow cytometric analyses of the primary tumors showed abnormal hyperdiploid deoxyribonucleic acid populations in accordance with those seen in high grade malignant neoplasms  immunohistochemical studies supported a mesenchymal origin for these tumors  these tumors shared clinical features with other reported cases of primary osteosarcoma of the lung such as large size at diagnosis  occurrence in older individuals  and aggressive behavior  
class8	inhibition of exercise induced bronchoconstriction by mk 571  a potent leukotriene d4 receptor antagonist background  exercise is a common stimulus of bronchoconstriction in subjects with asthma  who also have bronchoconstriction after inhaling the sulfidopeptide leukotriene d4  ltd4   the purpose of this study was to investigate the importance of ltd4 as a mediator of exercise induced bronchoconstriction  methods  in a double blind  randomized  crossover study  12 subjects with stable asthma were treated intravenously with mk 571  160 mg   a selective and potent ltd4 receptor antagonist  or placebo  20 minutes before each of two challenges involving exercise at a level previously demonstrated to cause a fall of at least 20 percent in the forced expiratory volume in one second  fev1   the two exercise challenges were separated by one week  the results of the challenges were expressed as both the maximal fall in fev1 after exercise and the time to recovery from bronchoconstriction  results  treatment with mk 571 attenuated exercise induced bronchoconstriction in all the subjects  the mean      sem  maximal percent decrease in fev1 after exercise was 25 2     3 5 percent in the subjects taking placebo and 9 2     2 5 percent in the subjects taking mk 571  p less than 0 001   the mean percent inhibition for the entire group was 69 5 percent  the mean time to recovery after exercise was 33 4     4 0 minutes in the placebo group and 8 4     2 5 minutes in the mk 571 group  p less than 0 001   conclusions  this study demonstrates that pretreatment with a potent and selective ltd4 antagonist markedly attenuates exercise induced bronchoconstriction  and it suggests that ltd4 is a major mediator of this type of bronchoconstriction  
class8	reduced allergen induced nasal congestion and leukotriene synthesis with an orally active 5 lipoxygenase inhibitor background and methods  the clinical importance of leukotrienes in human allergy has not been defined  in part because there have been no selective 5 lipoxygenase inhibitors that have been effective and safe for use in humans  to address the hypothesis that stimulated leukotriene synthesis causes symptoms of immediate hypersensitivity reactions in vivo  i investigated the effects of a new 5 lipoxygenase inhibitor  a 64077  on provoked allergic nasal symptoms and mediator release in a double blind  randomized  placebo controlled study  eight subjects with allergic rhinitis underwent nasal challenge on two occasions after an oral dose of 800 mg of a 64077 or an identical appearing placebo  results  allergen induced nasal congestion was significantly attenuated  p less than 0 02  by a 64077  peak levels of leukotriene b4  median  684 pg per milliliter  and 5 hydroxyeicosatetraenoic acid  median  704 pg per milliliter  in nasal rinse fluids were markedly reduced  to 67 and 185 pg per milliliter  respectively  p less than 0 01   whereas levels of prostaglandin d2 were not  histamine release and sneezing were not reduced significantly by a 64077  but there was a significant correlation  p less than 0 01  between the changes in these variables within subjects  the mean      sem  stimulated synthesis of leukotriene b4 in whole blood ex vivo was markedly reduced by a 64077  from 153     19 to 20     9 ng per milliliter  p less than 0 01   and the specificity of a 64077 for 5 lipoxygenase inhibition was verified by its lack of effect on the synthesis of serum thromboxane b2 or 12 hydroxyeicosatetraenoic acid  conclusions  these results provide direct evidence of an important role for the 5 lipoxygenase products of arachidonic acid in allergic rhinitis and support the notion that further experiments in this area may lead to new therapeutic approaches to allergic disorders  
class8	late pulmonary sequelae of bronchopulmonary dysplasia background  bronchopulmonary dysplasia is a chronic lung disease that often develops after mechanical ventilation in prematurely born infants with respiratory failure  it has become the most common form of chronic lung disease in infants in the united states  the long term outcome for infants with bronchopulmonary dysplasia has not been determined  methods  we studied the pulmonary function of 26 adolescents and young adults  born between 1964 and 1973  who had bronchopulmonary dysplasia in infancy  we compared the results with those in two control groups  26 age matched adolescents and young adults of similar birth weight and gestational age who had not undergone mechanical ventilation  and 53 age matched normal subjects  results  sixty eight percent of the subjects with bronchopulmonary dysplasia in infancy  17 of the 25 tested  had airway obstruction  including decreases in forced expiratory volume in one second  forced expiratory flow between 25 and 75 percent of vital capacity  and maximal expiratory flow velocity at 50 percent of vital capacity  as compared with both control groups  p less than 0 0001 for all comparisons   twenty four percent of the subjects with bronchopulmonary dysplasia in infancy had fixed airway obstruction  and 52 percent had reactive airway disease  as indicated by their responses to the administration of methacholine or a bronchodilator  hyperinflation  an increased ratio of residual volume to total lung capacity  was more frequent in the subjects with a history of bronchopulmonary dysplasia than in either the matched cohort  p less than 0 0006  or the normal controls  p less than 0 0004   six of the subjects who had bronchopulmonary dysplasia in infancy had severe pulmonary dysfunction or current symptoms of respiratory difficulty  conclusions  most adolescents and young adults who had bronchopulmonary dysplasia in infancy have some degree of pulmonary dysfunction  consisting of airway obstruction  airway hyperreactivity  and hyperinflation  the clinical consequences of this dysfunction are not known  
class8	n ras 61 oncogene mutations in hurthle cell tumors  mutations of ras oncogenes are believed to play an important role in the initiation or progression of human tumors  in thyroid tumors the incidence of ras activation by specific point mutations has been reported to range from 33  in follicular adenomas up to 60  in anaplastic carcinomas  because of our long standing interest in hurthle cell tumors  we began a study of 70 such cases to determine the incidence of ras mutations and their clinical correlates  analysis of n ras sequences at condon position 61  with the polymerase chain reaction method and oligonucleotide probe hybridization  showed point mutations of the normal codon caa  in eight tumor samples  one was a mutation from caa to aaa  one from caa to cta   and six from caa to cga  these mutations would result in amino acid substitutions of lysine  leucine  or arginine for the normal glutamine at position 61 in the n ras protein  identical ras mutations in two tumors and some of their surrounding thyroid tissue may indicate that activating ras point mutations are an early event in carcinogenesis  the incidence of mutations was 1 of 24  4   of the histologically benign tumors  5 of 34  15   of the intermediate tumors  with vascular or capsular permeation   and 2 of 12  17   in the malignant group  four of these eight patients died of metastatic thyroid disease and four are alive without evidence of recurrence  
class8	role of small calibre chest tube drainage for iatrogenic pneumothorax  a 2 mm teflon catheter was used as a chest tube in 28 patients with iatrogenic pneumothorax  frequent aspirations through the catheter were performed in 16 of the patients  in the remaining 12 patients the catheter was connected to a one way flutter valve  the treatment was successful in 27 of the 28 patients  one patient required a large calibre chest tube  the mean drainage time was 48 hours  the small catheter technique is superior to the use of a large intercostal drain as it is much less traumatic and troublesome  the small calibre chest tube with a one way valve is recommended as a safe and easy technique  
class8	intraluminal irradiation for the palliation of lung cancer with the high dose rate micro selectron  fifty patients with inoperable  symptomatic endobronchial carcinoma were treated by a single exposure of intraluminal radiotherapy  a high dose rate afterloading system  the micro selectron hdr  was used to minimise radiation exposure for staff  haemoptysis was relieved in 24 of 28 patients  breathlessness in 21 of 33 patients  and cough in nine of 18 patients  radiological collapse resolved in 11 of 24 patients  treatment was given on an outpatient basis and was well tolerated  intraluminal radiotherapy appears to offer an effective alternative to conventional fractionated external beam radiotherapy  
class8	granulomatous pneumocystis carinii pneumonia in a patient with the acquired immunodeficiency syndrome  a patient with an unusual granulomatous response to infection with pneumocystis carinii is described  the diagnosis was made by open lung biopsy after two negative bronchoalveolar lavages  
class8	bronchoalveolar lavage via a modified stomach tube in intubated patients with the acquired immunodeficiency syndrome and diffuse pneumonia  a simple non bronchoscopic bronchoalveolar lavage method was used in 30 patients with the acquired immunodeficiency syndrome undergoing assisted ventilation for respiratory failure  a modified argyle levin stomach tube was passed via the endotracheal tube and lavage performed  the lavage was well tolerated and performed quickly and easily  required little training  and had a high degree of sensitivity  73   a diagnosis in 22 of the 30 cases   
class8	giant lymph node hyperplasia of the lung  castleman s disease  associated with recurrent pleural effusion  a case of giant lymph node hyperplasia  castleman s disease  of the lung presented with pleural effusion  which was recurrent   an unusual complication  the patient was treated with pneumonectomy and has survived for three years without relapse  this is the first report of the disease from black africa  
class8	asymptomatic rhabdomyolysis of unknown etiology  a 7 year old boy developed rhabdomyolysis with a peak creatine phosphokinase level of 261 400 iu l after his appendectomy  these abnormalities occurred following a 2 3 day illness consisting of upper respiratory tract symptoms  fever  and abdominal pain mimicking acute appendicitis  at the time of operation  a normal appendix was removed  and mesenteric lymphadenitis was noted  the myoglobinuria and elevation of creatine phosphokinase were transient  and the patient remained asymptomatic  we review various causes of right lower quadrant pain and rhabdomyolysis and address the roles of malignant hyperthermia and infectious agents  the possible cause of the phenomena observed in this patient is discussed  
class8	malignant melanoma presenting as nasal obstruction  mucosal melanomas arising in the nasal cavity are rare tumors comprising less than 1 percent of all melanomas  often  the common clinical symptom is nasal obstruction  grossly  they may or may not be pigmented and frequently attain large sizes  histologic diagnosis of these tumors may be difficult  requiring immunohistochemical or electron microscopic confirmation  aggressive surgical management is the treatment of choice in clinical stage i disease  subsequent surveillance for recurrence is mandatory  markers such as 5 s cysteinyldopa may prove useful in staging  prognosticating  and postoperative surveillance for early recurrence  but their exact role has yet to be delineated  ultimate prognosis is poor  
class8	hypersensitivity pneumonitis  the lung is constantly exposed to a wide variety of environmental insults  in its defense against these environmental challenges  however  the lung responds through a limited number of pathophysiologic mechanisms  this is well illustrated by a group of diseases which are collectively referred to as hypersensitivity pneumonitis  this syndrome includes a very large number of different diseases  however  in the united states  only farmer s lung  bird breeder s lung  and ventilation hypersensitivity pneumonitis occur with any significant frequency  each of these is characterized by flu like symptoms  in conjunction with a pneumonitis consisting of lymphocytic granulomatous infiltration of the alveoli and terminal bronchioles  this disease is caused by the inhalation of antigenic material which usually originates from the dusts of organic material  a host of different dusts and antigens have been described in conjunction with hypersensitivity pneumonitis but each leads to the same characteristic clinical syndrome  thus  each of the diseases shares similar clinical features but differs primarily with respect to the nature of the exposure and causative antigens  the clinical features  pathogenesis  course  prognosis  and treatment of these related diseases are reviewed  
class8	capillary haemangioma presenting as a lung pseudocyst  a girl who developed a lung cyst at 24 hours of age during gentle ventilation for respiratory distress syndrome is reported  instead of resolving as expected of a pseudocyst it continued to expand  resection at 1 year of age showed a cyst entirely surrounded by capillary haemangioma  aspiration of this cyst would have been dangerous  
class8	corticosteroids in primary tuberculosis with bronchial obstruction  the usefulness of prednisolone in combination with the modern potent antituberculous drugs has been studied in 29 children with primary lung tuberculosis and hilar adenopathy causing bronchial obstruction  these children were divided at random in two groups of 15 and 14 patients  both groups were treated similarly except that one group received prednisolone  both groups were very similar before the onset of treatment for most variables  tuberculous infection healed in both groups but the group on steroids improved earlier and had significantly fewer complications  both on radiography and bronchoscopy  only two of the patients on steroids still had progressive lesions  a very young baby probably because he developed two severe viral infections consecutively  and another infant of 7 months whose treatment was unreliable  as the parents were not very compliant  some patients initially not treated with prednisolone improved only after it was given  prednisolone treatment is not recommended when the reliability of the treatment cannot be guaranteed  as the hazard of harm would exceed the expected benefit  
class8	ventilator dependency in the united kingdom  there are 24 children who are currently long term ventilator dependent in the uk  nine of these are cared for entirely at home  an additional 11 children have been long term ventilator dependent since march 1983  the prevalence of these children appears to be increasing  the financial and manpower resources needed for these children whether at home or in hospital is considerable  there are reasons to suppose that the apparent increase in prevalence will continue  
class8	air leaks and vasopressin release  eleven very low birthweight babies being ventilated for respiratory problems during the first week of life developed air leaks on 22 occasions  on 16 out of 19 occasions the infants showed increases in urinary excretion of vasopressin after these events and on 10 occasions out of 13 there was a rise in the plasma arginine vasopressin concentration  the peripheral signs of the syndrome of inappropriate antidiuretic hormone release were seen on only one occasion in response to the sometimes high vasopressin concentrations  
class8	crohn s disease of the lung two years after developing colonic crohn s disease  a 17 year old boy presented with focal pulmonary consolidation  a lung biopsy specimen showed areas of non caseating epithelioid granuloma  although some respiratory abnormalities appear to be associated with inflammatory bowel disease  granulomatous disease affecting the lung has not previously been reported in a child  
class8	nasal valve malfunction resulting from resection of cancer  following cancer resection of the nasal unit  nasal valve malfunction is manifested by the symptoms of nasal stuffiness or difficulty getting air into the nostril  these symptoms occur in cases in which the resection is in the alar crease at the junction with the lateral sidewall of the nose  wound scar contracture elevates the alar margin and causes the alar and lateral cartilages to move inward forming a visible and palpable shelf on the lateral wall of the nasal vestibule  this displacement of the alar and lateral cartilages and the rigid scar formed between these cartilages render the nasal valve immobile  since it is easier to prevent nasal valve malfunction than to repair it later  wounds that bridge the alar crease or are located in either the alae or lateral sidewall and come within 1 mm of the alar crease with a total diameter of 1 0 cm should be repaired to prevent nasal valve malfunction  in the process of repairing deep defects  the overlapping region of the lateral crus of the alar cartilage and the lateral cartilage may be stabilized by a conchal cartilage graft  this cartilage graft may be used in combination with reconstruction of the nasal skin with a forehead flap and repair of the nasal lining  in the event that the nasal lining is intact  the cartilage graft may be used with a full thickness skin graft  
class8	complications of nasotracheal intubation in neonates  infants and children  a review of 4 years  experience in a children s hospital  a computerized database was set up to study the incidence and outcome of complications of nasotracheal intubation in a paediatric hospital  we studied 2953 intensive care admissions over a 4 yr period  the overall complication rate was 8   accidental extubation and tube blockage were the most frequent events  accounting for a mean of 3 5  and 2 6  of the complications per year  respectively  complications were more common in smaller children and there were differences between fields of intensive care  none of the complications was fatal or resulted in serious sequelae  none of the children in the study showed clinical symptoms of acquired subglottic stenosis before discharge from hospital  and none has been readmitted for this condition subsequently  
class8	acute pulmonary oedema following administration of ornithine 8 vasopressin  we report the case of a patient who developed acute pulmonary oedema following a short and uneventful surgical procedure  among the differential diagnoses  the role of ornithine 8 vasopressin is emphasized  
class8	effect of oral omeprazole on intragastric ph and volume in women undergoing elective caesarean section we have studied in obstetric patients the efficacy of omeprazole in increasing intragastric ph to more than 2 5 and reducing volume to less than 25 ml  omeprazole 40 mg was given orally the night before and again on the morning of surgery to 30 asian women scheduled to undergo elective caesarean section  after induction of anaesthesia  a gastric tube was inserted and intragastric contents aspirated  volume and ph were recorded and measurements were repeated on completion of surgery  the median  range  volume was 2  1 13  ml before surgery and 4  0 14  ml at the end of surgery  there was insufficient volume to measure ph in all patients  the median  range  ph was 6 7  4 6 7 4  before surgery in 20 patients and 6 6  4 6 7 8  at the end of surgery in 28 patients  no adverse drug reactions were noted in mothers or neonates  omeprazole 40 mg orally twice before elective caesarean section appeared to be effective in reducing intragastric volume and acidity to acceptable values  
class8	what causes cryptogenic fibrosing alveolitis  a case control study of environmental exposure to dust  objective  to investigate the role of occupational and domestic exposure to dust in the aetiology of cryptogenic fibrosing alveolitis  design  matched case control study  subjects  40 patients with cryptogenic fibrosing alveolitis and 106 community controls matched for age and sex who responded to a questionnaire  main outcome measure  responses to self administered questionnaire asking about lifetime exposure to dust  animals  and smoke at home and at work  results  the patients with cryptogenic fibrosing alveolitis were more likely to report occupational exposure to metal dust  matched odds ratio 10 97  95  confidence interval 2 30 to 52 4   p less than 0 001  or wood dust  2 94  0 87 to 9 90   p   0 08   to have worked with cattle  10 89  1 24 to 96 0   p   0 01   and to have lived in a house heated by a wood fire  12 55  1 04 to 114   p   0 009   a history of smoking and social class based on occupation were not significantly related to disease state  conclusion  environmental exposure to dust may be an important factor in the aetiology of cryptogenic fibrosing alveolitis  
class8	rising mortality from cryptogenic fibrosing alveolitis  objective  to determine the pattern of mortality ascribed to cryptogenic fibrosing alveolitis and to identify factors that might be important in the aetiology of the disease  and to assess the validity of death certification of the disease  design  a retrospective examination of mortality ascribed to cryptogenic fibrosing alveolitis in england and wales between 1979 and 1988 with analysis  by multiple logistic regression  of independent effects of age  sex  region of residence  and social class as indicated by occupation on data for 1979 87  also a retrospective review of hospital records of patients certified as having died of cryptogenic fibrosing alveolitis in nottingham and of the certified cause of death of patients known to have had the disease  main outcome measures  time trends in mortality nationally  effects on mortality of age  sex  and region of residence  validity of death certification in nottingham  results  the annual number of deaths ascribed to cryptogenic fibrosing alveolitis doubled from 336 in 1979 to 702 in 1988  the increase occurring mainly at ages over 65  mortality standardised for age for both sexes likewise increased steadily over the period  deaths due to cryptogenic fibrosing alveolitis were commoner in men  odds ratio 2 24  95  confidence interval 2 11 to 2 33  and increased substantially with age  being 7 84  7 24 to 8 49  times higher in subjects aged much greater than 75 than those aged 45 64  odds ratios of death due to cryptogenic fibrosing alveolitis adjusted for age and sex were increased in the traditionally industrialised central areas of england and wales  p less than 0 02  maximum odds ratio between regions 1 25   but no significant increase in odds of death was found for manual occupations  of 23 people whose deaths were registered in nottingham as having been due to cryptogenic fibrosing alveolitis  19 were ascertained from clinical records to have had the disease  only 17 of 45 patients known to have had cryptogenic fibrosing alveolitis in life were recorded as having died from the disease  conclusions  the diagnostic accuracy of death certification of cryptogenic fibrosing alveolitis is high  but the number of deaths recorded as being due to the disease may underestimate the number of patients dying with the disease by up to half  mortality due to the disease is increasing  and the male predominance and regional differences in mortality suggest that environmental factors are important in its aetiology  
class8	clinical and prognostic assessment of patients with resected small peripheral lung cancer lesions  one hundred fifteen patients with small  less than or equal to 2 cm in diameter  peripheral lung cancer lesions underwent surgical treatment in the department of surgery  the research institute for chest diseases and cancer  tohoku university  miyagi prefecture  japan  the authors investigated several prognostic factors of these cases  the 5 year survival rate of these 115 patients was 70   various factors such as histologic type  nodal involvement  pleural involvement  pathologic stage  and curativity of the operation were revealed to affect survival significantly  in patients with and without nodal involvement  there was no significant difference between the survival rate of patients with lung cancer lesions smaller than 2 cm and those with lesions 2 1 to 3 cm  however  the rate of lymph node metastasis was significantly different in the group with lesions smaller than 2 cm compared with those with lesions 2 1 to 3 cm  21  versus 43   respectively   
class8	pulmonary problems in pregnancy  pregnant women with asthma and pulmonary infections should be treated essentially the same as nonpregnant women with similar disease severity  definitive diagnosis and prompt treatment with heparin should be used for patients with pulmonary thromboembolism  
class8	childhood pulmonary function following hyaline membrane disease  hyaline membrane disease per se is not associated with abnormal lung function or increased nonspecific airway reactivity in childhood or adulthood  very low birth weight infants who survive almost routinely in neonatal icus are at risk  however  for developing airflow obstruction and having airway hyperreactivity as children  and for having recurrent bouts of wheezing  cough  and respiratory infections  neonates who develop bpd have the greatest risk of abnormal pulmonary function as children  continued research into the prevention of premature birth and into the causes of neonatal lung injury  combined with improvements in the neonatal icu and follow up treatment  will undoubtedly contribute to improvement in the clinical course of premature infants  
class8	the adult respiratory distress syndrome  the adult respiratory distress syndrome remains an enigmatic disorder with a high mortality rate  although it can sometimes be managed effectively  recognizing the conditions with which it is associated is the first step in preventing its occurrence  decreasing the risk factors of developing ards remains the fundamental goal of initial management  once the syndrome has developed in a particular patient  the clinician s goals in management are to stabilize the patient  avoid further insults  maximize the support therapies available  and be cognizant of and avoid the potential adverse effects of these supportive therapies  
class8	approaches to the patient with aspiration and swallowing disabilities  aspiration  or soiling of the tracheobronchial tree  can produce life threatening pulmonary disease  intermittent or persistent aspiration may cause symptoms including cough  intermittent fever  recurrent tracheobronchitis  atelectasis  pneumonia  and or empyema  the pulmonary disease may be associated with weight loss  cachexia  and dehydration  in many cases the aspiration is caused by laryngeal dysfunction  allowing pulmonary contamination by swallowed material  in other cases the aspiration is caused by a dysfunction of the oral  pharyngeal  or esophageal phases of swallowing  in some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction  geriatric patients are more likely to experience aspiration  since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group  therefore  with the ever increasing aging of our population  these disabilities will be on the rise  with an associated increase in pulmonary disease and death  the approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment  
class8	effects of a multidisciplinary management program on neurologically impaired patients with dysphagia  dysphagia is a major problem in patients with neurologic disorders  aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates  assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively  this prospective study was conducted to determine if a dysphagia program would improve patients  caloric intake and body weight  decrease the instances of aspiration pneumonia  or improve patients  feeding ability  patients were referred from a 26 bed neurology neurosurgery unit  a time series design was utilized  the control group consisted of 15 patients  mean age   46 1 years   managed according to the existing ward routine  subsequently  nursing staff attended a dysphagia training program  following this  the treated group of 16 patients   mean age   49 3 years  was assessed by the dysphagia team  using bedside and videofluoroscopic examinations to determine the specific swallowing disorder  an individualized treatment program was designed for each patient  the groups were compared on the basis of deviation from their baseline weight  deviation from ideal energy intake  and the incidence of aspiration pneumonia  statistical analysis revealed that the groups were comparable in age  number of days on the study  and glasgow coma scale score  and that a significant weight gain and increase in caloric intake occurred in the treated group  no incidence of aspiration pneumonia was reported in either group  we speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups  
class8	bolus versus infusion regimens of etoposide and cisplatin in treatment of non small cell lung cancer  a study of the north central cancer treatment group in an effort to test clinically the hypothesis that the duration of cellular exposure to etoposide  vp 16  and cisplatin  cddp  is an important determinant of cytotoxicity  we performed a phase iii randomized trial comparing an outpatient bolus regimen of combined vp 16 and cddp with a sequential infusion over 72 hours of these same two drugs  all patients had stage iv non small cell lung cancer  and survival was the primary end point  of 113 patients randomly allocated to the study  108 were assessable for response  survival  and toxicity  a major response was observed in 20  37   of 54 patients on the bolus regimen and in 16  30   of 54 patients receiving infusion therapy  the median time to progression was 61 and 88 days for bolus and infusion therapy  respectively  the median survival time was 148 and 157 days  respectively  p    71   study results were not consistent with the possibility that infusion therapy could be associated with a 50  improvement in median survival  i e  from 5 months to 7 1 2 months  toxicity was primarily myelosuppression and was significantly greater with the infusion regimen  we conclude that infusion therapy as tested in this protocol with vp 16 and cddp does not offer any advantage in response rate  time to disease progression  or survival as compared with bolus therapy  in addition  infusion therapy is associated with a greater degree of neutropenia and more treatment related deaths  
class8	immune competent cells of regional lymph nodes in colorectal cancer patients  ii  immunohistochemical analysis of leu 7  cells  distribution of leu 7  cells in cancer tissues and regional lymph nodes was immunohistochemically examined to estimate the role of nk cells in colorectal cancer patients  leu 7  cells were rarely observed both in the primary and distant metastatic lesions  but the number of these cells was large in the germinal center of the lymph nodes  studies of leu 7  cell population in the lymph node indicated that intermediate nodes in n0 and n1 groups showed significantly higher values than those in the control group  comparative study of the population in identical patients revealed a significantly higher rate in the intermediate nodes than in the paracolic nodes both in n0 and n1 groups  these data suggest that leu 7  cells might be related to the defense mechanism of regional lymph nodes against tumor  
class8	carcinoid tumors  the authors carried out a retrospective study of 32 patients  23 m  9 f  with carcinoid tumors who were diagnosed and treated at harlem hospital center  new york  from 1967 to 1988  all the patients were black and the commonest sites were the ileum  28 1    rectosigmoid and rectum  21 9    and the appendix and lung  15 6  each   metastasis correlated with site  size  and depth of the primary tumor and occurred in 12 patients  38    most frequently to the regional lymph nodes and liver  carcinoid syndrome developed in 12 5   3 f  1 m   surgical resection for cure or palliation was the mainstay of treatment  overall 5 year survival rate was 66   and for those with metastases was 0   the poorer survival rates are probably related to the socioeconomic status of our patient population  the only observed racial difference compared to other series is the preponderance of males  and the disproportionately higher ratio of females with the carcinoid syndrome  
class8	congenital abnormalities of the lymphatic system  a new clinical classification  the numerous clinical presentations of congenital abnormalities of the lymphatic system in children and the confusing terminology used to describe their pathologic diagnoses impede the physician s understanding of the condition  the clinical classification based on the actual symptoms of the congenital problems we have presented here should help the physician identify the specific abnormality and a potential treatment  future research should concentrate on the specific causes and the treatment of these congenital abnormalities  
class8	hospitalization decision in patients with community acquired pneumonia  a prospective cohort study  purpose  to identify a low risk subset of patients with community acquired pneumonia that could safely be treated in the ambulatory setting  and to assess how clinicians make the hospitalization decision  patients and methods  we performed a prospective  observational study of 280 ambulatory and hospitalized adults with clinical and radiographic evidence of pneumonia  patients were followed to assess all potential morbid complications and 6 week mortality  physicians responsible for managing these patients were surveyed to assess the reasons for treating in a hospital or ambulatory setting and the therapies that dictate hospitalization  results  sixty one percent  170 of 280  of patients did not have an indication for admission at presentation using modified appropriateness evaluation protocol criteria  a severe vital sign abnormality  alteration in mental status  suppurative complication  arterial hypoxemia  severe laboratory abnormality  or an acute coexistent medical problem requiring admission independent of the pneumonia   among these 170 patients  38  had a complicated course defined as death within 6 weeks  development of a new suppurative or medical complication due to pneumonia  intensive care unit admission  persistent fever or use of intravenous fluids or oxygen beyond 3 days  hospitalization lasting more than 3 days  or subsequent hospitalization in patients initially treated in the ambulatory setting  five predisposing factors for a complicated course were identified in logistic regression models  the odds ratio for age more than 65 years was 2 7  for comorbid illness  3 2  for temperature more than 38 3 degrees c  101 degrees f   4 1  for immunosuppression  12 0  and for a high risk etiology  23 3  the risk of a complicated course increased linearly with the number of risk factors  from 12  with none to 100  with four or more factors  p less than 0 001   physicians most often relied on the general clinical appearance of the patient when making the triage decision  and most commonly cited intravenous antibiotics and chest physical therapy as treatments requiring hospitalization  conclusions  if validated  our findings could improve physicians  assessment of prognosis  and may identify a low risk subset of patients with community acquired pneumonia who could safely be managed in the ambulatory setting  
class8	ofloxacin treatment of chlamydia pneumoniae  strain twar  lower respiratory tract infections  purpose  limited data suggest that tetracycline or erythromycin is the antibiotic of choice for treating chlamydia pneumoniae infection  but they are not always effective or well tolerated  because the fluoroquinolone ofloxacin is effective for chlamydia trachomatis infections  we investigated its role in treating c  pneumoniae infections  patients and methods  eighty seven patients were enrolled in a randomized trial of antibiotic therapy for acute lower respiratory tract infections  the patients were randomly assigned to oral treatment with either ofloxacin  400 mg twice a day  or erythromycin  400 mg four times a day  for 10 days  frozen acute and convalescent serologic specimens were tested for twar antibody by microimmunofluorescence  susceptibility testing of c  pneumoniae to ofloxacin was also performed  results  four patients who received ofloxacin were retrospectively identified as having c  pneumoniae pneumonia  two  or bronchitis  two   within 2 weeks of starting ofloxacin therapy  all were cured or markedly improved  the minimum inhibitory concentrations of ofloxacin for three previously isolated clinical strains of c  pneumoniae were determined to be 1 0 to 2 0 micrograms ml  well within the achievable serum levels  3 to 5 micrograms ml  with ofloxacin therapy  conclusion  ofloxacin may be an effective alternative antibiotic treatment for c  pneumoniae respiratory infections  
class8	failure to limit quantities of benzodiazepine hypnotic drugs for outpatients  placing the elderly at risk  purpose  the long term use of benzodiazepine hypnotics by the elderly is associated with serious side effects  and prescriptions of large quantities of these agents allow such use  therefore  we determined the quantities of these agents prescribed to outpatients in our veterans administration teaching hospital  and the relationship of patient age to total number of doses prescribed per prescription  patients and methods  pharmacy and patient records related to 655 consecutive prescriptions for triazolam  halcion  and flurazepam  dalmane  were reviewed  only 266  41   of the prescriptions were for 30 or fewer doses  while 178  27   were written for 180 or more doses  results  thirty six percent of prescriptions for patients aged 65 years or older were for 180 or more doses  compared with 24  for those aged 45 to 64 years old  and 16  of the prescriptions for patients less than 45 years old  p less than 0 0001   in a multivariate analysis controlling for six other factors related to the total number of doses prescribed  patients aged 65 years or older were still more likely to receive a prescription for 180 or more doses  relative risk 1 9  95  confidence interval 1 3  2 8   conclusion  we conclude that inappropriately large quantities of benzodiazepine hypnotics were commonly prescribed  and that patients aged 65 years or older were at greatest risk for receiving such prescriptions  
class8	role of systemic therapy in advanced non small cell lung cancer  increasing evidence supports the investigation of chemotherapy in patients with non small cell lung cancer  nsclc   randomized studies in patients with stage iv disease have shown increased survival in chemotherapy treated patients compared to best supportive care and indicate the ability of chemotherapy to alter the natural history of this disease  randomized studies involving adjuvant and neoadjuvant chemotherapy have also shown encouraging results  these studies and results of recent pilot studies utilizing neoadjuvant chemotherapy and concomitant chemoradiotherapy indicate a potential benefit from the use of chemotherapy in patients with nsclc and call for its continued intensive investigation in clinical trials  
class8	admission and mid stay medisgroups scores as predictors of death within 30 days of hospital admission  we examined the ability of medisgroups  a severity measure based on clinical data abstracted from the medical record  to predict mortality 30 days following admission  medisgroups measures severity both on admission and approximately one week into the hospital stay  the data base was a random sample of 20 985 admissions of medicare beneficiaries with one of six conditions from 833 hospitals in seven states between january 1985 and may 1986  in all six conditions  higher admission and mid stay severity scores were generally associated with higher risk of death  across the six conditions  the r squared values for predicting death using admission scores ranged from 0 01 to 0 16  r squared values using mid stay scores ranged from 0 03 to 0 34  and r squared values from combining admission and mid stay scores ranged from 0 05 to 0 41  admission medisgroups score was thus only modestly predictive of 30 day mortality  while the mid stay score was more powerful  it may not be an appropriate severity adjuster to screen for quality using hospital mortality rates because it could be influenced by substandard care  
class8	perioperative blood transfusion adversely affects prognosis of patients with stage i non small cell lung cancer  it has been speculated that blood transfusion might adversely affect prognosis in cancer patients by immunosuppression  to avoid the confounding affect of advanced disease  we tested this hypothesis in 117 patients with stage i non small cell lung cancer  mean and median follow up were 49 7 months and 47 months  respectively  patients who died during the postoperative period were not included  perioperative transfusion was defined as administration of whole blood or packed cells within 30 days of operation  the overall cumulative 5 year disease free survival rate was 67   in patients with transfusion  it was 53  and in patients without transfusion it was 81   p   0 0055   a multivariate analysis was performed that included patient age  race  sex  cell type  extent of operation  pneumonectomy versus lobectomy segmentectomy   operative blood loss  admission hematocrit  discharge hematocrit  and the presence or absence of perioperative transfusion  the only variable that significantly correlated with 5 year disease free survival was the presence or absence of perioperative transfusion  p   0 0278   and this effect was not related to the number of transfusions  retrospective analysis of long term results of patients surviving curative operation for stage i lung cancer shows that any perioperative transfusion significantly worsens the patient s prognosis and suggests very strongly that this association is due to an adverse effect of the transfusion rather than the transfusion serving as a marker for another risk factor  
class8	life threatening complications during anaesthesia in a patient with a ventriculo atrial shunt and pulmonary hypertension  published erratum appears in anaesthesia 1991 mar 46 3  241  a 6 year old patient with hydrocephalus who underwent revision of a ventriculo atrial shunt is described  anaesthesia was complicated by the occurrence of systemic hypertension and arterial hypoxaemia  the patient was subsequently found to have pulmonary hypertension secondary to recurrent pulmonary thromboembolism  the pathophysiological mechanisms for the patient s deterioration are discussed and the anaesthetic management of children with pulmonary hypertension is outlined  it is concluded that patients with a ventriculo atrial shunt who present for surgery should be screened carefully for the presence of pulmonary hypertension  
class8	isolated lung transplantation for pulmonary fibrosis  the peri operative anaesthetic management of 11 patients with pulmonary fibrosis undergoing single lung transplantation is presented  intra operative problems  the early postoperative phase of recovery and intensive care  and other incidents in which general anaesthesia was required for the management of complications  are featured  results  both short  and long term  are mentioned  major intra operative events that cause concern appear to be related to the severity of the presenting illness and the development of respiratory failure  others have reported the development of intra operative cardiac failure  all cases were successfully managed operatively using conventional one lung anaesthesia  although resort to partial cardiopulmonary bypass may have been indicated in some  the indications and attitudes to utilising cardiopulmonary bypass in the evolution of techniques for facilitating single lung transplantation are reviewed  
class8	intact epithelial barrier function is critical for the resolution of alveolar edema in humans within 15 min of endotracheal intubation  the resolution of pulmonary edema was studied over the next 12 h in 34 mechanically ventilated patients by  1  serial measurements of the alveolar arterial oxygen difference   2  the extent of edema on the initial and follow up chest radiograph  and  3  by an initial and final measurement of total protein and albumin concentration in sequential samples of pulmonary edema fluid  based on the oxygenation and chest radiographic data  24 patients clinically improved and 10 patients did not improve  in the 10 patients who did not clinically improve  3  hydrostatic edema  7  permeability edema   there was no change in the final edema fluid protein concentration  4 1     1 1 g 100 ml  compared with the initial edema fluid protein concentration  4 2     1 0 g 100 ml   p   ns   however  in the 24 patients who clinically improved  15  hydrostatic edema  9  permeability edema   there was an increase in every patient s final edema protein concentration  5 6     2 3 g 100 ml  compared with their initial edema protein concentration  3 8     1 2 g 100 ml   p less than 0 01   in 13 of these 24 patients  the final edema fluid concentration  7 3     1 6 g 100 ml  exceeded the final plasma protein concentration  5 6     0 8 g 100 ml  by a mean value of 1 7 g 100 ml protein  the data provide the first evidence in humans to support the hypothesis that active ion transport across the alveolar epithelial barrier is the primary mechanism for clearance of edema fluid from the air spaces of the lung  
class8	the effect of corticosteroid or methotrexate therapy on lung lymphocytes and macrophages in sarcoidosis  methotrexate appears to be an effective alternative to corticosteroid therapy for some patients with sarcoidosis  the mechanism of action of methotrexate as an immunosuppressive is unknown  patients with symptomatic pulmonary sarcoidosis underwent pulmonary function tests and bronchoscopy with bronchoalveolar lavage  patients were treated with 10 mg methotrexate or prednisone weekly for at least 6 months and repeat studies were performed  a comparison was made between those patients receiving methotrexate  12 patients  and those receiving prednisone  12 patients   for both groups  there was a significant improvement in the vital capacity with therapy  prednisone  pre   2 5     0 14 l  mean     sem   post   3 1     0 18 l  p less than 0 01  methotrexate  pre   2 4     0 14 l  post   2 8     0 18 l  p less than 0 01   in addition  the percentage of lymphocytes in the lavage fell significantly for both the prednisone  pre  30     3 5   post  16     2 7   p less than 0 001  and methotrexate  pre  37     3 4   post  13     2 9   p less than 0 001  groups  alveolar macrophages from the symptomatic sarcoid patients were found to be spontaneously releasing hydrogen peroxide and tumor necrosis factor  after treatment with either prednisone or methotrexate  alveolar macrophages retrieved by lavage spontaneously released less of either macrophage product  we found that effective doses of methotrexate for sarcoidosis led to significant changes in lymphocyte and macrophages retrieved by lavage  
class8	surfactant replacement improves lung recoil in rabbit lungs after acid aspiration  we tested the hypothesis that surfactant replacement would be beneficial in the acid aspiration model of acute lung injury  hcl  0 1 n  2 ml kg  was injected into the trachea of excised rabbit lungs  n   8   control lungs  n   4  had no intervention  all were perfused with tyrode s solution mixed 1 1 with autologous whole blood at 40 ml min kg for 30 min  and then degassed  a modified natural surfactant  survanta  ross laboratories  was then injected into the trachea of four lungs injured with hcl  100 mg kg at 25 mg ml   two quasi static pressure volume curves were determined  the mean alveolar pressures at 50  60  70  80  and 90  of tlc were greater in the hcl group than in the control group  p less than 0 05   however  no difference was observed between the control lungs and those that received hcl   survanta  in 13 anesthetized  paralyzed  and ventilated rabbits  deflation pressure volume curves were determined from tlc to frc  measured by helium dilution   then  0 1 n hcl  3 ml kg  was injected into the trachea and  in seven  survanta was instilled 5 min later  the mean alveolar pressures at 60  70  80  and 90  tlc were higher at 15 and 60 min in the hcl group compared with their pre hcl time point  p less than 0 05   in the hcl   survanta group  no differences were seen at 15 min  and only slight increased were seen at 60 min  no effect of surfactant replacement on arterial blood gases was observed  hcl aspiration increased recoil in both excised and in vivo lungs  and surfactant replacement with survanta returned recoil to normal  
class8	inspiratory flow dynamics during mechanical ventilation in patients with respiratory failure  we studied the effect of inspiratory flow rate on respiratory resistance during mechanical ventilation in 15 patients with acute respiratory failure  arf   resistance was measured by both constant flow inflation and occlusion methods as inspiratory flow rates were increased from 0 66 to 2 0 l s  endotracheal tube resistance was subtracted from total resistance to obtain respiratory resistance  in contrast to the flow dependent increase in endotracheal tube resistance  respiratory resistance decreased continuously as flow rate and airway pressure increased  except in four of six patients with asthma in whom respiratory resistance increased as flow increased  mechanical airway dilatation  tissue resistance  stress relaxation  and time constant inequalities may contribute to the decrease in respiratory resistance  in status asthmaticus  however  the effects of turbulence  noncompliant airways  and or  reflex  bronchoconstriction may be sufficient to cause a flow dependent increase in resistance  
class8	nasal and oral flow volume loops in normal subjects and patients with obstructive sleep apnea  because flow volume loops  fvls  are clinically useful in evaluating upper airway  ua  obstruction and the fact that patency of the nasopharyngeal ventilatory pathway is important to the prevention of obstructive sleep apnea  osa   the present study examined the role of nasal compared with oral fvls in evaluating patients with osa  fourteen obese male patients 56     3 yr of age with a mean apnea plus hypopnea index  ahi  of 51     9 h were studied along with 14 nonobese  healthy  age  and sex matched control subjects whose mean ahi was 6     1 h  nasal and oral fvls obtained in the normal subjects indicated the nose behaved like a variable resistor  with flow limitation during inspiration but not during expiration  in the patient group  flow limitation was observed during expiration as well as inspiration indicating nondistensibility of the nasopharyngeal ventilatory pathway in the patients compared to the control subjects  a change in body position from upright to supine in the osa group was associated with small reductions in expiratory but not inspiratory flow rates  the area under the nasal supine flow volume loop  fvlanasup  was found to be highly correlated with awake resting pao2  r   0 80  and paco2  r    0 83  in the patient group  in addition  multiple linear regression analysis revealed that pao2 and the area under the nasal fvls independently contributed to the prediction of ahi with a multiple r of 0 89  these results suggest that limitations to ventilation via the nasopharynx may significantly influence both gas exchange and the frequency of sleep disordered breathing in patients with osa  
class8	decreased ventilation and hypoxic ventilatory responsiveness are not reversed by naloxone in lhasa residents with chronic mountain sickness  persons with chronic mountain sickness  cms  hypoventilate and are more hypoxemic than normal individuals  but the cause of the hypoventilation is unclear  studies of 14 patients with cms and 11 healthy age matched control subjects residing in lhasa  tibet  china  3 658 m  were conducted to test the hypothesis that hypoventilation  blunted hypoxic ventilatory responsiveness  hvr   and hypoxic ventilatory depression of cms were due to increased endogenous opioid production  patients with cms compared with control subjects exhibited hypoventilation  end tidal carbon dioxide pressure  petco2    36 6     1 0 versus 31 5     0 5 mm hg  p less than 0 05   lower tidal volume  vt   0 54     0 02 versus 0 61     0 02 ml btps  p less than 0 05   blunted hvr  shape parameter a   17     8 versus 114     22 mm hg l btps min  p less than 0 05   and a depressant effect of ambient hypoxia on ventilation  delta petco2 with acute hyperoxia    3 5     0 5 versus  1 0     0 6 mm hg  p less than 0 05   reduced forced expiratory volume in 1 s to vital capacity ratios  fev1 vc  and a higher proportion of cigarette smokers in the group of patients with cms compared with control subjects suggested that at least some patients with cms had mild airway obstructive lung disease  naloxone infusion  0 14 mg kg  to six patients with cms did not change resting vt  petco2  hvr  or sao2  
class8	radiologic detection of pleural thickening  the purpose of this study was to investigate four aspects of the radiologic detection of pleural thickening  the specificity of chest x rays read by b readers  the effects of threshold definitions of positivity  the extent of variability among different x ray readers  and the effect of film quality  a series of 421 chest x rays corresponding to consecutive autopsies was reviewed by six b readers working independently and using modified international labour organization forms  the prevalence of true pleural thickening was approximately 6   using a strict definition of positivity  the average specificity was 0 85  specificity decreased when a more liberal definition was used   the average sensitivity was 0 32  which appeared to increase with a more liberal definition of positivity  because of small numbers of true positives  the sensitivity estimates were unstable   kappa statistics for interreader agreement ranged from 0 06 to 0 40  suggesting considerable interreader variability  decreasing film quality was associated with decreasing sensitivity  but specificity was not affected by film quality  because the chest x ray has suboptimal test characteristics in the diagnosis of pleural thickening and because there is considerable interreader variability  we conclude that caution is required in interpreting radiologic detection of pleural thickening using ilo procedures  
class8	the south karelia air pollution study  the effects of malodorous sulfur compounds from pulp mills on respiratory and other symptoms  the paper mills in south karelia  the southeast part of finland  are responsible for releasing a substantial amount of malodorous sulfur compounds such as hydrogen sulfide  h2s   methyl mercaptan  ch3sh   and methyl sulfides   ch3 2s and  ch3 2s2   into ambient air  in the most polluted residential area the annual mean concentrations of hydrogen sulfide and methyl mercaptan are estimated to be 8 and 2 to 5 micrograms m3 and the highest daily average concentration 100 and 50 micrograms m3  the annual mean and highest daily concentrations of sulfur dioxide  so2  are very low  we studied the effects of malodorous sulfur compounds on eye  nasal and respiratory symptoms  and headache in adults  a cross sectional self administered questionnaire was distributed in february 1987 and responded to by 488 adults living in a severely  n   198   a moderately  n   204   and a nonpolluted community  n   86   this included questions about occurrence of the symptoms of interest during the previous 4 wk and 12 months and individual  behavioral  and other environmental determinants of the symptoms  the response rate was 83   the odds ratios  or  for symptoms experienced often or constantly in severely versus nonpolluted and moderately versus nonpolluted communities were estimated in logistic regression analysis controlling potential confounders  the odds ratios for eye  moderate exposure or 11 70  cl95  2 33 to 58 65  severe exposure or 11 78  cl95  2 35 to 59 09  and nasal symptoms  or 2 01  cl95  0 97 to 4 15  or 2 19  cl95  1 06 to 4 55  and cough  or 1 89  cl95  0 61 to 5 86  or 3 06  cl95  1 02 to 9 29  during the previous 12 months were increased  with a dose response pattern  
class8	methacholine responsiveness among working populations  relationship to smoking and airway caliber  it has been suggested that the development of bronchial hyperresponsiveness  bhr  in some smokers may be an intermediate event in the progression to chronic obstructive pulmonary disease in this group  if this is true  prevalence data on bhr in a general population should show an independent association between bhr and smoking status  to test this  we analyzed bhr to inhaled methacholine in 654 white men without known asthma  in relation to smoking  skin test reactivity  type of work  office versus industrial   and indicators of baseline airway caliber  fev1   predicted and fev1 fvc   bhr was measured in the traditional way  pc20  and as the slope of fev1 versus the methacholine concentration  linear scale   a pc20 of less than 16 mg ml was considered  responsive  for analyses of this outcome  we found that although a positive skin test  smoking  and being an industrial worker all appeared to be significant predictors of increased bhr  p less than 0 05   once fev1    predicted  and fev1 fvc  were taken into account  none of these variables alone remained significantly associated with bhr  the strongest predictors of bhr were prechallenge fev1 and fev1 fvc  both p less than 0 01   the combination of smoking  atopy  and work groups  which identified a small subgroup of atopic smokers who were office workers  also remained significantly associated with increased bhr  we also used a regression model that allowed for comparison of predictors for bhr between the most responsive subset of the population  n   84  and the remainder of the study population  
class8	cigarette smoke causes physiologic and morphologic changes of emphysema in the guinea pig  to investigate the long term effect of cigarette smoke on pulmonary structure and function  we exposed groups of guinea pigs to the smoke of 10 cigarettes each day  5 days per week  for 1  3  6  and 12 months  we found that the guinea pigs developed progressive lung destruction  emphysema  and alterations in their pulmonary function tests similar to that seen in humans with cigarette smoke induced chronic obstructive lung disease  this method of smoke induced lung destruction should provide a good model for the study of the early changes of emphysema  
class8	a rat model of prolonged pulmonary infection due to nontypable haemophilus influenzae  pulmonary colonization and infection with nontypable  unencapsulated  haemophilus influenzae  nthi  occurs commonly in the setting of chronic lung diseases  because the study of nthi pulmonary infection in animal models has been limited by the rapid clearance of organisms  a model of persistent pulmonary infection was developed  groups of rats were inoculated by transtracheal instillation of viable nthi suspended in broth or semisolid agar  some rats had received hexamethylphosphoramide  hmp  in drinking water before inoculation to cause respiratory epithelial mucosal damage  groups of animals were sacrificed serially  lungs were cultured quantitatively and their gross and microscopic anatomy examined  nthi was recovered in small quantities from few broth inoculated rats after the first day of infection and in none after day 7  in contrast  nthi was recovered from the majority of animals and in greater amounts through 2 wk after agar borne inoculation  hmp pretreatment further enhanced recovery through 4 wk after inoculation with an agar vehicle  the pulmonary inflammatory reaction was brief in broth inoculated rats  the longer persistence of gross and histologic changes seen in agar infected lungs paralleled the enhanced recovery of nthi  abscess formation occurred at 7 to 14 days in some agar inoculated animals  thus pulmonary inoculation of nthi in a viscous vehicle resulted in perpetuation of infection and inflammatory response  and previous damage to respiratory mucosal epithelium induced by hmp further enhanced such infection  
class8	bilateral intrapulmonary hematomas  a 67 yr old man  known to have chronic obstructive lung disease  developed bilateral localized pulmonary densities on chest radiographs after cardiopulmonary resuscitation  an autopsy disclosed bilateral intrapulmonary hematomas without communication with bronchi  pulmonary arteries  or pleural cavities  we suggest blunt pulmonary injury is the most probable cause of the hematomas and discuss its pathogenic mechanism  intrapulmonary hematomas should be considered in the differential diagnosis of pulmonary densities developing after a vigorous resuscitation  
class8	bombesin stimulation of mitogenesis  specific receptors  signal transduction  and early events  quiescent cultures of swiss 3t3 cells can be stimulated to recommence dna synthesis by polypeptide growth factors  neuropeptides  and various pharmacologic agents that act via multiple signal transduction pathways  neuropeptides of the bombesin family provide potent mitogens to elucidate these pathways  these peptides bind to specific receptors that have been characterized by radioligand binding and sensitivity to antagonists and identified as glycoproteins with a mr of 75 000 85 000 by chemical cross linking  after binding  bombesin elicits a cascade of early molecular events including stimulation of phosphorylation of the acidic mr 80 000 cellular protein  which is a major substrate of protein kinase c  ca2  mobilization mediated by ins 1 4 5 p3  na  and k  fluxes  transmodulation of egf receptor  enhancement of camp accumulation  and expression of the proto oncogenes c fos and c myc  studies using membrane preparations and permeabilized 3t3 cells indicate that g proteins play a role in the transduction of the mitogenic signal triggered by the binding of bombesin to its receptor  a pertussis toxin insensitive g protein couples the bombesin receptor to the generation of a signal that activates protein kinase c  whereas a pertussis toxin sensitive g protein mediates cross talk between transmembrane signaling pathways  bombesin mediated mitogenesis can be blocked by different antagonists and by interrupting the signal transduction process at various postreceptor levels  thus  prolonged treatment with vasopressin causes heterologous desensitization to the mitogenic action of bombesin  this mitogenic block is mediated by uncoupling the receptor from its signaling system  loss of responsiveness to bombesin stimulated dna synthesis is also induced by down regulation of protein kinase c  
class8	gene amplification in human lung cancer  the myc family genes and other proto oncogenes and growth factor genes  the development of human lung cancer may require multiple genetic deletions affecting a number of chromosomes  e g   1  3  11  13  and 17  these genetic aberrations may induce the activation of proto oncogenes  c jun  ras  c raf1  and the loss of tumor suppressor genes  p53   some of the activated proto oncogenes and tumor suppressor genes are more selectively expressed or absent in small cell lung cancer  l myc  c myb  c scr  rb gene  or non small cell lung cancer  c erbb 2  c sis  c fes   these genes may thus be of importance for selection of differentiation pathway  the c myc oncogene is frequently amplified in small cell lung cancer cell lines in a much higher frequency than in vivo  this indicates that c myc seems to be related to tumor progression and a relatively late event in the lung cancer development  the uncontrolled production of multiple growth factors has been identified in human lung cancer cell lines  these factors can promote and inhibit the proliferation via paracrine and autocrine loops via specific receptors  the products from some of the activated proto oncogenes  c sis  c erbb 2  are sequences homologous to a certain growth factor  pdgf  and a receptor  egf  identified in lung cancer  the production and action of these growth factors may be of major importance for further activation of proto oncogenes via intracellular signal transduction and specific oncogenic activation leading to further tumor progression  
class8	the ras oncogenes in human lung cancer  the three well characterized genes of the ras gene family h ras  k ras  and n ras  code for closely related 21 kd proteins that have a role in the transduction of growth signals  the ras proteins acquire transforming potential when a point mutation in the gene leads to replacement of an amino acid in one of the critical positions 12  13  or 61  overexpression of the normal protein  usually associated with gene amplification  can have similar effects  the detection of mutationally activated ras genes has been facilitated by the development of oligonucleotide hybridization assays that allow the identification of each possible mutation at the critical sites  employment of the polymerase chain reaction has greatly increased the sensitivity of these assays  studies of human lung cancer have shown that adenocarcinoma is the only subtype associated with ras mutations  these occur in about 30  of primary tumors  in almost all cases  the mutation is present in codon 12 of the k ras gene  no mutations have been observed to date in tumors of nonsmokers  suggesting that the mutation may result from exposure to carcinogenic ingredients of tobacco smoke  amplifications of ras genes were shown to be very uncommon in clinically early stages of lung cancer  analysis of the clinical data of patients who were operated on for adenocarcinoma of the lung shows that k ras mutations are not associated with particular histologic characteristics of the tumors or with specific presenting features  patients with k ras mutations  however  had significantly worse survival than did those without an activation  
class8	the beta type transforming growth factor  mediators of cell regulation in the lung  an increased interest in the role of growth factors in the regulation of processes concerning normal and pathologic lung physiology has spurred a flurry of research in this area  peptide growth factors are known to control not only cell proliferation but other events such as differentiation  chemotaxis  and matrix deposition as well  the transforming growth factor beta  tgf beta  family of regulatory peptides serves as a prime example to illustrate the multiplicity of effects elicited by peptide growth factors in various lung derived cell types  at present  the tgf beta family consists of at least 17 proteins and  based on sequence analysis  they can be divided into two groups  a cluster that shows very high sequence similarity to tgf beta 1  the closely related group  and a cluster that shows weaker sequence similarity to tgf beta 1  the distantly related group  the purpose of this brief review is to summarize the salient features of tgf beta structure and regulatory abilities of the closely related group  in addition  we will outline the evidence suggesting a role for tgf beta in normal lung development and physiology  emphasis will be placed on studies with the closely related members tgf beta 1 and tgf beta 2 because  until recently  purified protein was available only for these two proteins  
class8	positive and negative regulation of proliferation and differentiation in tracheobronchial epithelial cells  the lung  in particular the bronchial epithelium  is a major site for tumor formation in humans  environmental factors in conjunction with genetic factors are important determinants in this disease  the acquisition of defects in the control of proliferation and differentiation appears to constitute crucial steps in the transition of a normal to a neoplastic cell  several factors have been identified that control positively or negatively the proliferation and differentiation of tracheobronchial epithelial cells  these factors include egf tgf alpha  tgf beta  insulin igfi  kgf  certain cytokines  retinoids  and activators of protein kinase c  studies with neoplastic cells have identified several protooncogenes and tumor suppressor genes whose gene products are involved in the regulation of cell growth of normal tracheobronchial epithelial cells  and when mutated  lost  or activated  bring about a neoplastic phenotype  future studies on the precise function of these genes will help to elucidate the mechanisms by which proliferation and differentiation in normal tracheobronchial epithelial cells are regulated and help to understand the molecular changes involved in diseases such as cancer  
class8	genetic strategies of tumor suppression  the evaluation of the cancer cell is a complex multigene process  tumor suppressor genes that are lost or inactivated  as well as genes that are overexpressed  play key roles in tumor progression  the identification of overexpressed genes has been expedited by the presence of transforming genes in some animal retroviruses  however  tumor suppressor genes have been difficult to identify and isolate because of their loss or inactivation during tumorigenesis  by a variety of methods  summarized in this review  a few tumor suppressors have been cloned and characterized  and many more have been recognized indirectly  the general finding at this time is that the same tumor suppressors  and oncogenes  are found associated with many different tumors  that several different altered genes are found typically in the same tumors  and that other oncogenes and tumor suppressor genes seem to be characteristically altered in particular tumor types as well  functions of tumor suppressor genes include the control of normal cell activities such as proliferation and differentiation as well as senescence  which is a special kind of differentiation in which cells lose their ability to divide  the genetic basis of senescence and identification of genes involved in overcoming senescence  leading to immortalization  i e   indefinite growth potential   are important areas of current investigation  our laboratory is engaged in senescence immortalization studies as a result of our discovery that normal human mammary epithelial cells can be immortalized by dna of the human papilloma virus  these new studies are summarized here  
class8	recessive oncogenes in lung cancer  the observation that carcinogen exposure is strongly associated with the probability of developing pulmonary neoplasms has suggested for many years that acquired somatic mutations play a key role in the genesis of these environmentally induced cancers  with the advent of new techniques in cytogenetics and in the molecular analysis of dna extracted from lung tumors  it has now become possible to test this hypothesis and to search for candidate genes that may be targeted by the chronic exposure of these environmental insults  early work in this field  studying lung tumors of different histologic types  appears to implicate several distinct chromosomal loci  at chromosomes 3p  13q  17p  and others   suggesting that sequential genetic events occur during the initiation and progression pathways to pulmonary tumorigenesis  identifying the candidate gene products and understanding the chronology and stringency of mutational events at these loci will be an essential goal to understanding the cellular basis of lung tumors and for developing strategies for the next generation of diagnostic and therapeutic studies  
class8	src expression in small cell lung carcinoma and other neuroendocrine malignancies  the proto oncogene c src codes for two tyrosine kinases  pp60c src and pp60c srcn  the latter protein appears to be exclusively expressed in neurons and neuronally differentiated tumors  in cell lines derived from neuroblastoma and small cell lung carcinoma  src expression correlates positively with neuroendocrine differentiation  however  pp60c srcn is expressed only in highly differentiated neuroblastomas  although c src expression in neuroendocrine tumors probably reflects and is the result of the differentiation stage at which the tumors have been arrested  high c src expression and kinase activities in non neuroectodermal tumors  e g   colon carcinoma  breast carcinoma  might instead be a part of the malignant phenotype and contribute to the development of these tumors  
class8	aggravation of myasthenia gravis by erythromycin  erythromycin is not currently recognized as causing clinical aggravation of myasthenia gravis  we report the case of a patient who experienced exacerbations of myasthenia gravis subsequent to each of several doses of intravenous erythromycin  we suggest that erythromycin can cause clinical worsening in patients with disease of the neuromuscular junction  
class8	pulmonary capillaritis and glomerulonephritis in an antineutrophil cytoplasmic antibody positive patient with prior granulomatous aortitis  a 59 year old man showed asynchronous development of noninfectious granulomatous aortitis with aneurysm  followed 9 months later by pulmonary capillaritis and glomerulonephritis in association with elevated serum antineutrophil cytoplasmic antibody levels  to our knowledge  the combination of large artery vasculitis and small vessel systemic vasculitis  capillaritis  has not been previously reported  this case may represent a hybrid type of systemic vasculitis combining features of giant cell arteritis and wegener s granulomatosis  
class8	pulmonary malakoplakia in a patient with the acquired immunodeficiency syndrome  differential diagnostic considerations  malakoplakia is an unusual inflammatory condition characterized histopathologically by accumulations of benign macrophages  or von hansemann s cells  that are associated with diagnostic intracellular and extracellular calcospherites  termed michaelis gutmann bodies  currently believed to represent an acquired defect of macrophage digestion  malakoplakia most commonly occurs in the urinary tract and is associated with a variety of infectious agents  notably gram negative bacilli  we describe a patient with the acquired immunodeficiency syndrome who presented with a cavitating lingular mass  a transbronchial biopsy specimen revealed pulmonary malakoplakia  the seventh reported case of this condition and the second reported occurrence of pulmonary malakoplakia in a patient with acquired immunodeficiency syndrome  microbiological cultures were positive for rhodococcus equi  the significance of this finding  and the differential diagnosis of intra alveolar histiocytic proliferations in patients with acquired immunodeficiency syndrome  is discussed  
class8	extramedullary hematopoiesis in a bronchial carcinoid tumor  an unusual complication of agnogenic myeloid metaplasia  a case of bronchial carcinoid tumor with foci of extramedullary hematopoiesis is presented  the patient had a 6 year history of agnogenic myeloid metaplasia and hepatosplenomegaly  all three hematopoietic cell lines were represented in different areas of the bronchial tumor  to our knowledge  this is the first case of extramedullary hematopoiesis described in a bronchial carcinoid and only the fourth report of hematopoietic cells in a neoplasm of otherwise unrelated origin  the pathogenesis of this uncommon finding is discussed and the literature is reviewed  
class8	the role of indium labelled leukocyte imaging in pyrexia of unknown origin  indium 111 labeled white blood cell scanning is often used in the investigation of pyrexia of unknown origin  puo  to locate an otherwise occult source of sepsis  from a series of 166 white blood cell studies performed for sepsis  28 cases of true puo were identified and reviewed  the sensitivity was 60  and specificity 70   with a positive predictive value of 38  and negative predictive value of 90   only 11  of studies revealed a pyogenic cause for puo  these results are discussed and the potential role of gallium scanning in puo is raised  
class8	nicardipine reduces the cardio respiratory toxicity of intravenously administered bupivacaine in rats  the purpose of our study was to examine the effect of intravenous  iv  nicardipine pretreatment  30 micrograms kg 1   given three minutes before an iv bolus of bupivacaine to determine its effect on the incidence of fatal bupivacaine cardio respiratory toxicity in adult male sprague dawley rats anaesthetized with intraperitoneal pentobarbital  fifty rats were divided into four groups  groups i and ii  n   10 each  received 3 5 mg kg 1 0 5 per cent bupivacaine and groups iii and iv  n   15 each  received 5 0 mg kg 1  0 5 per cent bupivacaine  groups i and iii received pretreatment with normal saline before bupivacaine  whereas groups ii and iv were given pretreatment with nicardipine  30 mg kg 1  there was no difference in the incidence of survival between the nicardipine pretreatment group and the saline placebo pretreatment group given 3 5 mg kg 1  0 5 per cent bupivacaine  no fatalities in either group   however  there was significant protection by nicardipine pretreatment in the group given 5 mg kg 1  0 5 per cent bupivacaine  13 of 15 survived  compared with only 4 of 15 in the saline pretreatment group  p less than 0 001   in conclusion  our data demonstrate that in rats given 0 5 per cent bupivacaine  5 mg kg 1  nicardipine pretreatment protected against fatal cardio respiratory toxicity  
class8	an adherent subline of a unique small cell lung cancer cell line downregulates antigens of the neural cell adhesion molecule  small cell lung cancer  sclc  lines are distinguished from non small cell lung cancer  nsclc  lines by their growth in floating aggregates  in contrast to the adherent monolayers formed by nsclc cells in culture  of 50 well characterized sclc lines recently described by the national cancer institute  nci  navy medical oncology branch  only four variant cell lines  sclc v  grew as adherent monolayers  one line  nci h446  was unique in growing long term with coexisting floating and surface adherent subpopulations  we have physically segregated these two populations over many passages in vitro to enrich for relatively pure cultures of floating and adherent cells  no differences in c myc expression  keratin pattern  or cytogenetic appearance were found between the adherent and floating sublines  however  expression of the neuroendocrine marker neuron specific enolase in the floating cells was three times that found in the adherent cells  the floating subline also had much greater surface expression of neuroendocrine tumor antigens detected by monoclonal antibodies uj13a and hnk 1  which have been recently shown to detect the neural cell adhesion molecule  ncam  on sclc cells  two other adherent sclc v lines were also found to be unreactive with uj13a and hnk 1  generalizing the association between ncam expression and the growth of most sclc cultures as floating aggregates  in conclusion  we have an interesting model to study expression of ncam as related to the adhesive properties of sclc cells  
class8	causes of death in the elderly and their changing pattern in hisayama  a japanese community  results from a long term and autopsy based study  the causes of death for the elderly were prospectively studied in hisayama  japan  a rural community  we compared 1 621 subjects  aged 40 years or over  recruited in 1961  and 2 053 subjects recruited in 1974  each cohort was studied in a follow up that lasted 10 years  they had autopsy rates of 82 1  and 86 1  during each 10 year period  respectively  the most common causes of death for those aged 70 years or over were cerebrovascular disease  malignant neoplasms  and pneumonia  deaths due to cerebrovascular disease tended to decrease in the recent cohort  but the proportion of decline was more prominent in cases aged 40 to 69 years  there was a sex difference in the changing pattern of mortality from heart diseases including ischemic heart disease  deaths by both heart diseases and ischemic heart disease increased in the more recent cohort of aged women  whereas they decreased in the aged men  pneumonia was an important cause of death for the elderly in both cohorts  deaths due to  senility  were rare  being only 1  of the deceased aged 70 or over  with prolonged lifespan  especially for women  the impact of atherosclerosis and its related disorders on the recent japanese aged population appears to have increased  
class8	leukocyte larceny  spurious hypoxemia confirmed with pulse oximetry leukemic patients with extremely high white blood counts may exhibit the phenomenon of leukocyte larceny  in which white blood cells metabolize plasma oxygen in arterial blood gas samples  abg  producing a spuriously low oxygen tension  we report the case of a leukemic patient with a white blood count in excess of 500 000 in whom multiple abgs documented hypoxemia out of proportion to his clinical picture  pulse oximetry was used to confirm higher hemoglobin oxygen saturation to establish the leukocyte larceny  
class8	the electrocardiogram in chronic obstructive pulmonary disease  the electrocardiogram is often abnormal in patients who have chronic obstructive pulmonary disease  the most frequent abnormalities are a rightward p wave axis  greater than or equal to 70 degrees  and a rightward qrs axis  greater than or equal to 90 degrees   in addition  low voltage in the limb leads  an s1s2s3 pattern  poor r wave progression  a posterior superior terminal qrs vector or other changes may be present  transient atrial and ventricular dysrhythmias are common  knowledge of the usual electrocardiographic manifestations of chronic obstructive pulmonary disease enables the clinician to recognize uncharacteristic abnormalities  which often represent the effects of superimposed illnesses or drug toxicity  
class8	microscopic wegener s disease  a particular form of wegener s granulomatosis  we describe a case of wegener s granulomatosis in which the disease was manifested with crescentic glomerulonephritis  upper airway ulcerations  and microangiopathic hemolytic anemia with consumptive coagulopathy  no granuloma was identified but antibodies to cytoplasmic components of neutrophils were strongly positive with a diffuse pattern  because microscopic vessels were predominantly involved  capillaritis   and granuloma were absent  were refer to this particular form of the disease as  microscopic wegener s disease    
class8	multiple organ failure  inflammatory priming and activation sequences promote autologous tissue injury  systemic inflammation promotes multiple organ failure through the induction of diffuse microvascular leak  inflammatory cells such as neutrophils propagate this process  tissue injury by neutrophils may be viewed as a normal process  inflammation  that has become uncontrolled and generalized  multiple inflammatory stimuli synergistically promote neutrophil mediated tissue injury in priming and activation sequences  in some settings  cellular priming is mediated by platelet activating factor and can be prevented by platelet activating factor antagonists  inhibiting cellular priming could be efficacious in the therapy of multiple organ failure  
class8	endotoxin requirements for alveolar macrophage stimulation  acute pulmonary failure or ards in severely injured patients continues to be a significant problem  the most important clinical risk factor identified is sepsis syndrome  sepsis syndrome is the clinical correlate of a malignant systemic inflammatory process and is directed in large part by the tissue fixed macrophage  m phi   such as the alveolar m phi  the m phi is capable of producing most of the central inflammatory mediators responsible for the pathophysiology seen during sepsis and organ injury  two major mediators are procoagulant activity  pca   leading to diffuse microvascular thrombosis  and tumor necrosis factor  tnf   causing much of the physiologic derangement of sepsis  endotoxins  lps  derived from gram negative bacterial cell walls are the primary inflammatory stimulus for the tissue fixed m phi production of inflammatory mediators  it is not completely known how lps interacts with its various cellular targets  but it is hoped that knowledge of the molecular interactions involved in stimulation of the m phi by endotoxin will lead to therapies to modulate the response and prevent deleterious processes such as ards  in the present studies  lps from e  coli 0111 b4 was shown in a dose response to stimulate large levels of both pca and tnf in alveolar m phi  lps from bacteroides fragilis and lipid x  the monosaccharide precursor of endotoxin  were unable to cause stimulation of the m phi in vitro  however  both moieties  b  fragilis lps and lipid x  were able to effectively and specifically compete with e  coli lps and block m phi stimulation  
class8	neutrophil disorders in burn injury  complement  cytokines  and organ injury  because of the association of burn injury with subsequent bacterial infection  numerous studies have been performed characterizing neutrophil function in burn injury  these studies provide a picture of intravascular complement activation  neutrophil c5a interactions  and consequent disordered cellular function  neutrophil dysfunction includes suppressed random and c5a directed migration and hyperresponsiveness to oxidative stimuli  these observations do not explain the histologic and functional involvement of neutrophils in ards and perhaps other organ failure states  circumstantial and extrapolated information suggests that macrophage lineage cells function as regulators of neutrophil function within matrix environments in burn injury  elevated endotoxin levels have been found in burned patients  which would support the notion of endotoxin stimulated monocytes macrophages as inducing neutrophil migration into connective tissue matrices  ltb4 and il 8   inducing prolonged oxidant production  tnf alpha  gm csf   and inducing neutrophil release of regulatory substances from neutrophils  g csf   this information suggests a variety of experimental approaches to testing this hypothesis  
class8	a lethal complication of papaverine induced priapism  a large series of patients was treated for impotence with intracorporeal injections of papaverine and phentolamine with no major complications and no deaths reported  we report on a 45 year old black man with advanced multiple sclerosis who died after such therapy  when the first self administered injection of phentolamine and papaverine failed to produce an adequate erection the patient injected a second dose that resulted in priapism and death of massive pulmonary embolism  
class9	abnormal differentiation of human papillomavirus induced laryngeal papillomas  we studied the proliferation and differentiation of human laryngeal papillomas  which are benign tumors induced by human papillomaviruses  immunofluorescent stains of tissues for a number of differentiation specific proteins showed abnormal differentiation  papilloma tissue fragments in vitro showed a slightly decreased fraction of proliferating cells that incorporated tritiated thymidine and a markedly reduced incorporation of tritiated uridine when compared with normal tissue  we propose that papillomavirus infection results in normal basal cell proliferation but abnormal terminal differentiation and that this abnormality significantly contributes to the hyperplasia of the papillomas  
class9	transtympanic endoscopic findings in patients with otitis media with effusion  using a fine  rigid endoscope  olympus  ses 1711k   we examined the middle ear  including the tympanic orifice of the eustachian tube  of children with otitis media with effusion  ome  in its active stage  26 ears   in the convalescent stage  13 ears   and during treatment with ventilation tubes for 10 days to 6 months  five ears  through myringotomy with the patients under general anesthesia  several color photographs of representative ears are shown  in the active stage of ome  edema  73 1   and hyperemia  23 1   were characteristic features of the middle ear mucosa  and normal mucosa was seen in only one ear  3 1    the tympanic orifice of the eustachian tube  which could be examined in 12 ears  were stenosed with edema in four ears  33 3   or plugged with effusion in three ears  25 0   in this group  in the convalescent stage of ome  dilated vessels were most often seen  69 2    but the rest of the patients had normal mucosa  30 8   in the middle ear  and none of them had edema nor hyperemia  the tympanic orifice of the eustachian tube  which could be examined in five ears  was clearly patent in all the patients in this group  one ear that was treated with a ventilation tube for 1 month showed dilated vessels and less severe inflammation than did ears that were in the active stage of ome  and three ears that were treated for more than 3 months showed almost normal middle ear mucosa  
class9	pseudocyst of the auricle  case report and world literature review we treated a patient with pseudocyst of the auricle and reviewed the 113 cases previously published in the world literature  pseudocyst of the auricle is an asymptomatic  noninflammatory cystic swelling that involves the anthelix of the ear  results from an accumulation of fluid within an unlined intracartilaginous cavity  and occurs predominantly in men  93  of patients   characteristically  only one ear is involved  87  of patients   and the lesion is usually located within the scaphoid or triangular fossa of the anthelix  previous trauma to the involved ear is uncommon  the diagnosis may be suggested by the clinical features  and analysis of the aspirated cystic fluid and or histologic examination of a lesional biopsy specimen will confirm the diagnosis  therapeutic intervention that maintains the architecture of the patient s external ear should be used in the treatment of this benign condition  
class9	multiple intracranial mucoceles associated with phaeohyphomycosis of the paranasal sinuses  the purpose of this article is to alert clinicians to a new pathogenic fungus of the paranasal sinuses called exserohilum rostratum  exserohilum species are one of the etiologic agents of phaeohyphomycosis  a constellation of entities caused by dematiaceous fungi  this class of fungal sinus infection has emerged only in the past decade  it occurs primarily in immunocompetent individuals and produces a tenacious  progressive pansinusitis  to our knowledge  this study describes the first case of multiple intracranial mucoceles secondary to e rostratum  the diagnostic workup includes computed tomography and magnetic resonance imaging followed by direct microscopic examination of tissue biopsy specimens  a craniotomy followed by a bilateral external ethmoidectomy was necessary for complete extirpation of the infected mucoceles  aggressive surgical management of this mycotic infection is described  
class9	osteoma of the middle ear  report of a case  osteomas of the middle ear are rare  we report a case of a 7 year old boy with osteoma originating from the pyramidal eminence  combined with congenital cholesteatoma  the osteoma and cholesteatoma were successfully removed by tympanomastoidectomy  the long process of the incus and the superstructure of the stapes disappeared  the body of the incus was sculpted and used as a columella  histopathologically  the osteoma was much the same as an external auditory canal osteoma  the possibility of a primary congenital origin of this neoplasm is suggested  
class9	topographic classification  clinical characteristics  and diagnostic delay of cancer of the larynx hypopharynx in torino  italy  the case series of a population based case control study of laryngeal and hypopharyngeal cancers in torino  italy  included 281 men with clinical and anamnestic data  two hundred fifteen  28  and 38 cancers originated from the endolarynx  epilarynx  and hypopharynx  respectively  regions invaded by the tumor were divided into 26 subsites  a classification based on the number of invaded subsites was proposed  which agreed well with the t classification of the tnm system  cancers originating from the hypopharynx invaded more subsites than cancers from the endolarynx  and among the latter  supraglottic were more invasive than glottic lesions  the number of invaded subsites was strongly associated with nodal involvement  among symptoms at onset of disease and at diagnosis  patients with endolaryngeal lesions reported dysphonia and dyspnea more frequently  and patients with lesions from other regions had a higher prevalence of dysphagia  odynophagia  otalgia  and adenopathia  clinical and epidemiologic results of this study suggest considering the endolarynx  epilarynx  and hypopharynx as separate anatomic entities  diagnostic delay was not associated with tumor size and showed a negative trend with involvement of cervical lymph nodes  suggesting that stage at diagnosis is due to intrinsic differences in tumor aggressiveness  
class9	human papillomavirus type 16 associated with oral squamous carcinoma in a cardiac transplant recipient  human papillomavirus type 16  hpv 16  has been associated with a variety of squamous carcinomas  particularly those involving the anogenital tract  the authors report the development of an oropharyngeal carcinoma in a 43 year old man approximately 20 months after cardiac transplantation while he was on a maintenance regimen of cyclosporine a and prednisone  the carcinoma was resistant to treatment  and he died of complications related to metastatic disease 3 years posttransplantation  molecular biologic studies using nonisotopic labeled viral dna probes were done  in situ hybridization demonstrated the presence of hpv 16 dna in the tumor cells  dna dot blot analysis confirmed the presence of multiple copies of hpv 16 dna within the tumor cells and their absence from adjacent normal appearing tissue  southern blot analysis suggested that the hpv 16 dna was integrated into the tumor cell genome  with increasing recognition of the carcinogenicity of hpv type 16 infection  a role for this virus in the development of squamous cell malignancies in immunosuppressed organ transplant recipients is likely to be noted with increasing frequency  
class9	a clinical and flow cytometric analysis of patients with nasopharyngeal cancer  abnormal cellular dna content  a hallmark of malignancy  is known to be an important prognostic factor in many human solid tumors  however  no data have been published on whether cellular dna content carries prognostic significance for patients with nasopharyngeal cancer  npc   archival  formalin fixed  paraffin embedded pathology specimens representing pretreatment tissue biopsies from 55 patients  41 men and 14 women  with npc were analyzed for cellular dna content in a retrospective fashion from 1968 to 1988  individual tumors were classified as either lymphoepithelioma  squamous cell  or anaplastic carcinoma  and were staged according to international union against cancer  uicc  criteria  all patients were treated with curative intent using a 4 to 6 mev linear accelerator to total doses ranging from 50 to 60 gy in 4 to 6 weeks  the overall 5 year actuarial survival for all 55 patients was 44 4   men  41   women  52    survival by t stage was as follows  t1  65   t2  51   t3  36   and t4  27   similarly  the 5 year survival rate declined as the bulk of nodal metastases increased  n0  62   n2  50   n3  37   and n1  25   patients who had anaplastic carcinoma had a 5 year survival of 73   those with lymphoepithelioma had a 60  survival  and those with squamous cell cancer  scc  had a 30  survival  there was a statistically significant difference in 5 year survival between patients with scc and those with nonkeratinizing histologies  p less than 0 05   in addition  there was a significant association between patients older than 40 years of age with scc and patients younger than 40 years of age with nonkeratinizing malignancies  p less than 0 01   of the 55 tumors successfully analyzed  22  40   were diploid and 33  60   were aneuploid  the mean coefficient of variation  cv  of all 55 samples was 6 17   there was no significant difference in 5 year survival between patients with diploid and those with aneuploid tumors  48  versus 42    furthermore  there was no statistically significant survival difference between aneuploid and diploid tumors within any one histologic subgroup  there was also no significant survival difference related to the dna index  the results indicate that the extent of local tumor spread is still the most important prognostic factor for patients treated with radiotherapy for npc  the data support the conclusion that patients with lymphoepithelioma and anaplastic carcinomas have a superior survival to patients with squamous cell carcinoma  abstract truncated at 400 words   
class9	aqueous beclomethasone diproprionate nasal spray  regular versus  as required  use in the treatment of seasonal allergic rhinitis  objective  to determine the effect of alternative regimens of nasal steroid administration on symptoms and quality of life  design  randomized  double blind  parallel group comparison  subjects  sixty ragweed sensitive adults recruited from participants of previous studies and through media advertising  interventions  200 micrograms of aqueous beclomethasone diproprionate nasal spray  twice daily  from 1 week before until 1 week after the ragweed pollen season  regular  or 100 micrograms of the spray  taken as required  up to 400 micrograms daily  troublesome nasal symptoms were treated  in both groups  by increasing the daily dose to 800 micrograms until symptoms were controlled  if this treatment was insufficient  120 mg of terfenadine  daily  was added  results  one subject in the  as required  treated group withdrew with uncontrolled nasal symptoms  in the remaining subjects  sneezing  stuffy nose  and rhinorrhea  measured by a daily diary  were significantly better controlled in the regular treated group  p less than 0 025   impairment of quality of life  including sleep disturbance  nonhay fever symptoms  practical problems  and uncomfortable emotions were greater in the as required treated group  p less than 0 001   subjects in the regular treated group required less additional terfenadine  0 27 tablets per subject versus 1 40  p   0 022   eye symptoms and eye drop use were similar in the two treated groups  conclusion  in patients with seasonal allergic rhinitis  regular use of inhaled steroids results in fewer symptoms and better quality of life than when the spray is taken only as required  
class9	comparison of cefuroxime axetil  cefaclor  and amoxicillin clavulanate potassium suspensions in acute otitis media in infants and children  in this randomized  blinded  multicenter comparison study  377 infants and children with acute otitis media  aom  received a 10 day course of an oral suspension of one of the following  cefuroxime axetil  cae   30 mg kg day  cefaclor  cec   40 mg kg day  or amoxicillin clavulanate potassium  amx cl   40 mg kg day  clinical efficacy was determined by pneumatic otoscopy and tympanometric testing 3 to 5  11 to 14  and 22 to 26 days after the initiation of therapy  there was a statistically significant difference among the three treatment groups with respect to clinical outcome  more patients in the cae group  62   than in the cec group  46   or the amx cl group  52   had complete resolution of signs and symptoms of aom  including effusion   paired comparisons revealed a significant difference in efficacy between cae and cec and a nearly significant difference between amx cl and cec  taste acceptability was highest for cec and lowest for this formulation of cae  significantly more patients in the amx cl group than in the cae or cec group had a side effect  primarily diarrhea  vomiting  or diaper rash  we conclude that cae suspension has greater clinical efficacy than cec and fewer side effects than amx cl  
class9	nonendoscopic percutaneous gastrostomy  tight peritoneal adherence of the stomach to the abdominal wall as a prerequisite of percutaneous gastrostomy can be achieved by a newly developed cannula  it serves for puncture and fixation of the gastric wall  thus  percutaneous gastrostomy can be established safely even in instances of an endoscopically nonaccessible stomach  further applications of the device for the purpose of intestinopexy and facilitation of endoscopic procedures are being evaluated  
class9	magnetic resonance imaging of radiation optic neuropathy  three patients with delayed radiation optic neuropathy after radiation therapy for parasellar neoplasms underwent magnetic resonance imaging  the affected optic nerves and chiasms showed enlargement and focal gadopentetate dimeglumine enhancement  the magnetic resonance imaging technique effectively detected and defined anterior visual pathway changes of radionecrosis and excluded the clinical possibility of visual loss because of tumor recurrence  
class9	complications of the pectoralis major myocutaneous flap in head and neck reconstruction  a retrospective review of the complications in 211 patients undergoing pectoralis major myocutaneous flap reconstruction is presented  the flap was used for mucosal lining of the oral cavity or oropharynx in 109 patients  for pharyngoesophageal reconstruction in 44  for skin coverage in 47  and for other locations in 14 patients  flap related complications developed in 63  of the patients  these included flap necrosis  suture line dehiscence  fistula formation  infection  and hematoma  analysis of risk factors for the development of flap complications showed the following factors to be significant  age over 70  female gender  nomographic overweight  albumin less than 4 g dl  use of the flap in reconstruction of the oral cavity after major glossectomy  and presence of other systemic diseases  the median length of hospitalization for those developing complications was 33 days compared with 16 days for those who did not develop any complications  thirty five  26   of the 135 patients developing complications required reoperation and only 2 among these required a second flap  similarly  only 13 of the 61 patients who developed fistulas required surgical closure  
class9	patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract  a consecutive series of 1 081 previously untreated patients undergoing 1 119 radical neck dissections  rnds  for squamous carcinoma of the head and neck was reviewed to study the patterns of nodal metastases  primary tumors were located in the oral cavity in 501 patients  in the oropharynx in 207 patients  in the hypopharynx in 126 patients  and in the larynx in 247 patients  lymph node metastases were confirmed histologically in 82  of 776 therapeutic neck dissections  and micrometastases were discovered in 33  of 343 elective rnds  lymph node groups in the neck were described by levels  i to v   predominance of certain levels was seen for each primary site  levels i  ii  and iii were at highest risk for metastasis from cancer of the oral cavity  and levels ii  iii  and iv were at highest risk for metastasis from carcinomas of the oropharynx  hypopharynx  and larynx  supramohyoid neck dissection  clearing levels i  ii  and iii  for no patients with primary squamous cell carcinomas of the oral cavity and anterolateral neck dissection  clearing levels ii  iii  and iv  for no patients with primary squamous cell carcinomas of the oropharynx  hypopharynx  and larynx are recommended  
class9	efficacy of radical neck dissection for the control of cervical metastasis after radiotherapy for nasopharyngeal carcinoma  fifty one patients who had persistent or recurrent neck disease from nasopharyngeal carcinoma after radiotherapy underwent radical neck dissection  the follow up period ranged from 0 5 to 9 years  median  2 years   multiple cervical lymph node involvement was present in 51  of the patients  26 of 51   malignant cells were detected in 88  of the resected specimens  45 of 51   the clinical sign of fixation of lymph node is the only factor that affects the successful control of neck disease  p   0 04   extracapsular extension of the nodal disease was present  and 35  of the lymph nodes were adherent to surrounding structures at operation  18 of 51   there was one hospital mortality and the overall morbidity was minimal  the actuarial survival at 5 years was 38   and the probability of control of neck disease was 66   radical neck dissection is effective in controlling post irradiation cervical metastasis from nasopharyngeal carcinoma  
class9	comparison of propofol and thiopental halothane for short duration ent surgical procedures in children  experiences with propofol in pediatric anesthesia are limited  we undertook a study to evaluate the quality of induction and recovery from anesthesia with propofol compared to thiopental halothane  twenty children received 3 mg kg 1 min 1 of propofol as a loading dose followed by a maintenance dose of 0 1 mg kg 1 min 1      10    twenty children received 5 7 mg kg of thiopental  and maintenance was provided with halothane  0 5  1 5    the interval between the end of the administration of propofol or thiopental halothane and extubation  as well to discharge to the ward  was significantly shorter with propofol  4 4 versus 13 5 min and 7 22 versus 30 4 min  respectively   spontaneous movements and pain on injection were seen significantly more frequently with propofol  whereas laryngospasm and hiccup were only observed with thiopental  during the first 6 h after the surgical procedure  analgesics were needed significantly more often in the thiopental group  nausea and vomiting also were observed more frequently in the thiopental group  in conclusion  propofol used as a single anesthetic is a satisfactory technique for ent surgery of short duration in children  
class9	a controlled  double blind study of the effect of quazolast on nasal challenge with ragweed antigen  quazolast is a potent mediator release inhibitor as determined by in vitro and in vivo testing  a placebo controlled  double blind  two way crossover study compared the safety and efficacy of quazolast  400 mg bid orally  with placebo in 23 subjects with ragweed  rw  allergy  out of season  subjects were assigned to two 7 day treatments in a random sequence with an 8 day washout  subjects were challenged on days 1 and 7 of each trial with serial dilutions  10  100  1000  1350  and 2700 pnu 0 135 ml  of rw  using metered pump spray bottles   two sprays delivered 0 135 ml   preceded by saline control  efficacy evaluation consisted of nasal flow rates measured by rhinomanometry  sneeze counts  nasal itchiness scores  and weight of nasal secretions during challenges  during quazolast treatment  subjects had significantly lower  p less than  05  mean percent decreases in nasal flow rate at 1350 and 2700 pnu  nasal itchiness scores were significantly lower  p less than  05  during quazolast treatment than at placebo at 1000  1350  and 2700 pnu  although sneeze counts were lower during treatment with quazolast than with placebo  the results did not reach statistical significance  no significant improvement was seen in the weight of nasal secretions  adverse experiences  clinical laboratory results  and physical examinations were unremarkable  posttreatment  quazolast was superior to placebo in protecting against nasal congestion and nasal itchiness after ragweed nasal challenge  
class9	effect of vitamin c on histamine bronchial responsiveness of patients with allergic rhinitis  the effect of acute oral administration of 2 g vitamin c on bronchial responsiveness to inhaled histamine in 16 patients with allergic rhinitis was compared with placebo on two consecutive days in a double blind  crossover design  the pc15fev1 was significantly increased one hour after treatment with vitamin c but not after placebo  
class9	teflon versus thyroplasty versus nerve transfer  a comparison  surgical rehabilitation of the paralyzed larynx is currently performed by teflon injection  thyroplasty  and reinnervation techniques  proponents of the two newer techniques maintain that they are preferred to teflon injection because superior phonatory quality is achievable  this paper was written in an attempt to dissect the issues regarding this question  teflon remains the quickest and least expensive procedure  but further experience with stroboscopic and other voice analyses reveals that the other procedures demonstrate some superiority in phonatory quality over teflon  in this author s hands  the nerve transfer offers the best opportunity to achieve a normal phonatory voice  in addition  it is the only one of the three procedures that leaves the vocal cord entirely undisturbed  important in the event one of the other two procedures becomes necessary  
class9	endoscopic laser arytenoidectomy revisited  arytenoidectomy is currently the most reliable method of treating patients with bilateral vocal cord paralysis  although both endoscopic and external approaches have been described  the endoscopic laser technique is more desirable because it requires no incision and allows for the immediate assessment of airway size  eleven patients with bilateral vocal cord paralysis treated by endoscopic laser arytenoidectomy were presented in 1984  at that time  10 of the 11 patients had been successfully decannulated  follow up on that group of patients revealed that 7 of the 10 successfully treated patients remain decannulated with a good airway  although 2 of these patients required a revision procedure to excise a granuloma  one patient failed at 15 months and has failed two subsequent revision operations  and 2 patients have been lost to follow up  since 1984  17 additional patients with bilateral vocal cord paralysis have been treated by the authors using the same endoscopic laser arytenoidectomy technique  all have been successfully managed  with a minimum follow up of 3 years  the technique of this operation will be reviewed  this study demonstrates the clinical usefulness of endoscopic laser arytenoidectomy in the treatment of bilateral vocal cord paralysis  
class9	combined laryngeal framework medialization and reinnervation for unilateral vocal fold paralysis  the laryngeal framework silastic implant technique has become an increasingly attractive alternative to teflon injection  particularly when there is fixation of the cricoarytenoid joint or the defect to be corrected is larger than usual  but it does not restore ability to change tension in the vocal fold  unilateral vocal fold reinnervation can overcome this drawback and  when used in conjunction with surgical medialization  may offer return of function very close to normal  twenty nine patients with unrecovered unilateral vocal fold paralysis and or fixation of the cricoarytenoid joint have been managed by use of a silastic implant combined with unilateral vocal fold reinnervation with no complications  voice improvement has been assessed on preoperative and postoperative voice recordings  the combined surgical techniques for reinnervation and a modification of silastic implantation via the laryngeal framework approach are reported  
class9	immunohistochemical interpretation of early epithelial disorders of pyriform sinus  expression of cytokeratins  cks  was investigated immunohistochemically by use of monospecific monoclonal anti ck antibodies in normal epithelia of pyriform sinus and epithelial lesions such as simple hyperplasia  different degrees of dysplasia  in situ carcinoma  and invasive carcinoma  in normal epithelium  strong expression of ck 19 was consistently observed only in the basal layer as basic ck  while expression of ck 13 showed a completely reverse pattern  being expressed only in suprabasal layers as stratification related ck  characteristic changes in expression pattern of these two cks were observed in accordance with the degree of epithelial disorders and differentiation of carcinoma  cytokeratin 1  as keratinization associated ck  was observed only in keratinized cells of hyperplastic epithelia and well differentiated carcinomas  these findings may be useful in evaluating epithelial disorders and classifying carcinomas more objectively  and may assist earlier detection of carcinoma when used with standard histologic techniques  
class9	vestibular recruitment in meniere s disease  the aim of this study was to search for vestibular recruitment in a sample of patients with meniere s disease  recruitment was defined as an abnormal growth of response with increasing stimulus intensity  twenty nine patients were tested with sinusoidal rotation of three different magnitudes at four different frequencies  we also searched for auditory recruitment in each patient via tests of auditory brain stem responses  acoustic reflexes  and loudness balance and discomfort level  analysis of vestibular responses indicated  on average  a linear relationship between stimulus magnitude and response magnitude  ie  doubling the stimulus magnitude resulted in twice the response magnitude  meniere s patients did not yield results significantly different  although they were more variable  from those of the normal subjects  the vestibular responses of patients with auditory recruitment did not differ systematically from those of patients without auditory recruitment  we conclude that vestibular recruitment  if it exists in patients with meniere s disease  is not demonstrated by sinusoidal rotational testing  
class9	identification and characterization of middle ear vascular leakage sites in experimental otitis media  the site of leakage in middle ear vessels was determined and characterized in experimental otitis media in rats  middle ear effusion was induced by intravenous administration or local application in the tympanic bulla of substance p  sp   acetylcholine  and histamine  in another experiment  a 14 degrees c airstream was blown into the external auditory canal  colloidal carbon was used to trace leakage sites at the light and electron microscopic levels  all mediators tested and the 14 degrees c airstream resulted in an increased number of leaking vessels in the pars flaccida and the middle ear mucosa  the leakage sites were restricted to capillaries and postcapillary venules  increased numbers of degranulated pars flaccida mast cells were observed for sp only  interendothelial gaps formed in leakage vessels after administration of mediators and stimulation of the external auditory canal with a 14 degrees c airstream  also  cytoplasmic vesicle like structures within the endothelial cells increased in number following sp and histamine treatment  suggesting that an increased permeability in experimental otitis media does not occur exclusively through interendothelial gaps  
class9	histopathologic study of otitis media in individuals with head and neck tumors  five temporal bones  each including the eustachian tube  were obtained from five adults with advanced malignant tumors of the head and neck  the specimens were from the side on which the tumor had occurred  otitis media had been detected clinically in two cases  and was detected histopathologically in the other three  we discuss the possibility that otitis media might have been caused by tumor invasion of the paratubal area  by postoperative inflammation in the nasopharynx  or by an inflammatory reaction of tubal structures to radiotherapy  or that these conditions may have coexisted  
class9	nasal lymphoma  a retrospective analysis of 60 cases  sixty cases of nasal lymphomas were reviewed  there were 42 men and 18 women  the median age was 49 years  the histologic types were low grade in four cases  intermediate grade in 33  high grade in seven  and unclassifiable in 16  thirteen cases had features of polymorphic reticulosis  the immunophenotype was available in 18 cases and a majority of 67  of them were t cell  forty one of them  68   had clinically localized  stage i and ii  disease which often spread locally to neighboring tissues and they presented predominantly with nasal symptoms  nasal lymphoma appeared to carry a poor prognosis  although our patients with clinically localized disease had significantly better prognosis than those with advanced disease  the 5 year survival of stage i and ii patients was only 55   chemotherapy did not appear to be more effective than radiotherapy alone in preventing relapses but the patient number was too small to allow a firm conclusion to be made  patients with advanced disease had even poorer prognosis with a 5 year survival of only 17   innovative therapy has to be developed for these patients  
class9	osteosarcoma of the maxilla in hong kong chinese postirradiation for nasopharyngeal carcinoma  a report of four cases  postirradiation osteosarcoma of the maxilla was seen in four hong kong chinese patients treated for nasopharyngeal carcinoma  these cases represent four of 42  9   cases of osteosarcoma at all sites in this institution during the period 1979 to 1989  when more than 1000 patients were treated with radiotherapy for nasopharyngeal carcinoma  the latent periods varied from 8 to 11 years from completion of radiotherapy treatment to development of osteosarcoma  the radiation dosage varied from 6000 to 6280 cgy in three of the patients  these cases fit the criteria for diagnosis of postirradiation sarcomas  maxillary osteosarcomas after irradiation for nasopharyngeal carcinoma do not appear to have been described  the very high incidence of nasopharyngeal carcinoma  for which radiotherapy is the treatment of choice  in hong kong chinese would make the occurrence of such tumors more likely in hong kong  although the small risk does not contraindicate the use of radiation in the treatment of nasopharyngeal carcinoma in view of its well documented efficacy  
class9	possible involvement of the retinoblastoma gene in undifferentiated sinonasal carcinoma  retinoblastoma tumor formation is initiated by the loss of function of both alleles of the rb 1 gene on chromosome 13  patients with the hereditary form of retinoblastoma carry a germ line mutation at one of the two homologous gene loci in all cells and have an increased risk for nonocular tumors  mainly osteosarcoma and other mesenchymal tumors  in later life  the authors studied a 38 year old patient with sinonasal undifferentiated carcinoma  snuc  who had been treated for bilateral retinoblastoma by enucleation  left eye  and irradiation  right eye   respectively  using molecular probes for the rb 1 gene and other loci on chromosome 13  the authors detected a deletion at the rb 1 locus in metastatic snuc cells that was not present in normal tissue  these findings indicate that somatic mutations at rb 1 locus may be involved in the formation or progression of ectodermal tumors  
class9	informed consent in head and neck surgery  informed consent is the fastest growing problem in the medical negligence debate  it was highlighted recently in the united kingdom in the sidaway case  informed consent comprises the advice you would give the patient  the consequences of not taking your advice  the specific risks of the surgery or treatment you have in mind  and the risks of surgery in general  in an attempt to identify what the present practice in otolaryngology was  a postal survey was carried out of the members of the scottish and north of england otolaryngological societies  
class9	hearing aids for high frequency hearing loss  this cross over study compares the relative benefits of a standard nhs contracted hearing aid with a high frequency emphasis commercial aid in subjects with high frequency hearing loss  disability questionnaires and free field speech in noise  faaf ii  tests were used to assess subjects unaided and after 6 weeks of wearing each aid  total faaf ii test scores showed no significant difference with either aid  but analysis of frequency specific subscores demonstrated less use of low frequency information when using the high frequency emphasis aid  overall questionnaire responses relating to conversation showed more benefit with the high frequency emphasis aid  subjects generally preferred this aid  possibly due to less low tone gain than the standard nhs aid  
class9	analgesia and removal of nasal packing  we present a prospective controlled trial  comparing methods of analgesia for the relief of discomfort on removing nasal packing  including a general discussion on the considerations for  and methods of  nasal tamponade  on the basis that nasal packing is likely to continue to be used frequently  nitrous oxide  as entonox  is advocated as a safe and relatively cheap means of pain relief with a statistically significant advantage over papaveretum  
class9	sensorineural hearing loss in bullous myringitis  a prospective study of eighteen patients  eighteen patients were seen over a period of 3 years  twenty of their ears were diagnosed as having bullous myringitis  pure tone audiograms and stapedial reflexes were performed within 48 h of referral  six ears demonstrated sensorineural hearing loss  7 ears mixed loss and 4 conductive loss  recovery of sensorineural hearing loss complete in 8 out of 13 ears  stapedial reflexes were elicited in 5 patients and all showed recruitment  the findings of this study confirms the fact that sensorineural hearing loss is more common in bullous myringitis than previously thought and that it is temporary in many cases  the stapedial reflex results suggest that the site of the lesion is in the cochlea  
class9	chest infection following head and neck surgery  a pilot study  this paper reports the results of a pilot study which examined factors associated with chest infection following head and neck surgery  the overall rate of chest infection was 11   but was 20  in those patients having a tracheotomy  no infection developed in patients with an intact airway  other factors which emerged as possibly important were the duration of surgery and heavy regular alcohol intake  we recommend that prophylactic antibiotics be continued for at least 48 h in patients requiring a tracheotomy as part of their head and neck surgery  this is against the trend of shorter antibiotic regimens recommended for prevention of wound infections  
class9	the presence of human papillomavirus  hpv  in solitary adult laryngeal papillomas demonstrated by in situ dna hybridization with sulphonated probes  human papilloma virus  hpv  types 6 and 11 have been repeatedly demonstrated in multiple laryngeal papillomas  and there is little doubt that these lesions are caused by hpv  it has been clearly demonstrated in recent reports that the clinical course of solitary adult onset laryngeal papillomas is entirely different from that of multiple papillomas of juvenile as well as of adult onset  we here report the presence of hpv types 6 and 11 in 19 out of 20 solitary papillomas from 16 patients  while hpv types 16 and 18 were totally absent  we conclude that the milder clinical course in such patients is most likely to be due to host factors  rather than to viral factors  
class9	urinary n tau methylimidazole acetic acid excretion in respiratory disease  n tau methylimidazole acetic acid  n tau miaa  is the principal urinary metabolite of histamine  the basal urinary excretion rate of n tau miaa was determined as 0 117     0 008  se  mg h  with a renal clearance for n tau miaa of 273     27 ml min implying active secretion  after subpharmacological infusion of histamine  50 ng kg 1 min 1 over 2 h  in five volunteers that increased plasma histamine from 0 28     0 04 to 0 71     0 15 ng ml  urinary excretion of n tau miaa over 8 h was increased by less than 17  compared with a control saline infusion  urinary n tau miaa excretion in normal controls  273     14 micrograms mmol creatinine  was similar to that observed in patients with severe acute asthma  253     22 micrograms mmol   antigen induced bronchoconstriction  269     21 micrograms mmol   seasonal allergic rhinitis  304     31 micrograms mmol   and clinically stable bronchiectasis  270     22 micrograms mmol   in contrast  large increases in metabolite excretion  greater than 7 000 micrograms mmol creatinine  were observed in a patient with systemic mastocytosis where very high plasma histamine levels were recorded  greater than 500 ng ml  and marked systemic hemodynamic effects occurred  we conclude that urinary n tau miaa will only be increased in pathologies where sustained hyperhistaminemia occurs and that increased local histamine production in the lung or the upper airway does not cause a measurable change in the basal urinary excretion of this metabolite  
class9	vasopressin and oxytocin responses to illusory self motion and nausea in man  vasopressin and oxytocin are nonapeptides secreted from the neurohypophysis  increases in vasopressin are associated with nausea and vomiting in some  but not all  species  our aim was to determine whether plasma vasopressin and oxytocin levels were altered in healthy volunteers who did or did not develop nausea during vection  an optokinetic stimulus which produces the illusion of self motion  vection was produced by rotating a drum with an inner surface of black and white vertical stripes around the seated stationary subject  gastric myoelectrical activity was recorded continuously throughout the experiment with electrodes positioned on the abdominal surface  plasma samples were obtained before vection and after drum rotation stopped when nausea and tachygastria were present  vasopressin and oxytocin were extracted from plasma and quantified by ria  during vection six subjects reported nausea and developed gastric dysrhythmias  six other subjects had no nausea and remained in normal 3 cpm myoelectrical rhythms  vasopressin and oxytocin values before vection were similar in each group of subjects  one minute after vection stopped  plasma vasopressin levels were significantly greater  p less than 0 05  in subjects experiencing nausea and tachygastrias  35 4     26 7 pmol l  than in those without symptoms  2 7     0 47 pmol l   oxytocin levels were unchanged by either vection or nausea  it is concluded that 1  vasopressin  not oxytocin  neurons in the magnocellular neurohypophyseal system are activated during vection induced nausea and gastric dysrhythmias  and 2  illusory self motion may be used safely to study the neuroendocrine responses to brain gut interactions and nausea in man  
class9	sensitivity of digoxigenin and biotin labelled probes for detection of human papillomavirus by in situ hybridisation  the sensitivity of digoxigenin and biotin labelled dna probes for the detection of human papillomavirus  hpv  by dot blotting and in situ hybridisation was compared in tissues from cervical  laryngeal  and anogenital neoplasia  probes were either labelled with digoxigenin by the random primer technique and detected with anti digoxigenin antibody  or labelled with biotin by nick translation and detected with streptavidin  both methods having a common final visualisation procedure using alkaline phosphatase  digoxigenin labelled probes proved two to 10 fold more sensitive by quantitative dot blotting and four fold more sensitive in detecting hpv 16 dna in a series of 31 anal carcinomas  compared with biotinylated probes  the digoxigenin method also produced less non specific background staining of tissue sections than biotin labelled probes  it is concluded that digoxigenin dna labelling and detection provides a simple  reliable  and efficient alternative to the use of biotin or radioactive isotopes for the detection of hpv dna by in situ hybridisation  digoxigenin labelled probes also offer the possibility of double labelling in situ hybridisation procedures when used with biotin labelled probes to provide simultaneous identification of different dna sequences  
class9	different prevalence and degree of nonspecific bronchial hyperreactivity between seasonal and perennial rhinitis  from the patients observed at our respiratory allergology service  we selected patients with rhinitis only  without any past or present respiratory symptoms  for our study  all these patients had normal pulmonary function  were administered carbachol or methacholine bronchial challenges  and had one or more skin reactions to perennial or seasonal allergens  patients were allocated to three groups  group a  patients with seasonal rhinitis who were administered nonspecific challenges out of season  group b  patients with seasonal rhinitis tested during the season  and group c  patients with perennial rhinitis  the three groups were divided into subgroups according to the duration in years of rhinitis and to the degree of nonspecific bronchial responsiveness  the distribution into four groups of reactivity  arbitrarily defined as normal and mildly  moderately  and severely increased reactivity  was as follows  group a  124  21  30  22  group b  75  15  7  and 21  and group c  69  17  39  and 72  respectively  the patients of group c  perennial rhinitis  demonstrated a distribution significantly  p less than 0 001  different from subjects with seasonal rhinitis  both group a and group b  our results are consistent with the hypothesis that perennial rhinitis is much more important than seasonal rhinitis as a risk factor for developing nonspecific bronchial hyperresponsiveness  
class9	the role of histamine in allergic diseases  histamine  which is stored mainly in mast cells and basophils  is a prominent contributor to allergic disease  elevations in plasma or tissue histamine levels have been noted during anaphylaxis and experimental allergic responses of the skin  nose  and airways  of the four cardinal signs of asthma  bronchospasm  edema  inflammation  and mucus secretion   histamine is capable of mediating the first two through its h1 receptor and mucus secretion through its h2 receptor  of the five cardinal signs of allergic rhinitis  pruritus  mucosal edema  sneezing  mucus secretion  and late phase inflammatory reactions   histamine is capable of mediating the first three through its h1 receptor  in the nose  mucus secretion can be reflexively mediated by h1 and possibly also by h2 receptors  in the skin the cardinal features of urticaria  vasodilation  vascular permeability  and pruritus  can be mediated by stimulation of the h1 receptor  in anaphylaxis histamine h1 receptor stimulation can mediate vascular permeability  smooth muscle contraction  and tachycardia  whereas h2 receptor stimulation can mediate mucus secretion  stimulation of both receptors can mediate vasodilation and reduce peripheral vascular resistance  thus although histamine is only one of many mediators of allergic disease  it plays a primary role in allergic rhinitis  urticaria  anaphylaxis  and to a lesser degree  asthma  
class9	the role of histamine in allergic rhinitis  studies using nasal provocation followed by nasal lavage have demonstrated that histamine plays an important role in the mediation of allergic rhinitis but not of rhinovirus infection  the response to antigen challenge is often biphasic  during the early response  increases in histamine levels appear to be associated with activation of mast cells  in a subset of persons who exhibit an additional late response  however  the rise in histamine is concomitant with an increase in the number of basophils  further evidence of the role of histamine in allergic rhinitis has emerged from nasal provocation experiments involving pretreatment with a variety of drugs known to antagonize or affect release of histamine  nasal provocation with histamine causes sneezing  itching  rhinorrhea  and nasal congestion  most h1 antihistamines have been found to inhibit sneezing and to lessen the increase in vascular permeability  but they do not affect histamine release  the h1 antihistamine terfenadine  however  inhibits histamine release during the early response  effects on late response remain unknown  prednisone decreases histamine levels during the late  but not the early  response  one week pretreatment with topical steroids  on the other hand  affects both the early and the late response  
class9	the role of antihistamines in otitis  chronic and recurrent otitis media can manifest as otitis media with effusion  both infection and eustachian tube obstruction  eto  have been found to play an important role in its pathogenesis  eto can be demonstrated during both early  and late phase reactions in patients with allergic rhinitis after intranasal challenge with an allergen  intranasal challenge with either histamine or prostaglandin d2 also provokes eto  with the latter mediator perhaps more potent than the former  middle ear effusions from patients with chronic or recurrent otitis media have been found to contain dramatically increased concentrations of histamine relative to the concentrations in their plasma  the development of nasal and eustachian tube obstruction in allergic rhinitis patients has been prevented by pretreatment with an antihistamine plus decongestant before intranasal challenge with pollen allergen  investigations are currently under way to assess the effect of antihistamine pretreatment on nasal and eustachian tube obstruction in patients undergoing intranasal histamine challenge  
class9	immunotherapy abrogates the generation of eosinophil and neutrophil chemotactic activity during pollen season  in a group of 40 birch pollen allergic patients with a history of rhinoconjunctivitis and wheezing during the pollen season  20 were immunotherapy  it  treated preseasonally with birch pollen extract  pharmacia  uppsala  sweden   blood samples for determination of the levels of heat labile eosinophil chemotactic activity  hl eca   heat labile neutrophil chemotactic activity  hl nca   and heat stable neutrophil chemotactic activity were collected before the season  at the beginning of the study  at the start of the season  at the peak  at the end  and after the birch pollen season  the symptoms from rhinoconjunctivitis and airways  peak expiratory flow  and use of medication were recorded throughout the season  significant increases of hl eca and hl nca were observed in untreated compared with it treated patients at the start of the season  p less than 0 0001 for both activities  and at the peak of the birch pollen season  p less than 0 0005 and p less than 0 01  respectively   at the end of the season  hl eca levels were not significantly different between the patient groups  whereas hl nca levels were still higher in untreated patients  p less than 0 005   we conclude that it completely abrogates the generation of hl eca and hl nca during a pollen season  
class9	unterberger stepping test  a useful indicator of peripheral vestibular dysfunction  deviation of gait in a stepping test has been proposed as a useful indicator of peripheral labyrinthine dysfunction  a prospective study of 26 patients suspected of having uncompensated peripheral labyrinthine dysfunction and 49 normal patients with normal labyrinthine dysfunction showed no significant difference in performance of the unterberger stepping test between patients with electronystagmographically significant canal paresis and those with normal vestibular function  
class9	ligmaject system for local anaesthesia in otology  the ligmaject syringe for local anaesthetic injection incorporates a pistol grip handle and a ratchet system designed to inject a very tiny aliquot of anaesthetic per  click   this instrument was used to provide local anaesthesia for 22 otological procedures on consenting adults  the performance of the ligmaject syringe compared favourably with that of the conventional dental syringe in terms of patient acceptability and user convenience  
class9	comparison of the goode t tube with the armstrong tube in children with chronic otitis media with effusion  treatment of otitis media with effusion is focused on reaeration of the middle ear cavity  in achieving long term aeration  the insertion of ventilation tubes that have a long duration of stay can be beneficial  the results are presented of a trial in which the goode t tube was compared with the armstrong tube  fifteen children were treated between 1981 and 1986 with a t tube in one ear and a conventional tube in the other  the results are different with regard to duration of stay in the tympanic membrane  re insertions were necessary in 47 per cent in the armstrong group and in 20 per cent in the t tube group  otorrhoea occurred in 20 per cent of the armstrong and 13 per cent of the t tube intubated ears  a persistent perforation was present in 6 per cent of the ears in both groups  it is concluded that the goode t tube is indicated primarily in cases when long term ventilation is needed  
class9	long term results of revision endolymphatic sac surgery  the results of revision endolymphatic sac surgery on 30 patients with unilateral meniere s disease are presented  good control is achieved in 73 3 per cent of cases at six months  falling to 56 7 per cent at one year and only 33 3 per cent by four years  the long term results are disappointing but are more favourable if the initial surgery was successful  if the hearing remains fluctuant and improves on glycerol dehydration prior to the revision procedure and also if the sac is intubated  the current place of endolymphatic sac surgery is discussed and revision surgery only recommended for carefully selected cases  
class9	comparison of electro and chemical cautery in the treatment of anterior epistaxis  in the ent department of the royal victoria hospital  belfast  the impression  supported only by anecdotes  was that electro cautery was superior to chemical cautery in the treatment of simple anterior epistaxis  since no evaluation of the relative merits of electro and chemical cautery has been reported  a prospective randomized study was conducted to assess the effectiveness of electro cautery and cautery with silver nitrate  the results of the study showed that there was no statistically significant difference between the two methods in either controlling the epistaxis or in the incidence of complications  it is concluded that since cautery with a silver nitrate tipped applicator is simpler  and of equal effectiveness  it would appear to be the treatment of choice for simple anterior epistaxis  
class9	role of endoscopy in diagnosing scleroma in its uncommon sites  eighty cases suffering from rhinoscleroma were studied  suspected cases were examined by sinoscopy  nasopharyngoscopy and bronchoscopy for detection of secondary involvement in these sites  antroscleroma  salpingoscleroma and tracheo bronchoscleroma have been found in a relatively high percentage of cases  the role of endoscopy in early diagnosis  initial symptomatic treatment and follow up cases is discussed  
class9	smoking cessation in chronic reinke s oedema  in evaluating the long term results of surgical treatment of reinke s oedema  there has been found to be a high incidence of recurrence  the recurrence rate is significantly lower amongst those patients who gave up smoking after treatment  a group of patients with chronic reinke s oedema were followed for six months  maximum efforts were made to help the patients to stop smoking  twenty nine patients entered the study  but only eight of them  28 per cent  refrained from smoking  all were women  39 70 years  and all experienced reduced discomfort  although none of the voices were restored to normal  diffuse laryngitis disappeared completely  but the oedema did not disappear entirely in any patient  before treatment of chronic reinke s oedema patients must be well advised and informed  and if surgery is decided upon  they must be urged most strongly to stop smoking  if they wish to enhance the possibility of satisfactory long term results  
class9	second primary tumours of the larynx following bronchial carcinoma  the occurrence of multiple primary malignancies in patients with laryngeal cancer is well known  the possibility that lung cancer patients may be at risk of subsequent laryngeal cancer is less well recognized  the possibility of laryngeal cancer developing later has implications for the follow up of lung cancer patients  three cases of subsequent laryngeal primary cancer occurring in survivors of bronchial cancer are presented and the implications are discussed  
class9	endolymphatic hydrops precipitated by haemodialysis  we report a case of endolymphatic hydrops preceded by haemodialysis in the contralateral ear of a patient with known meniere s disease  and discuss the possible mechanism  it is suggested that the sudden decrease of plasma osmolality during haemodialysis acts as a reverse glycerol test  the audiometric and electrophysiological recordings pre  and post dialysis and the induction of the meniere s triad of symptoms during dialysis  were strongly indicative of the presence of endolymphatic hydrops  
class9	epistaxis as an unusual presentation of an antrochoanal polyp  antrochoanal polyps rarely present with severe epistaxis  we present the case of a young male patient who presented in such a manner  thus leading to the suspicion of an angiofibroma as the underlying pathology  the radiological investigations  treatment and pathological features are discussed  
class9	infectious mononucleosis complicated by lingual tonsillitis  although upper airway obstruction and superimposed infection are well known complications of infectious mononucleosis  lingual tonsillitis in this context has not been mentioned in the literature  we describe a case of acute bacterial lingual tonsillitis with airway obstruction complicating infectious mononucleosis  the role of the base of tongue region in the pathophysiology of infectious mononucleosis is discussed  
class9	acute upper airway obstruction following teflon injection of a vocal cord  the value of nebulized adrenaline and a helium oxygen mixture in its management a 67 year old man presented with a 45 year history of a week voice  this was result of polio which had left him with a right vocal cord palsy  the patient underwent a teflon injection of the right vocal cord under general anaesthesia to improve the quality of his voice  in the immediate post operative period  he suffered acute upper airway obstruction  the problem of acute upper airway obstruction following teflon injection is considered and its management with nebulized adrenaline and a helium oxygen mixture is discussed  
class9	adenoid cystic carcinoma  a comparison between ct  mr and gd mr imaging techniques  nasopharyngeal carcinoma continues to be a difficult diagnostic problem in many patients  it is well known that amongst the many and varied manifestations of this disease  a unilateral middle ear effusion in an adult should be regarded with suspicion  such a case in a 42 year old patient is presented  in this case the benefit of gadolinium enhanced magnetic resonance imaging over and above computerized tomography is demonstrated  
class9	dysequilibrium and otitis media with effusion  what is the association  an association between non suppurative otitis media  nsom  and symptoms of dysequilibrium has been observed but not previously quantified in children  gates  1980  busis  1983  blayney and coleman  1984   this study compared the incidence of balance related problems in 154 children with surgically proven glue ear and 51 children with normal ear function  symptoms ranging from true vertigo to mild ataxia were discovered in 22 per cent of the children with nsom but in none of those within the control group  p less than 0 001   periods of dysequilibrium were associated with episodes of otalgia in 64 per cent of the children but were not increased in those with unilateral compared to those with bilateral effusions  complete resolution of symptoms occurred in 85 per cent of children following the insertion of grommets  a history of balance disturbance should be actively sought in all children with otitis media with effusion  and when present  provides a strong indication for early operative intervention  
class9	mucosal thickening on sinus x rays and its significance  mucosal thickening is commonly seen on x rays of the paranasal sinuses taken in the ent department  this sometimes leads to a sinus washout  which is clear  even though the x rays were strongly suggestive of disease  this paper examines the prevalence of sinus x ray anomalies in a general population  having facial x rays for conditions other than possible sinus disease  the study suggests that up to 50 per cent of the so called normal population may have sinus x ray appearances consistent with sinus disease  and this may partly explain clear returns on sinus washout  
class9	multiple primary malignancies in patients with malignant tumours of the nasal cavities and paranasal sinuses  the incidence of multiple primary malignancies  mpm  was analysed in 1297 patients with malignant tumours of the nasal cavities and paranasal sinuses  the patients were followed for a minimum of six years or until death  the incidence of mpm was 3 4 per cent  44 1297  which is lower in patients with malignant tumours of other regions in the upper aerodigestive tract  five of the 44 patients had second malignancies within previously irradiated areas  there was a difference between the proportion of histologies occurring in irradiated tissues compared with the overall 1297 patients  this finding suggests that radiotherapy may induce a second cancer  
class9	radiation therapy of laryngeal cancer  a twenty year experience  this paper reviews a 20 year experience of radiation treatment of 286 laryngeal cancers and presents results with a minimum five year follow up  all cases presented had glottic or supraglottic squamous cell carcinomas with no clinical evidence of nodal metastasis  a policy of primary radiotherapy with surgery for salvage of treatment failures  produced control of primary disease and prevention of metastases superior to most other regimes documented in the literature  
class9	effect of microwave and ionizing radiation in patients with recurrent laryngeal carcinoma  this study describes the treatment and survival of 54 patients with gross recurrent laryngeal carcinoma after radiotherapy  twenty six patients were treated with local ultra high frequency hyperthermia in combination with radiotherapy and chemotherapy  hrch   twenty eight control patients were treated with radiotherapy and chemotherapy  rch   eight patients  33 per cent  in hrch showed a three year survival but no patient in the rch group  at two years 18 patients  75 per cent  in hrch and two  7 per cent  in rch survived  
class9	another hazard of ear syringing  malignant external otitis  a case of malignant external otitis is presented  this occurred in a healthy 72 year old non diabetic  non immuno compromised man after ear syringing  the infection was treated with oral ciprofloxacin for eight weeks with complete resolution  
class9	laryngeal metastasis from colonic adenocarcinoma  metastases to the larynx from distant primaries are very rare  usually the secondary lesion comes from an hypernephroma or malignant melanoma  a case of metastatic laryngeal tumour from a colonic adenocarcinoma  occurring in a 59 year old woman  is presented and the routes for laryngeal spread are discussed  the poor survival rate of these patients justified only conservative surgery  
class9	intralaryngotracheal thyroid  a case of intralaryngotracheal thyroid in a 57 year old man is presented  the treatment modalities are considered and the previous literature is reviewed  
class9	efficacy and morbidity of partial laryngectomy and postoperative radiation therapy  in recent years  we have seen increasing use of partial laryngectomies for larger lesions that were previously treated by total laryngectomy  the resultant closer margins have made postoperative radiation therapy an important adjuvant treatment to conservation laryngeal surgery  we review the university of california  los angeles  experience with combination partial laryngectomy and postoperative radiation therapy between 1973 and 1987 for treatment of carcinoma of the larynx  twenty four such patients who underwent partial laryngectomies and postoperative radiation therapy are examined  techniques of treatment  complications  and the functional ability of the remaining larynx are discussed  the locoregional control rate at 5 years was 80   risk factors associated with an increased risk of recurrence were positive margins  vascular invasion  and extranodal spread  there were no major problems with postoperative wound healing or airway management during the radiation treatment  vocal and swallowing function were well preserved in most cases  we conclude that combination partial laryngectomy and radiation therapy permits preservation of laryngeal function without serious complications  and therefore is an effective treatment for selected patients with carcinoma of the larynx  
class9	computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis  in this study  the computed tomography scans of 100 patients with chronic hyperplastic rhinosinusitis were reviewed to establish a clinical staging system  fourteen percent of the patients were classified as stage i  single focus disease   36  as stage ii  multifocal disease responsive to conservative therapy   32  as stage iii  diffuse disease partially responsive to medication   and 16  as stage iv  diffuse disease associated with bony changes and poorly responsive to conservative treatment   the incidence of recurrent or persistent disease ranged from 13  for stage ii to 30  for stage iv  stage i and iii patients had 13  and 18  recurrence rates  respectively  computed tomography staging is shown to be useful in outlining operative strategies and is a reliable prognosticator of the disease process  
class9	intraoral extramaxillary sinus approach for ligation of the maxillary artery  an anatomic study with clinical correlates  surgical control of severe epistaxis is usually reserved for cases refractory to more conservative techniques  we present our experience with intraoral ligation of the maxillary artery as it courses through the buccal fat pad before it enters the pterygopalatine fossa and branches posterior to the maxilla  this technique has been found useful in the control of nasal hemorrhage as well as an adjunct to other surgical procedures  such as removal of benign and malignant neoplasms involving the maxilla and paranasal sinuses  this technique was used for ligation of the maxillary artery in 20 patients  the artery was readily identified in some cases  but required more extensive dissection in others  therefore  an anatomic study in 18 preserved and fresh cadaver specimens was undertaken to investigate the variability of the maxillary artery in the region of the buccal fat pad  there appeared to be significant variation in the distance from the buccal mucosal incision site  as well as variation in the relationship to the pterygoid muscles  this relationship to the pterygoids explains the occasional difficulty in locating the artery for ligation  this technique represents a reasonable alternative to the more traditional transantral approach to ligation of the maxillary artery  as long as the surgeon understands the anatomy of the region  its variations  and where the artery may be located if not immediately apparent  no major complications have been experienced  
class9	vocal cord paralysis in children  bilateral vocal cord paralysis is a common cause of stridor in infants and children  there are significant differences in this entity between children and adults with regard to etiology  diagnosis  management  and outcome  a review of 10 years  experience at children s hospital of philadelphia identified 51 children seen with the diagnosis of vocal cord paralysis  these cases were evaluated with respect to etiology of paralysis  whether unilateral or bilateral  delay in diagnosis  need for tracheotomy  abnormality of voice  surgical treatment  and outcome  guidelines for management for a child with vocal cord paralysis are presented with emphasis on flexible endoscopic evaluation and conservative management  
class9	myogenic influences on the electrical auditory brainstem response  eabr  in humans  two cases demonstrating the effects of myogenic artifact on the electrical auditory brainstem response  eabr  when using a promontory stimulation site are presented  intensity response functions were obtained in the unparalyzed condition  then repeated after infusion of a neuromuscular paralyzing agent  in both cases  the myogenic response was observed at lower stimulus intensities than the eabr components  as intensity increased  the myogenic responses grew at extremely rapid rates and made any subsequent identification of auditory responses virtually impossible  to alleviate the adverse influence of myogenic components  general anesthesia and a paralyzing agent must be incorporated into the test protocol when acquiring the eabr using a promontory site of stimulation  
class9	evaluation of neonatal subglottic stenosis  a 3 year prospective study  subglottic stenosis is the most common cause of chronic airway obstruction  it results in prolonged tracheal cannulation of infants and children  following the widespread adoption over the past 20 years of prolonged intubation for respiratory support in neonates  the incidence of acquired subglottic stenosis increased dramatically  on january 1  1987  we began a 3 year prospective study to delineate potential etiologic factors involved in the development of subglottic stenosis in neonates  the present study analyzes data from 289 infants  relationships between birth weight  gestational age  endotracheal tube size  duration of intubation and ventilation  number and difficulty of intubations  and the subsequent need for medical and surgical therapy are discussed  whole organ larynges from autopsy specimens provide histological correlation  
class9	the efficacy of comprehensive neck dissection with or without postoperative radiotherapy in nodal metastases of squamous cell carcinoma of the upper respiratory and digestive tracts  neck recurrence free curves corrected for local recurrence were compared for 494 patients who underwent 565 comprehensive neck dissections  in 42 dissections  no radicality could be obtained  of the 523 histologically radical dissections  examination revealed tumor in 352 cases  patients in whom three or more positive nodes or extranodal spread in one or more nodes were found received postoperative radiotherapy  in the histologically n0 group  the incidence of neck recurrence after 5 years was 3   in the n  group as a whole  it was 10   analysis of the influence of extranodal spread and the number of positive nodes showed that the group with one or two positive nodes without extranodal spread  that did not receive postoperative radiotherapy  did not statistically differ from the other groups  this suggests that the results of the group with one or two positive nodes without extranodal spread can be improved by postoperative radiotherapy  
class9	esthesioneuroblastoma  surgical treatment without radiation  this study compares the treatment of two groups of patients diagnosed with esthesioneuroblastoma limited to the nasal cavity without evidence of cribriform plate erosion  five patients were treated with radiation and extracranial excision  and eight patients were treated by craniofacial resection only  the incidences of local recurrence were 60  and 12   respectively  the paper also presents a new staging classification for these tumors  
class9	artificial restoration of voice  i  experiments in phonatory control of the reinnervated canine larynx  coordinated electronic pacing of implanted nerve pedicles into paralyzed laryngeal muscles has allowed selective dynamic control of abduction  adduction  and elongation of the vocal cords  modifications of the original circuit in a cervical muscle model has added fine tuning to basic  all or none  pacing  rehabilitation of phonation illustrated the sophisticated nature of voice and the need for restoration of fine tuning  five mongrel dogs received nerve muscle pedicles into the thyroarytenoideus  cricothyroideus  and posterior cricothyroideus after denervation of one hemilarynx  following appropriate reinnervation time  pedicles and intact recurrent laryngeal nerves were injected with currents of variable amplitudes and pulse widths to achieve graded vocal fold control while air was blown intratracheally towards the glottic chink  videoscopic and spectral analyses indicated that artificial phonation could be restored to frequencies measured in the normal state  these experiments suggested that rehabilitation of the impaired voice by servocontrol might eventually be feasible  
class9	an in vivo canine model for testing treatment effects in laryngeal hyperadduction disorders  adductor spastic dysphonia is a voice disorder characterized by a strained  squeezed  effortful voice produced by true and false cord hyperadduction  an in vivo canine model has been developed to simulate hyperadduction of the true cords  using this model  the thyroarytenoid muscle was found to have a greater effect on intraglottic and subglottic pressure than cricothyroid muscle contraction  the intraglottic and subglottic pressure was reduced after simulated recurrent laryngeal paralysis  this model can be used in future studies to compare laryngeal treatment modalities for disorders that have a component of vocal cord hyperadduction  such as spastic dysphonia  
class9	lasers for otosclerosis  which one if any and why  laboratory stapedotomy and stapedectomy revisions were performed in human temporal bones while pyroelectric wave energy analyzers and ultrasensitive thermocouples measured energy absorption at the stapes footplate and in the vestibule  analysis of these data shows that the visible lasers  argon and ktp 532  possess ideal optical properties and precision for otosclerosis surgery but conversely have less than ideal tissue characteristics  the co2 laser possesses ideal tissue characteristics  recent advances in optical engineering and pulsing the energy have increased the precision of this laser to now provide the accuracy required for delicate microsurgery  two clinical studies analyze the long term hearing results and complications in patients who had undergone co2 laser stapedectomy revision  59 patients  and co2 laser stapedotomy  153 patients   the advantages that these laser techniques provide over conventional surgery methods are discussed  
class9	extrapulmonary pneumocystosis  clinical features in human immunodeficiency virus infection  pneumocystis carinii infection is reported with increasing frequency as a cause of disease outside of the respiratory tract in patients with human immunodeficiency virus  hiv  infection  extrapulmonary pneumocystosis is not limited to patients in any discrete risk group for hiv infection  patients with hiv infection who develop extrapulmonary pneumocystosis frequently do not have concurrent p  carinii pneumonia  signs and symptoms of extrapulmonary pneumocystosis are nonspecific but when present are frequently referable to the tissues or organs involved  extrapulmonary pneumocystosis can be diagnosed by examination of tissue biopsies from affected sites using standard histologic techniques  therapy with antimicrobial agents used to treat p  carinii pneumonia has been effective in some patients  an association between use of aerosolized pentamidine for prevention of p  carinii pneumonia and development of extrapulmonary pneumocystosis has been suggested but remains unconfirmed  other factors such as the use of zidovudine and duration of immunodeficiency may also be important to the pathogenesis of extrapulmonary pneumocystosis  further studies are needed to better identify risk factors that may predispose patients to the development of extrapulmonary pneumocystosis  
class9	chronic lyme disease with an expansive granulomatous lesion in the cerebellopontine angle  expansive granulomatous lesions in the posterior cranial fossa are rare and have not been reported in conjunction with lyme disease  we report a patient with verified borrelia burgdorferi infection who developed a tumor in the cerebellopontine angle  rapid growth of the tumor led to signs of cerebral compression and to hydrocephalus  surgical intervention was required despite florid meningitis  the histological examination showed inflammatory  nonspecific granulation tissue  the origin of this tissue is almost certainly causally related to the b  burgdorferi infection  signs of inflammation resolved rapidly after subtotal resection  the clinical  radiological  and biochemical course is documented  this is the first report of an expansive cerebral lesion in the chronic phase of lyme disease  
class9	management of chronic middle ear effusion with prednisone combined with trimethoprim sulfamethoxazole  fifty three patients were enrolled and evaluable in a randomized  double blinded controlled clinical trial comparing prednisone for 7 days plus trimethoprim sulfamethoxazole  tmp smz  for 30 days vs  tmp smz alone in treating chronic middle ear effusion  mee   clearing of the effusion in both ears or in one when only one was involved was called complete resolution  clearing in one of two affected ears was called partial resolution  the outcomes 2 weeks after initiation of therapy of 26 patients initially treated with prednisone plus tmp smz were complete resolution in 20  partial resolution in three  and unchanged in three  the outcomes in 27 patients initially treated with tmp smz alone were complete resolution in eight  partial resolution in three  unchanged in 13 and development of acute otitis media in three  p less than 0 01 for complete resolution   two weeks after initiation of therapy  patients with a mee that failed to clear were crossed over to the alternative regimen  overall 29 of 41 patients  71   who received oral prednisone plus tmp smz initially or after the crossover had complete resolution of their middle ear effusion at 2 weeks after starting prednisone and tmp smz  five of 35  14   patients treated with prednisone plus tmp smz and one of six  17   patients treated with tmp smz alone who had complete resolution at 4 weeks required subsequent referrals for tympanostomy tubes  a course of prednisone for 7 days plus tmp smz for 30 days with monthly follow up should be considered in children with mee persisting beyond 6 8 weeks before referral for tympanostomy tube placement  
class9	improved technique for a one stage repair of significant defects of the ear  an improved technique for repair of severe acquired partial defects of the auricle in one stage is described  the common postauricular flap with its base on the margin of the auricular defect is usually unable to repair a severe partial auricular defect in one stage because of the limited length of the flap  the authors developed this technique by means of lengthening the flap with a piece of subcutaneous tissue of the scalp  so that the ear framework can be covered completely in one stage  all flaps in this group survived totally  seven patients with severe acquired partial defects of the auricle underwent this procedure  and good results were obtained  
class9	nasolaryngoscopy for family physicians  nasolaryngoscopy is easy to learn and safe and convenient to perform  it is readily accepted by patients and is a rich source of clinical information  the flexible nasolaryngoscope allows the physician to directly observe the anatomy of the nasal passages  pharynx and larynx  the procedure is helpful for identifying the etiology of chronic nasal complaints and hoarseness  other possible indications for nasolaryngoscopy include suspected nasal foreign body  recurrent nasal or pharyngeal bleeding  and epiglottitis  with the use of this instrument  treatment of otolaryngologic conditions may be more specific  thereby reducing unnecessary referral or delay in treatment  
class9	laryngeal oedema from a neck haematoma  a complication of internal jugular vein cannulation  laryngeal oedema occurred after formation of a neck haematoma after attempted internal jugular vein cannulation  this resulted in complete respiratory obstruction and respiratory arrest and it was impossible to ventilate her lungs manually or intubate her trachea  oxygenation of the patient was only possible using transtracheal ventilation  
class9	toxic streptococcal syndrome  the streptococcal toxic shocklike syndrome is a recently recognized  multisystem disorder that shares many of the features of staphylococcal toxic shock syndrome  but is caused by toxins elaborated by group a beta hemolytic streptococcus  we describe a patient who fulfilled the major criteria for the clinical diagnosis of toxic shock syndrome  fever  hypotension  multisystem dysfunction  and diffuse macular erythroderma followed by desquamation  and who demonstrated serologic evidence suggesting streptococcal infection  in patients presenting with clinical findings consistent with a toxic shocklike syndrome  the emergency physician should consider streptococcal infection as a potential etiology  
class9	human basophil releasability  vi  changes in basophil releasability in patients with allergic rhinitis or bronchial asthma  we evaluated basophil releasability in two groups of allergic patients with positive skin tests to dermatophagoides pteronyssinus major allergen  der p l   29 adults with bronchial asthma and 17 with allergic rhinitis  and in 31 age matched normal donors  both basophil reactivity  maximal percent histamine release  and basophil sensitivity  the concentration that causes 50  of maximal percent histamine release  hc50  to der p l in patients with asthma were similar to those in patients with allergic rhinitis  on the contrary  basophil reactivity to anti ige was significantly higher in patients with asthma  58 0     3 6   than in patients with allergic rhinitis  46 3     5 2   p less than 0 05   both groups of patients showed an increased releasability compared to control subjects  27 3     4 6   p less than 0 001   whereas there were no significant differences in basophil sensitivity to anti ige among the three groups of donors  differences were also found with respect to basophil reactivity and sensitivity to f met peptide  whereas no differences appeared when basophils from the three groups of donors were challenged with the ca2  ionophore a23187  there was a significant correlation between basophil reactivity and sensitivity to der p l and to anti ige in both asthmatic and allergic rhinitis patients  a significant correlation was found between basophil reactivity and sensitivity to anti ige and serum ige level only in patients with bronchial asthma  whereas no correlations were found in patients with allergic rhinitis  there was no correlation between in vivo mast cell releasability and in vitro basophil releasability in response to der p l in either group of allergic patients  
class9	delayed endolymphatic hydrops and its relationship to meniere s disease  delayed endolymphatic hydrops  eh  can be characterized as having ipsilateral and contralateral types  they are similar in that both have early and late phases of otologic symptoms and that the early phase is a profound hearing loss in one ear  the late phases differ  however  in that the ipsilateral type develops the symptoms of eh  episodic vertigo  in the deaf ear and the contralateral type develops the symptoms of eh  fluctuating hearing loss and or episodic vertigo  in the hearing ear  in more than half the cases of both types of delayed eh  the profound hearing losses in the early phase are simply discovered to be present in early childhood without a known time of onset  the temporal bones of two patients with contralateral delayed eh show pathologic changes in the deaf ears that are similar to those known to occur in mumps and measles labyrinthitis  whereas the pathologic changes in the hearing ears are similar to those known to occur in meniere s disease  these observations support the proposition that meniere s disease may occur as a delayed sequela of inner ear damage sustained during an attack of subclinical viral labyrinthitis occurring in childhood  
class9	head stability and gaze during vertical whole body oscillations  to understand head and eye stabilities during upright locomotion  we investigated head and eye movements during vertical whole body oscillations of various amplitudes  1 to 10 cm  and frequencies  1 to 3 hz  in both normal subjects  n   10  and patients with bilateral labyrinthine loss  n   5   vertical oscillations produced pitching motions of the head  of which the amplitude was markedly altered by a change in the oscillation frequency or the displacement  vertical eye movements  being correlated with pitching head movements  were scarcely modified by gaze at 2 and 3 hz  acquired bilateral lesions presented deteriorated head stability and physically induced eye movements under stronger stimulations  however  significant increase of head movement upon stepping and suppression of pitching motion upon running  both characteristically found in bilateral lesions  were not reproduced by passive oscillations  thus  these features during active locomotion may result from imbalance produced by alternate bipedal motions and from adaptation to minimize oscillopsia  respectively  
class9	facial nerve monitoring in otologic surgery  clinical indications and intraoperative technique  while identification of the intratemporal portion of the facial nerve is mandatory in most otologic surgical procedures  inadvertent instrumentation  traction  or thermal injury may still result from inaccurate delineation  purposeful avoidance  or false protection of this critical structure  improved functional preservation of the facial nerve has been achieved in acoustic neuroma surgery through the monitoring of evoked facial electromyographic activity  this technique may also be used during otologic procedures in which facial nerve manipulation is anticipated in the management of recurrent cholesteatoma  temporal bone trauma  congenital deformity  or purposeful access for cochlear implantation  potential indications for using facial nerve monitoring in contemporary otologic surgery are detailed through illustrative case presentations  and necessary instrumentation and techniques are briefly reviewed  intraoperative monitoring can assist the surgeon in isolating the facial nerve when chronic inflammation  traumatic injury  or anomalous development has resulted in distortion or absence of microanatomic landmarks  
class9	titration streptomycin therapy for bilateral meniere s disease  follow up report  initial reports of the use of parenteral streptomycin for bilateral meniere s disease  md  have demonstrated success in reducing the vestibular symptoms and  in some patients  stabilizing hearing  the long term follow up  mean  5 1 years  of 19 patients treated with intramuscular streptomycin for bilateral md is presented  the amount of streptomycin administered  5 to 50 g  was determined by clinical symptoms and by serial testing of the reduction in the slow phase velocity on electronystagmography  episodic vertigo was totally relieved in 12 patients and improved in severity and frequency in an additional 4 patients  permanent posttreatment dysequilibrium occurred in 47  of the patients treated  the changes in hearing  speech reception threshold  were independent of the therapeutic effect of streptomycin on the vestibular system  the overall results suggest that the intramuscular titration of streptomycin should continue to be considered as one of the therapeutic options in patients with disabling vertigo due to bilateral md  
class9	drop attacks with meniere s syndrome  we report the clinical features of 12 patients with drop attacks associated with meniere s syndrome  each described a sensation of being pushed  thrown  or knocked to the ground or a sudden illusion of movement of the environment that led to a fall  these episodes were not accompanied by symptoms of their typical attacks of meniere s syndrome  the drop attacks occurred early and late in the course of the disease  they were the initial manifestation in 1 patient  in the majority the episodes spontaneously remitted  although meniere s syndrome continued to progress  these attacks probably result from a sudden mechanical deformation of the otolithic membrane of the utricle or saccule due to pressure gradients within the inner ear  they are important to recognize because their prognosis is relatively benign compared to other causes of drop attacks  
class9	the nasolabial flap as a single stage procedure  the nasolabial flap is a useful reconstructive technique for the repair of defects on the nose  an improved technique used in 32 patients is presented  which allows use of this procedure as a single stage rather than the more commonly seen two stage procedure  the alterations include the following   1  the excision of a burow s triangle superior edge of the defect toward the inner canthus   2  the use of a periosteal or suspension suture to minimize tenting across the concave junction of the nose and cheek   3  wide undermining of the skin surrounding the defect to create a stabilizing platelike scar   4  significant thinning of the donor flap  and  5  adjust the size of the flap to recreate the original preincisional skin tension on the flap after suturing  none of the 32 patients presented required a second stage procedure to correct trapdoor defects or to recreate natural folds or creases  
class9	left recurrent laryngeal nerve paralysis  an unusual presentation of histoplasmosis  a case of histoplasmosis seen as left recurrent laryngeal nerve paralysis in a 49 year old man is described  the patient had roentgenographic findings of a solitary  noncalcified left upper lobe mass and mediastinal adenopathy  tissue diagnosis of histoplasmosis was obtained using a thoracotomy  allowing institution of appropriate treatment  
class9	lovastatin  warfarin interaction  two patients who developed hypoprothrombinemia and bleeding due to lovastatin warfarin drug interaction are described  because of the wider use of lovastatin and warfarin  heightened clinical awareness of this potentially serious interaction must be publicized  therefore  prothrombin time should be monitored diligently when warfarin is prescribed to patients receiving lovastatin  
class9	leiomyosarcoma of the sinonasal tract  a clinicopathologic study of nine cases  the clinicopathologic features of nine cases of sinonasal tract leiomyosarcoma  sntl  referred to the armed forces institute of pathology  washington  dc  during the period from 1970 through 1988 are described  this report represents the largest study to date on sntl  and our results are compared with the 21 previously reported cases of sntl  of the nine cases described  patients ranged in age from 22 to 86 years  mean  55 years   the most frequent clinical presentation was nasal obstruction unilaterally  the neoplasms were limited solely to the nasal cavity in four cases  44   and involved both the nasal cavity and paranasal sinuses in the remaining five cases  light microscopic  immunocytochemical  and ultrastructural features served to characterize these tumors as malignant neoplasms of smooth muscle origin  in contrast with previous studies  immunocytochemistry was employed to differentiate sntl from other spindle cell malignancies of the region  using newly available monoclonal antibodies to smooth muscle antigens  treatment was surgical  radiotherapy or chemotherapy did not appear to affect the progression of the disease  furthermore  no relationship was found between the aggressiveness of sntl and morphologic parameters  eg  mitotic count and tumor size   instead  prognosis was dependent on the distribution of disease at presentation  of all 30 patients with sntl described to date  10 had the neoplasm confined solely to the nasal cavity  the 10 neoplasms did not recur  we conclude that sntl may best be regarded as a locally aggressive neoplasm with only limited metastatic potential and that it could be curable by complete surgical excision  
class9	epstein barr virus related antibody  changes in titers after therapy for nasopharyngeal carcinoma  using long term follow up data from a prospective  collaborative study of 182 north american patients  we evaluated the significance of various serologic tests for antibody to epstein barr virus in predicting outcome after treatment in patients with nasopharyngeal carcinoma  we restudied these patients by examining repeated measurements of each titer at various times after diagnosis and treatment  we looked for associations between trends of titers  measured as the slope of log titer  against time  and titer level  measured as the mean of log titer   with the outcome  alive and no evidence of disease  alive with recurrence  or dead of nasopharyngeal carcinoma  we found that posttreatment sequential measurements do not predict outcome  
class9	distortion product otoacoustic emissions in normal and impaired adult ears  distortion product otoacoustic emissions  dpoes  were recorded in a group of normally hearing subjects  29 ears  and a group of subjects whose conditions were diagnosed as sensorineural hearing loss  23 ears  to study any correlation that might exist between dpoe characteristics and hearing impairment of different configurations  three different dpoe paradigms have been used to investigate the influence of different test parameters on the dpoe data for normal and hearing impaired ears  all normally hearing ears demonstrated detectable dpoes  provided that the primary tone level was above a certain value  hearing impaired ears produced substantially reduced dpoes compared with normally hearing subjects when the primary frequencies f1 and f2 corresponded to the region of hearing loss  our data also suggested that  in general  more than one f2 f1 ratio is needed to examine any particular frequency region  the dpoes provide frequency specific information about cochlear function  which after further development  may form a basis for a noninvasive  objective method of evaluating cochlear function  
class9	a patient oriented approach to perilymph fistula  the subject of perilymph fistula is controversial in part because the preoperative diagnosis of perilymph fistula is difficult  patients suffering auditory and vestibular symptoms secondary to perilymph fistula  therefore  present a dilemma to the practicing physician  in some instances  patients with auditory and vestibular symptoms in the absence of perilymph fistula will be subjected to middle ear exploration without benefit  while in other instances patients with auditory and vestibular symptoms secondary to perilymph fistula will be denied surgical treatment  auditory and vestibular symptoms are a quality of life issue  therefore  in an effort to provide care of the highest quality the patient must be actively involved in the decision process  such involvement can be meaningful only after the patient is carefully counseled as to the pros and cons of surgery  as well as the alternatives  a prognostic paradigm based on the personal experience of one of us  w l m   with perilymph fistula patients is described and is used in patient consultation in an effort to facilitate decision making  
class9	chondrosarcoma of the larynx  diagnosis with magnetic resonance imaging and computed tomography  chondrosarcomas are the most common sarcomas of the larynx  they are generally slow growing lesions with insidious onset of symptoms  we are presenting a case of chondrosarcoma that recurred 10 years after excision of a presumed chondroma  computed tomographic and magnetic resonance imaging  mri  scans were performed  both studies delineated the lesion nicely  to the best of our knowledge  this is the first report on mri characteristics of chondrosarcoma of the larynx  a review of the literature regarding the use of computed tomography in the management of chondrosarcoma is presented  the mri characteristics are discussed and the two scanning modalities are compared  computed tomography is an excellent study in its ability to demonstrate the extent of the lesion within the laryngeal skeleton  furthermore  it is more highly sensitive than plain roentgenograms in the detection of calcifications that are highly suggestive of chondrosarcoma  alternatively  mri can also demonstrate the lesion within the larynx but it has the added advantage of superior contrast resolution of the tumor and paralaryngeal tissues  when the three dimensional imaging capacity of mri is considered as well  mri seems to be the superior study  
class9	small fenestra stapedotomy using a fiberoptic hand held argon laser in obliterative otosclerosis  obliterative otosclerosis has been a challenge since the advent of stapes surgery   drill out  procedures have had a generally poorer prognosis than conventional stapes surgery because of excessive bleeding  acoustic trauma from the burr  and reclosure of the oval window by otosclerosis  in this report  we describe our early experience using a hand held fiberoptic argon laser for small fenestra stapedotomy in 10 cases of obliterative otosclerosis  closure of the air bone gap to within 10 db was seen in 100  of the patients  there was no significant sensorineural hearing loss  vertigo  or facial weakness  argon laser stapedotomy using a hand held fiberoptic system is a safe and effective alternative to drill out stapedotomy in cases of obliterative otosclerosis  
class9	chondrogenic potential of tragal perichondrium  a cause of hearing loss following stapedectomy  tragal perichondrium is a widely used tissue seal in the oval window following stapes surgery  autogenous and easily accessible  it is a suitable substance to cover the vestibule in total stapedectomy  and to seal around the prosthesis in small fenestra stapedotomy  the incidence of complications from the use of perichondrium in this manner is exceedingly low  we report a case where tragal perichondrium in the oval window resulted in the proliferation of cartilage  the cartilage displaced the stapes prosthesis  resulting in a conductive loss  although the chondrogenic potential of perichondrium is known  we are not aware of other reports implicating this as a cause of failure in stapes surgery  the pertinent clinical and experimental literature regarding chondrogenesis is reviewed  this information suggests that the formation of cartilage from perichondrium in the oval window might be influenced by mechanical trauma and tissue orientation  
class9	selective management of early glottic cancer  seventy patients with stage i and ii glottic cancer were treated at the university of utah school of medicine hospitals from 1980 through 1987  forty four patients had stage i cancer and 26 patients had stage ii  the overall survival in the stage i group was 82   primary site control was 93  with only three deaths due to laryngeal cancer  local control rates were 93  with co2 laser excision  80  with co2 laser and irradiation  and 67  with radiation alone  stage ii glottic patients had an overall survival of 61 5  with a local control rate of 76   twenty one of 24 patients were treated by full course irradiation  of the eight patients who recurred at the primary site  all were irradiation failures who had initial bulky disease and impaired vocal cord mobility  selective co2 laser excision was highly effective  whereas radiation therapy results were somewhat disappointing  open partial laryngectomy should be considered in bulky stage ii disease patients  
class9	allograft tympanoplasty  predictive value of preoperative status  the functional and anatomical results of a series of 181 consecutive allograft tympanoplasties for ears with drum perforation and an intact ossicular chain were retrospectively reviewed and related to preoperative factors  drum closure was realized in 92   166 of 181 cases evaluated 1 year after surgery   and 96 6  of the reconstructed drums were still intact 3 years after surgery  118 cases evaluated   an air bone gap of less than 21 db was reached in 79 6   of a total of 162 cases  1 year after surgery  and in 78   of a total of 118 cases  3 years after surgery  age  contralateral pathology  the wet or dry status of the ear preoperatively  and the preoperative air bone gap had no influence on anatomical results  the preoperative air bone gap did not predict the postoperative air bone gap  the influence of age and existence of contralateral pathology on hearing gain was only visible in some of the strictly defined patient groups  the wet preoperative status of the ear generally predicted lower functional gain  
class9	otologic disease in aids patients  ct correlation  the contrast enhanced computed tomographic  ct  scans of the temporal bone and brain in 18 patients with otologic disease and acquired immunodeficiency syndrome  aids  were retrospectively reviewed  seven scans revealed middle ear and mastoid disease  three scans were consistent with central nervous system  cns  pathology  and eight scans demonstrated no abnormalities  ct scanning was found useful in localizing otopathology and diagnosing cns toxoplasmosis  aural polyps  osteomyelitis  mastoiditis  and middle ear effusion due to hypertrophic lymphoid tissue  the authors conclude that aids patients with sensorineural hearing loss should undergo contrast enhanced brain ct scans to rule out cns pathology  aids status does not alter criteria for ct scanning in patients with conductive hearing loss  and that images of the nasopharynx should be included on temporal bone ct scans of patients with conductive hearing loss in order to exclude eustachian tube obstruction by hypertrophic lymphoid tissue  
class9	the inferiorly based superior tympanomeatal flap for removal of congenital cholesteatoma  we believe that the ib stmf is preferable to the p tmf for removal of a congenital cholesteatoma from the anterior superior portion of the mesotympanum  though developing an ib stmf may require extra time and special care to avoid tearing the flap  the exposure that is achieved affords the best chance for complete removal of the mass  thus decreasing the chance for persistence or recurrence of the lesion  
class9	children with special needs in england and wales  the care of hearing impairment  myelomeningocele  and adolescent pregnancy  services for children with special needs in england and wales are described briefly  with attention to the services provided by the national health service  local authorities  the social security system  and voluntary organizations  for illustrative purposes  particular reference is made to children with hearing impairments and myelomeningoceles  a separate account is given of the provision for pregnant adolescents  again addressing services provided by all major sources of assistance  
class9	children with special needs in the netherlands  impaired hearing  adolescent pregnancy  and myelomeningocele  in the netherlands  treatment and management of children with special needs is characterized by the absence of financial barriers to care and the existence of a number of specialized services  for hearing impaired children  there are special audiologic centers and special schools  adolescents at risk of unintended pregnancy are protected through education and a dedicated system of family planning clinics  children with multiple handicaps  such as those associated with myelomeningocele  face greater difficulties but still have an array of services available to them at little or no cost  families are sheltered from excessive expense through social insurance  
class9	aminoglycosides  assessing the potential for nephrotoxicity  although aminoglycosides have been a mainstay of antibiotic therapy in postsurgical infections  certain patients may be at risk for potential aminoglycoside induced toxicities  aminoglycoside nephrotoxicity is one of the most frequent causes of iatrogenic renal failure  a narrow toxicity to therapeutic ratio  a relatively long serum half life and concentration in the renal cortex all contribute to renal dysfunction  patients at greatest risk for aminoglycoside induced nephrotoxicity include the elderly  patients with pre existing renal disease and those who are volume depleted  calculations based on the results of a multicenter study demonstrate that the average additional cost incurred for each patient who had aminoglycoside related nephrotoxicity was  2 501  methods are reviewed for prospectively assessing the potential for development of nephrotoxicity to identify patients for whom effective therapeutic substitutes for aminoglycosides should be sought  
class9	asymptomatic congenital cytomegalovirus infection  audiologic  neuroradiologic  and neurodevelopmental abnormalities during the first year  twenty eight infants with asymptomatic congenital cytomegalovirus infection and 13 control infants were followed up prospectively  congenital sensorineural hearing loss was documented by auditory brain stem responses in four infected infants  two had mild bilateral loss  one had mild unilateral loss  and one had extreme unilateral loss  but in no controls  four infected infants had diffuse periventricular radiolucencies on computed tomographic scan  none had calcifications or ventriculomegaly  no differences between groups were noted on neurologic examination results or on the bayley mental developmental index  however  one infected infant had a severely delayed bayley psychomotor developmental index score  in addition  the mean mental developmental index score of the four infected infants with diffuse periventricular radiolucencies was significantly below that of the remaining infected infants  93     8 vs 109     13   these data suggest that asymptomatic congenital cytomegalovirus infection may be associated with a broad range of audiologic  subtle neuroradiologic  and neurodevelopmental differences in early infancy  
class9	endoscopic management of early supraglottic cancer  an initial endoscopic surgical approach to early supraglottic cancer provides the surgeon with the ability to accurately stage these lesions  avoiding possible undertreatment while allowing for a valuable treatment option for those supraglottic cancers with histologically incontrovertibly superficial disease  early invasion of the preepiglottic and paraglottic spaces can be determined accurately without altering or delaying any treatment option  open surgical excision  radiotherapy  or chemotherapy   the tendency of supraglottic cancers to transgress the natural foramina of the epiglottis is well established  and the concern about this depth of invasion is reflected by the 1977 revised staging criteria  which required assessment of the preepiglottic space  pes   along with the microscope and the carbon dioxide laser  the adjustable supraglottiscope facilitates the determination of pes invasion and facilitates en bloc excision of superficial supraglottic cancers  the resulting morbidity typically is no different from that with routine direct endoscopy and biopsy  
class9	bilateral semicircular canal aplasia with near normal cochlear development  two case reports  congenital malformations of the vestibular labyrinth  pars superior  are rare  we present two patients with computed tomographic findings of bilateral semicircular canal aplasia with normal or near normal cochleas  initial bone conduction thresholds were within normal limits  although both patients had significant conductive hearing losses due to congenital middle ear malformations  bithermal caloric responses were absent in both  to our knowledge these are the first reports of vestibular aplasia concomitant with normal or near normal cochlear development  these findings conflict with conventional hypotheses that state that inner ear malformations result from arrested development during the normal stages of inner ear embryogenesis  
class9	effects of cyclophosphamide on the pathogenesis of cytomegalovirus induced labyrinthitis  cyclophosphamide was used in this study to define the contribution of the inflammatory response relative to direct cytopathic effects of guinea pig cytomegalovirus  gpcmv  in inducing sensorineural hearing loss in the guinea pig  the eighth nerve compound action potential  cap  threshold on day 7 after inoculation of gpcmv into the scala tympani was an average of 35 db greater for control animals than for those that were immunosuppressed with daily intraperitoneal injections of cyclophosphamide  20 mg kg body weight   the amount of gpcmv antigen in the cochlea  detected immunohistochemically did not correlate with the cap threshold  however  the greater the inflammatory response to gpcmv in the cochlea  the higher the cap threshold and thus the greater the hearing loss  this study demonstrates that the inflammatory response to gpcmv may be more important than direct cytopathic effects of the virus in producing sensorineural hearing loss in gpcmv induced labyrinthitis  
class9	idiopathic sudden sensorineural hearing loss and postnatal viral labyrinthitis  a statistical comparison of temporal bone findings  although the cause of idiopathic sudden sensorineural hearing loss remains uncertain  a viral origin has been suggested in many cases on the basis of anamnestic microbiologic and pathologic data  twenty two temporal bone specimens from 18 patients who during life suffered a sudden partial or complete sensorineural hearing loss were studied  on the basis of clinical data  these cases were assigned to one of three diagnostic categories  and the temporal bones were studied by light microscopy and serial section analysis  the implications of the histopathologic findings for the pathogenesis of idiopathic sudden sensorineural hearing loss are discussed  
class9	immunohistochemical study of cytokeratin expression in normal and pathologic middle ear mucosa of the rat  the expression of cytokeratins in the epithelium of the middle ear and external auditory meatus of the rat was studied on cryosections of ethylenediaminetetraacetic acid decalcified specimens by use of a panel of monoclonal antibodies  the normal middle ear epithelium revealed a complex cytokeratin profile  including regional differences  the induction of sterile middle ear effusions resulted in increased cytokeratin expression  infective effusions were accompanied by both quantitative and qualitative changes in the cytokeratin expression patterns  the differences observed between the cytokeratin profiles of external meatal skin and those of middle ear epithelium may form a useful tool for research into cholesteatoma development  
class9	the association of selected cancers with service in the us military in vietnam  iii  hodgkin s disease  nasal cancer  nasopharyngeal cancer  and primary liver cancer  the selected cancers cooperative study group as part of a series of investigations into the health of vietnam veterans  we conducted case control studies involving 310 men with hodgkin s disease  48 with nasal carcinoma  80 with nasopharyngeal carcinoma  130 with primary liver cancer  and 1776 controls between 1984 and 1988  all men born between 1929 and 1953 and diagnosed in an area covered by eight cancer registries were considered eligible as cases  controls were recruited by random digit dialing  whereas the study had excellent power  96   to detect a twofold increase in risk for hodgkin s disease among vietnam veterans  its ability to detect a similarly elevated risk in the other cancers was limited  ranging from 38   nasal carcinoma  to 75   primary liver cancer   analyses showed that risks among vietnam veterans relative to other men were 1 1  hodgkin s disease   0 7  nasal carcinoma   0 5  nasopharyngeal carcinoma   and 1 2  primary liver cancer   none of these relative risks was significantly different from 1 0  similar results were obtained if vietnam veterans were compared with  1  other veterans or  2  men who never served in the military  an examination of several attributes of military service in vietnam  eg  branch  duration of service  and other characteristics that may have been associated with the use of agent orange  failed to identify any groups of veterans who were at increased risk for hodgkin s disease  small numbers limited further analyses of nasal  nasopharyngeal  and liver cancer  these results provide no evidence that  15 to 25 years following service in vietnam  the risk of these malignant neoplasms is higher among veterans  
class9	angiocentric immunoproliferative lesion t cell non hodgkin s lymphoma and the acquired immune deficiency syndrome  a case report and review of the literature  the lesions known as lymphocytic vasculitis  polymorphic reticulosis  midline malignant reticulosis  lethal midline granuloma   lymphomatoid granulomatosis  and angiocentric lymphoma form what have been collectively termed the angiocentric immunoproliferative lesions  ail   because of recent reports demonstrating clonal rearrangements of the t cell receptor in these lesions  the ail are now thought to represent a continuous spectrum of post thymic t cell non hodgkin s lymphoma  nhl   nhl associated with the acquired immune deficiency syndrome  aids  represents intermediate or high grade b cell malignancies in hiv infected patients that may be etiologically related to the epstein barr virus  ebv   there have been reports of ebv associated t cell nhl  ail  and large granular lymphocyte  lgl  proliferations  as well as hiv associated t cell neoplasia  lgl t cell proliferations  and ail  we describe a case of polymorphic reticulosis  lethal midline granuloma  arising in an hiv infected individual  who later progressed to aids  and review the literature on hiv associated and ebv associated t cell neoplasia  lgl t cell proliferations  and ail  the etiology of this ail t cell nhl  especially in relation to ebv and hiv  is discussed  
class9	ear involvement in the yellow nail syndrome  recognized features of the yellow nail syndrome include yellow nails  lymphedema  and pleural effusions  we report a patient with the additional feature of keratosis obturans  which may be a manifestation of this syndrome in the external ear  
class9	osteoma of the middle ear  osteomas involving the middle ear and causing a functional disturbance are rare  we report a case of a patient with an osteoma arising from the lateral semicircular canal  the main symptom was vertigo and to halt this the defect of the canal was obliterated with a bone chip and fibrin glue after removal of the tumour  
class9	hearing loss due to cranio metaphysial dysplasia  craniometaphysial dysplasia is a rare cause of conductive hearing loss  it is a genetic disorder of bone due to decreased osteoclastic activity in the endosteal and periosteal regions of craniofacial and long bones  the characteristic temporal bone abnormalities are attic fixation  abnormally shaped ossicles and obliterated foramina ovale  computerised tomography is helpful in predicting operative findings  surgery should be reserved for those with a severe hearing loss  
class9	auro nasopharyngeal polyp and cholesteatoma  we report the association of an auronasopharyngeal polyp arising in a congenitally abnormal middle ear and eustachian tube  subsequently  ten years after removal of the polyp and insertion of a ventilation tube  there was recurrence of the polyp in association with cholesteatoma of the middle ear  
class9	chronic sinusitis and the yellow nail syndrome  diagnosing syndromes that include chronic sinusitis can expedite the management of both conditions  yellow nail syndrome is usually described as the combination of yellow nails  lymphoedema and often respiratory manifestations such as chronic sinusitis  bronchiectasis and pleural effusions  the pathology responsible for the syndrome is believed to be lymphatic hypoplasia  diagnosis of yellow nail syndrome is clinical not requiring any specialized tests  in the two cases described  the respiratory tract manifestations required the most active investigation and management  the significance of this syndrome to the otolaryngologist is discussed  
class9	direct extension of laryngeal carcinoma to the skin of the neck  invasion of the skin of the neck by laryngeal carcinoma is relatively uncommon  twelve cases of cancer of the larynx fungating through the cervical skin are presented  they mostly followed initial treatment by deep x ray therapy or partial laryngectomy  a high tracheostomy was also considered to be a contributing cause for the occurrence of such a mishap  the management and follow up of these patients is described  
class9	reduced allergen induced nasal congestion and leukotriene synthesis with an orally active 5 lipoxygenase inhibitor background and methods  the clinical importance of leukotrienes in human allergy has not been defined  in part because there have been no selective 5 lipoxygenase inhibitors that have been effective and safe for use in humans  to address the hypothesis that stimulated leukotriene synthesis causes symptoms of immediate hypersensitivity reactions in vivo  i investigated the effects of a new 5 lipoxygenase inhibitor  a 64077  on provoked allergic nasal symptoms and mediator release in a double blind  randomized  placebo controlled study  eight subjects with allergic rhinitis underwent nasal challenge on two occasions after an oral dose of 800 mg of a 64077 or an identical appearing placebo  results  allergen induced nasal congestion was significantly attenuated  p less than 0 02  by a 64077  peak levels of leukotriene b4  median  684 pg per milliliter  and 5 hydroxyeicosatetraenoic acid  median  704 pg per milliliter  in nasal rinse fluids were markedly reduced  to 67 and 185 pg per milliliter  respectively  p less than 0 01   whereas levels of prostaglandin d2 were not  histamine release and sneezing were not reduced significantly by a 64077  but there was a significant correlation  p less than 0 01  between the changes in these variables within subjects  the mean      sem  stimulated synthesis of leukotriene b4 in whole blood ex vivo was markedly reduced by a 64077  from 153     19 to 20     9 ng per milliliter  p less than 0 01   and the specificity of a 64077 for 5 lipoxygenase inhibition was verified by its lack of effect on the synthesis of serum thromboxane b2 or 12 hydroxyeicosatetraenoic acid  conclusions  these results provide direct evidence of an important role for the 5 lipoxygenase products of arachidonic acid in allergic rhinitis and support the notion that further experiments in this area may lead to new therapeutic approaches to allergic disorders  
class9	sensorineural hearing loss  a reversible effect of valproic acid  we report 2 patients over the age of 70 who  while on valproate  vpa  for complex partial seizures  developed sensorineural hearing loss  following discontinuation of vpa for nonaudiologic reasons  the patients reported improved hearing which was confirmed by audiometry  these findings represent vpa induced sensorineural hearing loss  possibly in preexisting presbycusis  
class9	the efficacy of oral steroids in the treatment of persistent otitis media with effusion  one hundred thirty six children with otitis media with effusion of at least 2 months  duration were investigated in a strict  double blind  randomized prospective study to evaluate the efficacy of oral steroids in the treatment of this disease  the results of our study showed a significant complete and partial recovery from otitis media with effusion in the group treated by a combination of antibiotics  amoxicillin  and oral steroids  prednisone   compared with an amoxicillin treated group and a placebo treated group  we believe that this treatment mostly benefits children aged 4 to 10 years without oversized adenoids  the findings of our study imply that a combined course of antibiotics and oral steroids deserves its place as a routine conservative trial before surgery  
class9	localized antigen challenge of the nasal mucosa  we describe a localized nasal antigen challenge and the measurement of mediators found at the same site  eight ragweed allergic subjects were challenged on 2 days  1 week apart  challenges consisted of six sequential provocations  beginning with two control challenges  diluent for antigen phenol buffered saline  followed by four increasing antigen doses  0 6  6  60  and 160 protein nitrogen units   antigen day  or an additional four control challenges  control day   the number of sneezes and the symptom scores increased significantly with increasing antigen doses  the levels of histamine and n alpha tosyl l arginine methyl ester esterase activity increased in the eluted secretions on the antigen day  but not on the control day  the amount of secretions collected also increased per unit of time on the antigen day  we found no significant increase in the concentration level of either histamine or n alpha tosyl l arginine methyl ester esterase in nasal secretions on either day  we conclude that the total amount of histamine and n alpha tosyl l arginine methyl ester esterase activity increased per unit of time while their concentration did not  
class9	genetics of asthma and hay fever in australian twins  the occurrence of self reported asthma wheezing and hay fever among 3 808 pairs of twins from the australian national health and medical research council twin registry was examined for evidence of genetic transmission by path analytic methods  the cumulative prevalence of asthma or wheezing was 13 2  and of hay fever  32   there were significant correlations in liability to reported disease among twins  and these were higher in monozygotic twins  mz   r   0 65  than in dizygotic twins  dz   r   0 25   and in male mz twins  r   0 75  compared with female mz twins  r   0 60   analysis under the assumptions of the classic twin model suggested that there were genetic factors common to asthma and hay fever  with a correlation in genetic liability to the traits of 0 52 for men and 0 65 for women  these genes acted substantially in a nonadditive fashion in men but not in women  as the genetic correlation was significantly less than unity  this implied additional genetic factors influencing either or both diseases individually  the estimated heritability of these diseases was 60 to 70  in this population  environmental causes of both diseases also were correlated  r   0 53 for men and 0 33 for women   cigarette smoking was only weakly associated with wheezing  
class9	excitation thresholds for nerves reinnervating the paralyzed canine larynx  electrical stimulation of paralyzed laryngeal muscles implanted with nerve muscle pedicles  nmp  has resulted in documented return of motion  no study  however  has yet determined how nmp excitability correlates with that of normal muscle or nerve  in six anesthetized dogs  one hemilarynx was denervated and the paralyzed thyroarytenoid  cricothyroid  and posterior cricoarytenoid muscles were reinnervated via nmps originating from the ansa hypoglossi nerve  after 4 6 to 5 7 months  an electric stimulator delivering biphasic pulses of variable amplitude and widths was used to test thresholds for contraction in nine stimulatable nmps  six intact recurrent laryngeal nerves  rln   and five normal cervical muscles  with one exception  2 1 ma   nmp rheobases varied between 0 0002 and 0 04 ma  mean   0 020 sd     0 012  n   6   two nmps belonging to animals stimulated for several hours had higher values  0 1 ma   rheobase varied from 0 01 to 0 09 ma for control rlns  mean   0 058 sd     0 025   and from 0 05 to 0 35 ma for muscles  mean   0 144 sd     0 109   histologic correspondence with reinnervation was established in implanted muscles by type grouping on atpase stains  these data suggest that 1  nerve pedicles may offer promise for the eventual construction of implantable low energy consuming laryngeal devices  and 2  the appropriate charge to be injected over time remains to be determined  
class9	sphenoid sinusitis  a cause of debilitating headache  we present a case of sphenoid sinusitis resulting in a debilitating headache refractory to both oral and intramuscular analgesics  despite an aggressive evaluation in the emergency department  the correct diagnosis and appropriate treatment were delayed  recognition of sphenoid sinusitis  the complications associated with it  and the need for aggressive management are addressed  
class10	excitatory amino acids in the developing brain  ontogeny  plasticity  and excitotoxicity  besides their role as neurotransmitters  excitatory amino acids  eaas  in the developing brain are crucially involved in plasticity and excitotoxicity which are modified by their distinct ontogeny  along with incomplete neuritogenesis and synaptogenesis  presynaptic markers of the eaa system are immature in the developing brain  however  postsynaptic eaa system activities  particularly of the n methyl d aspartate and quisqualate receptors  are transiently enhanced early in life  this transient enhancement is presumably beneficial to the immature brain because physiologic activation of the eaa system plays a critical role in plasticity of early learning and morphogenesis  at the same time  this transient hypersensitivity renders the immature brain vulnerable to pathologic excitation of the eaa system  excitotoxicity  as observed during neonatal hypoxia ischemia  
class10	periventricular hyperintensity detected by magnetic resonance imaging in infancy  twenty one infants younger than 12 months of age were diagnosed as having periventricular hyperintensity  pvh  on t2 weighted magnetic resonance imaging  ten infants had experienced neonatal asphyxia  6 intracranial hemorrhage  2 bacterial meningitis  and 3 apnea  pvh was classified according to its extent  round foci of pvh surrounding the frontal and occipital horns of the lateral ventricles were observed in 4 infants  pvh pattern i   continuous pvh was observed in 17 infants  pvh patterns ii and iii   fourteen infants with continuous pvh had spastic diplegia or quadriplegia  developmental delay was demonstrated in 15 infants with continuous pvh  no pvh pattern i infants had cerebral palsy  only 1 such infant had mild developmental delay  our study suggests that the extent of pvh reflects the severity of brain damage in neonates with cerebral injuries  
class10	anencephaly  clinical determination of brain death and neuropathologic studies  twelve liveborn anencephalic infants were serially examined to determine if they would meet our clinical criteria for whole brain death within a 7 day period  protocol 1 infants  6  received intensive care including intubation from birth  and protocol 2 infants  6  received intensive care during the period in which death was imminent  brain death was determined by absence of brainstem function  including loss of all cranial nerve responses and sustained apnea  pco2 greater than 60 torr  for 48 hours with confirmation of findings by an outside consulting child neurologist  the initial examinations of these 12 infants revealed spontaneous movements and startle myoclonus  12   suck  root  and gag responses  7   increased tone  8   deep tendon reflexes  9   absent pupillary responses  9   absent oculocephalic and corneal responses  6   absent auditory moro responses  7   and nonvisualization of the optic nerve  8   mild depression of neurologic function occurred during the first several days of life  subsequently  the infants  responses were easier to elicit and more sustained  only 2 infants met the clinical criteria for brain death  neuropathologic findings indicated that observed complex motor responses were not based upon cortical activity because no infant had a normally formed cerebrum  brainstem neuronal activity may have accounted for these motor responses in some patients but even at this level neurons were scanty or absent  our findings suggest that  although rare  clinical brain death can be determined in liveborn anencephalic infants  ophthalmologic and otologic developmental abnormalities may confound examination of cranial nerve function  and absence of cortical neurons supports the widely held opinion that these infants do not experience sensation  
class10	acth therapy in infantile spasms  relationship between dose of acth and initial effect or long term prognosis  the relationship between the dose of acth and the initial effect was investigated in 41 children with infantile spasms  more than 0 015 mg  0 6 iu  kg day of acth was needed for a good initial response of seizures and electroencephalographic abnormalities  the relationship between the dose of acth and long term prognosis was investigated in 29 patients  there was no relationship between the daily or total acth dosage  provided the dose was greater than 0 015 mg  0 6 iu  kg day  and the outcome of seizures and electroencephalographic abnormalities  however  acth 0 04 0 06 mg  1 6 2 4 iu  kg day and a total acth dose of 1 1 1 5 mg  44 60 iu  kg resulted in better mental development than smaller doses of acth  side effects of acth increased with dosage  too small or too large a dose of acth does not lead to better mental development  the proper dose of acth should be used with careful attention to potential side effects  
class10	gross motor patterns in children with cerebral palsy and spastic diplegia  rolling  sitting  and crawling patterns were motoscopically analyzed in 72 children with cerebral palsy and spastic diplegia  the relation between these patterns and the severity of the locomotive disability was studied  in rolling  trunk rotation and elbow support were difficult for the most severely diplegic children  when sitting  most patients had a between heel sitting pattern in which the thighs were adducted and the knees were flexed  when crawling  the reciprocal thigh movements were insufficient and accompanied by lateral bending of the trunk in many patients  in the more impaired patients  the thighs supported the weight in flexion and did not move reciprocally  creeping on the elbows without reciprocal leg movements was demonstrated in the most severely affected children after 2 years of age  
class10	multiple intracranial mucoceles associated with phaeohyphomycosis of the paranasal sinuses  the purpose of this article is to alert clinicians to a new pathogenic fungus of the paranasal sinuses called exserohilum rostratum  exserohilum species are one of the etiologic agents of phaeohyphomycosis  a constellation of entities caused by dematiaceous fungi  this class of fungal sinus infection has emerged only in the past decade  it occurs primarily in immunocompetent individuals and produces a tenacious  progressive pansinusitis  to our knowledge  this study describes the first case of multiple intracranial mucoceles secondary to e rostratum  the diagnostic workup includes computed tomography and magnetic resonance imaging followed by direct microscopic examination of tissue biopsy specimens  a craniotomy followed by a bilateral external ethmoidectomy was necessary for complete extirpation of the infected mucoceles  aggressive surgical management of this mycotic infection is described  
class10	hyponatraemia secondary to an inappropriately high release of antidiuretic hormone in cardiac tamponade  a spontaneous intrapericardial haemorrhage caused cardiac tamponade in a 29 year old paraplegic man who was being treated with warfarin  the associated persistent hyponatraemia  which was believed to be caused by an inappropriately high release of antidiuretic hormone  rapidly resolved after pericardiocentesis  
class10	primary leptomeningeal b cell lymphoma in a 8 year old child  a case of primary leptomeningeal b cell lymphoma in an 8 year old  previously healthy child is described  the child was found to have hypogammaglobulinemia  and the epstein barr virus genome was identified in cultured tumor cells despite blood serology being negative for the virus  the patient was treated with cyclophosphamide  doxorubicin  vincristine  and dexamethasone  plus intrathecal methotrexate  and initially improved  before the initiation of craniospinal radiation  the patient developed progressive disease  deteriorated  and died 9 months after the onset of symptoms  
class10	epidural morphine for analgesia after caesarean section  a report of 4880 patients this retrospective study was undertaken to assess the efficacy and safety of epidural morphine in providing analgesia following caesarean section under epidural anaesthesia  the morphine was administered as a single bolus  following delivery  in doses ranging from 2 to 5 mg  the charts of 4880 caesarean sections  performed on 4500 patients  were reviewed  the duration of analgesia and the occurrence of any symptoms which might be side effects of the epidural morphine were recorded  the duration of analgesia was 22 9     10 1 hr and was not correlated with the dose of epidural morphine  eleven per cent of the patients required no supplemental analgesia during the first 48 hr  twelve patients  0 25 per cent  had respiratory rates less than 10 breaths per minute  on at least one occasion  no serious sequelae resulted from these periods of bradypnoea  pruritus occurred in 58 per cent of patients  nausea and vomiting in 39 9 per cent and dizziness in ten per cent  herpes simplex labialis was recorded in 3 5 per cent of patients  epidural morphine is thus confirmed as an effective analgesic technique post caesarean section with 3 mg being the optimal dose  even in this young healthy patient population  clinically detectable respiratory depression occurs so clinical respiratory monitoring is indicated  
class10	ethyl chloride and venepuncture pain  a comparison with intradermal lidocaine  one hundred and twenty unpremedicated patients undergoing gynaecological surgery were randomly allocated to one of three equal treatment groups to assess the effectiveness of ethyl chloride in producing instant skin anaesthesia to prevent the pain of venepuncture from a 20 g cannula  they received either no anaesthetic  0 2 ml one per cent lidocaine plain intradermally or a ten second spray of ethyl chloride at the cannulation site  ethyl chloride produced skin anaesthesia that significantly reduced the pain of venepuncture  however  it was not as effective as intradermal lidocaine  it had no effect on vein visualisation or ease of cannulation  ethyl chloride can be recommended as a method of producing instant skin anaesthesia  
class10	brain protection  physiological and pharmacological considerations  part i  the physiology of brain injury  ischaemia  whether focal or global in nature  produces a sequence of intracellular events leading to increased cell permeability to water and ions including ca    there is a loss of cellular integrity and function  with increased production of prostaglandins  free radicals  and acidosis with lactate accumulation  these events may be exacerbated by glucose administration  pharmacological agents aimed at alleviating ischaemic injury could be directed at decreasing cerebral metabolic requirements for oxygen  improving flow to ischaemic areas  preventing ca     induced injury  inhibition of free radical formation  lactate removal  inhibition of prostaglandin synthesis  and prevention of complement mediated leukocyte aggregation  part i of this paper describes some of the pathophysiological events leading to ischaemic brain injury  part 2 of this paper will consider the current agents available for brain protection  
class10	transoesophageal pacing for perioperative control of neonatal paroxysmal supraventricular tachycardia  the perioperative management of a 16 day old infant with recurrent supraventricular tachycardia  svt  is discussed  vagal manoeuvres and medication were not adequate in controlling the svt  since the patient was scheduled for extensive surgery in the prone position  it was decided to use transoesophageal pacing as the method of choice for conversion of svt  transoesophageal pacing succeeded several times in overriding the svt and restoring normal heart rate and haemodynamic variables  the advantages and disadvantages of various methods of treating svt in the newborn are discussed  
class10	hospital admissions from the surgical day care centre of vancouver general hospital 1977 1987  the admissions to vancouver general hospital from its surgical day care centre were reviewed for the period 1977 to 1987  the overall mean rate of admission for the period was 0 28 per cent  for surgically related admissions 0 22 per cent and for anaesthesia related admissions 0 07 per cent  the principal reasons for surgery related admissions were postoperative bleeding  complications  the need for further surgery  the requirement for prolonged postoperative care  and pain  urology had a particularly high percentage of admissions compared with its workload  because of the diagnostic nature of much of the work  anaesthesia related admissions included  syncope   lack of an accompanying adult  aspiration pneumonitis and coincident acute disease  twelve of the 14 patients admitted with syncope had surgery in the afternoon and had received less than ideal amounts of intravenous fluid  seven of the 12 asa physical status ii patients admitted had an admission diagnosis related to the coincident disease  
class10	two siblings with phenotypes mimicking peroxisomal disorders but with discordant biochemical findings  the authors present a report on two sibling with a nearly identical phenotype mimicking peroxisomal disorder but with totally discordant biochemical findings  in an attempt to confirm the diagnosis of a peroxisomal disorder  plasma levels of very long chain fatty acids  vlcfa  and phytanic acid were determined  in addition  fibroblasts profile of vlcfa and plasmalogen levels were evaluated for case 2  pathomorphological examinations represented by lymph node and kidney biopsies as well as postmortem examinations of liver  adrenals and brain were performed in case 1  the phenotypes of both siblings showed marked resemblance to those observed in children with zellweger syndrome  the results of biochemical tests performed in case 1  together with abundant peroxisomes in the liver and the wide spectrum of clinical abnormalities suggest pseudo zellweger or zellweger like syndromes  but no conclusive data have been found  the plasmalogen level in fibroblasts as well as the fibroblasts profile of vlcfa noted in case 2 were within the normal range  thus excluding the possibility of a peroxisomal disorder  the striking phenotype resemblance of the siblings mimicking zellweger  together with discordant biochemical findings  are difficult to explain on the basis of currently available tests  
class10	the exeter dysphagia assessment technique  the exeter dysphagia assessment technique  edat  uses noninvasive equipment to record  simultaneously   feeding respiratory patterns   the time drink entered the mouth  and associated swallow sounds during feeding  the easily portable equipment enabled patients  swallowing ability to be tested  at the bedside if necessary  using a small amount of fruit flavored drink  the results appear in chart form  edat findings from groups of normal subjects aged 2 90 years were compared with those from patients with dysphagia of neurologic origin and normal subjects under experimental feeding conditions  the results revealed maturation of the feeding respiratory pattern in the teenage years and remarkable consistency thereafter  differences in the recordings between the normal and abnormal subjects were sufficiently marked to allow the findings to be used in the diagnosis of other patients with dysphagia of doubtful neurologic cause  interpretation of the charts and recorded timings of the oral and pharyngeal stages of swallowing permitted a more accurate identification of sensory nerve  motor nerve  and functional involvement causing dysphagia of neurologic origin and may be used as a guide to the origin of the sensory deficit  
class10	transient neuromuscular impairment resulting from prolonged inhalation of halothane and enflurane  inhalation anesthesia first with halothane followed by enflurane relieved a patient with status asthmaticus who was refractory to conventional therapy including mechanical ventilation  after 13 days of anesthesia while on mechanical ventilation and employing nondepolarizing muscle relaxants  significant neuromuscular impairment  manifested by tetraplegia and sensory disturbance  developed  anesthesia was discontinued on day 14  and the patient was weaned from mechanical ventilation on day 16  over the next two months  the neuromuscular impairment markedly improved  halothane was associated with cardiac arrhythmias and hepatitis necessitating replacement by enflurane  enflurane appeared to be as effective a treatment for refractory asthma as halothane  the most probable cause of the neuromuscular impairment in our patient was the long term use of inhalation anesthetics or nondepolarizing muscle relaxants  
class10	resolution of the adult respiratory distress syndrome following colectomy and liver transplantation  a 32 year old woman with liver failure from end stage cirrhosis and ulcerative colitis developed septicemia and severe ards  subtotal colectomy and a successful liver transplantation resulted in complete resolution of the ards  
class10	barrett s esophagus in children and young adults  frequent association with mental retardation  since few data are available on epidemiologic features of barrett s esophagus in young persons  we reviewed the case records of patients undergoing esophageal biopsies at children s hospital  boston  from 1982 through 1986  there were 1423 esophageal biopsies obtained from 1173 patients  and histological evidence of esophagitis was present in 397 cases  barrett s epithelium was diagnosed in 10 patients  0 9  of total and 2 5  of esophagitis cases   specialized columnar epithelium was present in seven of these 10 patients  the mean age of those with barrett s epithelium was 19 0     7 9 years  range 3 7 27 years  compared to 8 7     6 7 years  range 4 days to 31 years  for all patients biopsied  p less than 0 0001   80   8 10  of the barrett s cases were male compared to 54  of all cases  the relative importance of the possible risk factors was assessed by comparing the 10 patients with barrett s with the 541 patients that had esophageal biopsies in calendar years 1984 1985  mental retardation  a risk factor not previously described for young persons with barrett s esophagitis  was present in 70   7 10  of the barrett s patients but in only 15  of all patients biopsied  p less than 0 0002   the frequency of mental retardation was also higher  but not significantly so  p greater than 0 07   in patients with biopsies that were positive for esophagitis  19   than in those with normal biopsies  14    no significant differences were found between the barrett s group and all patients biopsied in regards to racial origin  prior stricture  or fundoplication  
class10	scintigraphic measurement of oropharyngeal transit in man  scintigraphic studies of the oropharyngeal transit of a liquid bolus were performed in 15 healthy controls  12 patients with symptoms of oral pharyngeal dysphagia  and 13 patients with neuromuscular disease  who did not have dysphagia  gamma camera imaging of the head  neck  and upper thorax was undertaken  in the lateral projection  during the swallowing of the radiolabeled bolus of water  inspection of summed images permitted the selection of regions of interest  roi  to represent the mouth  pharynx  and upper esophagus  transit times between each roi were calculated and compared  significant prolongation of bolus transit time between the mouth and esophagus was present in both patients with and without dysphagia  0 59     0 38 sec and 0 33     0 7 sec  mean     sd  respectively  compared with controls  0 26     0 04 sec p less than 0 001  p less than 0 01  respectively  mann whitney u test   repeat studies in 25 individuals indicated that the transit measurements were more reproducible between swallows in normal subjects than in patients with symptoms  deglutitive scintigraphy provides a noninvasive technique for the quantitative study of swallowing and its disorders  
class10	irritable bowel syndrome in women having diagnostic laparoscopy or hysterectomy  relation to gynecologic features and outcome  we identified irritable bowel syndrome  ibs  in 47 7  of 86 women having diagnostic laparoscopy for chronic pelvic pain  39 5  of 172 women having elective hysterectomy  and 32 0  of 172 controls age matched for the hysterectomy group  p   ns   constipation and pain subtype ibs were more common in hysterectomy patients than controls  p less than 0 05   in laparoscopy patients  dyspareunia was more common in those with ibs than in those without it  p less than 0 05   in the hysterectomy group  more ibs patients had chronic pelvic pain  p less than 0 005   and abnormal menses  p less than 0 01   chronic pelvic pain was more frequently the only prehysterectomy diagnosis in ibs patients  p less than 0 05   and ibs was present more often when pain was a reason for hysterectomy  p less than 0 01   one year after laparoscopy  ibs patients gave lower overall status ratings  p less than 0 01  and lower pain improvement ratings  p less than 0 05  than non ibs patients  in women who had a hysterectomy for pain  there was less pain improvement one year later in those with the pain subtype of ibs than in non ibs patients  p less than 0 05   ibs is associated with gynecologic symptoms and affects the symptomatic outcome of diagnostic laparoscopy and hysterectomy  
class10	myasthenia gravis  myasthenia gravis is a disorder of neuromuscular function resulting from an immunologically based premature destruction of acetylcholine receptors  the disease is characterized clinically by variable weakness accentuated by repetitive muscular activity and usually responding to the administration of acetylcholinesterase inhibitors  myasthenia gravis is a complex disease and requires understanding of the many facets of its natural history and immunological basis to ensure optimal individual patient management  the long term goal is control of the immunological imbalance  treatment regimens include thymectomy  corticosteroids  azathioprine  and plasmapheresis  the common use of acetylcholinesterase inhibitors provides symptomatic relief during variable daily muscular activity  disability due to myasthenia gravis is to a large extent reversible and death is preventable  early recognition of myasthenia gravis and appropriate treatment are often rewarded by remission that may be permanent  
class10	anorectal function in incontinent patients with cerebrospinal disease  anorectal manometry and the electrical activity of the external anal sphincter were measured in 20 patients with well defined  incomplete spinal lesions who were referred because of fecal incontinence and in 30 normal subjects  six patients had a high spinal lesion  11 had a low spinal lesion  and 3 had mixed high and low spinal lesions  patients with high spinal lesions had normal basal pressures but abnormally low squeeze pressures and impaired rectal sensation  unlike normal subjects  there was no relationship between the depth of sphincter relaxation and the distention volumes  the external sphincter responses to rectal distention and increases in intraabdominal pressure were enhanced  and leakage of perfusion fluid was uncommon  patients with low spinal lesions had abnormally low basal and squeeze pressures  blunted rectal sensation  and showed impaired external anal sphincter responses to rectal distention or increases in intraabdominal pressures  most of these patients leaked the infused fluid during these maneuvers  sphincter function in patients with mixed lesions was more severely impaired than in patients with low and high spinal lesions  patients with mixed lesions showed abnormally low basal and squeeze pressures  impaired rectal sensation  and no external anal sphincter responses to either rectal distention or increases in intraabdominal pressure  leakage occurred during these maneuvers in all patients with mixed lesions  
class10	dementia  depression  or grief  the differential diagnosis  depression  grief  and dementia are conditions frequently encountered among the community living elderly  this review offers a primary care perspective of the distinguishing features for each and discusses the special issues of managing the elderly  major depression in the elderly usually responds to antidepressant medication  whether the depression occurs alone  endogenous  or as a response to another condition  reactive   
class10	semantic deterioration in alzheimer s  the patterns to expect  differentiating language changes between the normal aged and those in the early stages of dementia is never simple  knowing the differences and what to expect can aid in making this diagnosis  
class10	the auditory p300 event related potential  an objective marker of the encephalopathy of chronic liver disease  recently many variants of electroencephalogram evoked responses have been studied as potential diagnostic aids in the detection and evaluation of hepatic encephalopathy  this study assesses the value of the auditory p300 event related potential  a slow component of the auditory evoked response  as a tool in this field  twenty one nonencephalopathic and 12 encephalopathic  grade 1 2  cirrhotic patients and 26 controls were assessed clinically and psychometrically  electroencephalogram spectral analysis and visual evoked response recordings were also conducted  an auditory p300 wave was elicited using the standard two tone discrimination paradigm  the latency and amplitude of this wave were measured  the latency of the p300 was found to be significantly increased in the encephalopathic patients compared with both nonencephalopathic cirrhotic and control groups  p less than 0 05   amplitude of the wave was decreased in both nonencephalopathic and encephalopathic patients  but this was not statistically significant  this study suggests that the latency of the p300 is a good marker of grades 1 and 2 clinical hepatic encephalopathy  the delays in the p300 latency may indicate that encephalopathic patients have a deterioration of their stimulus evaluation abilities  
class10	increased serotoninergic and noradrenergic activity in hepatic encephalopathy in rats with thioacetamide induced acute liver failure  functional changes of various neurotransmitter systems have been implicated in the pathogenesis of hepatic encephalopathy  in this study the role of brain monoaminergic neurotransmitter systems in hepatic encephalopathy was investigated in rats with thioacetamide induced acute liver failure  concentrations of serotonin  dopamine  noradrenaline and of their metabolites 5 hydroxyindoleacetic acid  dihydroxyphenylalanine  following inhibition of dihydroxyphenylalanine decarboxylase   dihydroxyphenylacetic acid  homovanillic acid and 3 methoxy 4 hydroxyphenyl glycol  were measured in the cerebral cortex  striatum and hippocampus by high performance liquid chromatography with electrochemical detection  in hepatic encephalopathy concentrations of 5 hydroxyindoleacetic acid were increased in all three brain areas  196   204  and 264  of saline treated controls  p less than 0 01   and concentrations of serotonin were increased in the frontal cortex  121   p less than 0 01   in the frontal cortex and hippocampus of encephalopathic rats dopamine levels were increased  157  and 289   p less than 0 05   and levels of noradrenaline  53  and 46   p less than 0 05  were decreased associated with increased 3 methoxy 4 hydroxyphenylglycol levels  173  and 206   p less than 0 05   the extent of these changes correlated with the stage of hepatic encephalopathy  in hepatic encephalopathy dihydroxyphenylalanine accumulation was increased in the hippocampus and unchanged in the cerebral cortex  dopamine  noradrenaline  dihydroxyphenylacetic acid and homovanillic acid concentrations were unchanged in the striatum  the results of this study indicate that hepatic encephalopathy in thioacetamide induced acute liver failure in rats is associated with neurochemical changes  suggesting an increased activity of the noradrenergic and serotoninergic neurotransmitter systems  
class10	pain experiences of intensive care unit patients  the purpose of this study was to describe various dimensions of the pain experiences of intensive care unit  icu  patients  a purposive  primarily surgical sample of 24 icu patients from two hospitals was interviewed after transfer from icu  all but one patient remembered their icu stay  although this and six other patients had no recall of pain  63  of the sample rated their pain as being moderate to severe in intensity  in a subgroup of nine patients having cardiac surgery  mean morphine sulfate administration during the first three postoperative days was 14 mg day  this group of patients reported a lack of total pain relief from analgesics  patients also described various sources of their pain  difficulties they had in communicating their pain  and nonpharmacologic methods that helped relieve their pain  results of this study clearly indicate that not only pain but its communication and treatment were significant problems for a substantial portion of this icu sample  further descriptive and experimental research of pain characteristics and treatment practices for icu patients is urgently needed  improvements in nursing practice that result from such research may make a substantial difference in the comfort and well being of critically ill patients  
class10	fungal pseudomeningitis superimposed on escherichia coli meningitis  pseudomeningitis is the demonstration of microorganisms from the cerebrospinal fluid by stain or culture in a patient with symptoms suggesting meningitis  this is a report of fungal pseudomeningitis superimposed on a case of nosocomial escherichia coli meningitis resulting from a neurosurgical procedure  critical care personnel need to be aware of the possibility of pseudomeningitis with or without associated meningitis in the appropriate setting  
class10	evaluating oxygen delivery and oxygen utilization with mixed venous oxygen saturation monitoring  a case study approach  three cases studies are presented to demonstrate clinical application of mixed venous oxygen saturation  svo2  monitoring in critical care nursing practice  examples of critically ill patients are used to demonstrate how svo2 monitoring can be used in clinical practice to reflect an imbalance between oxygen delivery and oxygen utilization  in the first case  the patient had a problem with oxygen delivery  continuous svo2 data aided nurses in guiding  adjusting  and assessing therapy  the second case demonstrates how svo2 monitoring can provide an early sign of a life threatening complication  the final case is one in which the patient had a problem with oxygen utilization  in all the cases  continuous svo2 data provided important information about the balance between oxygen delivery and oxygen utilization  
class10	the effect of improved cementing techniques on component loosening in total hip replacement  an 11 year radiographic review  improved cementing techniques have been shown to decrease the rate of aseptic loosening of femoral components of cemented total hip replacements at five to seven years  we now report our results in 105 hips in 93 patients at 10 to 12 7 years  mean 11 2   the improved techniques included use of a medullary plug  a cement gun  a doughy mix of simplex p and a collared stem of chrome cobalt  only three femoral components had definitely loosened  none were probably loose and 24 were graded as possibly loose  in contrast  the incidence of radiographic loosening on the acetabular side was 42   improved cementing techniques have produced a marked reduction in the rate of aseptic loosening of the femoral component  but the incidence of acetabular loosening is unchanged  
class10	chiari pelvic osteotomy for osteoarthritis  the influence of the torn and detached acetabular labrum  we assessed the results of chiari pelvic osteotomy in 64 hips with early osteoarthritis in terms of acetabular labral detachment detected pre operatively by arthrography  at an average follow up of four years  assessment by the merle d aubigne score showed 83  excellent or good results  these satisfactory results were achieved in only half the cases with a detached labrum  but in nearly all cases with normal or torn acetabular labra  other factors such as the acetabular index  the level and angle of osteotomy  and the displacement following osteotomy did not affect the results  chiari pelvic osteotomy is a worthwhile procedure for early osteoarthritis in selected cases  but a detached acetabular labrum increases the risk of clinical failure  
class10	the hastings bipolar hemiarthroplasty for subcapital fractures of the femoral neck  a 10 year prospective study  in a 10 year prospective study  561 displaced subcapital fractures of the femoral neck in 546 patients were treated with the hastings bipolar hemiarthroplasty  within six months of their operations  148 patients had died  in 322 hips followed up  243 with adequate serial radiographs separated by more than one year  only 14  5 6   showed acetabular erosion  a group of 91 had been reviewed for between three and nine years  mean  4 years 10 months  and of these  95  had no pain or slight pain only  comparison with an earlier series of conventional hemiarthroplasties reported from this institution showed that the clinical results were similar  but that the erosion rate had been halved  
class10	reduction of post traumatic swelling and compartment pressure by impulse compression of the foot  following the discovery of a powerful venous pump in the foot that is activated by weight bearing independently of muscular action  a pneumatic impulse device was developed to actuate this pump artificially  in a multicentre international trial the device was shown to reduce post traumatic and postoperative swelling  pain also was alleviated  evidence is also presented that dangerously high compartment pressures may be reduced to acceptable levels and fasciotomy avoided  we present an explanation of the clinical effects of activation of the venous footpump  based on recent improved understanding of the physiology of the microcirculation  the hyperaemic response that follows the liberation of endothelial derived relaxing factor  edrf  by sudden changes of pressure after weight bearing or impulse compression is particularly important  
class10	the management of the painful first metatarsophalangeal joint in the older patient  arthrodesis or keller s arthroplasty  we report a prospective randomised trial comparing keller s arthroplasty and arthrodesis of the first metatarsophalangeal joint for the management of symptomatic hallux valgus and hallux rigidus in the older patient  in 81 patients  110 feet   with a minimum of two years follow up  both procedures gave a similar degree of patient satisfaction and symptom relief  the incidence of metatarsalgia was also similar  as there were no obvious advantages to arthrodesis  and since six out of 50 arthrodesed toes required revision  we suggest that keller s arthroplasty is the better operation in these patients  
class10	the modified schollner costoplasty  the modified schollner costoplasty is a cosmetic procedure for the correction of rib prominence deformity in scoliosis  we present the results of the procedure in 21 patients who had previously undergone spinal fusion for scoliosis  we found the procedure to be well tolerated without major complications  objective cosmetic improvement was achieved in all but one case  all but one patient considered the procedure to have been of cosmetic benefit  
class10	a surgical approach to the cervicothoracic spine  we describe a method for approaching the lower cervical and upper thoracic spine  the brachial plexus and related vessels  the method involves the elevation of the medial corner of the manubrium  the sternoclavicular joint  and the medial half of the clavicle on a pedicle of the sternomastoid muscle  we have used this exposure in 17 cases with few complications and good results  its successful performance requires high standards of anaesthesia  surgical technique and postoperative care  
class10	operative and conservative treatment of moderate spondylolisthesis in young patients  we made a retrospective study of 149 children and adolescents with moderate spondylolisthesis  slip less than or equal to 30    77 treated by fusion and 72 conservatively at an average follow up of 13 3 years  both groups were fully comparable with regard to age at diagnosis  sex distribution  46  girls   and mean slip  the patients who were treated operatively had more pain before treatment and showed more initial progression of the slip  they had better clinical results and less pain at latest review  but the total progression of the slip over the whole follow up showed no statistical differences between the two groups  patients with a pseudarthrosis after attempted fusion had had a longer period of postoperative pain  but at the latest review had no more pain than those with sound fusion  none of those treated conservatively came to fusion later and the long term results in 18 patients who had refused the advised operation were no worse than those for other conservatively treated patients  our results suggest that a moderate grade of spondylolisthesis in adolescents usually has a benign course  it seems that spontaneous segmental stabilisation occurs as a result of degeneration of the disc at the level of the slip  
class10	combined epidural and general anesthesia in aortic surgery  the perioperative course of 144 consecutive patients undergoing aortic reconstructive surgery was studied to assess the potential benefit of employing a combined epidural and light general anesthesia technique  a group of 67 patients had general anesthesia alone  ga   while in the group of 77 remaining patients  a combined epidural and general anesthesia  epi ga  was employed  the two groups were similar in regards to age  medical risk factors  preoperative assessment of cardiac and pulmonary function  and type of surgical reconstruction  there was no significant difference in the anesthetic  operative time  or operative fluid requirements between the two groups  there was a lower rate pressure product in the epi ga group during aortic cross clamping  p less than 0 05   more patients in the ga group required a prolonged ventilatory support  p less than 0 05  and a high parenteral narcotic administration  p less than 0 025  during the first 48 hours  while the mortality rate was similar for the two groups  3 0  for ga group vs 5 2  for epi ga group   there was a higher percent of postoperative pulmonary complications observed in the ga group  7 6   compared to the epi ga group  2 6    by facilitating early extubation and a decreased need for systemic narcotics in the early postoperative period  epi ga may be beneficial in the high risk pulmonary patient undergoing aortic reconstruction  
class10	unusual haemostasis for an unusual tumour  catastrophic bleeding from a tactile neurofibroma affecting the thoracic vertebrae  case report  the symptomatology of a typical acute descending thoracic aorta dissection was imitated by profuse haemorrhage caused by a benign tumour composed almost exclusively of wagner meissner like tactile corpuscles and fatty tissue  the tumour caused extensive destruction of the bodies of the fifth and sixth thoracic vertebrae at the level of the vertebro costal articulation  emergency cross clamping of the descending aorta and haemostasis of the bleeding from osteal defects by tamponade with bone polymethyl methacrylate appeared the only way to control the life threatening haemorrhage  it seems that an intrathoracic tactile neurofibroma with a similar case history has not been reported till now  
class10	deletion of alu sequences in the fifth c sis intron in individuals with meningiomas  an abnormality in the c sis protooncogene was identified in leukocyte dna from members of a family predisposed to the development of meningioma  and was found to be associated with the development of the tumor in those individuals  molecular analysis of this abnormality demonstrated a deletion within the fifth intron of the c sis gene  the normal c sis gene has an alu sequence in this region which includes two perfect 130 nucleotide repeated sequences separated by 5 bp  the deleted c sis allele is missing precisely one copy of the 130 bp repeat and the intervening 5 bp  an identical deletion was also found in dna from 1 of 13 sporadic meningiomas  
class10	cheilitis granulomatosa  report of six cases and review of the literature  six cases of cheilitis granulomatosa  a rare inflammatory disorder of unknown origin  are reported  the condition produces nontender  persistent swelling of one or both lips and affects primarily young adults  histologically  nonnecrotizing granulomatous inflammation is seen  the clinical findings and results of therapy in these six cases are presented  one patient was treated with hydroxychloroquine sulfate  plaquenil  that stabilized the process  one of our patients had vesicular appearing lesions  microscopic examination showed the lesions to be dilated superficial lymphatic channels  a finding that to our knowledge has not been previously described  
class10	the relationship of pemphigus to neoplasia  a statistically increased incidence of malignancy has been observed in patients with pemphigus  a review of the literature reveals 42 cases of nonthymic malignancies and 18 cases of thymic malignancies  a significant predominance of men  with mean age at onset of 50 years  was observed  pemphigus vulgaris is more common in patients with nonthymic neoplasms  whereas pemphigus foliaceus or pemphigus erythematosus and pemphigus vulgaris are equally common in patients with thymic neoplasms  lymphoreticular malignancies  especially kaposi s sarcoma  are most frequently observed  the majority of patients with nonthymic neoplasms have pemphigus before the detection of the malignancy and have a favorable 5 year survival rate after tumor resection  the majority of the patients with thymic neoplasms have a thymoma before the development of pemphigus  in some patients pemphigus develops after thymectomy and myasthenia gravis is often associated  overall  37 of the 60 patients  or 61   had a neoplasm of the immune system  
class10	prevalence and characteristics of multiple analgesic drug use in an elderly study group  with few exceptions  use of multiple analgesic drugs achieves dubious increases in analgesia while placing elders at increased risk of the many potential adverse effects of analgesic drugs  the potential for duplication of analgesic therapy among the elderly is great due to prevalent painful chronic conditions and the variety of prescription and nonprescription analgesic remedies available  the prevalence of multiple analgesic product use and patterns of concurrent use of different analgesic categories was investigated in a geographically defined population of persons 65 years of age and older  the demographic characteristics of users of multiple analgesic drug products were examined  as were their smoking status  alcohol use  lifetime history rates of major illnesses  physical functioning  pain experiences  memory performance  and depressive symptoms  a substantial proportion of analgesic users reported taking multiple products in the preceding 2 weeks  14 4  of female and 10 5  of male analgesic users   men who reported pain in the preceding year were more likely to use multiple analgesic products  women who experienced pain or limited physical functioning  or who had higher depressive symptom scores or a life time history of ulcers were most likely to use multiple analgesic products  thus  although some users of multiple analgesic products reported significant pain  several other factors were shown to be related to the phenomenon of multiple use  
class10	pelvic pain  lessons from anatomy and physiology  pelvic pain is often a difficult differential diagnosis in the emergency department  for physiologic reasons  pain in the pelvis is difficult to localize to a specific organ  and pelvic peritonitis is hard to recognize  on the other hand  differences in types of pain can be very useful in arriving at a correct diagnosis  the clinician must learn to recognize superficial and deep somatic pain  and differentiate between various types of visceral pain which originate from inflammation  ischemia  or colic  a review of the anatomy and physiology of pelvic pain helps identify some of the problems as well as potential aids in approaching the patient with pelvic pain  
class10	treatment of phenobarbital poisoning with multiple dose activated charcoal in an infant  a 28 day old infant developed lethargy  hypotonia  and hypothermia following a phenobarbital overdose secondary to a pharmacist s error  he was treated with multiple dose activated charcoal  mdac  and alkalinization of the urine  which resulted in prompt recovery with rapid elimination of the drug  t1 2 11 2 hours  expected 45 to 118 hours   the use of mdac in this newborn was safe and effective  we suggest that age should not pose a barrier to the use of mdac  when indicated  
class10	extrageniculate vision in hemianopic humans  saccade inhibition by signals in the blind field  the functional competence of extrageniculate visual pathways in hemianopic humans was demonstrated by showing that distractor signals in the blind half of the visual field could inhibit saccades toward targets in the intact visual field  this inhibitory effect of unseen distractors in patients occurred only when distractors were presented in the temporal half of the visual field  was specific to oculomotor responses  and did not occur in normal subjects  these results show that a peripheral visual signal activates retinotectal pathways to prime the oculomotor system and that these pathways can mediate orienting behavior in hemianopic humans  
class10	dementia  what to do  dementia is a syndrome of acquired intellectual deterioration that interferes with personal or social functioning  diagnosis requires historical information from the family and the mental status evaluation of orientation  recent memory  comprehension  calculation  and abstraction  most dementias create permanent  even progressive cognitive deterioration  yet there are some presentations for which remission exists  common reversible conditions include depression  drug toxicity  normal pressure hydrocephalus  hypothyroidism  subdural hematoma  and neoplasm  screening laboratory studies consist of urinalysis  chemistry profile  blood count  thyroid survey  vitamin b12 and folate measurements  serology  chest roentgenogram  computerized tomographic scan of the head  electroencephalogram  and electrocardiogram  treatment focuses on potential reversibility  psychosocial issues  restoring deficits  and specific symptoms  
class10	hematoma of the optic nerve sheath after penetrating trauma  we have presented a case involving the diagnosis and management of optic nerve sheath hematoma  our patient s positive outcome demonstrates the usefulness of megadose steroid therapy for acute optic nerve injury  
class10	relationship between duration of spinal cord ischemia and postoperative neurologic deficits in animals  twenty hogs were administered the following procedures before  during  and after overdistraction of the spinal column at t5 t6  somatosensory  sep  and neurogenic motor evoked potentials  nmeps   hydrogen clearance procedures  stagnara wake up tests  and aortic injection of silastic plastic  to ensure that overdistraction was possible  a nonosseous  circumferential osteotomy was made at t5 t6 and distraction applied in one ratchet increments using harrington instrumentation  overdistraction was maintained for 3  5  6  10  15  20  25  or 30 minutes  results indicated that the duration of overdistraction  as represented by lost nmeps  was always correlated with the animal s clinical status on wake up test  if overdistraction was maintained more than 6 minutes  100  of the animals demonstrated positive wake up results  if maintained between 5 and 6 minutes  75  demonstrated positive wake up results  and if maintained less than 5 minutes  only 25  demonstrated positive wake up results  time to loss of the nmeps and seps  after onset of overdistraction  fell within two groups  slow and fast  in the slow group  it required slightly more than 20 minutes  mean   20 6  for the potentials to be lost  while in the fast loss group data were lost in slightly less than 4 minutes  mean   3 6   blood flow studies and inspection of the spinal cord revealed that the mechanism of action for the slow group appeared to be ischemia of the spinal cord that extended several centimeters above and below the site of maximum distraction  in the fast loss group  it appeared that gross structural damage  with some very localized ischemia  were the mechanisms of actions influencing the integrity of the spinal cord  
class10	histopathologic correlation of magnetic resonance imaging signal patterns in a spinal cord injury model  magnetic resonance imaging  mri  provides a noninvasive method of monitoring the pathologic response to spinal cord injury  specific mr signal intensity patterns appear to correlate with degrees of improvement in the neurologic status in spinal cord injury patients  histologic correlation of two types of mr signal intensity patterns are confirmed in the current study using a rat animal model  adult male sprague dawley rats underwent spinal cord trauma at the midthoracic level using a weight dropping technique  after laminectomy  5  and 10 gm brass weights were dropped from designated heights onto a 0 1 gm impounder placed on the exposed dura  animals allowed to regain consciousness demonstrated variable recovery of hind limb paraplegia  magnetic resonance images were obtained from 2 hours to 1 week after injury using a 2 tesla mri spectrometer  sacrifice under anesthesia was performed by perfusive fixation  spinal columns were excised en bloc  embedded  sectioned  and observed with the compound light microscope  magnetic resonance axial images obtained during the time sequence after injury demonstrate a distinct correlation between mr signal intensity patterns and the histologic appearance of the spinal cord  magnetic resonance imaging delineates the pathologic processes resulting from acute spinal cord injury and can be used to differentiate the type of injury and prognosis  
class10	cerebral cysticercosis  we studied 143 cases of cerebral cysticercosis over a 30 year period  in 46 there was hydrocephalus due to cysts obstructing the cerebrospinal fluid pathways  with signs of hydrocephalus and cerebellar dysfunction  in 97 there were cysts in the cerebral parenchyma  causing symptoms of intracranial hypertension alone in 22 cases  with additional neurological deficits in the remainder  before 1980 diagnosis was made by pneumoencephalography and ventriculography  but since then it has mostly been done by computed tomography  in 28 cases scanned  typical abnormalities were present in 25  complement fixation tests were positive in serum in 74  of cases and in cerebrospinal fluid in 73   and the enzyme linked immunosorbent assay test was positive in serum in 90  and in cerebrospinal fluid in 92   treatment of cases with hydrocephalus was by removal of the cysts at craniotomy  with placement of a shunt where necessary  intracranial hypertension caused by parenchymal cysts was treated with steroids and osmotic agents  if possible  in resistant cases subtemporal decompression was needed  unilateral in 55 cases and bilateral in eight  mortality in the acute stage was 11   with a further 20  at follow up  
class10	intractable complex partial seizures associated with occult temporal lobe encephalocele and meningoangiomatosis  a case report  occult congenital temporal lobe encephalocele has rarely been reported in association with medically intractable complex partial seizures  the four previously reported cases were unsuspected preoperatively  we present the case of an 18 year old woman with intractable complex partial seizures since age 13  seizure onset was electrically localized to the right temporal lobe  preoperative neuroimaging studies revealed a middle fossa defect and inferior herniation of the right temporal lobe  pathologic examination of the resected encephalocele revealed prominent features of meningoangiomatosis  we believe this to be the first case of temporal lobe encephalocele and epilepsy to be diagnosed preoperatively  and the first case also to be associated with meningoangiomatosis  the relevant literature on meningoangiomatosis and on temporal lobe encephalocele as a cause of epilepsy is reviewed  
class10	cavernous carotid thrombosis and ocular motor paresis a 64 year old man presented with the acute onset of unilateral blindness and ipsilateral ocular motor paresis  occlusion of the central retinal artery associated with thrombosis of the internal carotid artery in the cavernous sinus was demonstrated by angiography and magnetic resonance imaging  cases of carotid thrombosis associated with ipsilateral ocular motor paresis are rare  the pathophysiology of intracavernous carotid thrombosis is discussed in connection with blood supply of the cranial nerves in the cavernous sinus  
class10	value of magnetic resonance imaging in spontaneous extradural spinal hematoma due to vascular malformation  case report  a case of spinal cord compression due to spontaneous extradural spinal hematoma is reported  a spinal arteriovenous malformation was suspected on the basis of magnetic resonance imaging  early surgical exploration allowed a complete neurological recovery  the vascular malformation was histopathologically confirmed  the role of magnetic resonance imaging in the evaluation of acute spinal cord compression syndromes is stressed  
class10	naloxone and spinal fluid drainage as adjuncts in the surgical treatment of thoracoabdominal and thoracic aneurysms  forty seven patients who were treated for thoracoabdominal or thoracic aneurysms over a 5 1 2 year period were analyzed for neurologic deficit risk  patients were divided into two groups for analysis  twenty four patients  who were treated from january 1984 to december 1986  did not undergo spinal fluid drainage or naloxone administration  group a   twenty three patients  who were treated from january 1987 to august 1989  had spinal fluid drainage  group b   12 patients in this group also received naloxone as an intravenous drip at 1 microgram kg hr for 48 hours after surgery  permanent neurologic deficits occurred in seven  29   group a patients but in only one  4   group b patient  who did not receive naloxone  p less than 0 03   the first two group b patients to receive naloxone showed complete reversal of neurologic deficits on waking from anesthesia  this significant reduction in neurologic deficit was associated with an increased 1 year survival rate  72  in group a  91  in group b   we conclude that the use of naloxone and spinal fluid drainage reduces the incidence of neurologic deficit that is associated with repair of thoracoabdominal and thoracic aortic aneurysms  this reduction in neurologic deficit is associated with improved survival in the long term  the observed reversal of postoperative neurologic deficits with naloxone implicates opiates as a major factor in the pathophysiology of spinal cord ischemia  
class10	stroke and its modification in parkinson s disease  previous studies have not agreed on the incidence of ischemic stroke in persons with parkinson s disease  there are epidemiologic and neurochemical facets of parkinson s disease that might confer some benefit or protection against ischemic stroke  we used a case control method to determine the lifetime history of ischemic stroke in 200 patients with parkinson s disease and 200 controls of a similar age range  analysis was also carried out for myocardial infarction as a marker of generalized atherosclerotic disease and for stroke risk factors  the cumulative incidence of ischemic stroke was significantly less in the patients with parkinson s disease than in the controls  as was the cumulative incidence of myocardial infarction  among risk factors  significantly fewer patients with parkinson s disease used tobacco than controls  the decreased incidence of ischemic stroke in the patients with parkinson s disease appears to be related to their less severe generalized atherosclerosis  possibly due to their lower incidence of tobacco use  in view of the known potential for dopamine to exacerbate experimental ischemic tissue damage  the possibility that the dopamine deficiency in the central nervous system of persons with parkinson s disease confers an additional specific protective benefit against ischemic stroke cannot be excluded and requires further study  
class10	acute and long term changes in serum lipids after acute stroke  we studied serum lipid profiles in 171 patients less than or equal to 48 hours after the onset of acute stroke and 3 months later  the 83 patients suffering cerebral infarction had significantly higher serum concentrations of total cholesterol  low density lipoprotein cholesterol  and apolipoprotein b and significantly lower serum concentrations of triglycerides and lipoprotein  a  less than or equal to 48 hours after ictus than 3 months later  the lipid profiles of the 53 patients suffering lacunar infarction were similar on both occasions  the only significant differences being higher total cholesterol and low density lipoprotein cholesterol concentrations less than or equal to 48 hours after ictus  no significant changes were observed among the 35 patients suffering cerebral hemorrhage apart from a significantly higher concentration of high density lipoprotein3 cholesterol less than or equal to 48 hours after ictus  our study  with many patients classified according to stroke subtype  gives results different from those of previous studies with much fewer patients  we conclude that in studies of serum lipid and lipoprotein concentrations as risk factors for cerebral infarction  comparing values obtained less than or equal to 48 hours after admission with control values may incorrectly identify certain lipid fractions as risk factors  
class10	risk factors for white matter changes detected by magnetic resonance imaging in the elderly  we found increased age  p   0 001  and history or evidence of stroke  p   0 016  to be significant independent multivariate predictors of the presence and severity of leukoencephalopathy on magnetic resonance imaging brain scans in a mixed population of 35 elderly psychiatric patients and 25 neurologically healthy elderly volunteers  these results suggest that subcortical ischemia  as well as age related changes that may not be vascular in origin  contribute to the emergence of periventricular and other deep white matter hyperintensities that are commonly seen on the magnetic resonance imaging brain scans of older adults  
class10	evidence for platelet activating factor as a novel mediator in experimental stroke in rabbits  platelet activating factor is a potent mediator of inflammation  which has untoward effects on cerebrovascular and neural elements  while several investigators have reported attenuation of ischemic damage after treatment with antagonists of platelet activating factor  no study has proved endogenous production of platelet activating factor in ischemia of the central nervous system  we hypothesized that endogenous production of platelet activating factor participates in the early pathologic manifestations of deteriorating stroke  in 12 rabbits  we found tissue levels of platelet activating factor measured by the release of serotonin from washed platelets to be elevated by approximately 20 fold in spinal cord injured by 25 minutes of ischemia and 2 hours of reperfusion  2 80     0 98 ng g  compared with that in normal spinal cord  0 15     0 06 ng g  p less than 0 01   given during ischemia to seven rabbits  10 mg kg i p  of a highly selective and potent antagonist of platelet activating factor  bn 50739  accentuated the early postischemic hyperemia and prevented the delayed hypoperfusion measured by on line laser doppler flowmetry   35     7  of baseline  n   7  without versus 33     14  with treatment  p less than 0 01  and the edema formation measured as the increase in tissue water content  4 4     0 7  without  n   6  versus 2 1     0 6  with  n   7 treatment  p less than 0 05  after 2 hours of reperfusion  this neurochemical and pharmacologic evidence emphasizes a new perspective of ischemia induced phospholipid degradation and suggests an important role for platelet activating factor in the early manifestations of stroke  
class10	beneficial effect of 1 3 butanediol on cerebral energy metabolism and edema following brain embolization in rats  we assessed the effect of 1 3 butanediol on cerebral energy metabolism and edema after inducing multifocal brain infarcts in 108 rats by the intracarotid injection of 50 microns carbonized microspheres  an ethanol dimer that induces systemic ketosis  25 mmol kg i p  butanediol was injected every 3 hours to produce a sustained increase in the plasma level of beta hydroxybutyrate  treatment significantly attenuated ischemia induced metabolic changes by increasing the concentrations of phosphocreatine  adenosine triphosphate  and glycogen and by reducing the concentrations of pyruvate and lactate  lactate concentration 2  6  and 12 hours after embolization decreased by 13   44   and 46   respectively  brain water content increased from 78 63  in six unembolized rats to 80 93  in 12 saline treated and 79 57  in seven butanediol treated rats 12 hours after embolization   p less than 0 05   the decrease in water content was associated with significant decreases in the concentrations of sodium and chloride  the antiedema effect of butanediol could not be explained by an osmotic mechanism since equimolar doses of urea or ethanol were ineffective  our results support the hypothesis that the beneficial effect of butanediol is mediated through cerebral utilization of ketone bodies arising from butanediol metabolism  reducing the rate of glycolysis and the deleterious accumulation of lactic acid during ischemia  
class10	retinal infarction during sleep and wakefulness  brain and retinal infarctions during sleep have been attributed to focal hypoperfusion caused by systemic hypotension combined with underlying arterial stenosis  rather than to embolism  because some retinal emboli may be visualized on ophthalmoscopy  we studied 24 consecutive patients  18 men and six women  aged 26 78  mean 58  years with recent retinal infarction and determined whether the infarction had occurred during sleep or wakefulness  all patients underwent dilated ophthalmoscopy and a carotid artery study  arteriography in 20  duplex ultrasound in the remaining four   and 12 had echocardiography  retinal infarction occurred during sleep at an unexpectedly rate  14 of 24 observed compared with eight of 24 expected  p   0 02   retinal cholesterol emboli were seen in one half of the patients regardless of whether the retinal infarction had occurred during sleep or wakefulness  carotid artery disease was found in seven of the 14 patients in whom infarction had occurred during sleep and in eight of the 10 patients in whom infarction had occurred during wakefulness  p   0 21   cerebrovascular occlusive disease was not found in the five patients aged less than 50 years  our findings suggest that embolism is a common mechanism of retinal infarction during sleep or wakefulness  that in patients aged greater than 50 years extracranial carotid artery disease is a common source of retinal emboli  and that the retina may be especially susceptible to infarction during sleep  
class10	etiologic importance of the intimal flap of the external carotid artery in the development of postcarotid endarterectomy stroke  a technically unsatisfactory end point  transition from the removed diseased plaque to normal distal intima  leading to an intimal flap of the external carotid artery has been identified as a source of perioperative stroke  the mechanism involves thrombus formation with retrograde propagation of the thrombus and subsequent embolization of the internal carotid artery  this report describes three cases illustrating this mechanism and methods of identification and correction  this mechanism of postoperative stroke adds further justification for the routine use of intraoperative surveillance studies to document the technical result of endarterectomy involving the internal and external carotid arteries  when an unsatisfactory end point is identified in the external carotid artery  it should be corrected with the same sense of concern as a similar finding in the internal carotid artery  
class10	transitional cell carcinomatous meningitis after m vac  methotrexate  vinblastine  doxorubicin  and cisplatin  chemotherapy  the m vac  methotrexate  vinblastine  doxorubicin  and cisplatin  regimen has been utilized at our two institutions to treat 17 patients with advanced stage transitional cell carcinoma of the bladder  we report 2 cases of carcinomatous meningitis resulting from metastatic transitional cell carcinoma which occurred in patients treated with m vac  review of the literature suggests that our experience with central nervous system metastases is not unique  and that treatment of advanced stage transitional cell carcinoma of the bladder with m vac may enhance the incidence of meningeal metastases  carcinomatous meningitis  although rare  is a rapidly fatal manifestation of metastatic transitional cell carcinoma if left untreated  however  prompt diagnosis and early aggressive therapy may result in palliation and stabilization of neurologic status  we review the pathophysiology  diagnosis  and treatment of transitional cell carcinomatous meningitis  
class10	neurologic complications of cardiac transplantation  between 1984 and 1989  orthotopic cardiac transplantations were done in 90 patients from 10 to 65 years of age for end stage  refractory congestive cardiomyopathy  two patients had had ischemic strokes 5 months and 18 years  respectively  before transplantation  six patients  7   suffered acute neurologic events perioperatively  three patients suffered cerebral infarctions  in 1 case this occurred 10 days before transplantation  probably as a result of systemic hypoperfusion  with the placement of ventricular assist devices  two others suffered infarctions 5 and 21 days  respectively  after transplantation  each of probable embolic origin  two patients had an acute intracerebral hemorrhage 21 and 36 days  respectively  after transplantation  both were located within the basal ganglia and subcortical regions  both patients had moderate to severe hypertension  and in 1  renal failure and a coagulopathy developed before hemorrhage  tremor  seizures  and an altered level of consciousness developed in 1 patient as an apparent toxic reaction to cyclosporine treatment  only 1 patient died as a result of the neurologic complication  of an acute intracerebral hemorrhage  three patients recovered fully  2 partially  only the case of drug toxicity could be directly attributed to the transplantation procedure itself  we conclude that the risk of an acute neurologic insult with orthotopic cardiac transplantation is low but may result from drug toxicity  cerebral ischemia  or hemorrhagic mechanisms  
class10	tryptophan induced eosinophilia myalgia syndrome eight patients who became ill while taking tryptophan had myalgia  fatigue  rash  fever  edema  alopecia  arthralgias  diminished joint motion  skin tightening  muscle cramping  and distal paresthesias  three had shortness of breath  and one had pulmonary hypertension  laboratory abnormalities included peripheral eosinophilia  leukocytosis  thrombocytosis  raised erythrocyte sedimentation rate  and elevated serum levels of aldolase  lactate dehydrogenase  and liver enzymes  of 4 chest radiographs  3 were abnormal  of 5 skin and muscle biopsies  4 showed sclerosis or mixed inflammatory cell infiltration of the dermis  subcutis  and fascia  eosinophils were often present  but vasculitis was absent  muscle inflammation was minimal  we conclude that the  eosinophilia myalgia syndrome  is related to the ingestion of tryptophan and that abnormalities in the secretion of lymphokines may be important in its pathogenesis  
class10	does paramedic base hospital contact result in beneficial deviations from standard prehospital protocols  we reviewed written and audio records of paramedic base hospital radio contact to determine whether care differed from that suggested in standard prehospital care protocols  records of all 659 contacts for seizure  syncope  abdominal pain  or altered mental state during 1987  28 4  of all contacts  were scored for the use of standard therapies  such as intravenous access  oxygen  naloxone hydrochloride  and unanticipated therapies  intubation  nitroglycerin   cases that involved unanticipated treatments were reviewed to determine whether they could have been prospectively identified by simple clinical findings  standard therapies were used in the majority of patients  unanticipated therapies were administered to 13 patients  all of whom had abnormal vital signs  diaphoresis  respiratory distress  or a second prominent symptom  data suggest that protocols could replace radio contact for most patients and that the few who might benefit from radio contact can be easily identified  a 90  reduction in radio contacts in los angeles county could save  3 million each year  
class10	analysis of programmed stimulation methods in the evaluation of ventricular arrhythmias in patients 20 years old and younger  the purpose of this study was to systematically evaluate programmed ventricular stimulation in patients less than 21 years of age undergoing electrophysiologic testing  a standardized protocol was applied in 55 consecutive patients  mean age 14 years  with the following clinical presentations  sustained ventricular tachycardia  vt   n   17   ventricular fibrillation  vf   n   7   syncope with heart disease  n   10   nonsustained vt  n   6   and syncope with an ostensibly normal heart  n   15   the stimulation protocol consisted of 1 and 2 ventricular extrastimuli during sinus rhythm  followed by 1 to 4  s2  s3  s4  s5  extrastimuli during pacing at 2 ventricular sites  of the 17 patients with sustained vt  12 had induction of the arrhythmia  sensitivity   71    overall  18 of 55 patients had inducible sustained vt  with this response significantly enhanced by use of s4 or s5 protocols  p   0 02   although no syncope patients with an ostensibly normal heart had inducible sustained vt  7 had polymorphic nonsustained vt in response to ventricular stimulation  the mean number of extra stimuli preceding the induction of nonsustained or sustained vt or vf did not differ  the induction of vf in 5 cases during this study was preceded in each case by extrastimuli intervals less than or equal to 190 ms  thus  data indicate that aggressive stimulation protocols appear to be required for induction of sustained vt in most young patients  nonsustained polymorphic vt as a response to aggressive programmed stimulation is of uncertain significance  and that coupling intervals less than or equal to 190 ms may correlate with the induction of vf  
class10	aortic calcified plaques and cardiovascular disease  the framingham study   the relation between the presence of calcified plaques in the thoracic aorta  as detected on chest x rays  and the development of cardiovascular disease is examined during 12 years of follow up of the framingham cohort  n   5 209   the prevalence of aortic calcified plaques approximately doubled with each decade of age  with only a trivial male predominance  its presence was associated with a twofold increase in risk of cardiovascular death in men and women younger than age 65  even after other risk factors were taken into account  similar increases in risk were found for coronary artery disease  stroke and intermittent claudication among middle aged women  in middle aged men these risks were less marked  the predictive value of aortic calcified plaques generally diminished with age  risk of sudden coronary death in men with calcified plaques in the thoracic aorta ranged from a sevenfold increase at age 35 to no excess risk at age 70 years  these results support the view that atherosclerosis is a generalized process  the finding of aortic calcified plaques in a relatively young subject on a routine chest x ray should be regarded as a sign for potential development of clinically manifest atherosclerotic disease in the cardiac  cerebral and peripheral arterial circulation  
class10	atlanto occipital disarticulation  accident characteristics  a retrospective study of cases of atlanto occipital disarticulation was conducted to describe incident characteristics  24 cases were identified  including nine motor vehicle drivers  two passengers  seven pedestrians  and five motorcyclists  one other person had fallen four stories  the highest rates were found among motorcyclists and pedestrians  atlanto occipital disarticulations occur in high energy impacts and collisions and are associated with aortic laceration in 25  and basilar skull fracture in 21  of such cases  current restraint systems and motorcycle helmets do not appear to prevent this generally rapidly fatal injury  
class10	accidental death from a black powder rifle breech plug  authentic black powder muzzle loader weapons and replicas are used today primarily for hunting game such as deer and hogs  the following is a case presentation of accidental death from cerebral trauma caused by a  45 caliber black powder rifle breech plug implanting in the victim s brain  
class10	frequency of three hex a mutant alleles among jewish and non jewish carriers identified in a tay sachs screening program  mutations in the hex a gene  encoding the alpha subunit of beta hexosaminidase a  hex a   are the cause of tay sachs disease as well as of juvenile  chronic  and adult gm2 gangliosidoses  we have examined the distribution of three mutations  a 4 nucleotide insertion in exon 11  a g    c transversion at a 5  splice site in intron 12  and a 269gly    ser amino acid substitution in exon 7  among individuals enzymatically diagnosed as carriers of hex a deficiency  mutation analysis included polymerase chain reaction  pcr  amplification of the relevant regions of genomic dna  followed by allele specific oligonucleotide hybridization  another test for heterozygosity of the exon 11 insertion was based on the formation of heteroduplex pcr fragments of low electrophoretic mobility  the percentage distribution of the exon 11  intron 12  exon 7  and unidentified mutant alleles was 73 15 4 8 among 156 jewish carriers of hex a deficiency and 16 0 3 81 among 51 non jewish carriers  regardless of the mutation  the ancestral origin of the jewish carriers was primarily eastern and  somewhat less often  central europe  whereas for the non jewish carriers it was western europe  because a twelfth of the jewish carriers and four fifths of the non jewish carriers of hex a deficiency had mutant alleles other than the three common ones tested  enzyme based tests cannot be replaced by dna based tests at the present time  however  dna based tests for two carrier couples could identify those at risk for the chronic adult gm2 gangliosidoses rather than for infantile tay sachs disease  
class10	more than one mutant allele causes infantile tay sachs disease in french canadians  two tay sachs disease  tsd  patients of french canadian origin were shown by myerowitz and hogikyan to be homozygous for a 7 6 kb deletion mutation at the 5  end of the hexosaminidase a alpha subunit gene  in order to determine whether all french canadian tsd patients were homozygotes for the deletion allele and to assess the geographic origins of tsd in this population  we ascertained 12 tsd families of french canadian origin and screened for occurrence of mutations associated with infantile tsd  dna samples were obtained from 12 french canadian tsd families  samples were analyzed using polymerase chain reaction  pcr  amplification followed by hybridization to allele specific oligonucleotides  aso  or by restriction analysis of pcr products  in some cases southern analysis of genomic dna was performed  eighteen of the 22 independently segregating mutant chromosomes in this sample carried the 7 6 kb deletion mutation at the 5  end of the gene  one chromosome carried the 4 nucleotide insertion in exon 11  a  jewish  mutation   in this population no individuals were detected who had the substitution at the splice junction of exon 12 previously identified in ashkenazi jews  one chromosome carried an undescribed b1 mutation  this allele came from a parent of non french canadian origin  patients in three families carried tsd alleles different from any of the above mutations  the 5  deletion mutation clusters in persons originating in southeastern quebec  gaspe  and adjacent counties of northern new brunswick  
class10	laparoscopic ventrosuspensions  a review of 72 cases  laparoscopic ventrosuspension is simple to perform after diagnostic laparoscopy  serious postoperative complication is unlikely  however  patient follow up over 6 months has not confirmed the usefulness of laparoscopic ventrosuspension in the management of deep dyspareunia or pelvic pain in association with a retroverted uterus  the success rate of laparoscopic ventrosuspension at 6 months varies from 18 6  to 46 5   the prior use of a hodge pessary does not predict the success of laparoscopic ventrosuspension  
class10	magnetic resonance imaging of radiation optic neuropathy  three patients with delayed radiation optic neuropathy after radiation therapy for parasellar neoplasms underwent magnetic resonance imaging  the affected optic nerves and chiasms showed enlargement and focal gadopentetate dimeglumine enhancement  the magnetic resonance imaging technique effectively detected and defined anterior visual pathway changes of radionecrosis and excluded the clinical possibility of visual loss because of tumor recurrence  
class10	auditory hallucinations and smaller superior temporal gyral volume in schizophrenia  recent neuropathologic investigations in schizophrenia report smaller volume of medial temporal lobe structures  these findings are confirmed by preliminary magnetic resonance imaging  mri  studies  direct stimulation of lateral temporal lobe structures in the region of the superior temporal gyrus provokes hallucinations  the authors  mri study of young schizophrenic patients demonstrates smaller volume of the superior temporal gyrus  an auditory association area  and of the left amygdala  smaller size of the left superior temporal gyrus and left amygdala is not accounted for by smaller size of the overall brain or temporal lobe  shrinkage of the left superior temporal gyrus is strongly and selectively correlated with severity of auditory hallucinations  
class10	a discriminant validity study of negative symptoms with a special focus on depression and antipsychotic medication  if the construct validity of the negative symptom syndrome is to be established  the conceptual and operational overlap between negative symptoms and other syndromes such as depression and the effects of medication must be explained  the author assessed 26 patients with schizophrenia and 21 patients without schizophrenia  most of whom had depression  at the end of an average 2 week drug washout period and after approximately 2 months of psychotropic medication administration  negative symptoms were remarkably consistent in patients with schizophrenia despite pharmacological intervention  in contrast  the patients without schizophrenia manifested significant decreases in negative symptoms  
class10	depression in dementia of the alzheimer type and in multi infarct dementia  the authors used the hamilton rating scale for depression and a rating of depressed mood to investigate the prevalence of depression in 55 patients with alzheimer s disease  37 patients with multi infarct dementia  and 30 nondemented comparison subjects  the prevalence of depressed mood depended on the severity of dementia as measured by the mini mental state examination and was significantly lower among patients in more severe stages of alzheimer s disease but not among patients with severe multi infarct dementia  
class10	panic disorder and cardiovascular cerebrovascular problems  results from a community survey  follow up studies of psychiatric patients with panic disorder have shown an abnormally high mortality rate in men due to cardiovascular and cerebrovascular events  the authors report that in the new haven portion of the epidemiologic catchment area program the risk for stroke in persons with lifetime diagnoses of panic disorder was over twice that in persons with other psychiatric disorders or no psychiatric disorder  after adjustments for demographic differences between groups  the risk was even higher  while the results should be interpreted cautiously because of the small sample and absence of medical examinations  these findings are consistent with clinical studies showing an association between panic disorder and cardiovascular cerebrovascular events  
class10	nitrous oxide does not alter infarct volume in rats undergoing reversible middle cerebral artery occlusion  this experiment was designed to determine if nitrous oxide alters neurologic and pathologic outcome from temporary focal cerebral ischemia in spontaneously hypertensive rats deeply anesthetized with a barbiturate  two groups of rats were given intravenous methohexital such that a stable eeg pattern of burst suppression was achieved  in one group of rats  n   11   the lungs were mechanically ventilated with 70  n2o 30  o2  and in the other group  n   10   ventilation was done with 70  nitrogen 30  o2  the middle cerebral artery was then occluded for 2 h  during which time mean arterial pressure  blood gases  hematocrit  plasma glucose  and head temperature were held constant between groups  the total doses of methohexital administered were similar in both groups as were the plasma methohexital concentrations immediately prior to onset of ischemia  after reperfusion of the middle cerebral artery  the animals were allowed to awaken  neurologic evaluations were performed prior to ischemia and at 24 and 96 h postischemia  cerebral infarct volume was measured at 96 h postischemia using triphenyl tetrazolium chloride staining and computer imaging techniques  there were no neurologic differences between the n2o and nitrogen groups at any experimental interval although both groups exhibited deficits at both 24 and 96 h postischemia relative to preischemic values  the two groups also had nearly identical cerebral infarct volumes  n2o   231     97 mm3  nitrogen   226     75 mm3  mean     sd   
class10	resistance to d tubocurarine in lower motor neuron injury is related to increased acetylcholine receptors at the neuromuscular junction the hypothesis that lower motor neuron injury  with its associated proliferation of acetylcholine receptors  achr   induces resistance to the neuromuscular effects of d tubocurarine  dtc  was tested in the rat  the left gastrocnemius was denervated by a 75 80  lesion of the sciatic nerve  the effective dose for 95  twitch depression  ed95  was studied in the denervated gastrocnemius and compared to the contralateral undenervated and sham injured  control  gastrocnemius muscles approximately 2 weeks after injury  the achr number was quantitated by the specific ligand 125i alpha bungarotoxin  125i alpha bt   plasma dtc concentrations  measured by high performance liquid chromatography  hplc   were correlated to twitch tension during spontaneous recovery from neuromuscular blockade in the denervated animal  the ed95  mean     se  of dtc for the denervated leg was significantly  p less than 0 05  higher  0 26     0 06 mg kg 1  than contralateral  0 16     0 03  and sham operated left  0 13     0 03  legs  the twitch tension recovered to 50  of control twitch height at significantly  p less than 0 05  higher plasma dtc concentrations in the denervated  0 78 micrograms ml 1  compared to contralateral  0 24 micrograms ml 1  limb  the achr number was significantly increased in the denervated limb  1041     96 fmol mg protein 1  compared to contralateral right  109     4  and control left limb  113     11   there was a significant  p less than 0 05  positive correlation  r2   0 73  between ed95 and achr number  that is  73  of the variability in ed95 could be explained by changes in achr  this study  therefore  confirms the hypothesis that proliferation of achr after nerve denervation results in resistance to the neuromuscular effects of dtc  
class10	a comparative trial of three agents in the treatment of acute migraine headache  study objectives  a study was conducted to evaluate the relative efficacy of three non narcotic agents  chloropromazine  lidocaine  and dihydroergotamine  in the treatment of migraine headache in an emergency department setting  design  the trial was randomized and single blinded  setting  the study was conducted in two university affiliated eds  type of participants  all patients had an isolated diagnosis of common or classic migraine  interventions  patients were pretreated with 500 ml  iv  normal saline before randomization  study drugs as administered were dihydroergotamine 1 mg iv repeated after 30 minutes if the initial response was inadequate  lidocaine 50 mg iv at 20 minute intervals to a maximum total dose of 150 mg as required  or chloropromazine 12 5 mg iv repeated at 20 minute intervals to a total maximum dose of 37 5 mg as required  patients were asked to grade headache severity on a ten point scale before and one hour after the initiation of therapy  follow up by phone was sought the following day  measurements and main results  of 76 patients completing the trial  24 were randomized to receive chloropromazine  26 to receive dihydroergotamine  and 26 to receive lidocaine  reduction in mean headache intensity was significantly better among those treated with chloropromazine  p less than  005   persistent headache relief was experienced by 16 of the chloropromazine treated patients  88 9   contacted at 12 to 24 hours follow up compared with ten of the dihydroergotamine treated patients  52 6   and five of the lidocaine treated group  29 4    conclusion  the relative effectiveness of these three antimigraine therapies appears to favor chloropromazine in measures of headache relief  incidence of headache rebound  and patient satisfaction with therapy  
class10	a prospective  double blind study of metoclopramide hydrochloride for the control of migraine in the emergency department study objective  to determine the effectiveness of iv metoclopramide as sole therapy for relieving the pain of acute migraine in the emergency department  design  prospective study  fifty patients were divided randomly into subjects and placebo controls with blinding of the treating physician and the patient  participants  patients presenting to the ed with migraine requiring parenteral treatment  interventions  subjects received 10 mg iv metoclopramide and controls received iv normal saline  patient assessment of relief was followed by means of a numerical scale  measurements and main results  sixty seven percent of subjects compared with 19  of controls had effective pain relief within one hour  p less than  001   subjects achieved mean relief scores of 2 46 compared with 1 69 for controls  p less than  02   no significant side effects were observed  conclusion  iv metoclopramide as a single agent is effective and safe therapy for migraine in the ed  
class10	brain water content  brain blood volume  blood chemistry  and pathology in a model of cerebral edema  study objectives  the objective was to correlate regional changes during brain water content with alterations in blood chemistry and cerebral pathology during hypo osmotic edema  participants  sprague dawley male adult rats were used in these studies  design  animals were block randomized to receive either an intraperitoneal distilled water injection equivalent to 5  or 15  of their body weight or no injection  controls   rats were sacrificed 15 or 60 minutes after water injection or at an equivalent time for controls  interventions  no interventions were performed  measurements and main results  water content of cerebral cortical gray and white matter was calculated from measurements of tissue specific gravity  blood plasma osmolality and sodium and potassium concentrations were determined at various times after water injection  an index of blood brain barrier permeability was obtained by measuring brain red blood cell and plasma volumes  a qualitative assessment of edema was made from light and electron micrographs of the cerebral cortex  we found that water injection produced a dose dependent decrease in plasma osmolality and sodium concentration within 15 minutes  cortical water content was unchanged after this period  an influx of water into cerebral gray  and  less readily  into cerebral white matter occurred during the next 15 minutes  whole blood specific gravity and brain blood content were unchanged and thus did not confound the measurement of cerebral water content  hematocrit was increased 60 minutes after a 15  water injection  the blood brain barrier remained intact throughout this period  microscopy revealed astrocytic swelling with slight extracellular fluid accumulation 60 minutes after the water injection  conclusions  homeostatic mechanisms in the cerebral cortex can maintain constant water content for at least 15 minutes during maintained intravascular hypo osmolality  fluid that subsequently moves into the tissue primarily enters an intracellular compartment  this model will be useful in investigating physiological mechanisms of brain water regulation and the pathogenesis of brain edema  a common clinical entity in emergency conditions  
class10	spectral electroretinography in thioridazine toxicity  in three patients with thioridazine toxicity  the electroretinogram  erg  to red light was found to be below the average normal range  a significant increase in its amplitude appeared with cessation of therapy in two cases  a further deterioration of the erg amplitude to all stimulus conditions  white  blue  and red lights  occurred when the dose of the medication was increased in the third patient  
class10	a case of unilateral posterior ischemic optic neuropathy after radical neck dissection  we present a case of unilateral posterior ischemic optic neuropathy after bilateral radical neck dissection  etiologic factors are discussed  
class10	auditory brain stem implant  effect of tumor size and preoperative hearing level on function  the auditory brain stem implant is an investigational device designed to provide hearing sensations to patients without functioning auditory nerves  we analyzed results from 17 implants in 15 patients to determine if tumor size or preoperative hearing level might be related to proper device function  we found no significant correlation between preoperative hearing level or tumor size and device function  we also found no significant correlation between preoperative hearing level and tumor size in these 15 patients  
class10	cholinergic deficiency and frontal dysfunction in parkinson s disease  to investigate the influence of central cholinergic deficit on cognitive function in parkinson s disease  pd   we compared the neuropsychological performance of a group of 20 patients who were treated with anticholinergic drugs  mean daily dose  10 2 mg  with that of a group of 20 patients who received no anticholinergics  the two groups were matched for all the variables of parkinsonism and levodopa therapy  at the dose used  there was no significant difference between the two groups of patients for intellectual  visuospatial  instrumental  and memory function  in contrast  in the group that received anticholinergics severe impairment was observed on tests believed to assess frontal lobe function  these results suggest that the lesion of the ascending cholinergic neurons  which has been demonstrated post mortem in pd  may play a role in the subcorticofrontal behavioral impairment of this disease  
class10	posthypoxic glucose supplement reduces hypoxic ischemic brain damage in the neonatal rat  we evaluated the effect of posthypoxic glucose supplement in a neonatal hypoxic ischemic animal model  seven day old rats underwent bilateral ligation of the carotid arteries  followed by exposure to an 8  oxygen atmosphere for 1 hour  the extent of hypoxic ischemic brain damage was assessed histologically 72 hours later  glucose load immediately after the end of the hypoxic exposure reduced the volume of neocortical infarction to 37  of the unsupplemented value  and attenuated ischemic damage in the striatum and the dentate gyrus  at the end of the hypoxic exposure  the brain level of glucose was 0 3 mmol kg and the level of lactate 9 mmol kg  glucose supplement produced a rapid rise in brain glucose level to 3 to 5 mmol kg over the next 2 hours  lactate in both brain and plasma gradually fell toward the baseline level during the first hour of recovery  posthypoxic glucose supplement slightly retarded lactate restitution  at any period of this neonatal model  brain lactate levels did not exceed the toxic level  which is postulated to be responsible for cerebral infarction in adult ischemic models  these results illustrate the important role of glucose in the development of neonatal hypoxic ischemic encephalopathy and the fact that full cortical infarction can develop even if brain lactate levels are low  
class10	relation of hyperglycemia early in ischemic brain infarction to cerebral anatomy  metabolism  and clinical outcome  we studied the relation of serum glucose level measured in the first 12 hours of symptoms to the clinical findings  results of computed tomography  ct   and patterns of cerebral metabolism in 39 patients who had acute ischemic cerebral infarction  structural damage was assessed by ct  metabolic disruption was assessed using 18f fluorodeoxyglucose and positron emission tomography  pet   median initial serum glucose concentration was 155 mg dl  6 7 mm   clinical recovery was significantly poorer in patients with initial serum glucose levels higher than the median  p less than 0 05  chi square   pet tended to show normal results or minor abnormalities in patients with initial glucose levels less than the median  as opposed to lobar or multilobe abnormalities in patients with levels that were higher than the median  p less than 0 05  kendall s tau b   the severity of hypometabolism in the ischemic region  expressed as the percent asymmetry of local cerebral glucose metabolism between homologous brain regions  was greater in patients with initial glycemia concentrations higher than the median  p less than 0 001  t test   relationships of serum glucose level with metabolic derangement and structural damage  but not outcome  held true in patients without a history of diabetes mellitus  
class10	a clinical triad to diagnose paraneoplastic retinopathy  two elderly men developed photosensitivity and light induced glare  transient visual symptoms  and progressive visual loss several months before small cell carcinoma of the lung was discovered  both patients had impaired visual acuity and color vision  ring scotomas  and attenuated retinal arteriole caliber  electroretinography demonstrated abnormal cone and rod mediated responses  antiretinal antibodies were identified in their serum  their visual sensory function improved following therapy with immunosuppressive agents  the triad of photosensitivity  ring scotomatous visual field loss  and attenuated retinal arteriole caliber should alert one to a paraneoplastic disorder affecting the retina  
class10	soluble interleukin 2 receptors in cerebrospinal fluid from individuals with various neurological disorders  soluble interleukin 2  il 2r  levels in the cerebrospinal fluid  csf  were studied in infectious  inflammatory  degenerative  and neoplastic disorders to evaluate their usefulness as a marker for the presence of activated t cells  thus indicating an inflammatory process  csf from control subjects and patients with stationary  progressive  and treated multiple sclerosis  ms   aseptic meningitis  lymphoid and nonlymphoid central nervous system  cns  tumors  alzheimer s disease  as well as serum from ms patients and control subjects were studied for levels of soluble il 2r  a significant increase in csf il 2r levels was observed in patients with ms  meningitis  and lymphoid cns tumors  the ms group showed the highest values  csf from individuals with alzheimer s disease and from patients with nonlymphoid tumors did not show significantly elevated values  serum il 2r levels were significantly higher in ms patients than in control subjects  but there was no significant correlation between individual serum and csf il 2r levels  this study suggests the presence of activated t lymphocytes in the cns of patients with ms  
class10	ubiquitin immunoreactivity in kuru plaques in creutzfeldt jakob disease  cerebellar kuru plaques in 2 cases of creutzfeldt jakob disease were studied immunohistochemically  similar to cerebellar senile plaques in alzheimer s disease  many kuru plaques contained ubiquitin positive  tau negative small granular elements  presumably representing dystrophic neurites  our results suggest that similar mechanisms are involved in neuritic changes in cerebellar plaques in creutzfeldt jakob and alzheimer s diseases despite differences of amyloid proteins in the plaques  
class10	middle cerebral artery strokes causing homonymous hemianopia  positron emission tomography  eight patients were evaluated with 18f fluorodeoxyglucose positron emission tomography between 3 and 30 days after isolated stroke involving the middle cerebral artery territory that caused homonymous hemianopia  diffuse hypometabolism was present throughout the damaged cerebral hemisphere  even in cortical areas not obviously ischemic by clinical examination or neuro imaging  glucose metabolism in primary and association visual cortex of the damaged hemisphere was decreased by more than 47   p less than 0 01   metabolism in the undamaged hemisphere was less profoundly affected  but significant decrements were found in calcarine  40   p less than 0 01  and lateral occipital cortex  35   p less than 0 05   
class10	vasoactive peptide release in the extracerebral circulation of humans during migraine headache  the innervation of the cranial vessels by the trigeminal nerve  the trigeminovascular system  has recently been the subject of study in view of its possible role in the mediation of some aspects of migraine  since stimulation of the trigeminal ganglion in humans leads to facial pain and flushing and associated release of powerful neuropeptide vasodilator substances  their local release into the extracerebral circulation of humans was determined in patients who had either common or classic migraine  venous blood was sampled from both the external jugular and cubital fossa ipsilateral to the side of headache  plasma levels of neuropeptide y  vasoactive intestinal polypeptide  substance p  and calcitonin gene related peptide were determined using sensitive radioimmunoassays for each peptide  and values for the cubital fossa and external jugular and a control population were compared  a substantial elevation of the calcitonin gene related peptide level in the external jugular but not the cubital fossa blood was seen in both classic and common migraine  the increase seen in classic migraine was greater than that seen with common migraine  the other peptides measured were unaltered  this finding may have importance in the pathophysiology of migraine  
class10	richner hanhart s syndrome  electron microscopic study of the skin lesion  the plantar hyperkeratotic skin lesion in a case of richner hanhart s syndrome was investigated using ultrastructural examination  light microscopic examination showed remarkable hyperkeratosis and some aberrant keratinocytes with multiple nuclei  on ultrastructural examination  some abnormal structures were seen in the affected keratinocytes  aggregations of tonofilaments and intracytoplasmic inclusions  the inclusions were needle shaped and were considered to be  crystal ghosts   presumably of tyrosine  the formation of tyrosine crystalline inclusions seems to be an important factor in the pathogenesis of the cutaneous lesions in richner hanhart s syndrome  
class10	magnetic resonance imaging in neurological disorders  to investigate the role of magnetic resonance imaging  mri  in neurological disorders  115 children were studied in two groups  group a  78 patients  was studied by paired computed tomography and mri cranial scans  group b  37 patients  was studied by paired computed tomography assisted myelography  ctm  and mri spinal scans  in group a  the scans were generally equivalent for supratentorial tumours and for investigating fits  hydrocephalus  benign intracranial hypertension  and cerebral atrophies  but mri scanning was superior for posterior fossa tumours and cysts  in group b  mri scans were superior for intramedullary spinal tumours  spinal dysraphic problems with tethering or syrinx  and were complementary to ctm in diastematomyelia  
class10	slow release carbamazepine in treatment of poorly controlled seizures  thirty three children with poorly controlled epilepsy  and six new patients  were treated with slow release carbamazepine  twelve of the former had a reduction in the number of seizures of more than half  and 10 had fewer side effects  three of the new patients stopped having seizures  variations in plasma concentrations between doses was significantly less when patients took the slow release preparation  22   compared with the standard preparation  41    slow release carbamazepine may improve the conditions of children whose seizures are poorly controlled  
class10	the iris in williams syndrome  forty three children with williams syndrome and 124 control subjects had their eyes photographed  the photographs were examined by three ophthalmologists and four geneticists of varying experience  a stellate pattern was noted more often in the irides of patients with williams syndrome  51   than in those of the control subjects  12    and was more difficult to detect  or was absent  in heavily pigmented irides  we conclude that the stellate pattern is of diagnostic importance  particularly if the pattern is carefully defined and the clinician is experienced  
class10	analysis of prognostic factors and clinicopathological staging of thymoma the prognostic value of four clinical variables  age and sex of patients  association with myasthenia gravis  and clinical stage  and histological type was analyzed in 83 consecutive patients with thymoma  histologically classified as cortical  medullary  and mixed  age  sex  and association with myasthenia gravis did not prove to represent significant prognostic factors  clinical stage and histological type  on the contrary  had a highly significant prognostic value  p less than 0 001   a model of clinicopathological staging  based on both clinical stage and histological type  in which three major prognostic groups are considered is proposed  the degree of significance of this model is higher  p less than 0 0001  than that of clinical stage and histological type considered individually  its validity is further supported by the results of multivariate analysis according to the cox regression model  p   0 0001   we think it represents a prognostically valuable approach to the problem of management of thymoma  
class10	intraoperative ultrasonic imaging of the ascending aorta in ischemic heart disease  in an attempt to locate any atherosclerotic lesion in the ascending aorta and to prevent embolization  intraoperative b mode ultrasonography was performed in 100 patients with ischemic heart disease  31 women and 69 men   ultrasonography was carried out with a 10 mhz probe placed directly on the ascending aorta  ultrasonic imaging demonstrated an atherosclerotic lesion in the lower half of the aorta in 76 patients  76    a lesion in the upper half of the aorta in 89 patients  89    and a lesion at the orifice of the innominate artery in 99 patients  99    prospective palpation identified an atherosclerotic lesion in 12  25   of 48 patients  thoracic computed tomography in 79 patients showed calcification in the lower half of the aorta in 6 patients  7 6   and in the upper half of the aorta in 11  13 9    palpation and thoracic computed tomography underestimated the frequency of atherosclerotic lesions  intraoperative ultrasonography accurately identified atherosclerotic disease  this technique allows the surgeon to modify cannulation  aortic clamping  and operative technique to reduce the risk of perioperative stroke due to embolization of atherosclerotic debris from the ascending aorta  
class10	prevention of paraplegia during aortic operations  ischemic spinal cord injury after aortic cross clamping may be produced by a steal phenomenon  the present study investigates this possibility by directly measuring the oxygen tension on the spinal cord surface in pigs  after simple clamping of the aorta  oxygen tension decreased significantly distal to the clamping site both after occlusion of the thoracic aorta at t3 4  group 1  and after occlusion of the abdominal aorta at l 1  group 2   exclusion of the thoracic aorta by a second clamp at t 13 restored oxygen tension almost to the original level  whereas segmentation of the abdominal aorta up to s 1 hardly affected oxygen tension in the area of the artery of adamkiewicz in most of the animals  we conclude that after aortic cross clamping  blood tends to drain away from the spinal cord rather than supplying it longitudinally  without knowledge of the position of the adamkiewicz artery in humans as well as of the competence of the collateral circulation in the excluded segment  it is necessary to develop a new strategy for repair of the aorta  we describe and discuss two surgical techniques for the prevention of paraplegia after aortic cross clamping  the counterocclusion technique and the bypass fractionated technique  
class10	diagnostic imaging and surgical treatment of dumbbell tumors of the mediastinum  we describe the diagnostic procedures and surgical approaches employed in 5 patients with dumbbell tumors of the mediastinum  magnetic resonance imaging accurately described the existence and longitudinal extension of the intraspinal component of the tumor and assisted in choosing the appropriate surgical approach  both the intrathoracic and intraspinal components of the tumor were resected at one time by a thoracic and neurosurgical team  we employed the grillo technique three times and a separate laminectomy and thoracotomy approach  magnetic resonance imaging proved the most useful diagnostic technique for suspected dumbbell mediastinal tumors  in our experience  the extended thoracotomy proposed by grillo and co workers worked well for small tumors involving only one foramen in which the intraspinal extension was limited to 2 to 3 cm  and when no more than two laminectomies were required  on the other hand  thoracotomy and a longitudinal paravertebral incision are preferable for larger tumors  more than 4 cm  involving more than one foramen in which the intraspinal extension exceeds 2 to 3 cm  for tumors requiring multiple laminectomy  and when bony infiltration is present  
class10	coexisting thymic carcinoid tumor and thymoma  thymic carcinoid tumors are unusual neoplasms that are different from thymomas  we report a case of coexisting thymic carcinoid tumor and thymoma associated with myasthenia gravis  the clinicopathological findings are discussed with a review of the literature  
class10	electroencephalography should not be routine in the evaluation of syncope in adults we reviewed the reports of all electroencephalograms obtained at the nashville  tenn  veterans administration hospital from september 1987 to august 1989  seventy three patients were referred for evaluation of syncope or near syncope  of these 73 patients  10  13 7   had abnormal findings  twenty six patients were referred for other complaints similar to syncope  ie  blackouts  loss of consciousness  falling out  passing out  and fainting   of these 26 patients  five  19 2   had abnormal findings  we reviewed the medical records of the patients with abnormal findings and found that the final diagnosis or treatment of the syncope was affected by electroencephalogram in only one patient  these findings suggest that routine electroencephalography is not of significant value in the evaluation of syncope in adults  
class10	the influence of age vs peak serum concentration on life threatening events after chronic theophylline intoxication  to identify risk factors for the development of seizures and cardiac arrhythmias after chronic  unintentional theophylline intoxication we monitored the clinical course of 72 consecutive patients referred to a regional poison center with chronic theophylline intoxication  serum theophylline concentration  greater than or equal to 167 mumol l after protracted use   the median age of the sample was 47 5 years  range  4 days to 91 years   median peak theophylline concentration was 239 mumol l  with a range of 167 to 722 mumol l  a life threatening event  lte  occurred in 28 patients  39   that included seizures in eight and a major cardiac arrhythmia in 22  the median peak  theophylline  of patients who had an lte vs those who did not was 235 8 vs 238 7 mumol l  however  the median age of patients with an lte compared with those without an lte was significantly greater  70 5 vs 18 0 years   stratification of data by chronologic age revealed a stepwise increase in the frequency of lte with advancing years  patients more than 75 years old had a 16 7 fold greater risk of lte than patients less than 25 years old  95  confidence interval  3 56  77 5  despite comparable intergroup median serum  theophylline   these data suggest the primary determinant of ltes after chronic theophylline intoxication is chronologic age  elderly patients have an inordinately greater risk of lte than younger patients  peak serum theophylline concentration cannot predict which patients with chronic theophylline intoxication will have an lte  finally  these data indicate that theophylline should be used cautiously and with frequent monitoring of serum theophylline concentrations in elderly patients  
class10	morbidity  mortality  and quality of life for patients treated with levothyroxine in a population study of 1462 middle aged women initiated in 1968 and 1969 we identified 29 women treated with levothyroxine from 1 to 28 years  in a 12 year follow up in 1980 and 1981 we investigated the subjects for end point myocardial infarction  diabetes mellitus  stroke  cancer  and death  the status of 99 7  of the initial participants was established   the women treated with levothyroxine showed no increase in morbidity or mortality  of the 24 women still receiving levothyroxine in 1980 and 1981  22 had serum thyrotropin and triiodothyronine concentrations with in reference limits  these individuals were compared with the 968 women from the population study having no history of thyroid disease  and appeared identical as to laboratory and clinical data  with the exception of a slightly higher body mass  taller stature  and lower serum cholesterol concentration  the treated group did not differ in a life quality estimate based on 19 questions regarding life satisfaction and sensory function  we conclude that the levothyroxine treated woman suffers no side effects from her life long therapy  
class10	an immunofluorescence study of cerebral malaria  a correlation with histopathology  histopathologic and immunopathologic features of cerebral malaria have been defined in a study of six autopsy cases with severe plasmodium falciparum infection  in five cases  immunofluorescent studies demonstrated intense deposition of p falciparum antigen  igg  and fibrin in cerebral vessels associated with the histopathologic finding of hemorrhage in the white matter of cerebrum and cerebellum regardless of the presence of parasitized erythrocytes in the cerebral vessels  immunofluorescent study also demonstrated the extravascular deposits of p falciparum granular antigen associated with acute inflammatory lesion in cerebral tissue in one case  these findings suggested that the immunopathogenic mechanism may in some way play a role in the pathogenesis of cerebral malaria  
class10	physiologic responses to prolonged electrically stimulated leg cycle exercise in the spinal cord injured  this study determined the physiologic responses to prolonged functional neuromuscular stimulation  fns  leg cycle exercise in seven quadriplegic and seven paraplegic subjects  each subject completed 30 minutes of continuous fns leg cycling during which open circuit spirometry  impedance cardiography  auscultation  and fingertip capillary blood sampling were used to assess metabolic and hemodynamic responses  compared with resting values  oxygen uptake  carbon dioxide production  respiratory exchange ratio  rer   pulmonary ventilation  heart rate  hr   left ventricular stroke volume  sv   cardiac output  qt   and blood lactate  la  concentration were significantly  p less than  05  elevated  whereas plasma volume  bicarbonate concentration  and ph were significantly decreased in both groups during prolonged fns leg cycle exercise  mean arterial pressure remained unchanged in quadriplegic and paraplegic subjects during the prolonged fns leg cycle exercise bout  persons with quadriplegia elicited significantly lower map and tended to have lower sv and qt responses than persons with paraplegia  probably due to a higher degree of sympathetic dysfunction and circulatory hypokinesis during fns leg cycle exercise  all other physiologic variables responded similarly between groups  we speculate that the relative increases observed for hr  33  to 60    sv  45  to 69    and qt  113  to 142   during prolonged fns leg cycle exercise create a sufficient cardiac volume load to promote central cardiovascular conditioning in persons with both quadriplegia and paraplegia  the la accumulation  4 7 to 5 2 mmol l 1  in the spinal cord injured during prolonged fns leg cycling is unusually high for the power output attained  5 2w and 6 1w for quadriplegia and paraplegia  respectively   
class10	rehabilitation of chronic stroke patients  changes in functional performance  forty stroke patients who were at least one year post onset completed a one month intensive rehabilitation program  the month before the program served as a control period  during the program  patients received individual sessions in occupational and physical therapy four days a week  and they participated in group activities on the fifth day  therapy emphasized instruction in motor planning  balance and weight shift  and the use of adaptive equipment  these motor abilities were then practiced within real life situations  the patients demonstrated significant improvement in the outcome measures of weight shift  balance  and adl scores after the one month rehabilitation program  weight shift  f   16 1  p    0001  balance  f   6 26  p    0007  adl  f   13 8  p    0001   they retained these new skills during a three month follow up period  
class10	manual stretch  effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles  this study evaluated the effects of manual stretch of extrinsic finger flexor muscles on finger extension movement control and force control in 16 spastic hemiparetic subjects  these subjects were randomly divided into a control group and an experimental group  a group of able bodied subjects also participated  a joint movement tracking test  jmtt  quantified control of active finger extension movement at the metacarpophalangeal joint of the index finger within the available range of active movement  and a force tracking test  ftt  quantified control of isometric finger extension force at the same joint within the subject s available force range  electromyographic activity was monitored in the extensor digitorum and flexor digitorum superficialis muscles during both tracking tests  manual stretch was applied to the extrinsic finger flexor muscles of the experimental group between the pretest and posttest tracking tests  the jmtt performances of both control  p less than  025  and experimental  p less than  05  groups were significantly subnormal on the pretest as were ftt performances of controls  p less than  01  and study subjects  p less than  03   the jmtt improvement on posttest was significantly greater  p less than  05  in subjects than in controls  however  the change in ftt performance was not significantly different between the two groups  manual stretch treatment  properly applied to extrinsic finger flexor muscles  is an effective method of temporarily improving the control of finger extension movement in spastic hemiparetic subjects  
class10	strapless oral nasal interface for positive pressure ventilation  a custom fabricated strapless oral nasal interface  soni  is described  it was used in the long term administration of intermittent positive pressure ventilation  ippv  by 18 patients with paralytic or restrictive pulmonary insufficiency  this interface is an acrylic shell which is firmly fixed to an orthodontic bite plate  it is designed to form a seal over the nose and mouth for the entry of ippv  eight patients were ventilator dependent 24 hours a day  the ten patients who required only nocturnal aid had improvement in daytime arterial blood gases  although nine of these patients could manage less than 15 minutes of unassisted breathing  free time  supine  all slept supine on soni ippv  the 13 patients who underwent sleep monitoring maintained a mean oxygen saturation of 95 3      1 7  and acceptable end tidal pco2  30 to 45 mmhg   these 13 patients have used soni ippv for an average of 22 months  range   3 to 63 months   impediments to successful long term use of a soni include the presence of a hyperactive gag reflex or stimulation of excessive oral secretions  when combined with mouth ippv  glossopharyngeal breathing  the intermittent abdominal pressure ventilator  or the cuirass ventilator for daytime use  soni ippv is an option for the patient who prefers total ventilatory support by noninvasive means  
class10	stroke rehabilitation  a geropsychological perspective  rehabilitation medicine and geriatric medicine are similar in their concern for functional improvement in the face of chronic medical conditions  although many patients served by rehabilitation medicine fall within the geriatric age range  a knowledge of normal aging does not necessarily inform clinical decision making or research practices in rehabilitation  using stroke as an example of a disorder affecting primarily geriatric patients and requiring the technology of rehabilitation  ways in which age might affect assessment of outcome are examined  three areas dealing with conceptual and methodologic issues  depression  neurochemical interventions  and family  are highlighted  the final section outlines recommendations for research on rehabilitation outcome of geriatric stroke patients  
class10	childhood stroke after minor neck trauma  case report  cerebral infarction after minor trauma to the neck has rarely been reported  a case is presented of a child with trauma to the vertebrobasilar artery resulting in stroke  computerized tomography scan and angiography results are presented  despite two subsequent  separate transient episodes of vertigo  the child had good functional recovery with complete restoration of language and cognitive function  after 28 months  residual impairments identified were a mild right sided ataxia and hemiparesis  
class10	failure to detect human t cell leukemia virus related sequences in multiple sclerosis blood  we tested 11 patients with multiple sclerosis for the presence of human t cell leukemia virus type i  htlv i   or type ii  htlv ii  related sequences  dna from blood mononuclear cells was analyzed by the polymerase chain reaction utilizing three different oligonucleotide primer pairs  two of these primer pairs detect sequences shared between htlv i and htlv ii in either p24  gag protein  or in p21  env transmembrane protein  the third primer pair was synthesized based on regions in the pol gene where amino acid sequences are conserved between htlv i  htlv ii  and the related bovine leukemia virus  the multiple sclerosis samples were consistently negative while appropriate control samples were positive  we conclude that viruses related to htlv i  htlv ii  or bovine leukemia virus are not present in the blood of patients with multiple sclerosis and  therefore  that htlv bovine leukemia virus related viruses are not likely to be involved in the pathogenesis of multiple sclerosis  
class10	apneic oxygenation in apnea tests for brain death  a controlled trial  we performed a prospective controlled study of apneic oxygenation on 15 patients undergoing apnea tests for brain death  all patients were preoxygenated with 100  oxygen at existing respirator settings  during the 10 minute apnea tests  nine patients were given continuous apneic oxygenation by tracheal cannula  the other six patients had tracheal tubes open to room air  the patients given apneic oxygenation had little or no hypoxia by the end of the test  the patients given room air during the test became hypoxic  many neurologists perform apnea tests with no oxygenation or with preoxygenation alone  this is the first prospective controlled study  to our knowledge  of apneic oxygenation  it shows that preoxygenation alone does not prevent hypoxia during apnea tests for brain death  we recommend that all apnea tests be performed with apneic oxygenation  
class10	geographic patterns of parkinsonism dementia complex on guam  1956 through 1985  average annual age adjusted incidence rates of parkinsonism dementia complex were obtained for the 19 election districts of guam from 1956 through 1985  the highest rates were found in the southern and central districts  and the lowest rates were found in the northern and western districts  geographic and temporal patterns of incidence were associated with socioeconomic status but not with geochemical factors  the risk of parkinsonism dementia complex in susceptible sibships was much higher than that in the general population  even in districts with the highest incidence rates  but especially in districts with the lowest incidence rates  our evidence tends to support the hypothesis that multiple factors linked to cycad use play an important role in the cause of pdc  hypotheses related to metal exposure and simple genetic factors were unsatisfactory explanations for the epidemiologic patterns observed  
class10	racial differences in the anterior circulation in cerebrovascular disease  how much can be explained by risk factors  the entry characteristics of 1367 patients enrolled into the extracranial intracranial bypass study were examined to determine if site differences in intracranial and extracranial arterial lesions among racial groups could be explained by differences in risk factors  blacks were more often hypertensive  diabetic  or cigarette smokers  while whites had higher systolic blood pressure and hemoglobin values  orientals had the lowest prevalence of vascular risk factors  despite these differences in risk factors  multivariate analysis showed race to be an independent and strong predictor of the location of cerebrovascular lesions  to our knowledge  this study is unique in documenting risk factors prospectively and systematically in three racial groups simultaneously  although generalization is limited by possible biases related to patient selection  the results affirm previous tentative conclusions about the role of race in determining the location of cerebrovascular disease  
class10	the large striatocapsular infarct  a clinical and pathophysiological entity  we examined 29 patients with strictly subcortical large striatocapsular infarctions  eight of them had aphasia or neglect  all patients underwent transcranial doppler ultrasonography or selective carotid angiography  magnetic resonance imaging  and single photon emission tomography for assessment of cerebral blood flow  blood volume  and cerebral perfusion reserve  the signs were compatible with cortical territorial infarctions rather than lacunes  on both magnetic resonance imaging and computed tomographic scans  the lesions corresponded to the territories of the medial and lateral group of the lenticulostriate arteries  heubner s artery  or the anterior choroidal artery  the infarctions were either due to cerebral embolization into the m1 segment of the middle cerebral artery or due to stenosis at the same site  ie  lesions that acutely and simultaneously occluded the orifices of the lenticulostriate or neighboring arteries  persistent occlusion of the middle cerebral arteries and a decrease of cortical regional cerebral blood flow were only found in patients with aphasia or neglect  all patients without aphasia or neglect showed a rapid recanalization of the middle cerebral artery occlusion or a stenosis of the m1 segment and no cortical regional cerebral blood flow decrease  large striatocapsular infarctions occur due to occlusive disease of the middle cerebral artery  large vessel disease  and not due to a disseminated in situ occlusion of the long penetrating arteries  small vessel disease   as in lacunes  neuropsychological deficits can be explained by decreased cortical blood flow due to a persistent occlusive lesion of the middle cerebral artery  
class10	brain imaging abnormalities in mental disorders of late life  psychiatric inpatients with dementia  n   61  or depression  n   67  in late life were 2 6 times more likely to manifest magnetic resonance imaging abnormalities of the brain than were elderly controls  n   44   controlling for the effects of age and gender  demented patients were distinguishable from controls by an increased prevalence of cortical atrophy and infarction  while depressed patients exhibited an increased prevalence of cortical infarctions and leukoencephalopathy  patients with dementia were distinguishable from those with major depression by an increased prevalence of cortical atrophy  these results indicate that major depression in late life  like dementia  is associated with a remarkable increase in overt pathologic changes in the brain  
class10	adjuvant chemotherapy for primary lymphoma of the central nervous system  ten immunocompetent patients with primary non hodgkin s lymphoma of the central nervous system were treated by the neuro oncology service at the university of california at san francisco  ucsf   after undergoing surgery for biopsy or removal of their tumors  these patients  group 1  received irradiation with hydroxyurea followed by adjuvant chemotherapy with the combination of procarbazine  lomustine  ccnu   and vincristine  the outcome of treatment in this group was compared with that in three other groups of patients with primary cns lymphoma  patients treated at the ucsf cancer research institute who underwent surgery and radiation therapy  rt   group 2   patients described in the literature who had surgery and rt  group 3   or patients described in the literature who had surgery  rt  and chemotherapy  group 4   median and quartile survival times were greater in patients who received adjuvant chemotherapy  group 1  30 and 50 months  group 4  20 and 25 months  than in patients who did not receive chemotherapy after rt  group 2  13 and 20 months  group 3  15 and 24 months   these results suggest that adjuvant chemotherapy is useful in the treatment of primary cns lymphoma  
class10	x linked spinal muscular atrophy  kennedy s syndrome   a kindred with hypobetalipoproteinemia  kennedy s syndrome  x linked adult onset bulbospinal muscular atrophy  has been described in over 30 families  the characteristic distribution of weakness creates a recognizable syndrome  augmented by frequent findings of testicular atrophy and gynecomastia  type iv or type ii hyperlipoproteinemia has been found in some families  we have studied another family with kennedy s syndrome  this one with hypobetalipoproteinemia  the diversity of serum patterns suggests that lipoprotein abnormalities are not causally related to either the endocrinopathy or the spinal muscular atrophy  however  gene linkage studies indicate proximity of the gene for kennedy s syndrome and the gene encoding the androgen receptor  which could explain the combination of a motor neuron disorder and the endocrine abnormalities  
class10	unusual cause of  piriformis muscle syndrome   the piriformis muscle syndrome is a controversial  clinical  syndrome primarily characterized by signs and symptoms of sciatic nerve compression at the region of the piriformis muscle as it passes through the greater sciatic notch  the syndrome is often referred to  however  cases are rarely reported  and it is generally an uncommon diagnosis  of those cases reported  the incidence is six times more frequent in females than in males  and is typically temporally related to minor pelvic or buttock trauma  we describe a case of a 40 year old woman presenting with signs and symptoms suggestive of piriformis muscle syndrome following a gynecologic procedure performed in the dorsal lithotomy position  electromyographic findings were consistent with this clinical entity  operative exploration  however  revealed the source of neural compression to be a pseudoaneurysm of the inferior gluteal artery adjacent to the piriformis muscle  the diagnostic features of this clinical syndrome are discussed  
class10	botulinum vs adjustable suture surgery in the treatment of horizontal misalignment in adult patients lacking fusion  thirty patients were treated with either botulinum toxin or adjustable suture surgery in a prospective  randomized clinical trial  all patients had horizontal deviations greater than 10 prism diopters and absent fusion  seventeen patients were assigned to toxin treatment  and 13 were assigned to surgical treatment  follow up at 6 months after either procedure indicated that surgery was superior  with patient alignment showing a 92 7  average net change  compared with a 50 50  net change in the botulinum treated group  there was no difference in response between those patients with a starting deviation of 20 pd or less and greater than 20 pd in the surgery group  however  in the botulinum treated group  those patients with a starting deviation of 20 pd or less seemed to show better responses than those patients with greater than 20 pd  patients with esotropia showed an 88 89  change with surgery and a 51 55  change with toxin treatment  patients with exotropia had a 95 83  change with surgery but a 50 3  change with toxin treatment  since we had 20 patients with exotropia and 10 patients with esotropia  a more formal comparison would require larger numbers  
class10	experimental alcoholic skeletal muscle myopathy is characterised by a rapid and sustained decrease in muscle rna content  an investigation was made into the effects of ethanol feeding  36  of total calories  on skeletal muscle  from 7 to 42 days  muscle weights and protein and dna contents of alcohol treated rats were significantly lower  10 23   than pair fed controls  with glucose as 36  of total calories   ethanol feeding markedly reduced muscle rna content by 22 34   when compared to controls  muscle rna content of ethanol fed rats at 7  14  28 and 42 days of treatment was significantly lower than initial values  i e  at 3 days  by 22 38   thus  ethanol feeding caused an initial net loss and thereafter a reduction in the rate of accretion of rna  the marked and sustained loss in the muscle protein synthetic apparatus may be a precipitating event in the development of experimental skeletal muscle myopathy  
class10	epidural hematoma  an unusual presentation  the authors present a patient with a traumatic epidural hematoma who complained only of headache and presented to the emergency department 48 hours after a fall  mental status and neurological examination were normal  this delayed presentation is more commonly seen when a subdural hematoma is present but may result from epidural bleeding  delayed formation of a traumatic epidural hematoma may occur when the following are present  elevated intracranial pressure  hypovolemic shock  a concomitant mass lesion  coagulopathy  bleeding from dural or diploic veins  a dural sinus laceration  a traumatic pseudoaneurysm  or an arteriovenous fistula  although criteria for computed tomography of patients with head injuries remain variable in the literature  delayed presentation of epidural bleeding must be considered in the differential diagnosis of posttraumatic headache irregardless of the time interval or neurological presentation  
class10	cardiac arrhythmias from a malpositioned greenfield filter in a traumatic quadriplegic  a case study is presented of premature greenfield filter discharge with intracardiac migration and resulting life threatening arrhythmias  these arrhythmias also interfered with the patient s transition from ventilatory support via orotracheal intubation to noninvasive positive airway pressure ventilatory support methods  the patient s arrhythmias were controlled by a demand cardiac pacemaker and cardiac glycoside therapy  no anticoagulants were used  she had no further filter migration nor significant complications for 16 months after hospital discharge  
class10	the supraspinal anxiolytic effect of baclofen for spasticity reduction  recent studies in the psychiatric literature indicate that baclofen has an anxiolytic action in certain psychopathologic conditions  clinical observation has shown that manifestations of spasticity are increased in anxious individuals  implicating a supraspinal site of mediation for these responses  the purposes of this study were to determine if baclofen reduced anxiety in individuals with traumatic spinal cord lesions and whether that reduction was correlated with decreased spasticity from the baclofen  five adult males with traumatic spinal cord injury were randomly assigned to the study protocol  a double blind  repeated measures  multiple base line  single case research design was employed  the independent variable was dose of medication with the three levels being placebo  40 mg day of baclofen and 80 mg day of baclofen  in four evenly divided doses  the dependent variable was the score obtained on the beck inventory a anxiety scale  bia   the subjects were administered the bia twice per week for a nine week period of time  during which they received the doses of medication as described  quantitative measurements of spasticity were also taken at each session  visual inspection analysis of the data showed that two subjects had no measurable anxiety of the bia throughout the study  three subjects had measurable anxiety on the bia during the base line placebo phase  they showed a decreased level of their bia scores with 40 mg day of baclofen  and a further level reduction with 80 mg day of baclofen  the reduction in bia scores was statistically significant using the standard deviation band test in one of these subjects  these data indicate that bia probably has an anxiolytic effect for individuals status post traumatic spinal cord injury  
class10	effect of flumazenil on midazolam induced amnesia  we have studied the effect of i v  flumazenil 0 01 mg kg 1 on the amnesia and sedation caused by midazolam 2 mg and 5 mg i v  in volunteers in order to determine the relationship between the actions of the antagonist on these two effects  midazolam caused dose dependent central neural depression as assessed by critical flicker fusion frequency  and dose dependent amnesia for word cards  in subjects given flumazenil 5 min after administration of midazolam  fusion frequency readings and memory were restored to levels comparable to those before midazolam administration  these two effects of flumazenil were similar in time course and extent  suggesting that they share the same mechanism of action  flumazenil given alone had no effect on memory  the study has demonstrated anterograde amnesia following benzodiazepine administration and antagonism by flumazenil  there was neither retrograde amnesia nor retrograde antagonism of amnesia  
class10	double blind comparison of topical lignocaine prilocaine cream  emla  and lignocaine infiltration for arterial cannulation in adults  in a double blind  double dummy study  the efficacy of topical 5  emla cream was compared with that of lignocaine infiltration in alleviating the pain of arterial cannulation  forty unpremedicated adults were allocated randomly to four groups to receive emla cream alone  emla and 0 9  saline infiltration  emla and 1  lignocaine infiltration or placebo cream and 1  lignocaine infiltration  following arterial cannulation  pain was assessed by the patient using a visual analogue score and by an independent observer using a four category verbal rating score  significantly lower pain scores were observed in all patients receiving emla compared with those receiving placebo cream and lignocaine infiltration by both patient  p less than 0 01  and observer  p less than 0 001  assessments  there were no significant differences between the three emla groups  
class10	cerebral effects of sevoflurane in the dog  comparison with isoflurane and enflurane  the cerebral effects of sevoflurane were compared in dogs with those of enflurane and isoflurane  initially  the minimum alveolar concentrations  mac  of sevoflurane and enflurane were determined and the electroencephalographic  eeg  responses to increasing doses of sevoflurane  1 5  2 0 and 2 5 mac  or enflurane  1 5 and 2 0 mac  in unparalysed animals were examined  administration of sevoflurane was not associated with seizure activity at any concentration either during normocapnia  paco2 5 3 kpa  or hypocapnia  paco2 2 7 kpa   even in the presence of intense auditory stimuli  all dogs anaesthetized with enflurane demonstrated sustained eeg and motor evidence of seizure activity induced by auditory stimuli at concentrations of enflurane greater than 1 mac  particularly during hypocapnia  in a separate group of dogs  the effects of increasing concentrations of sevoflurane and isoflurane  0 5  1 5 and 2 15 mac  were compared directly on arterial pressure  cardiac output and heart rate  cerebral blood flow and the cerebral metabolic rate for oxygen  cmro2  using the venous outflow technique  sevoflurane  in common with isoflurane  had minimal effects on cerebral blood flow at the concentrations studied  but significantly reduced the cmro2 at end tidal concentrations sufficient to produce a burst suppression pattern on the eeg  approximately 2 15 mac   both sevoflurane and isoflurane significantly decreased arterial pressure in a dose dependent manner  but neither drug significantly altered cardiac output  
class10	homocystinuria presenting as central retinal artery occlusion and longstanding thromboembolic disease  a case of central retinal artery occlusion in a patient with a 10 year history of unexplained thromboembolic disease due to a secondary hypercoagulable state is presented  ophthalmological examination led to the final diagnosis  
class10	immunophenotypic characteristics of cerebrospinal fluid cells in children with acute lymphoblastic leukemia at diagnosis  the presence of meningeal involvement in children with acute lymphoblastic leukemia  all  may have important prognostic and therapeutic implications  conventional methods of diagnosing central nervous system  cns  leukemia rely on the interpretation of cerebrospinal fluid  csf  cell morphology  which may produce ambiguous results in the presence of minimal leukemic involvement  a methodology has been developed for immunophenotyping small numbers of csf cells while preserving cell morphology  csf samples from 33 children with cd10  common all antigen  calla   positive all were examined at initial presentation using both conventional morphology and this combined immunohistopathologic technique  six  18   of the samples contained lymphoblasts or cells considered morphologically suspicious for leukemic involvement  nine additional samples  27  of the total  had normal csf morphology  but contained increased numbers of calla positive cells  twelve of the 33 samples were also examined for the simultaneous presence of nuclear terminal deoxynucleotidyl transferase  tdt  and demonstrated increased numbers of cells positive for both tdt and cd10  these data suggest that a large proportion of children with all may have abnormalities of csf cells at initial diagnosis consistent with the presence of occult leukemic involvement  
class10	unawareness of hypoglycaemia and inadequate hypoglycaemic counterregulation  no causal relation with diabetic autonomic neuropathy objective  to examine the traditional view that unawareness of hypoglycaemia and inadequate hypoglycaemic counterregulation in insulin dependent diabetes mellitus are manifestations of autonomic neuropathy  design  perspective assessment of unawareness of hypoglycaemia and detailed assessment of autonomic neuropathy in patients with insulin dependent diabetes according to the adequacy of their hypoglycaemic counterregulation  setting  one routine diabetic unit in a university teaching hospital  patients  23 patients aged 21 52 with insulin dependent diabetes mellitus  seven with symptoms suggesting autonomic neuropathy  nine with a serious clinical problem with hypoglycaemia  and seven without symptoms of autonomic neuropathy and without problems with hypoglycaemia  and 10 controls with a similar age distribution  without a personal or family history of diabetes  main outcome measures  presence of autonomic neuropathy as assessed with a test of the longest sympathetic fibres  acetylcholine sweatspot test   a pupil test  and a battery of seven cardiovascular autonomic function tests  adequacy of hypoglycaemic glucose counterregulation during a 40 mu kg h insulin infusion test  history of unawareness of hypoglycaemia  and response of plasma pancreatic polypeptide during hypoglycaemia  which depends on an intact and responding autonomic innervation of the pancreas  results  there was little evidence of autonomic neuropathy in either the 12 diabetic patients with a history of unawareness of hypoglycaemia or the seven patients with inadequate hypoglycaemic counterregulation  by contrast  in all seven patients with clear evidence of autonomic neuropathy there was no history of unawareness of hypoglycaemia and in six out of seven there was adequate hypoglycaemic counterregulation  unawareness of hypoglycaemia and inadequate hypoglycaemic counterregulation were significantly associated  p less than 0 01   the response of plasma pancreatic polypeptide in the diabetic patients with adequate counterregulation but without autonomic neuropathy was not significantly different from that of the controls  change in plasma pancreatic polypeptide 226 8 v 414 pmol l   the patients with autonomic neuropathy had a negligible plasma pancreatic polypeptide response  3 7 pmol l   but this response was also blunted in the patients with inadequate hypoglycaemic counterregulation  72 4 pmol l  compared with that of the controls  p less than 0 05   conclusions  unawareness of hypoglycaemia and inadequate glucose counterregulation during hypoglycaemia are related to each other but are not due to autonomic neuropathy  the blunted plasma pancreatic polypeptide responses of the patients with inadequate hypoglycaemic counterregulation may reflect diminished autonomic activity consequent upon reduced responsiveness of a central glucoregulatory centre  rather than classical autonomic neuropathy  
class10	diffuse idiopathic skeletal hyperostosis  dish  of the shoulder  a cause of shoulder pain  shoulder pain is a common complaint and shoulder hyperostosis a frequent radiological condition  however  little is known about the association between the clinical and radiological findings  to evaluate the clinical relevance of shoulder hyperostosis we performed a controlled  blind study of 99 hospitalized probands with and without thoracospinal hyperostosis on lateral chest x rays  the study included grading of the shoulder hyperostosis on the basis of three bilateral standard radiographs  assessing shoulder pain in a standardized way by an interviewer and recording extraskeletal causes of shoulder pain  the prevalence of shoulder hyperostosis was doubled in probands with thoracospinal hyperostosis compared to controls  chi 2   5 90  p less than 0 025  n   99   shoulder hyperostosis  irrespective of thoracospinal hyperostosis  predisposed to shoulder pain  40  versus 18   chi 2   4 06  p less than 0 05  n   74   shoulder hyperostosis in combination with thoracospinal hyperostosis  shoulder dish  predisposed to shoulder pain to an even greater extent  46  versus 12   chi 2   6 64  p less than 0 01  n   47   we conclude that shoulder hyperostosis is a radiological finding of potential clinical relevance  
class10	does primary fibromyalgia exist  twenty one of 25 consecutive primary fibromyalgia or fibrositis patients  identified during a 5 year period in a tertiary care day ward for pain syndromes  were re examined  fifteen fulfilled criteria for fibromyalgia but unexpectedly  all cases had either psychiatric disturbance or thyroid dysfunction  of the four patients not seen at follow up  two had developed neurological diseases  another rheumatoid arthritis and one other hypothyroidism  thus  after 5 years no patient fulfilled the criteria for primary fibromyalgia  women occupied as manual workers were over represented  most patients reported beneficial effects of physiotherapy  none of the patients has been able to return to full time work  
class10	lesions of the mid shaft of the humerus presenting as shoulder capsulitis  we describe three patients who presented with pain and restriction of movement at the shoulder suggestive of capsulitis  but proved to have lesions of the mid shaft of the humerus  it is important to be aware of the possibility of this cause of a  frozen shoulder   since radiographs of the shoulder are usually cropped at the mid humerus and lesions at this level may easily be missed  a radiograph of the entire humerus  or an isotope bone scan  may be more useful than repeated shoulder radiographs in patients whose shoulder symptoms do not respond to standard treatment  
class10	mastalgia refractory to drug treatment  management of the patient with mastalgia who fails to respond to first line therapy is a difficult problem and there is a group of patients who do not respond to any therapy  a group of 126 patients with mastalgia who failed to respond to first line therapy and completed further treatment options was studied  the response rate of those with cyclical mastalgia fell to 57 and 25 per cent for second and third line therapy respectively  equivalent figures for non cyclical mastalgia were 24 and 21 per cent  danazol maintains a high response rate after the failure of other drugs  whereas the second line response to bromocriptine and evening primrose oil is poor  unresponsive patients were matched to a group of patients who responded to first line therapy  and reproductive and historical factors were compared using the chi 2 test  but failed to identify which patients would respond to therapy  
class10	abdominal wall pain  an alternative diagnosis  the cause of abdominal pain need not necessarily reside in the viscera  the abdominal wall is another source of symptoms  some causes of abdominal wall pain are obvious  e g  hernias  but not so others such as nerve entrapment syndromes  this review is concerned with causes of abdominal wall pain which  although common  may be easily overlooked  
class10	elevated serum bromide concentrations following repeated halothane anaesthesia in a child  a 20 month old child received 25 brief halothane general anaesthetics over a five week period to allow cranial irradiation treatments for a posterior fossa ependymoma  personality change during the last week of the treatment protocol raised the question of possible bromide intoxication  serum bromide concentrations  using a gold chloride assay technique  were monitored at that time  and at four  and six week intervals thereafter  serum bromide concentrations demonstrated a four fold change during this period ranging from peak levels of 2 2 meq l 1  176 micrograms kg 1  during the fifth week of treatment decreasing to less than 0 5 meq l 1  less than 40 micrograms ml 1  six weeks following the end of treatments  this demonstrates the possibility for repetitive  short halothane exposures to result in elevations of serum bromide and the potential of bromide intoxication in paediatric neuro oncology patients  
class10	anaesthetic management of the brain dead for organ donation  an increasing number of anaesthetists is being called upon to manage organ donors during organ retrieval procedures  we briefly describe the technical aspects of the surgical procedure together with a guide to the anaesthetic management  the aims of the latter may be summarized as the  rule of 100   systolic blood pressure greater than 100 mmhg  urine output greater than 100 ml hr 1  pao2 greater than 100 mmhg  haemoglobin concentration greater than 100 g l 1  common management problems  hypotension  arrhythmias  diabetes insipidus  oliguria  and coagulopathy  are discussed in detail  the intraoperative management of the brain dead organ donor provides the anaesthetist with the challenge of a major surgical procedure in a subject with important physiological derangements  
class10	left ventricular ejection fraction may not be useful as an end point of thrombolytic therapy comparative trials  in the era of comparative and adjunctive trials in reperfusion therapy  the need to develop alternative end points for mortality reduction is clear  left ventricular ejection fraction  which has been commonly used as a surrogate  is problematic due to missing values  technically inadequate studies  and lack of correlation with mortality results in controlled reperfusion trials performed to date  in this paper  we present a composite clinical end point that includes  in order  severity of adverse outcome death  hemorrhagic stroke  nonhemorrhagic stroke  poor ejection fraction  less than 30    reinfarction  heart failure  and pulmonary edema  such a composite index may be useful to detect true therapeutic benefit in reperfusion trials without necessitating greater than 20 30 000 patient enrollment  
class10	neurological and ophthalmological phenomena after aortic conduit surgery  transient neurological and visual signs have been observed in some patients after valved conduit replacement of the aortic valve and ascending aorta  twenty seven patients having valved conduit replacement between february 1982 and october 1988 were compared with 21 patients having combined aortic valve replacement  avr  and ascending aorta  aa  graft replacement  follow up in 100  of both groups was obtained for 0 3 6 6 years  mean  2 6     0 3 years   among 20 surviving valved conduit patients  10  50 0   experienced repetitive neurological and visual signs  including scotomata  seven   transient motor ischemic attacks  two   amaurosis fugax  four   and recurring attention lapses suggesting petit mal seizures  one   no patient with avr   aa graft experienced any events  p   0 004   all valved conduit and seven  53 8   of avr   aa graft patients were on warfarin  p   0 0016   these events retained the same pattern although they diminished in frequency after 12 months in seven patients  70 0   and after initiation of dipyridamole in two patients  rehabilitation was similar in both groups  18 of 20  90 0   valved conduit and 12 of 16  75 0   avr   aa graft patients  p   ns   transient  repetitive  nonprogressive neurological and ophthalmological phenomena are frequent after valved conduit replacement  the pathophysiological mechanism is unclear  but antiplatelet therapy may provide symptomatic control  
class10	obstructive sleep apnoea in children undergoing routine tonsillectomy and adenoidectomy  sleep screening was used to discover the incidence of sleep apnoea in 50 children undergoing routine adenotonsillectomy for recurrent upper respiratory tract infections  randomly selected from the waiting list  preoperative assessment included a detailed parental history  physical examination  and lateral cephalometry  in order to identify factors that might alert the clinician to a diagnosis of obstructive sleep apnoea  there were 2 equal groups of snorers and non snorers  grade 0   1 patient was found to have the sleep apnoea syndrome  iv   9 patients had obstructive snoring with apnoeic episodes  iii   3 patients had snoring with a disrupted sleep pattern  ii   and 12 patients snored with no disruption of sleep  i   in identifying patients with apnoea  a history of snoring was unhelpful  whereas one of breathing irregularities was found to be highly specific  nasal obstruction correlated poorly  however  there was a significant relationship between tonsillar position and size and sleep grade  chi squared p less than 0 01   stepwise regression analysis showed a large contribution to the grading was made by the size of the oropharyngeal airway measured by lateral cephalometry  the children in grade ii iv were re studied 3 months post operatively and all reverted to grades 0 or i  
class10	a randomized comparison of manipulation of the fractured nose under local and general anaesthesia  reduction of simple nasal fractures may be performed under local or general anaesthesia  the latter is by far the most popular method in britain  though why is hard to define  we have attempted to compare the 2 approaches by means of a randomized  prospective trial  fifty consecutive  adult patients with radiologically proved fractures of the nasal bones were randomized to a local or general anaesthesia group and underwent manipulation with asch s and walsham s forceps between 7 and 15 days post injury  analysis of results at 4 h and 8 weeks post operatively showed no significant benefit conferred by fracture reduction under general anaesthesia as opposed to local anaesthesia with respect to post operative airway patency or cosmesis  it is suggested that significant benefits can be obtained in terms of patient convenience and cost effectiveness if nasal fractures are reduced under local anaesthesia as an outpatient procedure  
class10	patellar resurfacing in total knee arthroplasty  technical errors in patellar resurfacing at the time of total knee arthroplasty  tka  are responsible for many of the complications that affect the patellofemoral joint  instability  patellar fracture  and wear of metal backed patellar implants are significantly affected by errors of patellar resurfacing  a review of 50 tkas using a condylar prosthesis and a standardized technique for patellar resurfacing was performed to evaluate the accuracy of the technique  the patients were evaluated at a mean of 2 5 years  range  two to five years  after surgery  the hospital for special surgery knee score improved from a preoperative mean of 56 to 92 at the last evaluation  the hospital for special surgery knee scores were excellent in 92  and good in 8   the knee society knee score improved from a preoperative mean of 28 for pain and 49 for function to a last evaluation mean of 96 for pain and 85 for function  none of the patients had symptoms referable to the patellofemoral joint  there were no patellar fractures  dislocations  or instances of implant loosening of the patella  roentgenograms revealed nine asymmetrically resurfaced patellae and five tilted patellae  there were no patellar subluxations  patellar thickness was maintained at the preoperative level of 21 mm  joint line height was elevated 1 mm  the patellar height was decreased 2 mm from the preoperative height  using a standard technique  satisfactory clinical results can be achieved  but minor errors in resurfacing and alignment will still occur  
class10	cemented total knee arthroplasty for gonarthrosis in patients 55 years old or younger  the results of 68 cemented total knee arthroplasties  tkas  in 50 patients with gonarthrosis who were 55 years old or younger at the time of surgery were reviewed  these patients were operated on between 1979 and 1987 and were followed for an average of 6 2 years  the average age of the patients was 50 years  patients were evaluated by the hospital for special surgery knee score  the average preoperative score was 53  and the average follow up score was 90  overall  55 tkas were rated as excellent and 13 as good  using the knee rating score advocated by the knee society  the average postoperative score was 92 for pain and 84 for function  there were four successful reoperations for patellar component loosening  all in metal backed patellae  the femoral and tibial components in these patients were intact  and at the follow up period  two knees were rated as excellent and two as good  detailed roentgenographic evaluation demonstrated that 20  of tibial components had radiolucencies in at least one zone on the anteroposterior roentgenogram and in 11  on the lateral roentgenogram  femoral radiolucencies occurred in only 2  of knees  patellar radiolucencies in one or more zones occurred in 20  of knees that had not had patellar revision  no complete or progressive radiolucencies at the bone cement interface were noted for any component  and no components were considered to be roentgenographically loose  cemented tkas can achieve excellent long term results in patients younger than 55 years old with gonarthrosis of the knee  these results compare with those obtained in published reports on older age groups  
class10	htlv i viral associated myelopathy after blood transfusion in a multiple trauma patient  this may be the first documented case in the united states and in the orthopedic literature of transfusion transmitted human t cell leukemia virus type i  htlv i  associated myelopathy  ham   progressive myelopathy occurred in a 58 year old white man with serologic and molecular evidence of htlv i infection after multiple trauma and subsequent transfusion with multiple units of banked blood products  symptoms of myelopathy occurred 15 months after the transfusions  myelopathy from htlv i infection simulates a disorder of orthopedic interest  physicians should be aware of the symptoms of ham and unexplained myelopathy  
class10	anterior acromioplasty for treatment of the shoulder impingement syndrome  between 1975 and 1979  anterior acromioplasty was performed in 65 patients with 66 involved shoulders  the procedure appears to be safe and reasonably effective  of the 65 patients in this study  50 had chronic tendon inflammation with fibrosis  and 16 also had a small supraspinatus tendon tear  these 16 had rotator cuff repairs  twenty six patients were also treated with distal clavicle excision  and seven had tenodesis of the long head of the biceps brachii  the average age of the patients was 50 years  range  23 75 years   all patients were followed for an average of eight years  range  three to 13 years   at final evaluation  no or slight pain was present in 77  of the shoulders  39 of 50 without tendon tearing and 12 of 16 with tendon tearing and repair  active shoulder abduction averaged 167 degrees  ninety two percent returned to employment  including 18  with some job modification  eighty six percent returned to recreational athletics  20  with some modification of activities  seven patients had additional surgical treatment  the progression of rotator cuff disease is not always prevented  but the need for subsequent shoulder treatment generally decreases  
class10	long term morphology of spastic or flaccid muscles in spinal cord transected rabbits  despite difficulty in long term maintenance of spinalized rabbits  muscular pathologic changes in chronic spinalized rabbits could be observed for a period of four weeks  rabbits were prepared by spinal cord transection at t10  spastic paralysis  or by spinal cord removal below l7  flaccid paralysis   spastic preparations showed hind limb spasticity and reflex incontinence one to two days after operation  hypertrophic fibers began to appear in spastic muscles after two weeks  this hypertrophy  thought to be caused by phasic repetitive contraction  was verified by electron microscopy to be different from normal exercise hypertrophy  flaccid preparations maintained hind limb flaccidity and overflow incontinence  in flaccid muscle  marked muscle fiber necrosis indicated rapid atrophy  spinal deformity and joint contracture inactivate spinalized rabbits  and cause pressure sores  however  feeding assistance and avoidance of complications make long term maintenance possible  
class10	total knee arthroplasty fixation  comparison of the early results of paired cemented versus uncemented porous coated anatomic knee prostheses  the results of 18 matched pairs of porous coated anatomic knee prostheses were studied to compare the early clinical and functional performance of cemented versus uncemented fixation with an average five year follow up period for both  the knee score improved from a preoperative average of 35 points to a postoperative average of 90 points in the cemented group  and from 38 points to 93 points in the uncemented group  in particular  the individual pain scores and the range of motion values were well matched at the three   six   and 12 month follow up visits and showed a steady improvement  subjectively  all patients were pleased with the results of surgery  one third preferred the cemented side  one third preferred the uncemented side  and one third found no difference in the performance of either knee  the clinical and functional performance of knee prostheses in patients who had one cemented knee and one uncemented knee were comparable and possibly unrelated to the type of fixation method  
class10	cemented and ingrowth fixation of the miller galante prosthesis  clinical and roentgenographic comparison after three  to six year follow up studies  one hundred thirty nine cemented and 132 cementless miller galante total knee prostheses were followed between three and six years  average  43 44 months   the fixation technique was based on patient age  bone quality  and ability to delay full weight bearing  clinical follow up studies were possible on 116 cemented knees  fifteen knees were lost because of death before the three year follow up study  and eight knees required component removal  one hundred twenty three cementless knees were available for clinical follow up studies  there were three deaths  and six failures required component removal  no cemented failure was due to fixation  and three cementless failures were due to lack of tibial ingrowth in two and pain of undetermined etiology in one  preoperative knee scores were slightly significant with cemented knees averaging 48 points and cementless knees averaging 52 points  a similar significant difference was maintained at the final follow up study  no significant differences were noted for pain  limp  or support scores  average range of motion was similar in the two groups  radiolucent lines about the femoral component were rare  cementless tibial radiolucencies were partial in up to 20  of examined zones  and complete tibial tray radiolucency was seen in only three patients  no correlation between radiolucency and knee scores was seen  
class10	seizures in the alcoholic patient  the first international symposium on alcohol and seizures  september 1988  washington  dc  convened experts from north america and europe to discuss the basic and clinical research findings in this field  most of the observations communicated at this symposium are included in this article  emergency physicians are familiar with the alcoholic patient who presents during or after a seizure s   this familiarity must not obscure the fact that a significant minority of these patients will have an underlying process that can cause morbidity or mortality if the unsuspecting physician does not have an organized and methodic approach to the evaluation and management of the seizing alcoholic patient  status epilepticus should be evaluated and treated in a similar fashion  whether or not the patient is an alcoholic  otherwise  almost without exception  there are nuances and controversies with respect to the evaluation and management of the alcoholic patient with a seizure s   from the indications for ct scan  to the proper role of sedatives and anticonvulsants  and the need for admission  the emergency physician must remain a patient advocate  the great majority of alcoholic patients with seizures who require admission can be treated satisfactorily at the hospital of presentation  
class10	neurologic complications of alcoholism  neurologic and myopathic complications of alcoholism are multiple and diverse  affecting both the central and peripheral nervous systems  in the ed  initial concern is for diagnosing readily reversible causes and ruling out possible life  or limb threatening etiologies  a rapid assessment of the abcs  a fingerstick blood glucose determination  and  in cases of ams  the administration of intravenous naloxone is indicated  in almost every instance of a potential neurologic complication  intravenous thiamine replacement is indicated initially  along with the parenteral administration of folic acid and the other b vitamins  including nicotinic acid and pyridoxine  metabolic screening with electrolytes  glucose  blood urea nitrogen  creatinine  calcium  magnesium  liver enzymes  ast  alkaline phosphatase   bilirubin  arterial blood gases with carboxyhemoglobin determination  and a complete blood count are often warranted  special tests such as ct scan  ck  ammonia  or toxicologic screens are indicated in specific instances  in terms of physical examination  attention to the presence of focal neurologic findings is paramount because of the possibility of a subdural or epidural hematoma  it is important not to miss meningitis and a low threshold for treatment or lumbar puncture should be maintained  specialized consultation and referral are needed only after stabilization and appropriate tests are performed  if an organized approach to the evaluation of an alcoholic with neurologic symptoms is undertaken  occult disease will not be missed and outcomes will be improved  
class10	anatomical  physiological  and theoretical basis for the antiepileptic effect of vagus nerve stimulation  the vagus is a mixed nerve carrying somatic and visceral afferents and efferents  the majority of vagal nerve fibers are visceral afferents and have a wide distribution throughout the central nervous system  cns  either monosynaptically or via the nucleus of the solitary tract  besides activation of well defined reflexes  vagal stimulation produces evoked potentials recorded from the cerebral cortex  the hippocampus  the thalamus  and the cerebellum  activation of vagal afferents can depress monosynaptic reflexes  decrease the activity of spinothalamic neurons  and increase pain threshold  depending on the stimulation parameters  vagal afferent stimulation in experimental animals can produce electroencephalographic  eeg  synchronization or desynchronization and has been shown to affect sleep states  the desychronization of the eeg appears to depend on activation of afferent fibers that have conduction velocities of less than or equal to 15 m s  vagal afferent stimulation can also influence the activity of interictal cortical spikes produced by topical strychnine application  and either attenuate or stop seizures produced by pentylenetetrazol  3 mercaptoproprionic acid  maximal electroshock  and topical alumina gel  the mechanisms for the antiepileptic effects of vagal stimulation are not fully understood but probably relate to effects on the reticular activating system  the vagus provides an easily accessible  peripheral route to modulate cns function  
class10	feasibility and safety of vagal stimulation in monkey model  the feasibility  safety  and preliminary effects of chronic vagal stimulation were studied in an aluminagel monkey model  pilot studies to perfect the equipment  determine stimulation thresholds  and insure the comfort and safety of the animals preceded this study  four monkeys were equipped with an indwelling  2 electrode cuff  titanium bands spaced 7 mm apart  silicone encased  1 5 cm total length  in contact around the right vagus nerve  avoidance of the cardiac branch was confirmed by electrocardiograms  after postsurgical recovery  the intact and awake animals received constant current stimulation  5 ma  83 hz  143 hz  or 50 250 hz randomly  0 5 ms pulse width  at the onset of every spontaneous seizure for the duration of the seizure or every 3 h for 40 s if stimulation had not occurred in the preceding hour  stimulation periods of 2 6 weeks  with differing levels of stimulation  were preceded and followed by at least a 2 week baseline period of no stimulation  during the stimulation periods  the seizure rate decreased to zero in two monkeys and the interseizure intervals became invariable in the remaining two monkeys  these effects carried over temporarily into the poststimulation baseline periods  vagal stimulation had no consistent effects on seizure severity or eeg interictal spikes  histological studies of six vagus nerves were unable to separate electrode cuff damage from any direct effects stimulation may have had on the nerves  although it appears that chronic vagal stimulation is feasible and that epileptogenic processes are influenced  the safety and efficacy of the procedure are still in question  
class10	an implantable neurocybernetic prosthesis system  the neurocybernetic prosthesis  cyberonics  inc   is an implantable  multiprogrammable pulse generator that delivers constant current electrical signals to the vagus nerve for the purpose of reducing the frequency and or severity of epileptic seizures  the device is implanted in a subcutaneous chest pocket just below the clavicle  similar to cardiac pacemaker placement  the stimulation signal is transmitted from the prosthesis to the vagus nerve through a stimulation lead  the prosthesis can be programmed using any ibm compatible personal computer with programming software and a programming wand  the electrodes used in the first group of patients were found to break at an unacceptable rate  design modifications appear to have resolved this problem  
class10	surgical technique for implantation of the neurocybernetic prosthesis  the surgical technique for the implantation of the neurocybernetic prosthesis is described in detail  this procedure is straightforward and is easily carried out by surgeons familiar with carotid surgery  
class10	efficacy and safety of vagus nerve stimulation in patients with complex partial seizures  a clinical trial of chronic intermittent vagal stimulation in five patients suggests that the procedure may be safe and effective as adjunctive treatment of medically intractable seizures of partial onset  patients tolerated well the implantation of the neurocybernetic prosthesis and the vagal stimulation without serious physiological or lifestyle changes  stimulation of the vagus nerve either reduced the seizure frequency or decreased the duration or intensity of seizures  adverse side effects were limited to a tingling sensation in the throat and hoarseness during stimulation  a major complication was mechanical interruption of the wire electrode circuitry  with consequent cessation of stimulation  the small number of patients and the relatively short follow up period make this a pilot study  but the results are promising  
class10	vagus nerve stimulation in humans  neurophysiological studies and electrophysiological monitoring  evidence from studies of experimental animals indicates that electrical stimulation of the vagus nerve alters behavioral and electrographic seizure activity  we report on effects of electrical stimulation of the vagus nerve in five patients with medically intractable seizures as part of a clinical trial of chronic vagal stimulation for control of epilepsy  the mechanism of action of the vagal antiepileptic effect is unknown  and it is hoped that analysis of electrophysiological effects of vagal nerve stimulation will help elucidate which brain areas are affected  stimulation of the left vagus nerve in the neck was accomplished with a programmable implanted stimulator  effects of stimulus amplitude  duration  and rate were studied  noncephalic reference recording of the vagus nerve evoked potential showed some unusual properties  a scalp negative component occurred with latency of 12 ms  very high amplitude  up to 60 microv   and widespread scalp distribution  field distribution studies indicate that this potential is generated in the neck  in the region of the stimulating electrodes  muscle paralysis confirms this observation  stimulation at various frequencies had no noticeable effect on electroencephalographic  eeg  activity regardless of whether the patient was under general anesthesia  awake  or asleep  
class10	effects of vagal stimulation on experimentally induced seizures in rats  repetitive stimulation of the vagus nerve inhibits chemically induced seizures in dogs  we report here the results and conclusions from studies designed to answer some of the immediate questions raised by this finding   1  maximal stimulation of vagal c fibers at frequencies greater than 4 hz prevents or reduces chemically and electrically induced seizures in young male rats   2  antiepileptic potency is directly related to the fraction of vagal c fibers stimulated   3  vagal stimulation shortens but does not shut down a chemical seizure once it has begun   4  in rats  optimal stimulus frequency is approximately 10 20 hz  duration of stimulus  0 5 1 ms  and stimulus strength  0 2 0 5 ma mm2 of nerve cross section  these results  when taken together with similar results obtained from dogs  monkeys  and humans  strongly suggest that periodic stimulation of the vagus nerve using appropriate stimulation parameters is a powerful method for preventing seizures  the data from the literature suggest that the antiepileptic actions of vagal stimulation are largely mediated by widespread release of gaba and glycine in the brainstem and cerebral cortex  the probable pathway is via projections from the nucleus of the solitary tract to the reticular formation and thence by diffuse projections to the cortex and other areas  intermittent vagal stimulation has the potentiality of reducing the number and or the intensity of seizures in patients with intractable epilepsy  these results indicate that feasibility studies in humans should be continued and expanded  
class10	gene mapping and other tools for discovery  genetic mapping provides a means of understanding the molecular basis of inherited diseases whose biochemistry is unknown  adequate pedigrees  informative genetic markers  and accurate identification of the disease phenotype are necessary  for dominant inheritance  mapping studies can be done in a single large pedigree  the larger the number of affected individuals sampled the better the estimate of recombination between the gene causing the disease and one or more nearby genetic markers  for recessive inheritance  nuclear families with more than one affected sibling provide the best information  the development of many polymorphic dna markers on the human genome has contributed to the success of mapping unknown genes because  as the genome is now densely covered with markers  the probability is good that at least one marker will be linked to the disease locus in a family that is segregating a disease allele  most genetic markers now in use depend upon restriction fragment length polymorphisms  rflps   which are either the result of single base pair substitution or the presence of a variable number of tandemly repeated oligonucleotide units at a locus  vntrs   rflps can be recognized by digesting dna with restriction enzymes and separating the fragments by size on an electrophoretic gel  vntrs can vary widely among individuals  and they provide more linkage information than single site polymorphic markers because family members are more likely to be heterozygous  genetic maps of each chromosome  constructed from linkage data relating marker loci to one another in normal reference families  permit rational choices of markers for disease mapping studies  
class10	the epilepsies  clinical implications of the international classification  from the earliest days of neurology  the classification of epileptic seizures into those generalized from the beginning and those with a definable localization in the cortex from the onset has added to knowledge about the function of the nervous system  further elaboration of the classification of seizures into those localized to the six layered isocortex and those whose elaboration involves regions of the brain involved with consciousness and memory has provided the basic focus for the burgeoning subspecialty of epilepsy surgery  it is increasingly apparent that the etiology of a seizure disorder is of at least equal or of greater significance than the nature of the seizures it spawns and is the product not only of localization in the nervous system but also of causative factors with implications reaching into areas of genetics  higher cortical function  and intelligence  the prognosis concerning the outcome of the epilepsy under consideration is based on all of these facets  this pathophysiological substratum  of which the seizure is only the presenting symptom  constitutes the epilepsy or epileptic syndrome on which the formulation of a rational treatment plan is based  
class10	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  
class10	mesial temporal sclerosis  pathogenesis  diagnosis  and management  mesial temporal sclerosis  mts  is probably the most common symptomatic pathologic entity  alone or mixed with other pathologic features  for seizures of temporal lobe origin  the pathophysiology of mts  including any genetic influence  needs clarification  a characteristic ictal expression for seizures of mts origin appears not to exist  the majority of patients  78   with postresection mts who are seizure free have tightly localized interictal abnormalities restricted to f7 f8  sp1 sp2  t3 t4  and t5 t6 more than 96  of the time  mri abnormalities may be seen in 55  of patients with mts if both  hard  and  soft  criteria are used or in 20  when only  hard  criteria are used  the neuropsychologic evaluation of patients with mts  which includes intracarotid amobarbital test  iat   may prove to be increasingly useful in identifying patterns of cognitive deficit that correlate with enhancement of both lateralizing and localizing preoperative information  
class10	post traumatic epilepsy  cellular mechanisms and implications for treatment  epilepsy complicates severe head trauma  development of persistent seizures appears to correlate with the extent of trauma  although early reports suggested that prophylactic administration of antiepileptic drugs would prevent epileptogenesis  controlled studies have failed to corroborate this assumption  head trauma initiates a sequence of responses that includes altered blood flow and vasoregulation  disruption of the blood brain barrier  increases in intracranial pressure  focal or diffuse ischemia  hemorrhage  inflammation  necrosis  and disruption of fiber tracts  the presence of an intracranial hematoma has a robust association with the development of post traumatic epilepsy  extravasation of blood is followed by hemolysis and deposition of heme containing compounds into the neuropil  initiating a sequence of univalent redox reactions and generating various free radical species  including superoxides  hydroxyl radicals  peroxides  and perferryl ions  free radicals initiate peroxidation reactions by hydrogen abstraction from methylene groups adjacent to double bonds of fatty acids and lipids within cellular membranes  intrinsic enzymatic mechanisms for control of free radical reactions include activation of catalase  peroxidase  and superoxide dismutase  steroids  proteins  and tocopherol also terminate peroxidative reactions  tocopherol and selenium are effective in preventing tissue injury initiated by ferrous chloride and heme compounds  treatment strategies for prevention or prophylaxis of post traumatic epilepsy must await absolute knowledge of mechanisms  antioxidants and chelators may be useful  given the speculation that peroxidative reactions may be an important component of brain injury responses  however  potential treatment strategies involving gamma aminobutyric acid  gaba  agonists  nmda receptor antagonists  and barbiturates need further scientific assessment  
class10	transient hyperprolactinemia is associated with a midcycle luteinizing hormone surge  this study demonstrates that lh surge cycles in ivf patients were associated with significantly higher serum prl concentrations than cycles in which a spontaneous lh surge did not occur  our findings support the hypothesis of concomitant lh and prl release at the time of the midcycle gonadotropin surge  as well as that of estrogen sensitization of pituitary lactotropes  and suggest a possible mechanism for transient midcycle hyperprolactinemia  
class10	local anesthesia for neonatal circumcisions  are family practice residents likely to use it  dorsal penile nerve block with lidocaine  dpnb  is a local anesthetic technique for neonatal circumcision which is both effective and consistent with ethical concerns for infant welfare  as such  it should be included in training programs that prepare residents to care for newborns  to assess the current level of dpnb use by residents in a family practice training program and to identify attitudes and other factors that relate to use  a survey was sent to 127 residents in the department of family practice and community health  university of minnesota  of the 101 respondents  55  had used dpnb  and 17  could be characterized as high users  employing the technique for over one half of the circumcisions they performed  residents with comprehensive understanding of the newborn s capacity to feel pain were more likely to be using dpnb than their less well informed counterparts  four factors were identified as predicting use  cooperation of nursery staff for the procedure  accessibility of instruction in pnb technique  belief that pnb is effective in reducing infant pain  and likelihood of parents giving consent for pnb  these results suggest strategies which may be implemented by family practice educators who wish to promote the principles and techniques of dpnb  
class10	fulminant hepatitis after lisinopril administration  a case of fulminant hepatitis in a patient taking lisinopril for 5 weeks for arterial hypertension is reported  jaundice  fever  myalgia  and marked increase in serum aminotransferase activities occurred after 2 weeks of treatment  continuation of lisinopril administration for 3 weeks after the onset of jaundice was associated with the development of grade iii encephalopathy and a marked decrease in prothrombin and proaccelerin levels  this case strongly suggests that lisinopril may induce acute hepatitis and that continuation of the treatment after the onset of jaundice can lead to life threatening hepatic failure  
class10	heterotopic liver transplantation for fulminant wilson s disease  wilson s disease may present with severe acute hepatocellular failure  the only effective treatment for fulminant wilson s disease is liver transplantation  which may lead to reversal of the underlying disease  some patients with cirrhosis who are too ill to undergo orthotopic liver transplantation have been treated with heterotopic liver transplantation  however  use of heterotopic liver transplantation for fulminant hepatocellular failure has not been successful  this case study involves a patient in whom a heterotopic liver transplant was successfully used for treatment of wilson s disease presenting with fulminant hepatocellular failure  
class10	pain on common bile duct injection during ercp  does it indicate sphincter of oddi dysfunction  the reproduction of a patient s biliary type pain upon initial injection of contrast material into the common bile duct during diagnostic ercp is a dramatic experience for both patient and physician  the significance of this phenomenon is not clear  but it is touted by some to be a provocative test for sphincter of oddi dysfunction  sphincter of oddi manometry was performed on 224 consecutive patients referred over a 2 year period for evaluation of post cholecystectomy syndrome and suspected sphincter of oddi dysfunction  all patients received only intravenous diazepam as premedication for ercp  delayed drainage time  greater than 45 min   bile duct dilation  greater than or equal to 12 mm   and a basal sphincter of oddi pressure of greater than 40 mm hg  mean     3 sd  were considered elevated  we observed a reproduction of pain in 15 of 224 patients  6 7   immediately following contrast injection  there was no correlation between pain on contrast injection and elevated basal sphincter of oddi pressure  delayed common bile duct drainage  bile duct dilation  or abnormal liver enzymes  therefore  we feel that reproduction of the patient s biliary type pain associated with contrast injection of ercp is not a provocative test for sphincter of oddi dysfunction  
class10	atrial fibrillation in the elderly  management update  non valvular atrial fibrillation is associated with a markedly increased risk of embolic stroke in elderly persons  evidence is accumulating that anticoagulation with warfarin or aspirin may be effective in reducing this risk  
class10	serious migraine  a study of some epidemiological aspects  data are scant concerning some epidemiological aspects of those severe headaches which cause serious personal and economic morbidity  our purpose was to study the incidence and other epidemiological features of patients suffering from severe migraine exacerbations  in an unselected population  the 64 patients who suffered from severe migraine bouts represented 10 5  of all the new walk in neurological consultations in the area covered in this study  70  of these patients were between 10 and 39 years old  although females clearly predominated in all ages after fifteen  below this age there was a slight male predominance  the calculated incidence of serious migraine exacerbations was 90 per 100 000 people per year  the corrected incidence for females being 143 100 000 and for males 37 100 000  the highest incidence for females was in 15 19 year olds  377 100 000  and for males in 10 14 year olds  166 100 000   our data seem to confirm the periodic nature of this condition since in 80  of patients the migraine bouts  ie  groups of attacks  lasted between two and nine months  also they support the reported existence of genetic and hormonal factors in the susceptibility to migraine exacerbations  our results may help in planning the public health aspect of migraine and add some light to the natural history of this common condition  
class10	swimmer s migraine  three cases of sudden  severe headache occurring during swimming are described  a 51 year old female had been engaging in a swimming exercise for about 20 minutes when she suddenly experienced a pulsating headache in the parietotemporal region  accompanied by nausea  a few days later  she experienced a similar episode  again during swimming practice  a 45 year old male developed a pulsating headache with nausea immediately after diving into a swimming pool  and had a similar attack during diving practice 1 week later  a 32 year old male developed a pulsating headache accompanied by nausea while swimming in the sea  in all three cases  blood pressure  pulse rate  neurological findings  cervical spinal x rays  brain ct scans  and hematological findings were normal and the outcome was good  although these patients  headaches were diagnosed as benign exertional headache  pathophysiologically they appeared to resemble the headache associated with sexual activity  
class10	platelet monoamine oxidase activity in female migraine patients  platelet monoamine oxidase activity  mao  in a group  n   17  of white  female migraineurs during an acute migraine attack was similar to both the values obtained for the same group of patients two to three weeks after the headache episode  pain free period  and to the results obtained for a group  n   18  of sex and race matched  age comparable  drug free healthy volunteers  blind study  substrate p tyramine  38 7     5 7  41 9     8 8 and 43 0     3 4 or p methoxybenzylamine  178 9     11 3  177 2     6 9 and 181 0     9 7 nmole hr 10 9  platelets     sd respectively   with each patient serving as its own control  mao activity during the migraine episode and when pain free failed to show a significant trend  neither a number of other medical conditions nor the use of several medications appeared to significantly influence our results  the present work  while dealing only with a small but well defined patient population  argues against the possible usefulness of platelet mao activity as a biological marker for migraine headaches  
class10	a protocol for butalbital  aspirin and caffeine  bac  detoxification in headache patients  the abuse of the combination drug containing butalbital 50 mg  aspirin 325 mg and caffeine 40 mg  or bac   is commonly recognized by headache specialists as causing headaches  despite this widespread problem  there is not a published treatment regimen for the bac detoxification of patients  i describe such a protocol which was used four times in three patients  these patients fulfilled the diagnostic criteria of the ihs headache classification for headaches induced by chronic substance abuse  8 2  and analgesics abuse headache  8 2 2   these patients took between 150 and 420 bac month for 2 15 years  two patients had previously undergone inpatient detoxification  one patient unsuccessfully tried detoxification twice as an outpatient  all patients were required to have psychological support prior to hospitalization for this protocol  bac was discontinued  a pentobarbital challenge test corroborated butalbital dosage  the patients were given phenobarbital and caffeine which were tapered over several days  dihydroergotamine  dhe  with metoclopramide was used  raskin   propranolol 60 mg bid was started  no narcotics were permitted  after hospital discharge  patients were allowed to continue subcutaneous dhe  as needed  one patient restarted bac use after 8 months without it  the other two patients were still bac free 18 and 14 months after detoxification  
class10	thermographic findings in cranio facial pain  this work assesses the differences in the thermographic findings in the craniofacial and neck areas between normal individuals and patients with craniofacial pain or headache  and investigates the influence of muscle contraction on such findings  thermographic records were taken in 10 healthy subjects and 47 patients suffering from craniofacial pain or headache of different kinds  in the patients with painful episodes the record was taken between attacks  in all the normal subjects and in 19 patients lateral thermograms were also taken during and after maximal tooth clenching for three minutes  the majority of the patients  as compared to the normal group  showed some thermal alterations and asymmetry  such alterations seem to be due both to vascular instability and muscle contraction  these two factors may be variably superimposed in the different conditions  in patients with cluster headache or chronic paroxysmal hemicrania the presence on the symptomatic side of a cold spot along the supraorbital area and or the inner orbital canthus  was a constant finding  we conclude that thermography is useful as an additional diagnostic means in patients with head and face pain  and that the clenching test may increase the amount of information provided  
class10	dissociation between pain and autonomic disturbances in cluster headache  the relationship between pain and autonomic disturbances in cluster headache was studied in 54 patients whose attack always recurred on the same side  and in 7 others whose attack had affected either side on different occasions  in one of these seven patients  facial flushing and ocular sympathetic deficit was observed on the original side of headaches  in most patients  the orbital region was warmer on the painful side but in three cases this region was cooler during and between attacks  lacrimation and rhinorrhoea were more common in severe attacks  and the temperature difference between the orbits increased with increasing severity of pain  these findings support the view that certain autonomic disturbances in cluster headache are provoked by pain  residual autonomic dysfunction could influence autonomic activity during cluster headache  if so  residual dysfunction on the pain free side could explain the dissociation between autonomic disturbances and pain observed in a few cases  
class10	a study of the seasonal variation of migraine  available evidence supports the contention that migraine involves a disturbance in serotonin function  several parameters of serotonin function in humans have been found to vary seasonally and may underlie the seasonal fluctuations observed in many clinical neuropsychiatric phenomena that are thought to involve serotonin dysfunction  we therefore postulated that migraine headaches might also vary seasonally and examined the admissions to our hospital over a 20 year period with a primary diagnosis of migraine  peak admissions were found to occur most frequently in the spring for females in comparison to males  p less than or equal to 0 04  chi square   the implications of these findings are discussed  
class10	clinical characteristics of migraine and episodic tension type headache in relation to old and new diagnostic criteria  eighty one patients were diagnosed as having migraine  tension headache or both according to previously used criteria  then we performed a standardized interview to determine the frequency and severity of headache characteristics used in the new operational diagnostic criteria of the international headache society  ihs   in every patient the original diagnosis fulfilled also the ihs criteria  but in 9 patients the criteria were only fulfilled in half or less of the attacks  and applying the ihs criteria they also achieved an additional diagnosis  in one patient these attacks did not fulfill the pain criteria and in 8  4 migraine  4 tension headache  they did not fulfill the criteria for accompanying symptoms  overall the ihs criteria are sensitive and specific  but they may possibly be improved with regard to accompanying symptoms  the present study suggests that recording of frequency and graded severity of characteristics using a headache diary may further improve the distinction between the different types of headache  
class10	fluctuation in timing of upper airway and chest wall inspiratory muscle activity in obstructive sleep apnea  an imbalance in the amplitude of electrical activity of the upper airway and chest wall inspiratory muscles is associated with both collapse and reopening of the upper airway in obstructive sleep apnea  osa   the purpose of this study was to examine whether timing of the phasic activity of these inspiratory muscles also was associated with changes in upper airway caliber in osa  we hypothesized that activation of upper airway muscle phasic electrical activity before activation of the chest wall pump muscles would help preserve upper airway patency  in contrast  we anticipated that the reversal of this pattern with delayed activation of upper airway inspiratory muscles would be associated with upper airway narrowing or collapse  therefore the timing and amplitude of midline transmandibular and costal margin moving time average  mta  electromyogram  emg  signals were analyzed from 58 apnea cycles in stage 2 sleep in six osa patients  in 86  of the postapnea breaths analyzed the upper airway mta peak activity preceded the chest wall peak activity  in 86  of the obstructed respiratory efforts the upper airway mta peak activity followed the chest wall peak activity  the onset of phasic electrical activity followed this same pattern  during inspiratory efforts when phasic inspiratory emg amplitude did not change from preapnea to apnea  the timing changes noted above occurred  even within breaths the relative timing of the upper airway and chest wall electrical activities was closely associated with changes in the pressure flow relationship  we conclude that the relative timing of inspiratory activity of the upper airway and chest wall inspiratory muscles fluctuates during sleep in osa  
class10	effect of sleep and sleep deprivation on ventilatory response to bronchoconstriction  to characterize ventilatory responses to bronchoconstriction during sleep and to assess the effect of prior sleep deprivation on ventilatory and arousal responses to bronchoconstriction  bronchoconstriction was induced in eight asthmatic subjects while they were awake  during normal sleep  and during sleep after a 36 h period of sleep deprivation  each subject was bronchoconstricted with increasing concentrations of aerosolized methacholine while ventilatory patterns and lower airway resistance  rla  were continually monitored  the asthmatic patients maintained their minute ventilation as rla increased under all conditions  demonstrating a stable tidal volume with a mild increase in respiratory frequency  inspiratory drive  as measured by occlusion pressure  p0 1   increased progressively and significantly as rla increased under all conditions  slopes of p0 1 vs  rla   0 249  0 112  and 0 154 for awake  normal sleep  and sleep after sleep deprivation  respectively  p less than 0 0006   chemostimuli did not appear to contribute significantly to the observed increases in p0 1  prior sleep deprivation had no effect on ventilatory and p0 1 responses to bronchoconstriction but did significantly raise the arousal threshold to induced bronchoconstriction  we conclude that ventilatory responses to bronchoconstriction  unlike extrinsic loading  are not imparied by the presence of sleep  nor are they chemically mediated  however  prior sleep deprivation does increase the subsequent arousal threshold  
class10	rat soleus muscle ultrastructure after hindlimb suspension  the aim of the present investigation was to determine  by quantitative electron microscopy  the effects of a 5 wk tail suspension period on rat soleus muscle ultrastructure  a marked decline   60   in muscle mass occurred  the mean fiber cross sectional area decreased to a greater extent   75   than the capillary to fiber ratio   37    leading to a higher capillary density   148   after hypokinesia  the total mitochondrial volume density remained unchanged  whereas the volume density of myofibrils was slightly but significantly reduced   6    a shift from subsarcolemmal to interfibrillar mitochondria occurred  interfibrillar mitochondrial volume density was highest near the fiber border and decreased toward the fiber center  an increase in volume density of satellite cells suggested muscle regenerative events  soleus atrophy with tail suspension greatly decreases the muscular volume but leaves the ultrastructural composition of muscle fibers relatively unaffected  
class10	cardiovascular responses to arm cranking and fns induced leg exercise in paraplegics  twelve spinal cord injured males performed arm crank exercise  ace  with and without concurrent functional neuromuscular stimulation  fns  of paralyzed leg muscles to investigate the hypothesis that fns would augment cardiovascular performance during submaximal ace  six men who exhibited vigorous isometric contractions of thigh and calf muscles were classed as  responders  to fns  r   and the remaining subjects with poor or nonexistent contractions served as  nonresponder controls   c   steady state heart rate and oxygen uptake during ace at 30  60  and 90 w were not appreciably different from the ace   fns condition  however  cardiac outputs in r were augmented by 30  during fns at rest  from 4 9 to 6 4 l min   by 18  during 30 w ace   fns  from 8 6 to 10 1 l min   and by 28  during 90 w ace   fns  from 12 1 to 15 6 l min   similarly  resting stroke volumes were increased by 18   9 ml  and by 23   19 ml  at 60 w during fns in the r group  calculated total peripheral resistance was reduced at rest and during 90 w ace   fns by approximately 24   in contrast  no alterations of circulatory hemodynamics were observed for c subjects  these data indicate that fns induced contractions of paralyzed leg muscles augment venous return to aid central cardiovascular control during upper body submaximal exercise in paraplegics  
class10	results of treatment of displaced patellar fractures by partial patellectomy  the results of partial patellectomy as a treatment for displaced patellar fractures were assessed retrospectively with use of clinical  radiographic  and isokinetic strength testing criteria  forty patients who had been followed for an average of 8 4 years were studied  in the extremity that had been operated on  the mean active range of motion was 94 per cent  the circumference of the thigh was 100 per cent  and the strength of the quadriceps was 85 per cent of these measurements in the contralateral extremity  the over all result was rated as excellent in twenty patients  good in eleven  fair in six  and poor in three  there was a significant statistical correlation between the type of fracture and the outcome  the results of this study indicate that partial patellectomy can be an effective treatment for selected patellar fractures  
class10	comparison of a hybrid with an uncemented total hip replacement  a retrospective matched pair study  the efficacy of a type of uncemented total hip replacement was compared with that of a hybrid total hip replacement in which an uncemented acetabular and a cemented femoral component were used  twenty five patients who had had a hybrid total hip replacement were matched  by age  weight  sex  and diagnosis  with twenty five patients who had had an uncemented total hip replacement  all of the operations were done by one surgeon  who used the same operative approach and the same regimen of postoperative rehabilitation  all of the patients were followed for at least two years  the mean postoperative hip score was 96 points for the hybrid group and 84 points for the cementless group  p less than 0 02   twenty four  96 per cent  of the patients who had a hybrid prosthesis reported no or only slight pain postoperatively  in the uncemented group  of the six patients  24 per cent  who reported mild to severe pain  five had pain in the thigh  a limp occurred more frequently  five femoral components had migrated  and four hips needed reoperation  the results with the hybrid replacement that had a cemented femoral component were superior to those with the uncemented femoral component over the relatively brief period for which these patients were followed  
class10	the patellofemoral joint after total knee arthroplasty without patellar resurfacing  one hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years  eighty four per cent of the knees were affected by osteoarthrosis  graded according to the knee rating system of the hospital for special surgery  there were eighteen excellent  fifty three good  eighteen fair  and eleven poor results  at the most recent follow up  twenty nine knees  29 per cent   nine of which were affected by rheumatoid arthritis  were still painful in the patellofemoral area  the height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively  small patients who had osteoarthrosis were exceptionally free of pain  regardless of sex  age  or level of activity  it seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain  are more than 160 centimeters tall  weigh more than sixty kilograms  and have advanced changes in the patella at the time of the operation  
class10	intraoperative assessment of cerebral ischemia during carotid surgery  one of the problems in carotid surgery is the intraoperative detection of brain ischemia  none of the methods  eeg  stump pressure  applied so far have been successful  branston et al   1974  found a threshold relationship between cortical cerebral blood flow and cortical somatosensory evoked potential  sep   as the local blood flow fell below about 16 ml 100 g min a progressive reduction occurred in the amplitude of the cortical evoked potential  n20 p25   implying a fundamental failure of neuronal function in the somatosensory cortex  we have monitored cortical sep  somatosensory evoked potential  during 734 cea s  carotid endarterectomies  in order to find an index of risk of incipient cerebral ischemia during carotid cross clamping  to determine the need for shunting and the causes of early irreversible neurologic deficits  in 59 cases evaluation of sep was not possible because of technical difficulties  during 586 cea s no alteration of sep occurred  however  4 patients had an immediate postoperative neurologic deficit  while the sep remained normal  abnormal sep occurred in 89 cases and in 6 of these an irreversible loss of sep was seen  these patients awoke with a new neurologic deficit  we found a reversible abnormal sep in 83 cases  reversible changes of sep occurred mainly during carotid clamping  the diagnostic sensitivity of intraoperative sep monitoring in predicting neurologic outcome was 60  with a specificity of 100   
class10	reappraisal of surgical treatment of traumatic transection of the thoracic aorta  since crawford s report in 1973  repair of traumatic transection of the thoracic aorta without shunt or bypass has emerged as a popular technique which simplifies the operation and avoids use of heparin  growing evidence  however  indicates that the incidence of paraplegia is higher with this method and may outweigh its advantages  with this in mind  we have examined our experience with 40 patients who underwent repair of aortic transection from 1975 1988  the operated patients in our series all survived  fourteen were repaired using some type of bypass or shunt  none of whom developed paraplegia  the remaining 26 patients were repaired without a shunt and 9  34 6   developed paraplegia or paraparesis  p less than 0 02   paraplegia was related to aortic occlusion time  p less than 0 002   it did not occur in 11 patients with times less than 27 minutes  but happened in 2 of 8 patients with times between 28 and 35 minutes and in all 7 patients with clamp times over 35 minutes  these data suggest that shunt or bypass should be used in most cases of aortic transection  
class10	clonal origin of pituitary adenomas  as the pathogenesis of pituitary adenomas remains unclear  the tumor clonal composition of these common neoplasms was studied  clonality was determined in female patients by analysis of restriction fragment length polymorphisms of the x chromosome genes hypoxanthine phosphoribosyl transferase and phosphoglycerate kinase in conjunction with their respective methylation patterns  peripheral lymphocyte dna was screened from 62 female patients undergoing transsphenoidal surgery for pituitary adenoma  eleven patients were heterozygous for the bgli site on pgk  4 for the bamhi site on hprt  and 1 patient for both sites  of these 16 patients  3 had acromegaly  4 had cushing s disease  7 had hyperprolactinemia  and 2 were clinically nonfunctional  after surgery  morphological study  including immunohistochemistry and electron microscopy of the pathological specimens  allowed a direct comparison between clonality and tumor cell type  control fresh normal pituitary tissue was found to be polyclonal  the following tumors were monoclonal  all 3 somatotroph adenomas  4 of 4 lactotroph tumors  3 of 4 corticotroph cell adenomas  a gonadotroph adenoma  and a nonsecretory adenoma  a mixed plurihormonal adenoma was polyclonal  as were 2 tumors consisting of adenomatous lactotrophs interspersed with nontumorous adenohypophyseal pituitary tissue and one corticotroph adenoma mixed with normal pituitary tissue  functional pituitary adenomas derived from somatotrophs  corticotrophs  or lactotrophs and nonsecretory tumors are monoclonal in nature  suggesting that somatic cell mutations precede clonal expansion of these cells and play a major role in pituitary tumorigenesis  
class10	severe lidocaine intoxication by cutaneous absorption  a severe lidocaine intoxication by cutaneous absorption is described  data are presented to show a significant absorption of lidocaine through diseased skin when lidocaine cream is used as a local anesthetic  awareness of this route of intoxication might be important in patients in whom neurologic or psychiatric symptoms develop while large amounts of lidocaine cream are being used  
class10	traumatic asphyxia  traumatic asphyxia is a distinctive clinical syndrome characterized by cervicofacial cyanosis and edema  multiple petechiae  and subconjunctival hemorrhage after a severe crush injury of the thorax or of the upper part of the abdomen  a case of traumatic asphyxia is reported  and its clinical and pathophysiologic features are discussed  
class10	mandibular osteomyelitis in a patient with sickle cell anemia  report of case  a case is presented in which mandibular osteomyelitis and mental nerve paresthesia developed in a patient with sickle cell anemia  this infection appeared to precipitate a sickle cell crisis  the mechanisms for these patients  propensity to infection and the diagnosis and management of sickle cell osteomyelitis of the jaws are discussed  
class10	lip paresthesia associated with a jaw mass  a case is reported in which mandibular swelling and lower lip numbness were the first signs of a metastatic adenocarcinoma of the lung  the development of paresthesia  with or without other oral symptoms  requires that a diagnosis of malignancy be considered until confirmed or ruled out by tissue biopsy  a thorough head and neck examination in all patients  especially in those whose history or habits may indicate increased risk of malignancy is necessary  
class10	plasma homocyst e ine levels in men with premature coronary artery disease  plasma homocyst e ine  that is  the sum of free and bound homocysteine and its oxidized forms  homocystine and homocysteine cysteine mixed disulfide  levels were determined in 170 men  mean age     sd 50     7 years  with premature coronary artery disease diagnosed at coronary angiography and in 255 control subjects clinically free of coronary artery disease  mean age 49     6 years   patients with coronary artery disease had a higher homocyst e ine level than control subjects  13 66     6 44 versus 10 93     4 92 nmol ml  p less than 0 001   high density lipoprotein  hdl  cholesterol levels were lower  32     10 versus 46     13 mg dl  p less than 0 001  and triglycerides levels were higher  193     103 versus 136     106 mg dl  p less than 0 001  in the coronary disease group  plasma total cholesterol and low density lipoprotein  ldl  cholesterol levels were not significantly different between patients with coronary disease and control subjects  the presence of hypertension  smoking or diabetes mellitus did not significantly alter homocyst e ine levels in the patient or the control group  patients who were not taking a beta adrenergic blocking drug  n   70  had a nonsignificantly higher homocyst e ine level than did patients taking this class of drugs  n   100   14 67     8 92 versus 12 95     3 77 nmol ml  p   0 087   by design  none of the control subjects were taking a beta blocker  no significant correlations were observed between homocyst e ine and age  serum cholesterol  ldl cholesterol  hdl cholesterol or triglyceride levels  it is concluded that an elevated plasma homocyst e ine level is an independent risk factor for the development of premature coronary atherosclerosis in men  
class10	prolonged anginal perceptual threshold in diabetes  effects on exercise capacity and myocardial ischemia  anginal perceptual threshold  the time from onset of 0 1 mv of st segment depression to onset of angina during treadmill exercise  is prolonged in diabetic patients with coronary artery disease  in the present study  the functional significance of this perceptual abnormality was evaluated by analysis of its effect on exercise capacity and the severity of myocardial ischemia  treadmill exercise in 32 diabetic patients and 36 nondiabetic control patients showed a close linear correlation between the time to onset of electrical ischemia  st segment depression  and exercise capacity in both groups  r   0 8 and 0 9  respectively  p less than 0 001   however  the slope of the relation was flatter in the diabetic group because prolongation of the anginal perceptual threshold permitted continued exercise as ischemia intensified  the anginal perceptual threshold itself showed a close linear correlation with exercise capacity in the diabetic group  r   0 8  p less than 0 001   although in the nondiabetic group these variables were unrelated  the permissive effect of a prolonged anginal perceptual threshold on exercise capacity is undesirable as reflected by its correlation with ischemia at peak exercise  r   0 6  p less than 0 001   the longer the threshold  the greater the exercise capacity and the more severe the ischemia  indeed  the inverse relation between the severity of ischemia at peak exercise and exercise capacity in the nondiabetic group  r   0 4  p less than 0 02  was completely lost in the diabetic group  thus  in diabetic patients with coronary artery disease  anginal perceptual threshold is a major determinant of exercise capacity  
class10	the role of antihistamine therapy in vascular headaches  migraine  vascular  headache is a complex syndrome that involves vascular hyperreactivity  the functions of systemic mediators in migraine are not fully understood  it is unclear which mediators provoke this probably atopic disorder and which represent an attempt to correct an imbalance  however  it has been demonstrated fairly conclusively that increased histamine levels correlate with migraine attacks in susceptible persons  recent studies showing that histamine seems to have many different receptors and to adopt different conformations for different receptors may serve as a useful guide to future scientific investigation  further impetus may come from ongoing studies of h3 histamine receptors  which indicate that h3 agonists offer promise as prophylactic agents for people who suffer from vascular headaches  
class10	cognitive function testing in comprehensive geriatric assessment  a comparison of cognitive test performance in residential and clinic settings  tests of cognitive function are frequently used in geriatric assessment  but the effect of test setting has rarely been explored  to determine the effect of testing site on the performance of elderly patients undergoing a comprehensive geriatric assessment  we administered the mini mental state exam to 116 geriatric patients in the clinic and at their residence  their cognitive abilities varied from normal to severely impaired  the patients  scores were 1 5     3 6  mean     sd  higher at their residence  the clinical importance of a difference in score of 1 5 is not clear  for this reason a second analysis was performed in which a difference in scores of five points or greater between settings was considered clinically meaningful  twenty five percent  29 of 116  differed by five points or more  of these 29 patients  22  76   tested better in the residential setting  these differences were statistically significant  p    001   we conclude that the testing site may affect test performance and that in home assessment may reveal the optimal cognitive function of geriatric patients  
class10	reference values for the mini mental state examination  mmse  in octo  and nonagenarians the mini mental state examination  mmse  was used in a population survey of all inhabitants of leiden  the netherlands  over 85 years  n   1258   in this paper we report on 532 subjects without neurological or psychiatric disease  results show that the median score and lowest quartile cut off score remain high until the tenth decade  median score   28  lowest quartile cut off score   26   thus age  in itself  is not a major limitation in using the mmse  in this study a comparatively low level of education  the majority had 6 to 7 years of education  did not affect the results on the mmse in a negative way  nor did we find an association with the use of psychoactive drugs  
class10	foci of increased t2 signal intensity in mr images of healthy elderly subjects  a follow up study  an 18 month follow up study was conducted on 26 healthy elderly subjects with and without foci of increased t2 signal intensity on mr imaging  the subjects did not differ with respect to health status or cognitive performance as measured by the cognitive subscale of the cambridge mental disorders of the elderly examination and the mini mental state examination at follow up  there was a significant decline in performance on the digit symbol substitution test in subjects who had evidence of t2 foci compared to the performance of subjects without t2 foci  this may indicate that the presence of t2 foci is correlated with subtle difficulties in learning and memory  
class10	characteristics of an elderly driving population referred to a geriatric assessment center  a retrospective  case control study was performed to determine the characteristics of elderly drivers referred to an outpatient geriatric assessment center  it was hypothesized that the driving population was operating at a higher cognitive and functional level than nondrivers  one hundred eighty two subjects meeting the entry criteria were studied  twenty three percent of the subjects were driving at the time of their assessment  compared to nondrivers  drivers were younger  p    0001   were more likely to be male  p    003   scored higher on a mental status examination  p    0001   and were more independent in physical and instrumental activities of daily living  p less than  0001   despite these findings  the mean folstein mini mental score for drivers  23 7  was below normal  40  of drivers were diagnosed as having alzheimer s dementia at the time of their evaluation  and over 26  of the drivers needed help with either dressing or bathing  the frequency of impaired elderly drivers in this referral setting was high  the authors conclude that conditions that affect the driving task are common in geriatric assessment centers  prospective studies of elderly drivers are needed to answer the difficult question of who among the elderly should drive  
class10	bacterial meningitis in the united states  1986  report of a multistate surveillance study  the bacterial meningitis study group  a prospective  laboratory based surveillance project obtained accurate data on meningitis in a population of 34 million people during 1986  haemophilus influenzae was the most common cause of bacterial meningitis  45    followed by streptococcus pneumoniae  18    and neisseria meningitidis  14    rates of h  influenzae meningitis varied significantly by region  from 1 9 100 000 in new jersey to 4 0 100 000 in washington state  the overall case fatality rates for meningitis were lower than those reported in several studies from the early 1970s  suggesting that improvements in early detection and antibiotic treatment may have occurred since that time  concurrent surveillance was also performed for all invasive disease due to the five most common causes of bacterial meningitis  serotypes of group b streptococcus other than type iii caused more than half of neonatal group b streptococcal disease and mortality  suggesting that an optimal vaccine preparation must be multivalent  of the organisms evaluated  group b streptococcus was the second most common cause of invasive disease in persons greater than 5 years old  
class10	decline in the prevalence of childhood deafness in the jewish population of jerusalem  ethnic and genetic aspects  a longitudinal study was performed on 147 jewish children with bilaterally sensorineural hearing loss of moderately severe to profound degree  born in jerusalem during the eighteen years 1968 85  the prevalence rate of these children declined during the years 1977 85  and at the same time the rate of consanguinity of their parents decreased  this decline was more evident in the genetic group among children with non ashkenazi ethnic origin  no such decline was found among the ashkenazi children and no consanguinity among parents of these children was recorded  our study supports the assumption that restriction of consanguineous matings may affect the prevalence of genetic deafness in children in a well defined population  we have tried to remain unbiased and concede certain shortcomings in our present study  
class10	hoarseness as the sole presenting symptom of foramen magnum meningioma  foramen magnum tumours are rare  they may present with bizarre symptoms and mimic many conditions  we report a presentation with the sole complaint of hoarseness  never previously described in the literature  voice returned to normal after surgical removal of the foramen magnum meningioma  
class10	compliance  reliability  and validity of self monitoring for physical disturbances of parkinson s disease  the parkinson s symptom diary  previous clinical research in parkinson s disease has recognized the value of self monitoring procedures in which patients observe and record the frequency and severity of their own symptoms as these occur within the patient s social and work environment  we discuss issues of methodology and report a study of compliance  test retest reliability  and validity with a new self monitoring instrument  the parkinson s symptom diary  two recordings of frequency  loss of balance  hesitation freezing  and two ratings of severity  tremor  difficulty walking  were made four times daily for one week by patients  n   73  who were without apparent loss of cognitive or memory functions  a total of 91  of the diaries received  97  of requested  met strict compliance criteria so that independent sampling over days could be assumed  test retest stability over one month was demonstrated for each score  all spearman rho greater than  85  in a representative subsample of 28 patients  criterion validity was demonstrated for each score by an expected pattern of correlations with independently obtained observer ratings of the same or related indices of disease  and by comparison with hoehn and yahr disability stages  by its simplicity  this self assessment device can be an invaluable complement to traditional methods of clinical and laboratory assessment in the care and evaluation of parkinson patients  
class10	articulatory impairment associated with tardive dyskinesia  the speech of two patients with tardive dyskinesia was studied  and one neuroleptic treated patient having no signs of overt tardive dyskinesia served as control  a structured interview  including reading  repetition of sentences  and spontaneous conversation  was performed  a phonetic transcription and analysis of abnormal phonemes was done by a linguist under blind conditions  both patients with tardive dyskinesia had abnormal phonemes whereas the control patient had none  these differences could not be explained by age  direct neuroleptic effect  or neuroleptic exposure time  the abnormal phonemes were all consonants  the authors conclude that tardive dyskinesia may cause articulatory communication problems  
class10	untying the gordian knot  the genetics of tourette syndrome  a review of the current status of the genetics of tourette syndrome is presented  over the course of the 104 years since gilles de la tourette described the syndrome that bears his name  a body of carefully collected  described  and analyzed data has produced a model of the genetics that implicates a single dominant gene that is variably penetrant in males and females  moreover  the locus of action of this gene is most likely in the dopaminergic system of the midbrain  a systematic search for this gene using recombinant dna techniques is under way  
class10	dexamethasone increases plasma levels of albendazole  therapy of neurocysticercosis with cysticidal drugs is frequently complicated by the exacerbation of symptoms that follows the inflammation triggered by the acute destruction of cysticerci  treatment of such adverse reactions with dexamethasone is highly effective  however  it has been shown that dexamethasone lowers the plasma levels of praziquantel  thus reducing its cysticidal efficacy  we measured plasma levels of albendazole  another strong cysticidal drug  when dexamethasone was given simultaneously  we found that dexamethasone increased the plasma levels of albendazole by about 50   p less than 0 002   hence  it seems that cysticercosis and the ensuing inflammation can be treated simultaneously with albendazole and dexamethasone without diminishing the efficacy of the cysticidal drug  
class10	herpes simplex virus type 2 meningitis without genital lesions  an immunoblot study  two sexually active female patients presented with acute meningitis  the csf abnormalities were severe and persistent  in spite of the absence of genital lesions  serological studies revealed a primary infection by herpes simplex virus type 2  an immunoblot study revealed intrathecal synthesis of anti herpes antibodies early in the course of the disease  
class10	headaches and multiple sclerosis  a clinical study and review of the literature  whether multiple sclerosis  ms  can cause headaches is controversial  to clarify the association between headaches and ms we prospectively analyzed 104 consecutive ms patients using detailed headache evaluations  fifty four patients  52   reported headaches  compared with 5 of 35  14   patients initially suspected to have ms but subsequently proven to have other disorders  and 18 of 100  18   matched general neurology patients  the ms patients had tension headaches or vascular headaches of the migraine type  there was no distinctive  ms headache   seven of these patients had headaches with their first ms symptoms  but in only one did headaches recur with disease activity  headaches did not correlate with any clinical features of ms  we conclude that an association between headaches and ms may exist  
class10	fatal or severely disabling cerebral infarction during hospitalization for stroke or transient ischemic attack  six  1   of 578 patients admitted for cerebral infarction or transient ischemic attack  tia  suffered a fatal or severely disabling in hospital cerebral infarction following a period of stabilization or improvement lasting more than 1 day  these infarctions were characterized by the sudden onset of stupor or coma and subsequent development of transtentorial herniation due to carotid or middle cerebral artery territory infarction  or widespread brain stem infarction due to basilar occlusion  only one patient survived  four patients had large vessel disease documented by doppler  angiography  or at autopsy  each of these six infarcts occurred during the morning hours  4 9 days after the initial event  3 8 days after initiation of intravenous heparin  and within 4 8 h after intravenous heparin had been discontinued  no coagulation abnormalities were documented  we believe that these cases indicate that among patients admitted for cerebral infarction or tia  fatal or severely disabling in hospital cerebral infarction after a period of stabilization or improvement may occur in patients having an initially mild to moderate clinical deficit  that those suffering large artery disease may be at greater risk  and that there may be a relationship between heparin withdrawal and cerebral infarction in some patients  
class10	unusual blink reflex with four components in a patient with periodic ataxia  characteristic findings in blink reflex are reported in a 55 year old female with periodic ataxia  the blink reflexes on the side ipsilateral to the stimulation consisted of four components with latencies of 11  21  35 and 47 ms  instead of the usual two components seen in normal subjects  on the contralateral side  the last three components were also present  the second component was different from the normal r2 response in that its latency was shorter than normal and it did not habituate by stimulation at a rate of 10 hz  in addition  it was more affected by diazepam than the third or fourth components  it is considered that r2 may have consisted of three components and that a shorter latency of the second component could be explained by facilitation  
class10	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  
class10	alcohol dependent unilateral vestibular impairment persisting after a closed head injury  a 20 year old man suffered a closed head injury followed by symptoms of right sided labyrinthine concussion with complete clinical recovery within 3 weeks  episodic vertigo and ataxic gait occurred after the ingestion of small amounts of alcohol over the next 2 years  electro oculography revealed a right sided peripheral type vestibular lesion  only after taking alcohol  this was interpreted as an alcohol induced impairment of central compensation following an incomplete recovery from right sided labyrinthine trauma  
class10	questionable role of cns radioprophylaxis in the therapeutic management of childhood rhabdomyosarcoma with meningeal extension  a series of 15 consecutive children with head and neck nonorbital rhabdomyosarcoma  rmsa  with meningeal extension were prospectively treated with chemotherapy consisting of adriamycin  doxorubicin  adria laboratory  columbus  oh   adm   vincristine  vcr   cyclophosphamide  cpm   and dactinomycin  dact  followed by radiotherapy  60 gy  to the primary tumor volume  along with intrathecal methotrexate  it mtx   thirteen of 15 responded to preradiation chemotherapy  four of 13 relapsed  relapse occurred at the level of the primary tumor in three of four  the 3 year progression free survival  pfs  was 59   similar to that achieved in a previous series treated with a comparable therapeutic approach that also included whole brain radiotherapy as a prophylaxis of possible occult meningeal seeding  it is concluded that cns prophylaxis with radiotherapy is questionable in the management of childhood rmsa with meningeal extension  
class10	magnetic resonance imaging contrast agents  theory and application to the central nervous system  the theoretical aspects of magnetic resonance  mr  imaging contrast agents are reviewed  and their current applications to the central nervous system  cns  and their future applications are discussed  profound differences exist between contrast agents used for mr imaging and computerized tomography  ct   in mr imaging  the contrast agents are not imaged directly but rather act on adjacent protons to shorten t1 and t2 relaxation times  this in turn results in signal intensity changes  the lanthanide metal  gadolinium  in the form of gadopentetate dimeglumine  has been found to be both safe and efficacious as the only currently approved contrast agent for mr imaging  magnetic resonance imaging revolutionized the detection and treatment of disease affecting the brain and spine  initially  it was thought that signal characteristics on mr imaging would allow differentiation of specific pathology  it was soon found that mr studies were able to detect more abnormalities but were less able to characterize them  the recent development of contrast agents for mr imaging has allowed this modality to surpass ct for the evaluation of most cns lesions  at present  contrast enhanced mr imaging is generally accepted as the study of choice for evaluating acoustic neurinomas  pituitary lesions  meningeal disease  primary and secondary brain tumors  active multiple sclerosis  intradural spinal neoplasms  intramedullary spinal disease  and postoperative states in both the spine and brain  even when contrast enhanced ct can detect the same abnormalities  evaluation of the lesions in multiple planes on mr imaging can sometimes yield invaluable information  especially prior to surgery  future developments of contrast material for mr imaging include non gadolinium compounds  intrathecal contrast media  cerebral blood flow and volume evaluation  and  possibly  antibody labeled contrast agents  
class10	clinoidal meningiomas  anterior clinoidal meningiomas are frequently grouped with suprasellar or sphenoid ridge meningiomas  masking their notorious association with a high mortality and morbidity rate  failure of total removal  and recurrence  to avoid injury to encased cerebral vessels  most surgeons are content with subtotal removal  without total removal  however  recurrence is expected  recent advances in cranial base exposure and cavernous sinus surgery have facilitated radical total removal  the author reports 24 cases operated on with vigorous attempts at total removal of the tumor with involved dura and bone  this experience has distinguished three groups  i  ii  and iii  which influence surgical difficulties  the success of total removal  and outcome  these subgroups relate to the presence of interfacing arachnoid membranes between the tumor and cerebral vessels  the presence or absence of arachnoid membranes depends on the origin of the tumor and its relation to the naked segment of carotid artery lying outside the carotid cistern  total removal was impossible in the three patients in group i  with postoperative death occurring in one patient and hemiplegia in another  total removal was achieved in 18 of the 19 patients in group ii  with one death from pulmonary embolism  in the two patients in group iii  total removal without complications was easily achieved  
class10	characterization of periventricular edema in normal pressure hydrocephalus by measurement of water proton relaxation times  the magnetic resonance longitudinal relaxation time  t1  and transverse relaxation time  t2  of the water proton of the periventricular white and cortical gray matter were measured for 17 control patients and 21 patients with suspected normal pressure hydrocephalus  nph   of the latter group  14 showed good response to shunting  true nph group  and seven showed no response  false nph group   in the true nph group  both the t1 and the t2 of the periventricular white matter were significantly prolonged compared to the control values  and slowly shortened after cerebrospinal fluid  csf  shunting  the true nph group showed significantly longer t1 and t2 of the white matter than did the false nph group  the t1 and t2 of the white matter were longer than those of the gray matter in this group  which was the reverse of the relationship observed in the control patients  in the white matter of the false nph group  there was a significant prolongation of t1 only  no difference was seen in the t2 compared to control values  there was no change in either t1 or t2 of this region after csf shunting  the false nph group showed no significant difference in either t1 or t2 between the white and the gray matter  there was no difference in either t1 or t2 of the gray matter between the false nph and control groups or between preshunt and postshunt measurements in each patient group  it is suggested that a distinction between true  and false nph  which cannot be made from the radiographic appearance alone  may be possible from measurement of relaxation times  the mechanism of varied relaxation behavior between two entities may be explained by a difference in properties of the biological water and its environment  
class10	systems analysis of cerebrovascular pressure transmission  an observational study in head injured patients  in an observational study in head injured patients  cerebrovascular pressure transmission was investigated using a systems analysis approach whereby the blood pressure  bp  waveform was used as a measure of an input stimulus to the cerebrovascular bed  cvb  and the intracranial pressure  icp  waveform as the response to that stimulus  the transfer function is a measure of how much pressure is transmitted through the cvb at a given frequency and is calculated using fourier analysis of the pressure waveforms  the transfer function allows quantification of the pressure transmission performance of the cvb  thus providing a basis for comparison between normal and abnormal function  fifteen hundred samples of icp and bp waveforms were collected from 30 head injured patients via microcomputer  off line spectral analysis of the waveform database revealed four main classes of transfer function  those with an overall flat transfer function  curve type 1   those with an elevated low frequency response  curve type 2   those with an elevated high frequency response  curve type 3   and those exhibiting both an elevated low  and high frequency response  curve type 4   curve types 2 and 4 were most often associated with raised icp  greater than 20 mm hg   whereas curve types 1 and 3 were most often affiliated with icp less than 15 mm hg  studies of this type may provide insight into the pathophysiology of the cvb and ultimately aid in the prediction and treatment of raised icp  
class10	massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury  an increase in extracellular k  concentration   k  c  of the rat hippocampus following fluid percussion concussive brain injury was demonstrated with microdialysis  the role of neuronal discharge was examined with in situ administration of 0 1 mm tetrodotoxin  a potent depressant of neuronal discharges  and of 0 5 to 20 mm cobalt  a blocker of ca   channels  while a small short lasting  k  c increase  1 40  to 2 15 fold  was observed after a mild insult  a more pronounced longer lasting increase  4 28  to 5 90 fold  was induced without overt morphological damage as the severity of injury rose above a certain threshold  unconscious for 200 to 250 seconds   the small short lasting increase was reduced with prior administration of tetrodotoxin but not with cobalt  indicating that neuronal discharges are the source of this increase  in contrast  the larger longer lasting increase was resistant to tetrodotoxin and partially dependent on ca    suggesting that neurotransmitter release is involved  in order to test the hypothesis that the release of the excitatory amino acid neurotransmitter glutamate mediates this increase in  k  c  the extracellular concentration of glutamate   glu c  was measured along with  k  c  the results indicate that a relatively specific increase in  glu c  as compared with other amino acids  was induced concomitantly with the increase in  k  c  furthermore  the in situ administration of 1 to 25 mm kynurenic acid  an excitatory amino acid antagonist  effectively attenuated the increase in  k  c  a dose response curve suggested that a maximum effect of kynurenic acid is obtained at a concentration that substantially blocks all receptor subtypes of excitatory amino acids  these data suggest that concussive brain injury causes a massive k  flux which is likely to be related to an indiscriminate release of excitatory amino acids occurring immediately after brain injury  
class10	cerebrovascular and metabolic effects on the rat brain of focal nd yag laser irradiation  to investigate the effects of focal neodymium yttrium aluminum garnet  nd yag  laser irradiation  lambda   1060 nm  on regional cerebral blood flow  cerebral protein synthesis  and blood brain barrier permeability  the parietal brain surface of 44 rats was irradiated with a focused laser beam at a constant output energy of 30 j  survival times ranged from 5 minutes to 48 hours  laser irradiation immediately caused well defined cortical coagulation necrosis  within 5 minutes after unilateral irradiation  14c iodoantipyrine autoradiographs demonstrated severely reduced blood flow to the irradiation site and perilesional neocortex  but a distinct reactive hyperemia in all other areas of the forebrain  apart from a persistent ischemic focus in the vicinity of the cortical coagulation necrosis  blood flow alterations in remote areas of the brain subsided within 3 hours after irradiation  autoradiographic assessment of 3h tyrosine incorporation into brain proteins revealed rapid onset and prolonged duration of protein synthesis inhibition in perifocal morphologically intact cortical and subcortical structures  impairment of amino acid incorporation proved to be completely reversible within 48 hours  immunoautoradiographic visualization of extravasated plasma proteins using 3h labeled rabbit anti rat immunoglobulins showed that  up to 1 hour after irradiation  immunoreactive proteins were confined to the neocortex at the irradiation site  at 4 hours  vasogenic edema was present in the vicinity of the irradiation site and the subcortical white matter  and  at later stages  16 to 36 hours   also extended into the contralateral hemisphere  although this was followed by a gradual decrease in labeling intensity  resolution of edema was still not complete after 48 hours  analysis of sequential functional changes in conjunction with morphological alterations indicates that the evolution of morphological damage after laser irradiation does not correlate with the time course and spatial distribution of protein synthesis inhibition or vasogenic edema  although the central coagulation necrosis represents a direct effect of radiation  the final size of the laser induced lesion is determined by a delayed colliquation necrosis due to persistent perifocal ischemia  extent and severity of ischemia in a zone with initial preservation of neuroglial cells can be explained by the optical properties of the nd yag laser  extensive scattering of light within brain parenchyma associated with a high blood to brain absorption ratio selectively affects blood vessels outside the irradiation focus  
class10	long term evaluation of hemiparkinsonian monkeys after adrenal autografting or cavitation alone  autografts of adrenal medulla were implanted into preformed cavities in the caudate nuclei of four rhesus monkeys with hemiparkinsonism induced by 1 methyl 4 phenyl 1 2 3 6 tetrahydropyridine  mptp   five other hemiparkinsonian monkeys underwent caudate cavitation  but received no tissue implant  all of the animals had marked bradykinesia of the affected arm and stable apomorphine induced turning before cavitation or implantation  moderate behavioral recovery was seen in all five monkeys with cavitation and two of the three monkey with long term adrenal autografts  the fourth adrenal recipient was sacrificed 10 days after grafting   the improvement occurred months after the procedure and was not as early or as complete as that seen after fetal dopaminergic grafts  surviving adrenal tissue was found only in the animal that showed no behavioral recovery  the other two adrenal autograft recipients  with no surviving adrenal medulla  and all of the animals with cavitation had ingrowth of dopaminergic fibers from the area olfactoria and nucleus accumbens into the caudate  oriented toward the cavity  these findings show that the mechanism of improvement after adrenal medullary implants for parkinsonism is not dopamine secretion by chromaffin cells  but may be related to the sprouted host fibers  the results also indicate that the limited recovery after adrenal implants in parkinsonian patients may be a result of the cavitation  and not necessarily the result of tissue implantation  
class10	cerebral venous oxygen content as a measure of brain energy metabolism with increased intracranial pressure and hyperventilation  in order to test the hypothesis that the cerebral arteriovenous oxygen difference  avdo2  and venous oxygen content  vo2  could be used to monitor brain energy metabolism in the setting of increased intracranial pressure  icp   12 cats were studied with 31p magnetic resonance spectroscopy  six cats were subjected to intracranial hypertension by cisternal infusion of saline  energy failure occurred at an average avdo2 of 8 4     3 2 vol       standard deviation   range 4 7 to 14 7 vol    the vo2 at the point of metabolic failure averaged 1 45     0 6 vol  and extended over a narrower range  1 0 to 2 9 vol    in an additional six cats  icp was raised to the threshold of metabolic failure and hyperventilation was then instituted  pco2 10 to 18 torr   five of the six cats experienced a drop in vo2 with hyperventilation  in two of these animals  hyperventilation resulted in a vo2 of 1 1 vol  or less and in metabolic failure as evidenced by a fall in phosphocreatine  it is concluded that a vo2 of less than 2 vol  is correlated with brain ischemia and that the safety of hyperventilation in the setting of increased icp can be monitored by the use of vo2  
class10	evidence of a local immune activation in cystic brain tumors  the fluid of cystic brain tumors was characterized with regard to the protein content  in most malignant tumors  the concentrations of immunoglobulins g and m  igg and igm  were higher relative to other proteins in the cyst fluid than in the serum of the same patient  a markedly elevated ratio of monomeric to pentameric igm was detected in the cyst fluid of two patients with glioblastomas  the results indicate a local immunoglobulin synthesis in malignant cystic brain tumors  it is hypothesized that higher than expected concentrations of igg and igm in cyst fluid as compared to plasma are a sign of an ongoing immune response triggered by the tumor  
class10	epithelial cyst of the fourth ventricle  case report  a case of epithelial cyst in the fourth ventricle of a 4 year old child is described  a single epithelial layer with a clear basement membrane lining the cyst wall was observed  there were no prominent histological findings to suggest a pathogenesis for this cyst based on immunohistochemical or ultrastructural studies  however  the cyst fluid contained significant amounts of carcinoembryonic antigen  it is considered that the epithelial layer lining the cyst wall was possibly of endodermal origin  
class10	recurrence of acoustic neurilemoma as a malignant spindle cell neoplasm  case report  a 75 year old man presented with a right cerebellopontine angle tumor 11 months after complete macroscopic resection of a right acoustic neurilemoma  histological examination of the recurrent tumor showed a malignant spindle cell neoplasm with positive staining for s 100 protein  the patient had no stigmata of von recklinghausen s disease  it is proposed that this recurrence represents progression from a benign to a malignant acoustic nerve sheath tumor  an event that is extremely rare outside the clinicopathological context of neurofibromatosis  
class10	toxoplasmosis of the conus medullaris in a patient with hemophilia a associated aids  case report  toxoplasma gondii has been reported to be the most common cause of focal brain lesions in patients with acquired immunodeficiency syndrome  aids   a case of intramedullary toxoplasmosis of the conus medullaris is reported in a patient with hemophilia a associated aids  the diagnosis is discussed  with particular emphasis on the magnetic resonance imaging appearance  
class10	subarachnoid hemorrhage caused by a fungal aneurysm of the vertebral artery as a complication of intracranial aneurysm clipping  case report  intracranial aneurysms are an uncommon manifestation of fungal infection  a case is described in which the formation of an aneurysm followed an intracranial intraoperative aspergillus infection attributable to a long period of preoperative antibiotic medication and immunosuppressive therapy with steroids  
class10	prevention of cardiovascular disease  risks and benefits of aspirin  aspirin has been tested for its benefit in preventing cardiovascular disease in randomized trials in three categories of patients  in secondary prevention among those with a history of myocardial infarction  mi   stroke or transient cerebral ischemia  or unstable angina pectoris  25 randomized trials demonstrated significant reductions from aspirin of 25  for the occurrence of an  important vascular event   nonfatal mi  nonfatal stroke  or vascular death   32  for nonfatal mi  27  for nonfatal stroke  and 15  for vascular mortality  among those evolving an mi  the second international study of infarct survival  isis 2  showed a significant reduction of 23  in five week vascular mortality among those started on a one month regimen of daily aspirin within 24 hours of the onset of symptoms of suspected mi  aspirin also significantly reduced reinfarction  nonfatal stroke  and important vascular events  finally  in primary prevention  the us physicians  health study  phs  showed a significant 44  reduction in the occurrence of a first mi among apparently healthy male physicians  numbers of strokes and vascular deaths were insufficient to permit conclusions for these endpoints  thus  aspirin is of clear benefit in reducing mi  stroke  and vascular death in secondary prevention and among those evolving an mi  it is also beneficial in the primary prevention of mi among men over 40  but data concerning its effects on stroke and vascular death remain inconclusive  
class10	speech  velopharyngeal function  and hearing before and after orthognathic surgery  articulation  voice  resonance  hearing sensitivity  and middle ear function were examined in 34 patients before and 3  6  9  and 12 months after orthognathic surgery  thirty of the 34 patients had articulation errors before surgery  errors on the sibilants  s  and  z  occurred most frequently  followed by those on  j zh ch  and  sh   errors were predominantly distortions with both visual and acoustic components  after surgery  articulation improved spontaneously in the absence of intervention  most of the preoperative articulation errors were eliminated by 3 months postoperative  but  thereafter  a gradual decline was noted so that by 12 months  errors occurred on  s  and  z   voice  resonance  velopharyngeal port area  and hearing sensitivity were not altered by surgery  this study suggests that severe skeletal malocclusions requiring surgical correction have deleterious effects on the patients  articulation of consonants and that surgical alteration leads to the correction of most of these errors  
class10	very low birth weight children  behavior problems and school difficulty in a national sample we addressed three questions concerning the behavioral and academic status of low and very low birth weight infants through a secondary analysis of the 1981 national health interview survey  child health supplement   1  in children born with very low birth weight  what is the risk of behavior problems and school difficulty compared with that in heavier low birth weight and normal birth weight children   2  what are the correlates of school difficulty   3  are behavior problems associated with school difficulty when variables are controlled for these correlates  the analysis revealed that 34  of very low birth weight children could be characterized as having school difficulty  compared with 20  and 14  of the other groups  respectively  and that they were more likely to have higher scores on the hyperactive subscale of the behavior problems index  although a broad array of sociodemographic factors correlated with school difficulty  very low birth weight and hyperactivity scores contributed independently to the risk of academic problems  we conclude that very low birth weight infants are at risk of having school problems that are in part associated with hyperactive behavior  
class10	serial magnetic resonance imaging in neonatal hypoxic ischemic encephalopathy  we prospectively performed magnetic resonance imaging  mri  studies during the neonatal period  and at 4 and 8 months of age  on 15 term infants with hypoxic ischemic encephalopathy  and compared the results with their neurodevelopmental outcome at 18 months of age  cerebral palsy developed in nine infants  two infants were classified as having abnormalities of tone and delayed motor milestones that were suggestive of cerebral palsy  and four infants were normal  structural abnormalities  delayed myelination  or a combination of the two were detected with mri at 8 months of age in all nine infants with later development of cerebral palsy  three of the four normal infants and one infant with suggestive abnormalities had normal serial mri findings  each of the remaining two infants  one normal  one with suggestive abnormalities  had isolated persistent ventricular dilation on all three mri studies  our results suggest that 8 months appears to be the earliest time at which mri findings correlate well with later adverse neurodevelopmental outcome in this population  
class10	intrapartum  intranasal cocaine use and acute fetal distress  a case report  intrapartum  intranasal cocaine was used for relief of labor pains by a healthy woman with an uncomplicated pregnancy  fetal hypoxemia and distress followed the event  a causal relationship between the intrapartum use of cocaine and the fetal distress was postulated  cocaine abusers could benefit from hospitalization early in labor for close surveillance and monitoring  thus avoiding exposure to cocaine and its unpredictable systemic effects  
class10	facial bone fracture associated with carotid cavernous sinus fistula  out of 989 cases of facial bone fracture  ten patients had carotid cavernous sinus fistulas  1 01    their ages ranged from 25 to 48 years  seven were male and three female  two of the ten patients had lower third  three patients had middle third  three patients had upper third  and two patients had combined middle and lower third facial bone fractures  the signs and symptoms of a fistula appeared from the first postinjury day up to 50 days after the injury  mean  21 days   four patients had symptoms after operation for facial bone fracture  most fistulae were identified by arteriography before treatment  followup ranged from 1 year  8 months  to 5 years  9 months  mean  2 years  9 months   one patient had a malocclusion  nine patients had complete resolution of their bruits  complications included unilateral complete visual loss  two   csf rhinorrhea  two   and stroke in one of the two csf rhinorrhea patients  one patient expired due to a severe head injury  and there was one death from an unrelated cause  
class10	alcoholic blackouts  legal implications  alcoholic blackouts are defined as the temporary  complete inability to form long term memory as the result of a high blood alcohol level  this means that a neuron to neuron system has been blocked  since that is the case  such central nervous dysfunction should have legal implications  both from the blackout itself and also from the fact that this degree of neural interference in one system is at least suggestive that other dysfunction may be present  the subject of blackouts is updated with recent developments in neuroscience  the legal significance of the blackout is examined in enough depth to allow for further discussion and exploration  
class10	enveloping the bladder with displacement of flap of the rectus abdominis muscle for the treatment of neurogenic bladder  neurogenic bladder is a frequent occurrence  a new surgical technique has been designed and was used successfully in 18 patients with ideal results  the key point of the operation is to turn over a flap of rectus abdominis muscle to envelop the bladder  contraction of the muscle flap and the abdominal muscles would enhance voiding ability  in the meantime  the bladder is displaced forward and the resultant change in the bladder posterior urethral angle also favors voiding  since the bladder is near the anterior abdominal wall manual compression during voiding is made easier  all of these advantages greatly facilitate voiding  
class10	urinary retention due to sacral myeloradiculitis  a clinical and neurophysiological study  we report 5 cases of sacral myeloradiculitis presenting with transient urinary retention  neurophysiological testing  including bulbocavernosus reflex  pudendal evoked response and external anal sphincter electromyography  was performed  parasympathetic pelvic nerves  pudendal nerves as well as the spinal cord seem to be involved to various degrees in this infrequent disorder  
class10	management of children with myelodysplasia  urological alternatives  recent reports have suggested that the prophylactic use of clean intermittent catheterization in selected infants with myelodysplasia and with normal upper tracts may prevent their deterioration  the selection of these patients at risk depends on urodynamic criteria  we reviewed our experience with clean intermittent catheterization instituted when upper tract deterioration was found  of 130 patients with myelodysplasia followed at our clinic 25  19   had or presented with radiological upper urinary tract deterioration  a total of 21 patients had vesicoureteral reflux and 4 had hydronephrosis without reflux  treatment consisted of clean intermittent catheterization alone in 5 patients and combined with anticholinergic medication in 16  four patients with no post void residual urine were carefully observed without intervention  urodynamic evaluation was performed selectively in 11 of these 25 patients for persistence of upper urinary tract deterioration or urinary incontinence after institution of treatment  of the 21 children with reflux 19  90   had resolution or improvement for an average followup of 47 months  hydronephrosis completely resolved in the 4 patients without reflux  thus  the over all resolution or improvement rate was 92  for an average of 41 months  although these excellent results may not be superior to the prophylactic use of clean intermittent catheterization  they validate the assumption that upper tract deterioration can be reversed  the application of current urodynamic selection criteria may result in overtreating a significant number of infants who otherwise may not have upper tract deterioration  further refinements in these criteria may be necessary to select better not only patients at risk but also to determine the frequency of imaging necessary in this urologically heterogeneous population  in addition  careful consideration should be given to urethral dilation as a third and equally viable alternative to prevent upper tract deterioration  
class10	reverse coitus  mechanism of urethral injury in male partner  reverse coitus  a rarely used sexual position  makes the male urethra more vulnerable to injury from the pubic arch and symphysis pubis of the female partner  severe pain  bleeding and immediate detumescence were observed in 3 patients  the lesion usually occurred at the fossa navicularis  responded well to conservative management and did not hinder micturition  potency has been well preserved in all 3 patients  
class10	the effect of an alpha 2 agonist on bladder function and cord histology after spinal cord injury  retracted by weiss r  tomasula jj  sotologo jr jr  in  j urol 1991 aug 146 2  426  spinal injury in cats is accompanied by urinary bladder and hind limb dysfunction  ten cats subjected to spinal contusion at the ninth thoracic segment were treated with guanabenz  an alpha 2 agonist  intraperitoneally  0 65 mg  kg   three hours after injury  and twice daily for eight weeks  an additional six spinal cats were untreated and served as controls  urodynamic studies were performed on a weekly basis on all animals  guanabenz modified the vesico somatic reflex  detrusor sphincter dyssynergia was either ablated or abolished  in contrast  the controls demonstrated detrusor sphincter dyssynergia  high residual urine  and spasticity below the lesion  histological evaluations of the spinal cords revealed that the six paraplegic animals  untreated  suffered marked cavitation of the cord and complete destruction of the grey matter  the five incomplete paraplegic animals  treated  showed minimal cavitation with some preservation of the grey matter  the five ambulators  treated  demonstrated some distortion of grey matter with preservation of white matter  treatment with guanabenz post traumatic cord injury results in decreased cord cavitation  detrusor sphincter dyssynergia is diminished and hind limb function is improved in treated animals  
class10	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  
class10	parathyroid hormone related peptide in lactation and in umbilical cord blood  parathyroid hormone related peptide  pthrp  is expressed in lactating rat mammary glands after suckling  as a result of increases in prolactin rather than suckling per se  in addition  pthrp produced in the fetal parathyroid glands and placenta may be responsible for stimulation of placental calcium transport  in the current study  we used a radioimmunoassay for human pthrp to measure levels of the peptide in  1  human breast milk  cow s milk  and two infant formulas   2  sequential plasma samples in prepartum and postpartum lactating women   3  women with pathologic hyperprolactinemia  and  4  human umbilical cord blood  in normal subjects  plasma pthrp levels ranged from less than 2 to 5 pmol liter  in contrast  human breast milk contained substantially increased levels of immunoreactive pthrp  similar elevations were found in cow s milk and in one infant formula  column chromatography of breast milk demonstrated that pthrp immunoreactivity included a region of adenylate cyclase stimulating activity  consistent with the presence of biologically active pthrp  plasma prepartum pthrp values did not differ from corresponding postpartum values in lactating women  women with hyperprolactinemia had a mean plasma pthrp value in the high normal range  umbilical cord blood had considerably suppressed parathyroid hormone values but pthrp levels that were indistinguishable from those in normal human plasma  thus  pthrp is present in high concentrations in breast milk but apparently does not gain access to the maternal circulation in significant amounts  in addition  women with pathologic hyperprolactinemia seem not to have increased levels of circulating pthrp  
class10	randomised  double blind  placebo controlled trial of nimodipine in acute stroke  trust study group  the value of oral nimodipine 120 mg per day for acute stroke was assessed in a randomised  double blind  placebo controlled multicentre study of 1215 patients  the primary end point was independence after 6 months  defined as a score of 60 or more on an activities of daily living  adl  scale  the barthel index  patients were entered into the trial if they were aged over 40  became hemiparetic in the previous 48 h  were conscious  were able to swallow  and had been living independently before the stroke  at 6 months  55  of the nimodipine group and 58  of the placebo group were independent  the odds ratio for independence on nimodipine being 0 88  95  confidence limits 0 70 1 10   for mortality the odds ratio with nimodipine was 1 22  95  confidence limits 0 95 1 57   adl and neurological scores also suggested delayed recovery in the nimodipine group at 3 weeks  the results do not support the case for oral nimodipine therapy 120 mg per day starting within 48 h of the stroke  for patients with acute stroke  
class10	national general practice study of epilepsy  newly diagnosed epileptic seizures in a general population  the national general practice study of epilepsy is a prospective population based cohort study of 1195 patients with newly diagnosed or suspected epileptic seizures  at the time of initial classification  6 months after notification   104 patients were excluded  of the remaining 1091 patients  220  20   95  confidence interval 18 23    had febrile seizures  564  52   49 55    definite epileptic seizures  and 228  21   19 23    possible epilepsy  in the definite epilepsy group the proportions of males and females were similar  25   21 28   were younger than 15 years and 24   21 28   were 60 years or older  the definite seizures were classified as cryptogenic in 62   58 66    remote symptomatic in 21   18 25    and acute symptomatic in 15   12 18    the aetiology of epilepsy was vascular disease in 15   12 18   and tumour in 6   4 8    among older subjects the proportion with an identifiable cause was much higher  49   41 58   were due to vascular disease and 11   6 16   to tumour  only 252  45   41 49    of the 564 patients with definite epileptic seizures were registered at the time of their first seizure  52   48 56   of the patients had partial or secondarily generalised seizures  and only 39   35 43   seizures generalised from the outset  
class10	national general practice study of epilepsy  recurrence after a first seizure in the national general practice study of epilepsy 564 patients classified as having definite seizures have been followed up for 2 4 years  67   95  confidence interval 63 71   had a recurrence within 12 months of the first seizure  and 78   74 81   had a recurrence within 36 months  seizures associated with a neurological deficit presumed present at birth had a high rate of recurrence  100  by 12 months   whereas seizures that occurred within 3 months of an acute insult to the brain  such as head injury or stroke  or in the context of an acute precipitant such as alcohol  carried a much lower risk of recurrence  40   29 51   by 12 months   other factors affecting the risk of recurrence were age the highest risk being for patients under the age of 16  83   77 89   by 36 months  or over the age of 59  83   76 90   by 36 months and type of first seizure the risk of recurrence being much higher for patients with simple partial or complex partial seizures  94   90 99   by 36 months  than for those with generalised tonic clonic seizures  72   67 77   by 36 months   
class10	cerebral malaria in children cerebral malaria is a rapidly progressive encephalopathy with up to 50  mortality  a cardinal feature is the massing of red cells containing mature plasmodium falciparum within the cerebral capillaries  adhesion of these parasitised red cells to endothelium  an event which may initiate cerebral malaria  is being studied at the molecular level  however  the relevance of these studies to the pathophysiology and treatment of human cerebral malaria is uncertain  although chloroquine is still widely used to treat falciparum malaria  resistance has spread to most of the endemic zone  quinine is emerging as the only effective treatment for cerebral malaria  though resistance to this drug threatens to become a problem  alternative drugs are urgently needed  
class10	auditory evoked responses in benign intracranial hypertension syndrome  in this study  auditory brainstem evoked responses were conducted on 28 patients with otologic symptoms  pulsatile tinnitus  hearing loss  aural fullness  secondary to benign intracranial hypertension syndrome  abnormalities consisting mainly of prolonged interpeak latencies were detected in one third of these patients  it is speculated that the pathophysiologic mechanisms responsible for these auditory brainstem evoked abnormalities are stretching compression of the cochlear nerve and brainstem caused by the intracranial hypertension and or primary edema of the same structures due to the benign intracranial hypertension syndrome itself  normalization or improvement was noticed in the majority of the patients after management  since the number of patients in this study is small  it is felt that the diagnostic and prognostic value of this test needs further evaluation  
class10	the efficacy of brainstem auditory evoked potentials in acoustic tumor surgery  as the identification of patients with small acoustic neuromas and salvageable hearing increases  intraoperative auditory nerve monitoring has been used increasingly in an attempt to improve the hearing preservation rate  far field recordings obtained by brainstem auditory evoked potentials  baep   at times enhanced by electrocochleography  have become a standard method of intraoperative auditory nerve assessment  to evaluate the usefulness of this monitoring technique  the hearing preservation results of a series of unmonitored acoustic tumor removals were compared to a series of patients monitored via the standard brainstem auditory evoked potentials  with comparable average tumor sizes  4 of 7 unmonitored patients had hearing preserved at preoperative levels compared to 4 of 9 monitored patients  neither preoperative baep assessments nor absolute tumor size were predictive of hearing preservation  this report brings into question the effectiveness of far field intraoperative baep monitoring during acoustic tumor resection and suggests that direct auditory nerve monitoring may be more appropriate  
class10	circulatory and thermal adjustments to prolonged exercise in paraplegic women  the circulatory and thermal responses to 90 min of wheelchair ergometer exercise were examined in five wheelchair dependent  wd  women with low level spinal dysfunction and five able bodied  ab  women who served as a comparison group  metabolic rate during exercise was 221 w for wd and 255 w for ab  p greater than 0 05   oral temperature  tor   mean skin temperature  tsk   oxygen uptake  vo2   heart rate  hr   and cardiac output  qc  were assessed periodically throughout the exercise period  ambient conditions were 24 25 degrees c and 38 52  relative humidity  a significant group x time interaction was found for tor  p less than 0 001  and tsk  p less than 0 001   tor of the wd group steadily increased during the exercise  whereas the ab group showed a stable tor  tsk of wd increased rapidly during the first 5 10 min of exercise and continued to rise at a slower rate throughout the exercise  in contrast  tsk of ab rose to a peak during the first 10 min and then showed a decreasing trend  vo2 and hr remained stable in both groups throughout the exercise period  following an initial increase in qc from minute 10 to minute 20 in both groups  values for wd continually decreased until qc at 80 min was 14  lower than at 10 min  the findings suggest that the wd women had greater thermoregulatory strain than the ab women as indicated by a higher tor and tsk and by an inability to maintain qc due to paralysis of the lower limbs and perhaps an increase in cutaneous blood volume  
class10	coccidioidomycosis during human immunodeficiency virus infection  a review of 77 patients  through a retrospective review  we identified 77 previously unreported cases of coccidioidomycosis during hiv infection  patients were classified into 1 of 6 categories based on their primary clinical presentation  20 had focal pulmonary disease  group 1   31 had diffuse pulmonary disease  group 2   4 had cutaneous coccidioidomycosis  group 3   9 had meningitis  group 4   7 had extrathoracic lymph node or liver involvement  group 5   and 6 has positive coccidioidal serology without a clinical focus of infection  group 6   coccidioidal serologies were positive on initial testing in 83  of the patients in whom such serologic testing was performed  sera from 39  of patients were positive for tp antibodies while 74  had cf antibodies  eleven of 12 seronegative patients had pulmonary disease  group 1 or 2   serologic results of other patients sent to a single reference laboratory were similar  with 26  positive for immunodiffusion tp antibodies and 79  positive for immunodiffusion cf antibodies  for the 77 patients in this study  the cd4 lymphocyte count was below 0 250 x 10 9  cells l in 46 of the 55 patients who had this test performed  and a low cd4 count was significantly associated with mortality  p less than 0 01   at the time of follow up  32 of the 77 patients  42   had died  there were significantly more deaths in those with diffuse pulmonary disease  group 2  than in other groups  p less than 0 001   amphotericin b  ketoconazole  fluconazole  and itraconazole were all used as antifungal therapies  outcome could not be related to the therapy used  of note  3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions  
class10	extrapulmonary pneumocystosis  clinical features in human immunodeficiency virus infection  pneumocystis carinii infection is reported with increasing frequency as a cause of disease outside of the respiratory tract in patients with human immunodeficiency virus  hiv  infection  extrapulmonary pneumocystosis is not limited to patients in any discrete risk group for hiv infection  patients with hiv infection who develop extrapulmonary pneumocystosis frequently do not have concurrent p  carinii pneumonia  signs and symptoms of extrapulmonary pneumocystosis are nonspecific but when present are frequently referable to the tissues or organs involved  extrapulmonary pneumocystosis can be diagnosed by examination of tissue biopsies from affected sites using standard histologic techniques  therapy with antimicrobial agents used to treat p  carinii pneumonia has been effective in some patients  an association between use of aerosolized pentamidine for prevention of p  carinii pneumonia and development of extrapulmonary pneumocystosis has been suggested but remains unconfirmed  other factors such as the use of zidovudine and duration of immunodeficiency may also be important to the pathogenesis of extrapulmonary pneumocystosis  further studies are needed to better identify risk factors that may predispose patients to the development of extrapulmonary pneumocystosis  
class10	responses of intercostal muscle biopsies from normal subjects and patients with myasthenia gravis  in order to evaluate the mechanisms of weakness in muscles of patients with myasthenia gravis  mg   intercostal muscle biopsies were obtained from 9 normal subjects and 6 mg patients  and the compound muscle action potential  ap  and tension responses to nerve and muscle stimulation  and contracture responses on exposure to caffeine  were monitored in vitro  in normal muscle  on stimulation of the nerve or muscle at 30 to 100 hz  the ap responses showed decrement in amplitude  one third of which was attributable to failure of neuromuscular transmission and two thirds to failure of muscle membrane excitation  on stimulation at 1 to 5 hz  the ap responses showed very little decrement  while the contractile responses showed significant fade in tension  due to failure of e c coupling or contractility  in muscle from patients with generalized mg  stimulation of the nerve at all frequencies  1 to 100 hz  caused much greater decrement in aps and fade in tension responses than in normal muscle  due mainly to failure of neuromuscular transmission  however  at 100 hz  40  of the decrement in aps was due to failure of muscle membrane excitation  and at 1 to 5 hz  40  of the fade in tension was due to failure of e c coupling or contractility  as in normal muscle  on direct stimulation the contraction and half relaxation times were slower and the tetanic tension was smaller than in normal muscle  especially in the mg patient with thymoma  caffeine induced contractures were smaller in mg muscle than in normal muscle  these results indicate that while the weakness of mg muscle is due mainly to failure of neuromuscular transmission  it is also partly due to reduced e c coupling or contractility  
class10	sensitivity for detecting fibrillation potentials  a comparison between concentric and monopolar needle electrodes  the sensitivity of monopolar and concentric electrodes for detecting fibrillation potentials  fp  has never been formally compared  we studied 35 muscles with fp  sampling 20 sites each with concentric and monopolar needles  the concentric needle identified 0 88     3 44  mean     standard deviation  more sites with spontaneous activity  although statistically significant  wilcoxon signed rank test p less than  03   this difference in sensitivity did not appreciably affect diagnostic interpretation  subjects described the concentric needles as more painful  needle insertions in 25 other muscles demonstrated that needle movement generated the majority of fp  we suggest that the increased tissue injury caused by concentric needles may account for both their increased sensitivity and discomfort  
class10	a review of techniques employed to estimate the number of motor units in a muscle  being the smallest functional units under neural control  motor units play an integral role in muscle physiology  however  at the present time  there does not exist any widely accepted technique for quantifying or estimating the number of motor units in a muscle  specifically  the existing techniques are the increment counting technique  a technique based on spike triggered averaging  and a macro emg based technique which vary in invasiveness from noninvasive to highly invasive  respectively  we discuss each of these techniques  along with their associated shortcomings  in detail  
class10	spatial dispersion of magnetic stimulation in peripheral nerves  to assess the longitudinal dispersion of the stimulus induced by the magnetic coil  collision experiments were performed in seven normal ulnar nerves  a supramaximal electrical stimulus s1 was delivered at the wrist  and followed by a supramaximal stimulus s2 in the upper arm  which was either electrical  electrical collision studies   or magnetic  magnetic collision studies   the interstimulus interval was varied by 0 2 msec increments from the time of complete cancellation of the s2 evoked motor response onwards  to include the entire span of recovery of that compound motor action potential  collision curves were obtained for both magnetic and electrical stimuli by plotting the amplitude of the motor response elicited by s2 as a function of the interstimulus interval  in all seven normal ulnar nerves  comparison of the collision curves showed that the s2 evoked motor response is restored significantly more slowly when magnetic stimulation is used  this finding is best explained by longitudinal dispersion of the stimulus induced by the magnetic coil relative to conventional electrical stimulation  the large fibers being stimulated further away from the coil than the small ones  this interpretation is confirmed by the findings obtained with the same method in two cases of ulnar neuropathy  and by comparison of different intensities of magnetic stimulation  
class10	aaem minimonograph  35  clinical experience with transcranial magnetic stimulation  we elicited motor evoked potentials  meps  using transcortical magnetic stimulation in 150 control subjects aged 14 to 85 years and 275 patients with a variety of diseases  there were no significant side effects  cortex to target muscle latencies measured 20 2     1 6 ms  thenar   14 2     1 7 ms  extensor digitorum communis   9 4     1 7 ms  biceps   and 27 2     2 9 ms  tibialis anterior   central motor delay between the cortex and the c 7 and l 5 measured 6 7     1 2 ms and 13 1     3 8 ms  respectively  mean spinal cord motor conduction velocity measured 65 4 m s  mep amplitude expressed as a percentage of the maximum m wave was never less than 20  of the m wave  a value of less than 10  is considered abnormal  mep latency increases linearly with age and central motor delay is longer in older subjects  compound muscle action potentials and absolute mep amplitudes decreased linearly with age  in multiple sclerosis  ms   mep latency and central delay were often very prolonged  the mep was more sensitive than the sep in ms  in amyotrophic lateral sclerosis  mep latencies were only modestly prolonged  the characteristic abnormality was reduced amplitude  when pseudobulbar features predominated meps were often absent  the mep was of normal latency in parkinson s disease  but age related amplitude was often increased  mep latency and amplitude were normal in huntington s disease  abnormal meps persisted several months after stroke despite good functional recovery  the mep could be used to advantage to demonstrate proximal conduction slowing and block in demyelinating neuropathies  in plexopathy  ability to elicit an mep several days after onset of paresis was good evidence of neuronal continuity in motor fibers  
class10	fibrillation potential amplitude and muscle atrophy following peripheral nerve injury  maximum peak to peak fibrillation potential amplitude was measured in 69 subjects between 7 days and 10 1 2 years post complete or partial peripheral nerve injury  mean amplitude during the first 2 months was 612 muv  third and fourth months 512 muv  fifth and sixth months 320 muv  after the first year  no population of fibrillation potentials greater than 100 muv was recorded  the sciatic nerve was sectioned in 13 guinea pigs and animals studied up to 17 weeks  fibrillation potential amplitude in gastrocnemius muscles declined paralleling that in humans  by the end of the study  type i fibers had lost almost half of their initial diameter and type ii fibers had atrophied more than twice this amount  fibrillation potential amplitude may be useful in estimating the time post nerve injury and appears to correlate with the surface area and fiber diameter of a type i muscle fiber  
class10	critical review of gangliosides and thyrotropin releasing hormone in peripheral neuromuscular diseases  the lack of effective therapy for many of the chronic neuromuscular diseases such as amyotrophic lateral sclerosis  hereditary motor sensory neuropathy  charcot marie tooth disease   spinocerebellar degenerations and idiopathic polyneuropathy has led to a search for substances that may stimulate peripheral nerve regeneration  two such agents that have been proposed are gangliosides  mixed purified bovine brain gangliosides  cronassial  and thyrotropin releasing factor  trh   studies on both of these agents were initially reported with enthusiasm to be successful  but later double blind controlled studies have failed to confirm these findings  this review provides critical analysis of the designs of studies of potentially effective agents in chronic neuromuscular diseases  and emphasizes the power of the placebo response  and the importance of designing placebos which are indistinguishable from the trial medication other than in the active effect  
class10	the effect of low dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation  the boston area anticoagulation trial for atrial fibrillation investigators background  nonrheumatic atrial fibrillation increases the risk of stroke  presumably from atrial thromboemboli  there is uncertainty about the efficacy and risks of long term warfarin therapy to prevent stroke  methods  we conducted an unblinded  randomized  controlled trial of long term  low dose warfarin therapy  target prothrombin time ratio  1 2 to 1 5  in patients with nonrheumatic atrial fibrillation  the control group was not given warfarin but could choose to take aspirin  results  a total of 420 patients entered the trial  212 in the warfarin group and 208 in the control group  and were followed for an average of 2 2 years  prothrombin times in the warfarin group were in the target range 83 percent of the time  only 10 percent of the patients assigned to receive warfarin discontinued the drug permanently  there were 2 strokes in the warfarin group  incidence  0 41 percent per year  as compared with 13 strokes in the control group  incidence  2 98 percent per year   for a reduction of 86 percent in the risk of stroke  warfarin control incidence ratio   0 14  95 percent confidence interval  0 04 to 0 49  p   0 0022   there were 37 deaths altogether  the death rate was markedly lower in the warfarin group than in the control group  2 25 percent as compared with 5 97 percent per year  for an incidence ratio of 0 38  95 percent confidence interval  0 17 to 0 82  p   0 005   there was one fatal hemorrhage in each group  the frequency of bleeding events that led to hospitalization or transfusion was essentially the same in both groups  the warfarin group had a higher rate of minor hemorrhage than the control group  38 vs  21 patients   conclusions  long term low dose warfarin therapy is highly effective in preventing stroke in patients with non rheumatic atrial fibrillation  and can be quite safe with careful monitoring  
class10	seizures and other neurologic sequelae of bacterial meningitis in children  background  although the mortality rate among children with bacterial meningitis has decreased dramatically in recent decades  some patients are left with neurologic sequelae  it has not been clearly established which features of the acute illness predict the chronic neurologic sequelae  including late seizures or epilepsy  methods  we followed 185 infants and children prospectively during and after acute bacterial meningitis  the mean duration of follow up was 8 9 years  range  0 1 to 15 5   during the first six years standard neurologic examinations were performed  telephone interviews were conducted thereafter  results  one month after meningitis  69 children  37 percent  had neurologic abnormalities  many of these signs resolved within a year  leaving only 26 children  14 percent  with persistent deficits  18  10 percent  had only sensorineural hearing loss  and 8  4 percent  had multiple neurologic deficits  thirteen children  7 percent  had one or more late seizures not associated with fever  the presence of persistent neurologic deficits indicative of cerebral injury was the only independent predictor of late afebrile seizures  p less than 0 001   conclusions  after bacterial meningitis only children with permanent neurologic deficits are at high risk for epilepsy  those with normal examinations after the acute illness have an excellent change of escaping serious neurologic sequelae  including epilepsy  
class10	the sequelae of haemophilus influenzae meningitis in school age children  background  previous data on the consequences of haemophilus influenzae type b meningitis for school age children have been inconsistent  and much of the information on risk factors has been inconclusive  the present study was designed to evaluate the sequelae of this disease with a protocol for the comprehensive assessment of neuropsychological function  methods  ninety seven school age children  mean age  9 6 years   each of whom had a school age sibling  were recruited from a survey of the medical records of 519 children treated for h  influenzae type b meningitis between 1972 and 1984  at a mean age of 17 months  at the children s hospitals of toronto  ottawa  and montreal  of the 97 children  41 had had an acute neurologic complication  sequelae were assessed by comparing the index children with their nearest siblings on the basis of standardized measures of cognitive  academic  and behavioral status  results  only 14 children  14 percent  had persisting neurologic sequelae  sensorineural hearing loss in 11  unilateral in 6 and bilateral in 5   seizure disorder in 2  and hemiplegia and mental retardation in 1  although the total sample of index children scored slightly below the siblings in reading ability  the 56 children without acute phase neurologic complications  58 percent  were indistinguishable from their siblings on all measures  the differences between the groups were small even for the 41 pairs in which the index child had had an acute neurologic complication  mean full scale iq  102 for the index children vs  109 for the siblings   sequelae were also associated with lower socioeconomic status and a lower ratio of glucose in cerebrospinal fluid to that in blood at the time of the meningitis  behavioral problems were more prominent in index boys than index girls and in those who were older at the time of testing  but sex and age were not related to cognitive or academic sequelae  conclusions  we find a favorable prognosis for the majority of children who are treated for meningitis caused by h  influenzae type b  
class10	structure  expression and function of a schwannoma derived growth factor  during the development of the nervous system  cells require growth factors that regulate their division and survival  to identify new growth factors  serum free growth conditioned media from many clonal cell lines were screened for the presence of mitogens for central nervous system glial cells  a cell line secreting a potent glial mitogen was established from a tumour  or  schwannoma   derived from the sheath of the sciatic nerve  the cells of the tumour  named js1 cells  were adapted to clonal culture and identified as schwann cells  schwann cells secrete an autocrine mitogen and human schwannoma extracts have mitogenic activity on glial cells  until now  neither mitogen has been purified  here we report the purification and characterization of a mitogenic molecule  designated schwannoma derived growth factor  sdgf   from the growth conditioned medium of the js1 schwann cell line  sdgf belongs to the epidermal growth factor family  and is an autocrine growth factor as well as a mitogen for astrocytes  schwann cells and fibroblasts  
class10	posterior interosseous nerve palsies  one hundred seventy patients with radial nerve disorders were reviewed at the louisiana state university medical center over a 15 year period  of these  32 had involvement of the posterior interosseous nerve exclusively  findings included weak wrist extension with a radial drift  inability to extend the fingers  paralysis of thumb extension  and weak thumb abduction  causes included entrapment at the arcade of froshe  14 patients   laceration  6 patients   fracture  6 patients   compression or contusion  3 patients   and loss associated with tumor  3 patients   the ratio of men to women was 2 1  and the right arm was involved twice as often as the left  preoperative evaluation included physical examination  electrophysiological testing  electromyogram nerve conduction velocity   and roentgenograms of the elbow and forearm  of the 30 patients  2 patients had bilateral lesions   26 underwent operation  in the operative series  all 28 nerves had a function of grade 3 or more of a possible 5 after 4 years of follow up  seventeen had achieved grade 4 5  and 7 had obtained grade 5 5  at operation  23 nerves were found to be in continuity  fourteen lesions of nerves in continuity were associated with entrapment and  not unexpectedly  transmitted a nerve action potential with slowed conduction and low amplitude across the lesion  four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis  and another 4 had no nerve action potentials and were treated by graft or suture repair  five injured nerves were not in continuity  two could be repaired by end to end suture  and 3 required graft repair  a large ganglion cyst involving the posterior interosseous nerve was also resected  
class10	functional results of facial nerve suture after removal of acoustic neurinoma  analysis of 25 cases  the facial nerve is sometimes severed during the removal of acoustic neurinomas  either intentionally to ensure complete removal  or unintentionally because of difficulties in identification  in such cases we have  if possible  sutured the nerve stumps microsurgically  either end to end or by use of an intervening nerve graft  we analyzed the outcome of 25 instances of facial nerve suturing in a series of 219 patients operated on for acoustic neurinoma from 1979 to 1987  the first signs of recovery appeared at an average of 12 months  and there was continued improvement for several years  recovery was graded from 1 to 6  the anastomosis was successful in 24 of the 25 sutured nerves  in that at least some facial movement and tone were restored  grade 5 or higher   in 11 of the 25 cases  facial appearance at rest and with movement was moderately good  grade 2 or 3   a grade 1 result  with no perceivable facial dysfunction  was never achieved  typically  oral muscles showed the most improvement and frontal muscles the least  facial appearance was better at rest than with movement  which was always complicated by some degree of synkinesis  closure of the eye was so good in 13 of the 25 cases that neither tarsorrhaphy nor an eyelid spring was necessary  when the facial nerve is severed  intraoperative suture is recommended  because it provides a chance for moderately good restoration of facial appearance  
class10	extracranial repair of cerebrospinal fluid fistulas  technique and results in 37 patients  although neurosurgeons have traditionally preferred intracranial repair for the management of cerebrospinal fluid  csf  fistulas  this approach is associated with the complications of a craniotomy  anosmia  and a high incidence of recurrent fistulas  extracranial repair  on the other hand  produces no central nervous system morbidity  preserves olfaction  and is associated with a low incidence of recurrence  although there have been several reports of extracranial repair of csf fistulas by otorhinolaryngologists  this approach has received scant mention in the neurosurgical literature  we report here our experience with 37 patients with csf rhinorrhea or otorrhea who underwent extracranial repair  the etiology of the fistula was postoperative in 22  traumatic in 6  and spontaneous in 9  the fistulas were repaired using one of four techniques  external ethmoid sphenoid in 18 patients  transmastoid in 9  transseptosphenoid in 7  and osteoplastic frontal sinusotomy in 3  in 32 of the 37 patients  86   the fistulas were successfully repaired with the initial procedure  of the 5 patients requiring a second operation  the fistula was successfully closed in 4 for an overall success rate of 97   complications were few and consisted of a transient facial paresis in a patient undergoing transmastoid repair and one death from meningitis  the authors conclude that because of low morbidity and mortality and a high success rate in closing fistulas  extracranial repair is the preferred technique for the operative management of csf rhinorrhea and otorrhea  
class10	whither short course chemotherapy for tuberculous meningitis  short course chemotherapy is well established for the treatment of pulmonary tuberculosis but not for extrapulmonary disease  we present a series of 35 cases in which chemotherapy for tuberculous meningitis was given for a period of less than 2 years  short term therapy was associated with recrudescence of tuberculous meningitis and  in some cases  with the development of deep cerebral infarcts and permanent neurological deficits  we think short term chemotherapy for tuberculosis of the central nervous system is inadequate  
class10	mild head injury classification  inconsistencies across studies concerning outcome after mild head injury may reflect differences in the diagnostic criteria used for selection of patients  consequently  we compared the neurobehavioral outcome in three groups of consecutively hospitalized patients  aged 16 to 50 years  who sustained a closed head injury  chi  and had a glasgow coma scale  gcs  score in the 9 to 15 range  these groups included patients with uncomplicated chi with mild impairment of consciousness as reflected by a gcs score in the 13 to 15 range  n   78   patients with initially mild impairment of consciousness complicated by brain lesion or depressed skull fracture  n   77   and patients with moderate chi  n   60   tests of memory  information processing  and verbal fluency were administered within 1 to 3 months after injury  and the glasgow outcome scale was completed at 6 months  neurobehavioral functioning was impaired in the groups with complicated mild chi and moderate chi as compared to the group with uncomplicated mild chi  although moderate chi produced longer durations of impaired consciousness and posttraumatic amnesia than complicated mild head injury  patients in these groups did not differ in neurobehavioral performance  global outcome at 6 months was better in the patients with mild chi than in patients with complicated mild and moderate injuries  analysis of the various complications of mild chi revealed that the presence of an intracranial lesion was related to more severe neurobehavioral sequelae than injuries complicated by a depressed fracture  
class10	diffuse axonal injury  analysis of 100 patients with radiological signs  one hundred patients with head injuries who showed diffuse axonal injury on computed tomographic scans are reported  evaluation of the glasgow coma score  pupillary signs  and computed tomographic findings on admission led to an improved ability to forecast outcomes  our relatively good results as compared with other series  can be explained by the high proportion of children and by the liberal use of computed tomography to evaluate head injuries  thus revealing that concussion may sometimes be regarded as an early form of diffuse axonal injury  
class10	chronic lyme disease with an expansive granulomatous lesion in the cerebellopontine angle  expansive granulomatous lesions in the posterior cranial fossa are rare and have not been reported in conjunction with lyme disease  we report a patient with verified borrelia burgdorferi infection who developed a tumor in the cerebellopontine angle  rapid growth of the tumor led to signs of cerebral compression and to hydrocephalus  surgical intervention was required despite florid meningitis  the histological examination showed inflammatory  nonspecific granulation tissue  the origin of this tissue is almost certainly causally related to the b  burgdorferi infection  signs of inflammation resolved rapidly after subtotal resection  the clinical  radiological  and biochemical course is documented  this is the first report of an expansive cerebral lesion in the chronic phase of lyme disease  
class10	symptomatic pineal cyst  case report  pineal cysts are being described with increasing frequency since the advent of magnetic resonance imaging  although pineal cysts are incidental findings in as many as 4  of magnetic resonance imaging studies  symptomatic pineal cysts are quite rare  we present a case of pineal cyst causing aqueductal obstruction with symptomatic hydrocephalus and resultant headache and syncope  which was treated by surgical resection  a review of the relevant literature and discussion follow  
class10	clinical study of intracranial nongerminomatous germ cell tumors producing alpha fetoprotein  we present six patients with intracranial nongerminomatous germ cell tumors that produced alpha fetoprotein  afp   their ages ranged from 8 to 20 years  average  11 5 years old   two were male and four were female  four of the tumors originated in the pineal region and two in the suprachiasmatic region  one patient treated with only radiation therapy died within 3 months of admission as a result of intraperitoneal metastasis via a ventriculoperitoneal shunt  another patient  treated with radiation therapy and intrathecal administration of neocarzinostatin  died after 12 months because of tumor progression and subarachnoid dissemination  two patients who received radiation and combination therapy with cisplatin  vinblastine  and bleomycin died after 13 and 25 months  the remaining two patients treated with radiation therapy and adjuvant chemotherapy  cisplatin and etoposide  are now alive without recurrence after 16 and 19 months from admission  adjuvant chemotherapy with cisplatin and etoposide appears to be efficacious in the treatment of intracranial nongerminomatous germ cell tumor  
class10	vagal schwannoma associated with syncopal attacks and postural hypotension  a case report  a case of vagal schwannoma in the cerebellomedullary angle is reported  preoperatively  the patient had paroxysmal episodes of postural hypotension with syncope  after total removal of the vagal tumor  her systemic blood pressure returned to normal  
class10	occult vascular malformations of the optic chiasm  magnetic resonance imaging diagnosis and surgical laser resection  angiographically occult vascular malformations of the optic nerve and chiasm are extremely rare  before the advent of magnetic resonance imaging  mri   it was difficult to diagnose these lesions preoperatively  we report mri scan findings of optic chiasm cavernous angiomas in two patients with chiasmal syndrome  mri was useful in localizing the vascular malformation and delineating its characteristics  especially chronic hemorrhage  one patient underwent biopsy of the lesion  the other patient underwent complete microsurgical resection of the malformation with the carbon dioxide laser with preservation of vision  occult vascular malformations of the optic nerve and chiasm may be a more common cause of visual deterioration than previously recognized  the mri scan is the imaging modality of choice for diagnosing and following these lesions  in certain patients  these vascular malformations may be amenable to complete surgical removal with stabilization or improvement of visual function  
class10	cyst of the choroid plexus in the lateral ventricle  case report and review of the literature  we report an intraventricular cyst in a 2 year old boy who had myoclonic jerks of the extremities  the cyst had no communication with the ventricular system or subarachnoid space  total removal of the cyst adhering to the choroid plexus was accomplished  the glial cyst wall was lined in part by flattened or cuboidal epithelium  the preoperative and postoperative computed tomographic scans and magnetic resonance images are presented  and congenital benign cysts in the lateral ventricle are reviewed and discussed  
class10	traumatic aneurysm of the superior cerebellar artery  case report and review of the literature  less than 10  of the 250 reported cases of traumatic intracranial aneurysms have involved the posterior circulation  traumatic aneurysms of the superior cerebellar artery are extremely rare  with only three cases previously reported  this is the first report of a traumatic superior cerebellar artery aneurysm in which the diagnosis was suggested by computed tomographic scan  the potential for a good outcome suggests the value of early angiography when the history and diagnostic imaging studies suggest the possibility of a traumatic aneurysm  
class10	intradural herniation of a thoracic disc presenting as flaccid paraplegia  case report  a case of intradural herniation of a thoracic disc in a patient with a flaccid paraplegia is described  intradural herniation of a thoracic disc is considered a rare event  a review of the relevant patient literature revealed 14 other reports involving 28 patients  no other report has described a patient with an intradural thoracic disc herniation who developed a flaccid paraplegia  
class10	an unusual complication of silastic dural substitute  case report  a case is presented in which a patient developed an unusual complication after the use of silastic dural substitute  in 1983  the patient underwent removal of a meningioma with the involved dura  five years later  he developed around the graft material a very thick connective tissue capsule  which simulated a recurrent meningioma clinically and radiologically  
class10	epidermoid tumors of the 4th ventricle  report of seven cases  epidermoid tumors occur very rarely in the 4th ventricle  we discuss the history  clinical course  and the surgical results for seven patients  one patient had a remittal of symptoms  probably due to the emergence of the tumor from the 4th ventricle into the cisterna magna  total removal of the capsule was possible only in the youngest patient  at present  four patients  mean follow up  6 years  enjoy good general and neurological health  
class10	limited selective posterior rhizotomy for the treatment of spasticity secondary to infantile cerebral palsy  a preliminary report  a limited selective posterior rhizotomy was performed on 30 children suffering from spasticity secondary to infantile cerebral palsy  as opposed to standard techniques that stimulate and divide the dorsal rootlets from l2 to s1  we dissected l4  l5  and s1 dorsal roots through an l5 to s1 laminectomy  eight to 12 rootlets from each root were electrically stimulated with two unipolar electrodes  pulse width  50 microseconds  10 50 v   the muscle responses were observed visually and registered by electromyography  those rootlets associated with an abnormal motor response as evidenced by sustained muscular contraction or by prolonged electromyographic response were divided  spasticity was scored from 0 to    the muscular groups assessed were those involved in the flexion of the shoulder  elbow and wrist in the upper limbs  and those involved in flexion and adduction of the hip  flexion of the leg  and plantar flexion in the lower limbs  the patients were assessed 1 week before and 6 months after the operation  reduction of spasticity was observed in all the muscular groups  and all the patients presented functional improvement of motor abilities  these preliminary results indicate that a limited procedure that reduces the extension of the laminectomy and the length of the operation could be effective for treating spasticity secondary to infantile cerebral palsy  
class10	xenon enhanced computed tomographic measurement of cerebral blood flow in patients with chronic subdural hematomas  we compared clinical symptoms with extent of brain shift on computed tomographic  ct  scans and quantitative and three dimensional measurements of cerebral blood flow  cbf  on xenon enhanced ct scans in 10 patients with chronic subdural hematomas  five patients had only headache and minimal or no brain shift on a ct scan  the other five had hemiparesis and or mental disturbance in addition to headache and moderate or severe brain shift on a ct scan  the mean hemispheric cbf decreased about 7  in patients with headache and about 35  in patients with hemiparesis and or mental disturbance  it decreased also on the side without the hematoma  the cbf reduction was always more pronounced in the putamen and thalamus than in the cortex  on the contrary  the cortex cbf was mostly preserved or even elevated in both groups of patients  we speculate that cbf reduction in patients with a chronic subdural hematoma occurs initially in central cerebral areas like the basal ganglia and thalamus  and then extends to the entire hemisphere including the cortex as brain compression and displacement progress  central cerebral area involvement might be more responsible for clinical symptoms than the cortex  
class10	hypertension as a risk factor for epilepsy after aneurysmal subarachnoid hemorrhage and surgery  a prospective  consecutive series of 307 patients with aneurysmal subarachnoid hemorrhage ranging from grades 1 to v according to the classification of hunt and hess on admission were evaluated to determine the incidence of epilepsy 1 to 3 years  mean  1 4 years  after aneurysmal subarachnoid hemorrhage  sah  and surgery  sixty three patients had died and one patient was lost to follow up  twenty nine patients developed epileptic seizures after the sah and surgery  the mean time from the sah to epileptic seizure varied from 0 days  day of the sah  to 2 years  mean  6 7 months   the seizures were classified as focal in 9 patients  31   and as generalized in 20 patients  69    all patients received anticonvulsant medication after more than one seizure  the risk factors for development of posthemorrhagic postoperative epilepsy were  in order of importance  a history of hypertension  an infarct on late computed tomographic scan  and the duration of coma after the ictus  of the 85 patients with histories of hypertension  17  20 0   developed epilepsy  only 12  5 4   of the 222 nonhypertensive patients developed epileptic seizures  the difference between the groups was significant  p   0 0001   computed tomographic scans were undertaken in 237 patients 1 to 3 years  mean  1 4 years  after the sah and surgery  postoperative epilepsy was significantly associated with infarcts visualized on computed tomographic scan  p   0 0005   
class10	changes in intracochlear and intracanalicular nerves after acoustic neurinoma excision confirmed by magnetic resonance imaging  postoperative magnetic resonance imaging findings related to the vestibulocochlear and facial nerves within the internal auditory canal were analyzed in acoustic neurinomas  t1  and proton weighted magnetic resonance images showed that the vestibulocochlear nerves distal to the internal auditory meatus increased in signal intensity after surgical intervention  these nerves were conspicuously enhanced after intravenous administration of gadolinium diethylene triamine pentaacetic acid  the preserved facial nerves were also markedly enhanced postoperatively  as a possible cause of these findings  we suggest operative disruption of the blood nerve barrier with ensuing nerve edema  although the operative procedures were carefully carried out using a surgical microscope  the clinical significance of traumatic disruption of the blood nerve barrier and subsequent nerve edema are discussed from the standpoint of preservation of cochlear nerve function  
class10	fractures of the clivus  classification and clinical features  fractures of the clival complex were diagnosed in a series of 17 patients admitted to the maryland institute for emergency medical services system and the university of maryland medical system over a 30 month period  these fractures were divided pathologically into three types based upon their appearance on computed tomography  longitudinal  transverse  and oblique  the mechanisms of injury were similar in all groups  and the glasgow coma scale scores at admission were comparable  regardless of fracture type  in survivors and nonsurvivors  longitudinal fractures were associated with severe injury to the central nervous system and with brain stem infarction  and 4 of 6  67   of these patients died  transverse fractures of the clival complex were found in 6 patients  3 of whom  50   died  all of these patients had fractures of the petrous ridge  2 of the 3 survivors had multiple cranial nerve deficits  and one patient developed a carotid cavernous fistula  of the 5 patients with oblique clival fractures  2 survived  40    both of whom had multiple cranial nerve palsies  in addition  one of these patients developed a carotid cavernous fistula  using the present generation of computed tomographic scanners  fractures of the clival complex can be reliably diagnosed  they are probably more common than previously believed and can be separated into three groups based on the characteristics on computed tomographic scans and clinical findings  
class10	clinicopathological experience with pineocytomas  report of five surgically treated cases  the clinicopathological experience associated with five cases of pineocytoma is presented  all patients were treated by surgical removal without postoperative radiotherapy  in three individuals  2000 cgy was administered to the tumor as a presurgical diagnostic test  with no evidence of response  all cases demonstrated histological features of pineocytoma  according to the criteria of borit et al   and of the so called  pineocytoma with neuronal differentiation   according to the criteria of rubinstein  the experience obtained from the present series reveals that these tumors can occur in the initial decades of life  that a cystic appearance and the presence of calcifications are distinctive features of their radiological evaluation  and that they have a good prognosis after surgical removal  even when the histological data indicate local invasion  the convenience of reserving the term  pineocytoma  for these tumors  and of including the so called  pineocytomas without further differentiation  within the group of pineoblastomas  is suggested in order to achieve a practical clinicopathological assessment of parenchymatous pineal tumors  
class10	concurrent intradural and extradural meningiomas of the cervical spine  a case of an extradural spinal meningioma presenting with a separate intradural meningioma at the same cord level is reported  review of the english literature on spinal epidural meningiomas reveals a high incidence of concurrent intradural tumors in patients with epidural meningiomas  this leads to the conclusion that the intradural space should be evaluated carefully when an epidural meningioma is encountered  
class10	intradural spinal cord tumor presenting as a subarachnoid hemorrhage  magnetic resonance imaging diagnosis  negative findings on four vessel angiography after a subarachnoid hemorrhage are seen in 5 to 30  of patients  a previously silent lesion in the spinal canal may be responsible for the ictus in a small percentage of this group  the etiological factors include tumors and arteriovenous malformations  however  investigations of such lesions have been limited to patients with signs and symptoms of spinal cord or nerve root pathological processes  this report describes the management of a 56 year old woman with clinical findings typical of an aneurysmal subarachnoid hemorrhage and negative findings on cerebral angiography  in whom magnetic resonance imaging with gadolinium enhancement revealed an intradural extramedullary cervical schwannoma  for this reason  cervicothoracic magnetic resonance imaging with gadolinium enhancement should be considered as an adjunctive scanning examination in all patients with a subarachnoid hemorrhage and negative findings on angiography  
class10	myelopathy presenting decades after surgery for congenital cervical cutaneous lesions  we report on two patients in whom cervical myelopathy developed decades after they had undergone surgery for congenital cervical cutaneous lesions  preoperative magnetic resonance imaging demonstrated dorsal tethering and cavitation of the cervical cord in the area of the previous surgery and was helpful in decision making regarding surgical exploration and in planning for it  we stress the importance of long term follow up by both clinical examination and magnetic resonance imaging in children who have been operated on for cervical cutaneous masses that may have central connections  
class10	paraplegia after a routine lumbar laminectomy  report of a rare complication and successful management  arachnoid cysts of the spinal canal are relatively common lesions that may be either intra  or extradural  these cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots  we report a case in which an intradural thoracic arachnoid cyst became symptomatic after a routine decompressive lumbar laminectomy for spinal stenosis  myelography revealed no abnormality  although magnetic resonance imaging and computed tomography after myelography demonstrated a mass within the posterior aspect of the thoracic spinal canal associated with anterior displacement and compression of the spinal cord  a change in the flow dynamics of the cerebrospinal fluid probably allowed the development of spinal cord compression due to one of the following  expansion of the cyst  decreased cerebrospinal fluid buffer between the cord and the cyst  or epidural venous engorgement  a concomitant and more cephalad lesion such as an arachnoid cyst should be considered when myelopathic complications arise after lumbar surgery  magnetic resonance imaging and computed tomography after myelography are useful to demonstrate the additional pathological processes  
class10	pituitary hemorrhage into a rathke s cleft cyst this report describes a case of symptomatic pituitary hemorrhage into a rathke s cleft cyst in a 25 year old woman  the literature on pituitary hemorrhage in nonadenomatous sellar tumors is reviewed  
class10	mechanism of stroke in patients taking aspirin  during a 1 year period  we prospectively studied the mechanism and severity of stroke in 47 patients sustaining a cerebral infarction while taking aspirin  the mechanism of stroke was undetermined in 12 patients  26    in the remaining 35 patients  we identified 39 potential mechanisms  large artery atherosclerosis  19 patients  40    cardioembolism  15 patients  32    and small vessel occlusive disease  5 patients  11    of 11 patients with carotid atherosclerosis and stroke  9  82   had greater than 90  carotid stenosis or occlusion  of 12 patients with stroke of undetermined mechanism  10  83   had previous stroke  of which 8 were also of undetermined mechanisms  disability after stroke was moderate or severe in 27 patients  57    these data suggest that  1  stroke in patients taking aspirin has a variety of etiologies and frequently causes moderate or severe disability   2  patients with carotid disease failing aspirin often have high grade carotid stenosis or occlusion   3  stroke of undetermined mechanism may recur more frequently than other stroke subtypes in patients taking aspirin  
class10	aspiration in bilateral stroke patients  seventy patients with bilateral strokes underwent neurologic and videofluoroscopic barium swallowing examinations  34  48 6   aspirated  patients with aspiration were more likely to have posterior circulation strokes  abnormal cough  abnormal gag  and dysphonia  however  patients likely to aspirate can be identified best by the presence of an abnormal voluntary cough  an abnormal gag reflex  or both  the prediction of patients at risk for aspiration was not improved by additional clinical information  ie  presence of dysphonia or bilateral neurologic signs   
class10	prolonged confusion following convulsions due to generalized nonconvulsive status epilepticus  among patients with a prolonged confusional state after convulsive seizure  we diagnosed 8 cases as generalized nonconvulsive status epilepticus  six had a history of seizures  and 2 had new onset  the convulsive seizures were generalized in 6 and focal in two  the postictal confusion lasted up to 36 hours in the most prolonged case  and a delayed response to anticonvulsant medications occurred in all cases  the clinical symptoms ranged from mild confusion to coma  psychiatric manifestations or automatisms were rare  the presumed etiology was due to diverse causes  but a withdrawal state was the most common  eeg demonstrated continuous or nearly continuous generalized ictal discharges of variable morphology  these cases call attention to the fact that some prolonged confusional states following convulsive seizures are in fact due to persistent seizure activity that can be diagnosed by eeg  
class10	verbal memory impairment correlates with hippocampal pyramidal cell density  thirty five patients with medically refractory epilepsy localized to the temporal lobe  18 left  17 right  completed the verbal selective reminding test before surgery  verbal memory impairments existed before surgery regardless of the lateralization of the seizure focus  but patients with left temporal seizure foci were significantly more impaired  after surgical removal of the mesial temporal lobe structures  2 blinded observers established volumetric cell densities for hippocampal subfields ca1  ca2  ca3  the hilar area  and the granule cell layer of the area dentata  statistically significant correlations existed between presurgical memory impairment and cell counts  in ca3 and the hilar area  only  for patients with left temporal seizure foci  these findings support the hippocampal model of memory and complement prior research documenting the memory impairments present after surgical removal of the mesial temporal structures  
class10	a case control study of alzheimer s disease in australia  we conducted a case control study of clinically diagnosed alzheimer s disease  ad  on 170 cases aged 52 to 96 years  and 170 controls matched for age  sex and  where possible  the general practice of origin  trained lay interviewers naive to the hypotheses and to the clinical status of the elderly person carried out risk factor interviews with informants  significant odds ratios were found for 4 variables  a history of either dementia  probable ad  or down s syndrome in a 1st degree relative  and underactivity as a behavioral trait in both the recent and more distant past  previously reported or suggested associations not confirmed by this study include head injury  starvation  thyroid disease  analgesic abuse  antacid use  aluminum exposure   alcohol abuse  smoking  and being left handed  
class10	the opposite pupil in herniation  i serially examined the pupil opposite the one already enlarged from transtentorial herniation in 13 patients  the main abnormalities  stereotyped in most patients  were an initially diminished light reaction with a 2 5  to 4 mm diameter pupil  followed by slight reduction in size  and then reenlargement to greater than original size  all with preserved roundness  subsequent deterioration varied among patients  but a transitional oval shape was infrequent and oculomotor function was preserved until both pupils were enlarged and fixed  once the pupil on the side of a mass enlarges  heralding herniation  subsequent deterioration can be appreciated through changes in reactivity and size of the opposite pupil  
class10	spatiotemporal contrast sensitivity differs in normal aging and parkinson s disease  we measured contrast sensitivity for static and laterally drifting vertical gratings in 12 young adults  7 normal elderly adults  and 8 patients with parkinson s disease  pd   we compared static and motion contrast sensitivity for spatial frequencies of 0 25  1  and 4 cycles per degree  cpd   and temporal frequencies of 1  3  and 9 hz  results show that normal aging leads to a reduction of motion sensitivity for the spatial frequency of 0 25 cpd  compared with elderly controls  pd patients do not present specific abnormalities in this domain  however  for spatial frequencies of 1 and 4 cpd and temporal frequencies of 1 and 3 hz  motion sensitivity is worse than static sensitivity in pd patients and not in elderly controls  these findings suggest a specific deficit of motion perception in pd  and possible dopaminergic involvement in the control of visuospatial behavior  
class10	cytokine accumulations in csf of multiple sclerosis patients  frequent detection of interleukin 1 and tumor necrosis factor but not interleukin 6  we identified the cytokines interleukin 1 beta  il 1 beta   tumor necrosis factor  tnf   and interleukin 6  il 6  by specific radioimmunoassays in the csf of patients with multiple sclerosis  ms  and other neurologic diseases  ond   there was a high incidence of detectable il 1 beta in patients with active ms compared with inactive ms or ond patients  tnf was also more frequently present in active ms than in ond csf  by contrast  most ms csf did not contain detectable il 6  there was no correlation between the degree of csf pleocytosis and the level of individual cytokines  suggesting that cytokine accumulations may be derived from cns  and not csf  cells  as il 1 beta and tnf experimentally induce astrogliosis  demyelination  temperature elevation  lassitude  and sleep  and results raise the possibility that these cytokines may contribute to a variety of manifestations in ms and in other disease states  
class10	catecholaminergic systems in the medulla oblongata in parkinsonian syndromes  a quantitative immunohistochemical study in parkinson s disease  progressive supranuclear palsy  and striatonigral degeneration  we investigated tyrosine hydroxylase  th  immunoreactive neurons in the medulla oblongata corresponding to the a1 and a2 cell groups in autopsy tissue of patients with parkinson s disease  pd   n   3   progressive supranuclear palsy  psp   n   3   striatonigral degeneration  snd   n   2   and in controls  n   4   the estimated total number of th positive neurons in the a1 and the a2 regions was normal in pd and psp patients  the sparing of medullary catecholaminergic cells in pd and psp may be related to their minor degree of melanization and the possibility that intermediate compounds associated with the oxidative catabolism of norepinephrine and epinephrine may be less cytotoxic than those generated by degradation of dopamine  patients with snd showed a marked loss of th immunoreactive cells in the a1 and the a2 groups  which may contribute to the impairment of vasomotor control characteristic of the disease  
class10	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  
class10	kearns sayre syndrome presenting as renal tubular acidosis  renal tubular acidosis and tetany were the 1st manifestations of kearns sayre syndrome in a 5 year old child  subsequently  he developed progressive external ophthalmoplegia  ptosis  retinopathy  heart block  and endocrinopathy  there was a 7 5 kb deletion of mitochondrial dna documented in muscle  kidney  skin fibroblasts  and leukocytes  providing evidence for a multisystem mitochondrial cytopathy  
class10	antibodies to synthetic peptide  125 148  of the alpha subunit of human nicotinic acetylcholine receptor in sera from patients with myasthenia gravis  we measured the amount of antibodies to a synthetic peptide that corresponds to the alpha subunit residues lys125 thr148 of human acetylcholine receptor  achr  in myasthenic sera  we detected anti peptide antibodies in 52   89 171  of the patients with myasthenia gravis  mg   but none in any of the healthy controls  anti peptide antibodies should provide a valuable immunologic parameter for the clinical evaluation of mg  but no apparent correlation was observed between the titers of anti peptide and anti achr antibodies  
class10	streptococcus bovis meningitis  report of 2 cases  we describe 2 cases of streptococcus bovis meningitis and review the 9 cases previously reported  this microorganism is a rare cause of meningitis in which there are no distinctive clinical or laboratory features  the gram stain of the csf is usually negative  ten of the 11 cases had some underlying disease or comorbid condition that predisposed to s bovis infection  gastrointestinal disorder  endocarditis  csf leak  polymyalgia rheumatica  and mandibular block  treatment with high dose penicillin is usually adequate  
class10	a comparison of regulatory cells in spinal fluid and blood in patients with multiple sclerosis and other neurologic diseases  multiple sclerosis is a disease in which immune abnormalities are present both in the cns and peripheral blood  whether these changes are primary or secondary to the disease process is not known  we tested t cell clones derived from activated lymphocytes in the blood and csf of ms patients and controls for their capacity to regulate t cell responses to alloantigens  a wide spectrum of regulatory functions were observed  ranging from marked enhancement to almost complete suppression  clones from different patient populations and anatomic sites were equivalent in their regulatory functions with the net effect of clones in each compartment being suppression  however  certain clones from csf and peripheral blood had the capacity to stimulate autologous t cells  percentages of such clones in the peripheral blood of ms patients were significantly higher than in controls  while percentages in ms and other neurologic diseases  ond  csf were equivalent  our data suggest that  1  functional suppressor cells are not lost from the blood or csf or ms and ond patients   2  lymphocytes that have entered the cns in patients with ms and other cns diseases have equivalent regulatory functions   3  ms may be an illness in which peripheral immunologic events are important in perpetuating the disease process  and  4  responses to autologous antigens may also play a role in this perpetuation  
class10	eosinophilia myalgia syndrome  l tryptophan associated neuromyopathy   histopathologic study of skeletal muscle biopsy in a patient with eosinophilia myalgia syndrome following l tryptophan use showed prominent lymphocytic perineuritis  neuritis  and perimysial fasciitis  the presence of perineuritis and neuritis provides a histopathologic basis for clinical features of neuropathy in eosinophilia myalgia syndrome and occurred in conjunction with a fasciitis or interstitial myositis that was predominantly perimysial and focally endomysial  
class10	visual disturbance in patients with melanocytoma of the optic disk  visual disturbance in 11 patients with melanocytoma of the optic disk was analyzed  goldmann visual field examination showed enlargement of mariotte s blind spot in 7 of 10 patients  70   and visual field defect or depression in 7 patients  70    in 6 of the 7 patients with visual field defect of depression  86    the portion of visual field damage corresponded with the location of the tumor and retinal nerve fiber bundle defect  in 1 patient  sudden loss of visual acuity occurred  presumably due to anterior ischemic optic neuropathy induced by melanocytoma  
class10	signs distinguishing spasmus nutans  with and without central nervous system lesions  from infantile nystagmus  clinical findings as well as eye and head movement recordings were analyzed from 23 patients with spasmus nutans without central nervous system  cns  changes  10 patients with spasmus nutans like disease  head nodding  intermittent nystagmus associated with intracranial anomalies or visual pathway disorders   and 25 patients with infantile nystagmus  ten diagnostic signs were established to differentiate between the patient groups  although they were helpful in separating patients with infantile nystagmus from those with spasmus nutans  no difference was found between the patients with spasmus nutans with and without cns lesions  this study indicates that eye and head movement recordings do not allow differentiation between benign spasmus nutans and spasmus nutans like disease  the differentiation must be made on the basis of neuroimaging  
class10	late juvenile onset krabbe s disease  krabbe s disease is an autosomal recessive leukodystrophy characterized by a lack of galactocerebroside beta galactosidase activity  in contrast to the classic early infantile onset form of krabbe s disease  less recognized  late onset variants exist  the authors present a case of late juvenile onset krabbe s disease  including the associated magnetic resonance imaging  mri  findings  most patients with late onset krabbe s disease present with visual loss due to optic atrophy  associated gait abnormalities and parental consanguinity should increase the clinician s suspicion that a child may have late onset krabbe s disease  because of the prolonged survival in late onset krabbe s disease  the recent development of bone marrow transplantation for these patient makes diagnosis of this disorder particularly important  
class10	pharmacological versus non pharmacological prophylaxis of recurrent migraine headache  a meta analytic review of clinical trials  in order to generate information about the relative effectiveness of the most widely used pharmacological and non pharmacological interventions for the prophylaxis of recurrent migraine  i e   propranolol hcl and combined relaxation thermal biofeedback training   meta analysis was used to integrate results from 25 clinical trials evaluating the effectiveness of propranolol and 35 clinical trials evaluating the effectiveness of relaxation biofeedback training  2445 patients  collectively   meta analysis revealed substantial  but very similar improvements have been obtained with propranolol and with relaxation biofeedback training  when daily recordings have been used to assess treatment outcome  both propranolol and relaxation biofeedback have yielded a 43  reduction in migraine headache activity in the average patient  when improvements have been assessed using other outcome measures  e g   physician therapist ratings   improvements observed with each treatment have been about 20  greater  in both cases  improvements observed with propranolol and relaxation biofeedback have been significantly larger than improvement observed with placebo medication  14  reduction  or in untreated patients  no reduction   meta analysis thus revealed substantial empirical support for the effectiveness of both propranolol and relaxation biofeedback training  but revealed no support for the contention that the two treatments differ in effectiveness  these results suggest that greater attention should be paid to determining the relative costs and benefits of widely used pharmacological and non pharmacological treatments  
class10	antinociception and cardiovascular responses produced by electrical stimulation in the nucleus tractus solitarius  nucleus reticularis ventralis  and the caudal medulla  in experiment 1  quantitative regional comparisons of the antinociceptive and cardiovascular responses produced by electrical stimulation in the caudal medulla  including regions such as the nucleus tractus solitarius  nts   nucleus reticularis ventralis  nrv   nucleus reticularis gigantocellularis  nrgc   nucleus reticularis paragigantocellularis  nrpgc   nucleus raphe obscurus  nro   and medial portions of the lateral reticular nucleus  lrn   were made in the rat  electrical stimulation in all of these regions resulted in inhibition of the nociceptive tail flick reflex  although the threshold intensity for inhibition was greater for sites in nts compared to many sites ventral to the nts  antinociception was generally accompanied by an increase in mean arterial blood pressure  with the exception of sites in the nro  where depressor responses were evoked by stimulation  detailed comparisons between the nts and nrv revealed that greater intensities of electrical stimulation were required to produce antinociception for sites in the nts as compared to the nrv  there were no significant differences in threshold intensities for antinociception as a function of rostrocaudal subdivisions of the nts  but the lateral subdivision of the nts was significantly more efficacious than the medial subdivision  this mediolateral difference within nts was primarily due to stimulation in medial sites producing overt movements in some animals  probably due to stimulation of adjacent midline nuclei or pathways  within the nrv  thresholds for inhibition of the tail flick reflex were greater for sites in the dorsal subdivision as compared to the ventral subdivision  which contains spinopetal projections from the nrm  the slopes of the lines of recruitment for inhibition of the tail flick reflex at stimulation sites in either the nts or nrv were both very steep  similar to other forms of antinociception  in experiment 2  the pulse duration of electrical stimulation was varied for sites of stimulation in the lateral nts and nrv to generate strength duration curves  this experiment confirmed that stimulation sites in the lateral nts required greater current intensities to inhibit the tail flick reflex than sites in the nrv  however  the chronaxies derived from the strength duration functions for the nts or nrv were both approximately 170 microseconds  indicating that the antinociceptive effects in these regions may not be exclusively due to the stimulation of fibers of passage  these results are discussed in terms of the role of the nts  nrv  and caudal medulla in the modulation of nociceptive responses and cardiovascular function  
class10	clinical judgments in pain management  from research reports published over the last 20 years  it appears that moderate to severe uncontrolled pain may be the norm for hospitalized patients despite recent advances in the management of pain  research on the extent of under management of pain and the factors associated with it is examined and summarized in this paper  methodological imperfections of the research are identified  several explanations for pain under management have been proposed and these are reported  a clinical decision making model is also reviewed and it is suggested that this model could be applied to pain management problems  further  it is suggested that this model may be very useful in developing educational interventions to improve health practitioners  clinical skills in pain management  
class10	pain relief achieved by transcutaneous electrical nerve stimulation and or vibratory stimulation in a case of painful legs and moving toes  a patient is described with painful legs and moving toes  the pain had been occurring for more than 15 years  and a variety of therapies had been attempted with only partial  if any  success  only morphine had succeeded in relieving the pain  but it had to be discontinued to avoid tolerance and dependence  we devised a treatment consisting of transcutaneous electrical nerve stimulation  tens   vibratory stimulation  vs   and a combination of the two methods  tens   vs   tens brought about partial pain relief  but was less effective than vs  dual stimulation  tens   vs  led to complete alleviation of the pain  four months later  the patient was applying dual stimulation himself at home and was thus able to maintain complete relief with 3 or 4 weekly sessions  we suggest that dual stimulation results in a large scale recruitment of large diameter afferent fibres and may thus set up a powerful inhibitory control of nociception in our patient  
class10	heritability of symptoms in an experimental model of neuropathic pain  male and female rats underwent transection and ligation of the sciatic and saphenous nerves  and the development of autonomy was monitored  the deafferented animals were then interbred  always selecting males and females that expressed relatively high and  alternatively  relatively low levels of autotomy  offspring were similarly operated and interbred  by the sixth generation of selective breeding  lines were achieved in which autotomy was consistently high  ha  or consistently low  la   there was no indication of sex linkage  thermal and mechanical nocifensive responsiveness co selected with propensity to express autotomy following nerve injury  response thresholds were lower in ha than in la rats  f1 hybrids formed by crossing homozygous ha and la animals showed low levels of autotomy  similar to la stock  this indicates recessive inheritance of the autotomy trait  backcrossing f1 hybrids onto the la line yielded a low autotomy phenotype in almost all cases  backcrossing f1 hybrids onto ha stock yielded about 50  high autotomy and 50  low autotomy  these ratios are consistent with simple mendelian inheritance of a single gene  taken together  the data suggest that autotomy is inherited as a single gene autosomal recessive trait  
class10	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  
class10	interactions between substance p  calcitonin gene related peptide  taurine and excitatory amino acids in the spinal cord  using in vivo microdialysis in the dorsal spinal cord of the rat  we have previously observed increases in glutamate and aspartate during exposure to a noxious stimulus  the present investigation was designed to determine whether these increases may be mediated by substance p  infusion of 1 mm of substance p in the dialysis fluid increased the concentrations of glutamate and aspartate  similar to the response seen during noxious stimulation  in addition  substance p also increased the concentrations of the inhibitory amino acids glycine and taurine  calcitonin gene related peptide  previously shown to enhance substance p induced biting and scratching behavior  produced no effect on amino acid release by itself but potentiated the apparent release of taurine by substance p  to assess the importance of substance p induced amino acid release in sensory processing  we examined the influence of taurine and of excitatory amino acid antagonists on the biting and scratching behavior produced by excitatory amino acids and substance p  taurine selectively inhibited only substance p induced biting and scratching while excitatory amino acid antagonists inhibited only excitatory amino acid induced behavior  to further explore the ability of taurine to inhibit the substance p induced behavior  3 tests of nociception were then used  pretreatment with taurine inhibited the nociceptive related writhing behavior produced by an intraperitoneal injection of acetic acid in mice but failed to alter the latency of response in the hot plate or tail flick assay  
class10	thrombocytosis after pneumonia with empyema and other bacterial infections in children  thrombocytosis is seen in association with many conditions  including infectious diseases  we studied thrombocytosis after severe bacterial infections  particularly pneumonia with empyema in children  a systematic survey of the phenomenon was conducted  twenty seven children admitted for pneumonia with empyema were studied  thrombocytosis  platelet counts greater than 500 x 10 3  microliters  was present in 92 5   platelet counts reached their maximum at 15 1     3 7 days  range  7 to 25  and declined to normal after 3 weeks of illness  compared with a healthy control group  significant thrombocytosis  but of lower incidence  was also noted in children with lobar pneumonia without pleural effusion  bacterial meningitis and osteomyelitis  platelet functions were examined in seven of the children but no abnormalities were observed  bone marrow aspiration of three children with pneumonia and empyema showed megakaryocytic hyperplasia  we found no correlation between thrombocytosis  neutrophilia  fever  the clinical course  complications  prognosis or treatment  neither thromboembolic nor hemorrhagic phenomena were observed  
class10	central nervous system tuberculosis in children  a review of 30 cases  the medical records of 30 children with central nervous system tuberculosis  cns tuberculosis  who were treated between march  1976  and february  1989  were reviewed  all had cranial computerized tomography scans at presentation  the mean cerebrospinal fluid leukocyte count was 200 mm3  protein 239 mg dl  glucose 25 mg dl and csf serum glucose ratio 21   mantoux skin tests with 5 tuberculin units were greater than or equal to 10 mm induration in 50   and chest radiographs were positive in 40  of patients  hydrocephalus was demonstrated by cranial computerized tomography in all 30 patients  100    cranial computerized tomography scan demonstrating hydrocephalus is a sensitive radiographic nervous system tuberculosis and should be part of the early evaluation of children with suspected central nervous system tuberculosis  
class10	acute pain relief  pain is a multidimensional psychophysiologic phenomenon  systematic multidimensional assessment is an essential first component of an effective plan to relieve the pain  nurses are key to effective pain management because of the close  24 hour a day relationship with the hospitalized patient  it is the nurse who is most critical to the adequate assessment of pain  to the implementation of the treatment plan  and to the evaluation of efficacy  nurses should continue to develop a better knowledge base about pain and pain therapies and assessment skills  be assertive in obtaining effective treatment for their patients  and perceive themselves as responsible for pain relief  
class10	chronic pain  understanding of the etiology of chronic pain is growing rapidly as researchers seek to integrate physiologic and psychosocial mechanisms  when nurses assess clients with chronic pain  they should make their assessments using both verbal and nonverbal methods and realize that no one instrument is comprehensive enough to be used alone  the key to successful treatment of these difficult clients lies in the use of a comprehensive approach that takes the client seriously and integrates both physiologic and psychosocial approaches  
class10	pain in children  the assessment and management of children s pain is a topic that has received a great deal of attention since the late 1970s  nurse researchers have played a dominant role in all areas of pediatric pain relief and likely will continue to do so  there are currently a number of pediatric pain assessment instruments developed that are used in selected practice settings  but their use should be extended to document the existence of pediatric pain and its relief  pharmacologic interventions for pediatric pain relief have been hampered by incorrect beliefs about analgesic risks  prescribing and administrating habits  and a virtual explosion of information in the area of analgesics  although nurses have traditionally used nonpharmacologic interventions for pain relief  these methods have not been well researched  continued research efforts in this important area will result in improved diagnosis and management of pediatric pain  
class10	confusion  the term confusion describes a plethora of possible cognitive deficits and behavioral manifestations  a subjective assessment of confusion must be followed by an objective systematic evaluation to develop the cognitive behavior profile  because of age associated physiologic and pathologic changes  elderly patients are at high risk for developing acute confusion  the management of confusion presents a challenge to nursing  nursing can play a significant role in the prevention and the early detection of acute confusion  preventing or identifying confusion early will decrease the physical and psychological stress of the patient as well as decrease the cost of hospitalization by shortening length of stay  additional research is needed to determine the efficacy of present nursing activities and to identify new approaches for management  
class10	when epilepsy masquerades as heart disease  awareness is key to avoiding misdiagnosis  autonomic neural impulses that accompany discharges during a seizure can cause a variety of cardiac manifestations  including cardiac arrhythmias  sudden death  anginal chest pain  neurogenic pulmonary edema  and symptoms of pheochromocytoma  either generalized or focal seizures may generate such signs and symptoms  a better appreciation of cardiac problems caused by epilepsy is helpful in preventing misdiagnosis  because the clinical picture in such a patient may be confusing  
class10	steroids induce acetylcholine receptors on cultured human muscle  implications for myasthenia gravis  antibodies to the acetylcholine receptor  achr   which are diagnostic of the human autoimmune disease myasthenia gravis  block achr function and increase the rate of achr degradation leading to impaired neuromuscular transmission  steroids are frequently used to alleviate symptoms of muscle fatigue and weakness in patients with myasthenia gravis because of their well documented immunosuppressive effects  we show here that the steroid dexamethasone significantly increases total surface achrs on cultured human muscle exposed to myasthenia gravis sera  our results suggest that the clinical improvement observed in myasthenic patients treated with steroids is due not only to an effect on the immune system but also to a direct effect on muscle  we propose that the identification and development of pharmacologic agents that augment receptors and other proteins that are reduced by human genetic or autoimmune disease will have broad therapeutic applications  
class10	controlling stability of a complex movement system  human movement systems have frequently been treated as one dimensional  single axis  rigid bodies in order to simplify the gathering  analysis  and interpretation of data  the problem with this approach is that the results of such assumptions often lead to conclusions about the production and control of movement that do not relate to the control demands placed on the central nervous system  in order to truly understand how the central nervous system plans and produces movements to match environmental demands  we must take into account the many variations available within the body  the purpose of this article is to examine two movement systems that have the potential to act in multiple spatial dimensions with variable muscle action patterns when performing a stabilizing task  methods of analyzing how the systems operate under differing task constraints and results of the experiments will be presented  hypothetical models that have been proposed to explain how complex movement systems operate will also be discussed  
class10	interferon system and natural killer cell activity in myasthenia gravis  the autoimmune response in myasthenia gravis is well characterized  but little is known about the mechanisms initiating it  we have studied the interferon system and natural killer cell activity in 25 patients with myasthenia gravis and compared them to 68 healthy subjects and 96 patients with acute viral infections  forty four per cent of patients had circulating interferon  greater than 16 mu ml   and in a similar proportion their peripheral blood mononuclear cells were in an antiviral state  i e   showed low levels of viral replication when infected by vesicular stomatitis virus  spontaneous in vitro interferon production by patients  peripheral blood mononuclear cells was also common  greater than 10 mu ml  32 per cent   while the response to the alpha interferon inducer poly i c was lower than expected  possibly reflecting the already high state of activation of the interferon system  these results were essentially similar to those obtained in patients with viral illnesses and differed significantly from healthy controls  in many myasthenia gravis patients  16 of 22  73 per cent   a markedly deficient natural killer cell activity was found  with a median cytotoxicity of 6 5 per cent compared to 29 per cent in healthy subjects  p less than 0 005   thus  many patients with myasthenia gravis have evidence of an activated interferon system and defective natural killer cell activity  suggesting an occult viral infection or reflecting nonspecific stimulation which may nevertheless contribute to the pathogenesis of the autoimmune response  
class10	haemostatic changes in the loin pain and haematuria syndrome  secondary to renal vasospasm  twenty five patients  seven male  18 female  were diagnosed as having the loin pain and haematuria syndrome  presenting symptoms were either loin pain alone or pain associated with macroscopic or microscopic haematuria  and were longstanding  having been present for mean of 9 3 years in males  and 10 years in females  ten patients described symptoms of passing gravel or renal stones but these were only demonstrated radiologically in two patients  investigation of all patients showed anatomically normal renal tracts  normal renal function  and no significant proteinuria  phase contrast microscopy during episodes of haematuria revealed dysmorphic red cells in all 10 patients studied  renal biopsies were performed in 20 patients and showed no glomerular pathology  but arteriolar and arterial hyalinosis was seen in 13 of 20  65 per cent   fibro elastosis in larger vessels in eight of 20  40 per cent  and red blood cells in tubules in 13 of 20  65 per cent  patients  the histological appearance in vessels was similar to that seen in cyclosporin a nephrotoxicity and would be consistent with the hypothesis that regional vasospasm occurs in the cortical circulation  haematological studies in 22 patients  when compared with age and sex matched controls  showed the presence of circulating platelet aggregates  elevation of plasma beta thromboglobulin  p less than 0 001   and increased platelet aggregation in response to serotonin and adp  p less than 0 05 and p less than 0 03  respectively   plasma concentrations of d dimer  p less than 0 02  and c reactive protein  p less than 0 03  were also significantly elevated in the patient group  there was no deterioration of renal function during a mean observation period of 3 7 years and no patients developed proteinuria  treatment was largely supportive  seven patients with intractable loin pain underwent surgical denervation with the relief of pain in four  
class10	tropical neuromyelopathies and retroviruses  a review  debilitating disorders of the nervous system have a relatively high prevalence in the tropics  a geographic region that is often deficient in specialists in the fields of neurology and epidemiology  during world war ii  attention was called to a possible nutritional origin for most of these diseases  recently  however  human t lymphotropic virus type i  htlv i   formerly linked only to a rare form of leukemia  adult t cell leukemia   has been associated with a spastic paraplegia observed mostly in tropical areas and referred to as tropical spastic paraparesis  this entity is also observed in nontropical areas endemic for htlv i  including japan  south america  and the southern united states  viruses of the htlv family are being associated increasingly with pathology in humans  the pathogenesis of htlv i associated tropical spastic paraparesis remains to be understood  however  future research is expected to favor a multidisciplinary approach  with exciting potential insights derived from the fields of neurology  immunology  and infectious diseases  the aim of this review is to summarize contemporary research related to the viral etiology of this clinical entity  
class10	tamoxifen therapy for painful idiopathic gynecomastia  we have evaluated the efficacy of the antiestrogen tamoxifen in six men with painful idiopathic gynecomastia  subjects were given either tamoxifen or placebo for 2 to 4 months and then were given the other agent for an identical period  breast size was considered to have been reduced only if it had decreased by one or more marshall tanner stages during the treatment period  pain reduction with tamoxifen therapy was statistically significant for the group  occurring in five of six subjects during tamoxifen treatment and in only one of six during the placebo period  size reduction with tamoxifen was only marginally significant for the entire group  but occurred in all three subjects who were initially in marshall tanner stage iii and in none of the three subjects who were initially in stage v  during tamoxifen treatment  there was a significant increase in the serum levels of luteinizing hormone and total estradiol and a marginally significant increment in the total testosterone level  
class10	normeperidine induced seizures in hereditary coproporphyria  seizures are common in acute exacerbations of hepatic porphyria  even though the etiology is not identified in most cases  we have reported a case of normeperidine induced seizures in a patient with hereditary coproporphyria  although meperidine is commonly used for pain control during acute attacks in these patients  this report suggests that meperidine is not a good analgesic choice in porphyria  normeperidine induced seizures in patients with porphyria may be treated by withdrawal of meperidine therapy and selective use of anticonvulsants  
class10	postural hypotension  pressor effect of octreotide not mediated by norepinephrine  orthostatic hypotension of the shy drager syndrome is a chronic incapacitating condition characterized by lack of an appropriate increase in the plasma norepinephrine level in response to standing  recently  the somatostatin analogue octreotide has been reported to induce a pressor response in patients having this syndrome  we have reported a case of shy drager syndrome in which octreotide was effective  but the rise in blood pressure was not accompanied by an increase in the plasma norepinephrine level  hence  the pressor effect of octreotide is not mediated by stimulation of the sympathetic nervous system  but probably through splanchnic vasoconstriction  
class10	synchronous hodgkin s disease and myelofibrosis terminating with granulocytic sarcoma and acute megakaryocytic leukemia  our patient had stage iiiai hodgkin s disease with synchronous myelofibrosis and myeloid metaplasia  a slowly progressive myeloproliferative disease developed over 9 1 2 years and terminated in a painful osteolytic bone disease  spinal extradural granulocytic sarcoma and acute megakaryocytic leukemia  it is likely that this was a result of the myeloproliferative disease rather than a late complication from combination chemotherapy  our case demonstrates the importance of a curative approach to hodgkin s disease even in the face of a coexistent disease with a long or unknown natural history  
class10	persistent segmental cutaneous anesthesia after a brown recluse spider bite  patients with brown recluse spider bites commonly suffer from pain  muscular aching  and a variety of local dysesthesias during the acute and resolution phases of toxin induced injury  this is our first well documented observation of persistent cutaneous anesthesia caused by a spider bite  the anesthetic area conformed to the distribution of a specific nerve  the transverse cervical cutaneous nerve  the identification of the spider as a brown recluse and the location of the bite over the nerve s usual pathway strongly suggest that the venom was responsible for this complication  
class10	neurologic abnormalities in a patient with human ehrlichiosis  human ehrlichiosis is a tick borne rickettsial disease characterized by fever  headache  myalgias  anorexia  and occasionally rash  in our patient  changes in mental status  upper motor neuron signs  cerebrospinal fluid pleocytosis  and increased serum protein levels were found in association with serologically confirmed ehrlichiosis and were most likely due to vasculitis involving the central nervous system  intraleukocytic inclusions  although observed in our case  have been infrequently found in other reported cases of ehrlichiosis  
class10	stroke in systemic lupus erythematosus  published erratum appears in stroke 1991 mar 22 3  417  we investigated the clinical and pathologic characteristics of stroke in 234 patients with systemic lupus erythematosus  thirteen patients  5 6   developed cerebrovascular disease  cerebral infarction was noted in eight  cerebral hemorrhage in two  and subarachnoid hemorrhage in three  in seven  54   of these 13 patients  stroke occurred less than or equal to 5 years after systemic lupus erythematosus was diagnosed  among the predisposing risk factors for stroke  hypertension was the most important  lupus anticoagulant was detected in three  38   and anticardiolipin antibody in three  43  of seven investigated  of the patients with infarction  evaluation of the clinical manifestations and autoantibodies indicated that renal involvement and high titers of anti deoxyribonucleic acid antibody were more frequent in the stroke group than in the non stroke group  autopsy studies on six of the patients with stroke revealed small infarcts and hemorrhages in all  but in no case was true angiitis observed  libman sacks endocarditis was found in two of the three patients with infarction  in conclusion  the important contributory factor to the development of stroke in patients with systemic lupus erythematosus is considered to be hypertension mediated by immunologic abnormalities  antiphospholipid antibodies and libman sacks endocarditis are closely associated with occlusive cerebrovascular disease  
class10	surgical experience with cerebral amyloid angiopathy  cerebral amyloid angiopathy can present as lobar intracerebral hemorrhage in an elderly person  presumably due to increased fragility of the vessels affected by amyloid deposition  for this reason  patients presenting with intracerebral hemorrhage and suspected of having cerebral amyloid angiopathy have often been treated nonsurgically  since 1983 we have evaluated 11 patients with cerebral amyloid angiopathy  nine women and two men  mean age 73 years  who have undergone either intracerebral hematoma evacuation or brain biopsy  nine of the 11 patients presented with intracerebral hemorrhage  which was unilobar in three patients and multilobar in six and involved the parietal lobes seven times  the frontal lobes four times  the temporal lobes four times  and the occipital lobes twice  these nine patients underwent hematoma removal  with no cases of abnormal intraoperative bleeding or recurrent hemorrhage  six patients improved neurologically  and two were unchanged after hematoma evacuation  the remaining patient had a fatal cardiopulmonary arrest during the immediate postoperative period  during follow up in seven patients  median 11 months  range 1 week to 74 months  none experienced a recurrent intracerebral hemorrhage and four continued to improve  two of the 11 patients had cerebral amyloid angiopathy diagnosed by brain biopsy as part of an evaluation for dementia  also without surgical complications  this series suggests that patients with cerebral amyloid angiopathy may safely undergo operative procedures  and patients presenting with intracerebral hemorrhage may show neurologic improvement following evacuation of the hematoma  
class10	remote effect of deep seated vascular brain lesions on cerebral blood flow  we measured regional cerebral blood flow using the xenon 133 inhalation method  at approximately 1 month after onset  in 60 stroke patients who had no evidence of major carotid artery stenosis or occlusion  their single lesions  43 infarcts and 17 hematomas  were located in the capsulothalamolenticular region  sparing the cortex  hemispheric mean cerebral blood flow was reduced on the side of the lesion in 25 patients and on both sides in 20  regional hypoperfusion was observed in 46 patients  ipsilaterally in 34  bilaterally in 10  and contralaterally in two   regional hypoperfusion was observed most frequently in the frontal lobe  particularly in the motor and premotor cortices of the prerolandic area  the 46 patients with regional hypoperfusion were compared with the 14 patients without regional hypoperfusion  considering the size and location of the lesion as well as the functional and analytic motor performances  as a rule  the lesion was slightly smaller and more posterior and the functional  p less than 0 001  and analytic  p less than 0 05  motor performances were significantly better in the 14 patients without regional hypoperfusion  since the xenon 133 inhalation method examines cortical blood flow  we can attribute blood flow reductions resulting from deep seated lesions to a functional depression akin to diaschisis  interpretation of the clinical consequences and pathogenesis of this phenomenon requires further sequential and pathologic studies  
class10	correlation of clinical and computed tomographic findings in stroke patients  we evaluated the correlation between clinical features and computed tomographic findings in a prospective study of 1 191 consecutive patients with acute cerebrovascular disease seen during 1 year  in the 386 patients in whom symptoms and signs initially suggested a cerebrovascular disorder  computed tomography revealed a relevant lesion in 154  hemorrhagic in 52  33 8    ischemic in 102  66 2    and a significant nonstroke abnormality in 14  3 1    among the remaining 805 patients with symptoms and signs suggesting some central nervous system disorder other than stroke  computed tomography revealed a cerebrovascular lesion in 38  4 7    35 of these lesions were ischemic  the computed tomographic findings was compatible with the final clinical diagnosis in 192  84 2   of the 228 patients with lesions  in the entire sample of 1 191 patients  a cerebrovascular disorder would have been missed in 38  3 2   without computed tomography  on the other hand  computed tomography failed to visualize a cerebrovascular lesion in 40 patients in whom such a lesion was clinically obvious  our results emphasize that both careful neurologic assessment and a policy of early computed tomography are of crucial importance in the diagnosis of stroke and for therapeutic considerations  
class10	effect of emitted power on waveform intensity in transcranial doppler this study assesses the problem of transcranial doppler recording failure and seeks to determine the extent to which this can be ameliorated by increased emitted power  we hypothesized that waveform intensity is directly related to the rate and quality of successful recording and may be compared quantitatively among groups of patients  among a large group of patients recorded at 800 mw cm2 emitted power  intensity was strongest in white men  weakest in black women  and intermediate in black men and white women  it declined with age in women of either race  but not in men of either race  analysis of the effect of emitted power on intensity predicted that significant numbers of waveforms recorded at 800 mw cm2 could not be recorded at the current clinical standards of 100 mw cm2  the difference being most pronounced in elderly black women  temporal bone window thickness measured in a series of adult cadaver skulls was least in white men  greatest in black women  and intermediate in black men and white women  the findings of this study support the hypothesis that temporal bone window thickness is an important determinant of recording difficulty and suggest that increased emitted power can significantly increase successful recording  particularly in black and elderly patients  increased power alone  however  cannot completely solve the recording problem within safe limits  
class10	moderate hypothermia after cardiac arrest of 17 minutes in dogs  effect on cerebral and cardiac outcome  moderate hypothermia  30 degrees c  induced before circulatory arrest is known to improve neurologic outcome  we explored  for the first time in a reproducible dog outcome model  moderate hypothermia induced during reperfusion after cardiac arrest  resuscitation   in three groups of six dogs each  n   18   normothermic ventricular fibrillation cardiac arrest  no blood flow  of 17 minutes was reversed by cardiopulmonary bypass  normothermic in control group i  37 5 degrees c  and hypothermic to 3 hours in groups ii  32 degrees c  and iii  28 degrees c   defibrillation was achieved in less than or equal to 5 minutes and partial bypass was continued to 4 hours  controlled ventilation to 20 hours  and intensive care to 96 hours  all 18 dogs survived  electroencephalographic activity returned significantly earlier in groups ii and iii  mean     sd best neurologic deficit between 48 and 96 hours was 44     8  in group i  38     12  in group ii  and 35     7  in group iii  differences not significant   best overall performance category 2  good outcome  between 48 and 96 hours was achieved in none of the six dogs in group i and in four of the 12 dogs in the combined hypothermic groups ii and iii  difference not significant   mean     sd brain total histologic damage score was 130     22 in group i  93     28 in group ii  p   0 05   and 80     26 in group iii  p   0 03   gross myocardial damage was greater in groups ii and iii than in group i  numerically higher overall and significantly higher in group iii for the right ventricle alone  p   0 02   moderate hypothermia after prolonged cardiac arrest may or may not improve cerebral outcome slightly and can worsen myocardial damage  
class10	progressing cerebral infarction in relation to plasma glucose in gerbils  we studied neurologic morbidity and its evolution during hyperglycemia induced immediately after permanent unilateral common carotid artery ligation in mongolian gerbils  a total of 60 animals were divided into five groups  one experiencing severe hyperglycemia for 1 hour after the onset of ischemia  brief hyperglycemia group  n   13   a normoglycemic control group for the brief hyperglycemia group  n   12   a group with severe hyperglycemia for 4 hours after the onset of ischemia  prolonged hyperglycemia group  n   11   a normoglycemic control group for the prolonged hyperglycemia group  n   13   and a hyperosmolar normoglycemic control group for the prolonged hyperglycemia group  n   11   neurologic morbidity and mortality were higher in the two hyperglycemic groups than in the three normoglycemic control groups  the neurologic deficit progressed according to the duration of severe hyperglycemia  in the three normoglycemic control groups neurologic status stabilized 120 minutes after the onset of ischemia  in the brief hyperglycemia group stabilization occurred at 210 minutes  and in the prolonged hyperglycemia group neurologic deficit progressed for approximately 360 minutes  coinciding with the death of all but one gerbil  in which the neurologic deficit remained stable until death 23 hours after ischemia  we suggest that hyperglycemia is another cause of progressing cerebral infarction  
class10	embolic stroke after smoking  crack  cocaine  a 39 year old woman had an embolic upper division middle cerebral artery branch occlusion 3 hours after smoking the free base of cocaine   crack    radionuclide ventriculography demonstrated cardiomyopathy  and echocardiography documented a left atrial thrombus  this case demonstrates that embolism is one mechanism of ischemic stroke after cocaine use  and that cardiomyopathy  possibly cocaine induced  may be the source of embolus  a cardiac source of embolus should be sought in patients with cocaine associated cerebral infarction  
class10	progress report of the stroke prevention in atrial fibrillation study  the stroke prevention in atrial fibrillation study recently found and reported  spaf investigators  n engl j med  1990 322 863 868  a beneficial effect of both warfarin and aspirin compared with placebo in the primary prevention of ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation  among warfarin eligible patients  the event rates were 1 6  yr for those receiving active antithrombotic therapy  warfarin or aspirin  and 8 3  yr for those receiving placebo  p less than 0 00005   risk reduction 81   95  confidence interval 56 91   ironically  we did not find a beneficial effect of aspirin in warfarin ineligible patients  on the basis of these results  the study has been reshaped to directly compare these two antithrombotic agents  insight into the apparent aspirin unresponsiveness noted in some patients also is being sought  interpretation of the preliminary results and the reshaping of the study have been made more complex by the continued blinding of the investigators to certain portions of the data  presented is an account of the study from its inception through its recent redesign  
class10	growth factor expression after stroke  fibroblast growth factors are polypeptides with potent trophic effects on central nervous system cells  both acidic and basic forms of fibroblast growth factor are found in the mammalian brain  we have examined the expression of these factors after focal brain injury or stroke  after infarction of the lateral cerebral cortex in the mature rat brain  we found a twofold to threefold increase during the first 3 weeks after stroke in levels of fibroblast growth factors in tissue surrounding infarcts  this increase persisted for at least 2 months and appeared mainly to be due to increased levels of basic  but not acidic  fibroblast growth factor  because of its gliotrophic  angiogenic  and neuronotrophic properties  basic fibroblast growth factor may play an important role in the cascade of cellular reactions that contributes to wound healing and functional recovery after stroke  
class10	genetics of cerebrovascular disease  stroke is a complex disease  with both genetic and environmental factors having a role in its pathogenesis  a review of past studies shows some evidence of genetic influences in the development of stroke  this is supported by studies of cardiovascular disease  which indicate major genetic influences at several levels including the development of risk factors  new approaches to phenotypic classifications  patient ascertainment  and genetic analysis will stimulate research into the role of genetics in cerebrovascular disease  
class10	molecular biology of atherothrombotic brain infarction  because reduced high density lipoproteins may contribute to atherothrombotic brain infarction  we performed molecular biologic and metabolic studies to characterize high density lipoprotein metabolism with respect to its role in reverse cholesterol transport  to clone the high density lipoprotein receptor  and to determine gene polymorphism for apolipoprotein a i  the major protein of high density lipoprotein  because altered structure may impair reverse cholesterol transport  for high density lipoprotein metabolism measurements  high density lipoprotein 3 was isolated  purified  and labeled with iodine 125  the radiolabeled high density lipoprotein 3 was reinjected  and daily blood samples were taken for 10 days  synthesis rates and fractional catabolic rates were determined from the specific activities and daily decrements  preliminary data indicate that stroke prone individuals  fractional catabolic rates for high density lipoprotein 3 are twice those of normal individuals  also  the conversion of high density lipoprotein 3 to high density lipoprotein 2 is reduced in these individuals  suggesting that high density lipoprotein may be abnormally processed in individuals prone to atherothrombic brain infarctions  we surveyed more than 100 patients with carotid stenosis using a 2 2 kb probe for the apolipoprotein a i gene  a subset of these patients displays polymorphism with restriction enzymes saci or psti  these preliminary findings suggest that gene polymorphism for apolipoprotein a i may provide a molecular clue of atherothrombic brain infarction  
class10	modification of stroke susceptibility by genotype dependent maternal influences  the influence of the prenatal and postnatal maternal environment on stroke susceptibility was evaluated by reciprocally crossing the spontaneously hypertensive  shr  and the dahl salt sensitive  ss jr  inbred rat strains to produce reciprocal f1 hybrids that were nurtured  respectively  during prenatal and postnatal life by shr or ss jr mothers  following placement on a high salt diet containing 8  nacl at 35 days of age  f1 rats reared by shr mothers had shorter survival times and were more likely to die with cerebral hemorrhage than f1s reared by ss jrs  across reciprocal f1 female groups  enhanced susceptibility to stroke was associated with greater elevations of systolic blood pressure  but this association was not seen across reciprocal f1 male groups  there was also an association between blood pressure and stroke within each f1 gender subgroup  rats eventually suffering strokes developed higher blood pressure after placement on the high salt diet than rats that did not suffer stroke  lower day 35 body weights  before exposure to the high salt diet  were associated with greater likelihood of stroke both across the reciprocal f1 groups  and within three of the four f1 gender subgroups  the differences in stroke susceptibility between the reciprocal f1 groupings may be due to systematic differences in the prenatal and or postnatal environments of shr and ss jr mothers and may be mediated by variations in the nutritive capacity of the two inbred mothers  
class10	pharmacology of recovery after stroke  laboratory research during the past decade has begun to provide insights into the neurobiologic basis of functional recovery after brain injury  it is clear that drugs influencing specific neurotransmitters also can influence the recovery process  some of these drugs may be beneficial  but others may be detrimental  some of the difficulties in interpreting the results of these behavioral studies are reviewed  and potential mechanisms of drug effects are discussed  these types of studies are leading to an increased awareness of the potentially harmful effects of some drugs often given to stroke patients  pharmacotherapy designed to enhance functional recovery after stroke may be possible in the future  
class10	multilevel transneuronal degeneration after brain damage  behavioral events and effects of anticonvulsant gamma aminobutyric acid related drugs  recent morphologic and behavioral studies of the effects of gamma aminobutyric acid agents on transsynaptic degeneration after cortical and striatal damage are reviewed and discussed  following unilateral lesions of the anteromedial cortex  mild atrophy appears in the ipsilateral striatum and substantia nigra pars reticulata  long term diazepam administration greatly enhances this degeneration  extends the degeneration into the thalamus  and severely disrupts recovery from somatosensory asymmetries  following unilateral excitotoxic lesions of the striatum  progressive degeneration of neurons occurs in the substantia nigra pars reticulata and efferent targets in the thalamus  this degeneration can be prevented by chronic infusion of muscimol  a gamma aminobutyric acid agonist  unexpectedly  this treatment did not facilitate recovery from somatosensory asymmetries  recovery in muscimol treated animals was impaired relative to saline treated controls  thus  gamma aminobutyric acid agonists either may enhance or prevent neural atrophy secondary to brain damage  but the behavioral outcome appears to depend importantly on the excitatory and inhibitory characteristics of the affected networks  
class10	influence of amphetamine treatment on somatosensory function of the normal and infarcted rat brain  the consequences of acute amphetamine administration on the metabolic responsiveness of the cerebral cortex to physiologic activation were studied in normal and infarcted rats  treated rats received a 4 mg kg intravenous injection of d amphetamine 1 hour before unilateral vibrissae stimulation and 2 deoxyglucose study  in nontreated normal rats  metabolic activation was restricted to the major relay stations of the vibrissae barrel circuit  in amphetamine treated rats  stimulation induced increased glucose utilization was widespread  including ipsilateral and contralateral cortical regions outside the barrel field circuit  for example  an 84  increase in glucose utilization above control was seen in cortical areas anterior to the barrel field region  increased glucose utilization induced by stimulation was severely depressed in nontreated rats that had undergone infarction of the left cortical barrel field 2 weeks previously  vibrissae stimulation failed to increase glucose utilization significantly in cortical areas remote from the infarct  in contrast  bilateral increases in glucose utilization were observed within cortical regions of treated infarcted rats  for example  a 50  increase in glucose utilization was detected in cortical areas bordering the infarct  thus  in the normal and infarcted rat  amphetamine appears to promote alternate circuit activation  a pharmacologic property that may be advantageous for recovery after injury  
class10	effects of mk 801 on recovery from sensorimotor cortex lesions  histologic evidence suggests that drugs acting as noncompetitive antagonists at the n methyl d aspartate receptor can have beneficial or pathologic effects on central nervous system neurons  in the present experiments we examined the effects of mk 801 on recovery of behavioral function after unilateral lesions in the rat somatic sensorimotor cortex  in the first experiment  rats with unilateral sensorimotor cortex lesions were given either mk 801  1 mg kg  or saline 12 16 hours after surgery  additional injections were given on postoperative days 2  4  and 6  behavioral tests measured somatosensory asymmetries  i e   bilateral tactile stimulation tests  and forelimb placing  after creation of sensorimotor cortex lesions  rats showed an ipsilateral somatosensory bias and an impairment in placing the contralateral forelimb  rats treated with mk 801 recovered slightly faster than saline treated animals as measured by a bilateral tactile stimulation test  p less than 0 05   in contrast  there was no significant difference between the groups in the recovery of forelimb placing  in a second experiment  rats with sensorimotor cortex lesions were treated with a single injection of mk 801 after behavioral recovery  twenty hours after the mk 801 injection  rats with sensorimotor cortex lesions showed a reinstatement of the placing deficits  the impairment endured for at least 7 days after injection  these behavioral data support the idea that mk 801 can have either beneficial or detrimental effects when administered after brain damage  
class10	ionic channels  cholinergic mechanisms  and recovery of sensorimotor function after neocortical infarcts in rats  unilateral photochemical infarcts were produced in the hind limb sensorimotor neocortex of 243 rats by intravenous injection of the fluorescein derivative rose bengal and focal illumination of the intact skull surface  facial contact stimuli governed the degree and recovery rate of contralateral tactile proprioceptive forelimb placing reactions  contralateral forelimb placing recovered  whereas hind limb placing was resistant to recovery  infarcted rats displayed marked recovery of spontaneous limb usage  beam traversing   however  deficits in isolated tactile proprioceptive hind limb placing reactions endured  posttreatment with the class iv calcium antagonist flunarizine after neocortical infarction protected sensorimotor function in a dose dependent manner  this protective effect may be due to the peculiar ionic channel blocking profile of flunarizine  scopolamine hydrobromide reinstated contralateral placing errors in infarcted rats at a dosage that did not affect neurologically intact rats  the cognitive enhancer sabeluzole  a novel benzothiazol derivative  dose dependently blocked the anticholinergic induced deterioration of a sensorimotor deficit in rats  
class10	magnetic resonance imaging demonstrates that electric stimulation of cerebellar fastigial nucleus reduces cerebral infarction in rats  we sought to determine whether high spatial resolution magnetic resonance imaging is useful for noninvasive quantitation of the ischemic infarct produced by occlusion of the middle cerebral artery and for detection of reduced infarct volume elicited by electric stimulation of the cerebellar fastigial nucleus  male rats of the spontaneously hypertensive strain were anesthetized  the middle cerebral artery was occluded  and the fastigial nucleus was stimulated for 1 hour  twenty four hours later  rats were reanesthetized and t1  and t2 weighted images were obtained  rats were killed and the volume and distribution of the lesion was established by histopathology  magnetic resonance imaging estimates of the lesion volume were 271     41 0 mm3  middle cerebral artery  n   5  and 148     8 4 mm3  middle cerebral artery   fastigial nucleus stimulation  n   6  45  reduction  p less than 0 05   histopathological analysis revealed a lesion of 229 8     15 4 mm3 involving somatosensory cortex  lateral caudate putamen  and lateral hippocampus  fastigial nucleus stimulation resulted in a 36  reduction in infarct volume to 146 0     10 3 mm3  the retrieved zone was largely in the cortex dorsal and ventral to the lesion and mostly posterior to the lesion  the estimates of lesion volume by magnetic resonance imaging and histopathology did not differ and were highly correlated  r   0 90  p less than 0 001   this study confirms our previous finding that fastigial nucleus stimulation reduces the volume of a focal ischemic infarct and demonstrates that magnetic resonance imaging not only accurately estimates the volume of the lesion but also can detect changes as small as 50 100 mm3  
class10	symptomatic carotid endarterectomy trials  the possible benefit of carotid endarterectomy in stroke prevention is being evaluated in three major clinical trials  to date  the european carotid surgery trial has randomized 2 200 patients  30  of whom have a carotid stenosis of greater than 70  appropriate to their symptoms  the north american symptomatic carotid endarterectomy trial has randomized 1 000 patients  of whom more than half have this severity of appropriate stenosis  quality control and the evaluation of outcome events in this trial is achieved by a three tier review  including review by medical and surgical adjudicators who are blinded to the treatment arm of each patient  baseline characteristics of the patients eligible but not randomized are similar to those of patients who have been randomized  two percent of the patients randomized to the surgical arm have declined surgery and crossed over to the medical arm  and 3  have elected surgery after randomization to the medical arm  both of these studies  as well as a veterans administration trial  are continuing to randomize patients  
class10	the pathophysiology of anoxic injury in central nervous system white matter  white matter of the mammalian brain is susceptible to anoxic injury  but little is known about the pathophysiology of this process  we studied the mechanisms of anoxic injury in white matter using the isolated rat optic nerve  a typical central nervous system white matter tract  optic nerve function  measured as the area under the compound action potential  rapidly failed when exposed to anoxia  postanoxic recovery was variable  depending on duration of the anoxic insult  after a standard 60 minute period of anoxia  the compound action potential recovered to 28 5  of control  irreversible anoxic injury was critically dependent on extracellular ca2   maintaining the tissue in zero  ca2   solution throughout the anoxic period resulted in 100  compound action potential recovery  increasing perfusate  ca2   during anoxia from zero to 4 mm resulted in progressively less recovery  anoxic damage to the optic nerve appears to depend on the gradual accumulation  over tens of minutes  of ca2  in a cytoplasmic compartment  the inorganic ca2  channel blockers mn2   1 mm   co2   1 mm   or la3   0 1 mm  had no effect on recovery of the compound action potential after anoxia  only mg2   10 mm  significantly improved recovery  treatment with the dihydropyridine ca2  channel blockers nifedipine  1 10 microm  or nimodipine  1 40 microm  also had no effect on recovery from anoxia  thus  ca2  influx during anoxia does not occur via conventional ca2  channels  preliminary evidence suggests that this ca2  influx may occur via other cation channels that are imperfectly selective for ca2  or via the na    ca2  exchanger  
class10	putative neuroexcitation in cerebral ischemia and brain injury  involvement of neuroexcitatory mechanisms in cerebral ischemia and brain injury was explored in experimental models of repetitive forebrain ischemia by temporary occlusion of carotid arteries in gerbils and cryogenic injury to the cerebral cortex in rats and gerbils  our observations in these models revealed a pattern of injury that involved some anatomic structures outside the areas of direct ischemic or traumatic insult  such foci of injury revealed conspicuously abnormal uptake of 45ca associated with slight or moderate neuronal alteration  whereas severely injured areas showed no 45ca uptake  electron microscopic observations revealed a characteristic presence of calcium in swollen dendrites  closely resembling pictures obtained in neuroexcitatory conditions such as epileptic seizures  abnormal uptake of 45ca was associated with apparent blood brain barrier changes characterized by intracytoplasmic uptake of extravasated albumin into the neurons  protein synthesis assayed by in vivo  3h leucine incorporation was reduced in regions showing calcium accumulation  our observations suggest that neuroexcitation may play an important role in development of secondary and chronic changes after ischemic or traumatic brain insults  
class10	platelet activating factor  a putative mediator in central nervous system injury  platelet activating factor  1 o hexadecyl 2 acetyl sn glycero 3 phosphorylcholine  is a potent lipid autacoid produced by many cell types  platelet activating factor is produced by cerebellar granule cells in culture and has been extracted from brain tissue  multiple platelet activating factor receptors have been demonstrated in brain tissue  activation of platelet activating factor receptors in transformed neuronal cell lines involved increases in intracellular calcium  platelet activating factor has potent actions on cerebral vessels and cerebral metabolism when administered in vivo  but may not have direct effects on brain microvessels  excessive platelet activating factor production in pathological states of the nervous system such as neurotrauma and stroke has been shown in only a few models  e g   spinal cord ischemia and reperfusion or focal repercussion brain injury   in multiple studies using highly specific and potent platelet activating factor antagonists  reversal or prevention of key consequences of brain injury such as hypoperfusion following ischemia  reperfusion and edema  inflammatory cell accumulation  neurologic motor deficits  and neuronal salvage were demonstrated  this review provides and analyzes evidence in support of the role that platelet activating factor might have in modulation of brain function and pathophysiological processes in brain ischemia and trauma  
class10	bacteremia in an ambulatory setting  improved outcome in children treated with antibiotics  we undertook a study of 414 bacteremic patients  167 with haemophilus influenzae and 247 with streptococcus pneumoniae bacteremia  to evaluate their clinical presentation  laboratory and clinical results  and subsequent outcomes  patients with h influenzae bacteremia were more likely to have soft tissue foci  poorer clinical appearance at presentation  and be at higher risk for subsequent serious focal infections  persistent bacteremia  and subsequent hospital admissions than patients with s pneumoniae  patients with h influenzae bacteremia had a 21 1 fold increase in risk of meningitis  95  confidence interval  ci  of 3 8 to 78 0  compared with those with s pneumoniae  the odds ratio for initial lumbar puncture was 5 25  95  ci  1 1 23 6    ambulatory patients treated with antibiotics at presentation were less likely to develop new serious soft tissue infections  persistent bacteremia  or to require subsequent hospital admissions than untreated patients  the effect of treatment was greater for patients with s pneumoniae than those with h influenzae  careful follow up and reevaluation of patients with presumptive bacteremia is essential because treated and untreated patients can still develop serious soft tissue infections  
class10	physical features of prader willi syndrome in neonates  a retrospective study of 16 patients was undertaken to identify physical features that may typify neonates with prader willi syndrome  several features known to be typical of prader willi syndrome in early infancy were confirmed  including hypotonia and genital hypoplasia  a number of features that have not previously been emphasized as characterizing prader willi syndrome were also identified  most notably abnormal cry and  in males  signs of genital hypoplasia but with an apparently normal phallus  other features included disproportionately large head circumference  disproportionately large anterior fontanelle  mild micrognathia  mild anomalies of the gingivae or alveolar ridges  and changes in the appearance of the skin  appreciation of these features may assist the pediatrician in recognizing the child with prader willi syndrome during the neonatal period  before the appearance of better known findings of later onset  such as obesity and acromicria  
class10	replication patterns of the fragile x in heterozygous carriers  analysis by a brdurd antibody method  the replication status of the fragile x chromosomes was studied in short term cultures of lymphocytes from six female heterozygous carriers  the fragile x was induced by adding 0 1 microm fluorodeoxyuridine during the last 24 h of culturing  the replication status of the x chromosomes was studied using a bromodeoxyuridine  brdurd  antibody method  brdurd was added  1  at a final concentration of 0 2 micrograms ml during the early s phase of chromosome replication  16 10 h before harvest    2  at 0 2 microgram ml during the late s phase  the last 6 h of culturing    3  at 20 micrograms ml during the early s phase  and  4  at 20 micrograms ml during the late s phase  brdurd that was incorporated into replicating chromosomes was detected by using a nuclease and brdurd monoclonal antibody  the frequency of the fragile x was reduced by brdurd treatment  the degree of reduction was more severe in the 20 micrograms ml than in the 0 2 microgram ml series and was more severe with late s than with early s treatment  of the early  and late replicating fragile x chromosomes  those which were actively replicating during a brdurd treatment were more reduced than the others  thus  the average rate of early and late s treatment with 0 2 microgram brdurd ml was assumed to be the closest reflection of the situation in vivo  there was no correlation between the average rate of the early replicating  active fragile x and the intelligence of the heterozygous carriers studied  
class10	serum aldolase isozyme levels in patients with cerebrovascular diseases  a subunit specific radioimmunoassay was developed for the quantification of human aldolase a  b  and c  the method used was a double antibody radioimmunoassay using radioiodinated purified aldolase a  b  or c subunits as the ligand  specific chicken antibodies to aldolase isozymes and rabbit antibodies to chicken igg  the iodogen method was used for iodination of the purified isozyme subunits in this study  human brain tissue contained similar concentrations of aldolase a and aldolase c  and a smaller amount of aldolase b  which was the main isozyme of liver tissue  levels of serum aldolase a were greater than 203 ng ml  the upper limit of normal  in six of 24 patients with cerebral infarction and in 11 of 31 patients with cerebral hemorrhage  nine of 24 patients with cerebral infarction and 16 of 31 patients with cerebral hemorrhage had serum aldolase c levels greater than 4 1 ng ml  the upper limit in normal sera  these data suggest that serum aldolase c may be a more specific and sensitive marker of cerebrovascular diseases than aldolase a  we also demonstrated that serial measurement of serum aldolase c in patients with cerebrovascular diseases might be useful in estimating prognosis  since serially increasing serum aldolase c levels during the course of these diseases were correlated with a high mortality rate  
class10	the  stuck twin  phenomenon  ultrasonographic findings  pregnancy outcome  and management with serial amniocenteses  thirteen consecutive twin pregnancies affected by the  stuck twin  phenomenon were reviewed to determine the potential benefit of serial amniocenteses  the fetal survival rate for the eight pregnancies that underwent serial amniocenteses was 69   11 of 16 fetuses   this is significantly improved compared with a fetal survival rate of 20  among the five preceding pregnancies managed without serial amniocenteses at the same institution  p   0 01   it is also markedly improved compared with a combined fetal survival rate of 16  among 48 previously reported pregnancies with the stuck twin phenomenon managed without serial amniocenteses  p less than 0 0001   survival correlated with the absence of concomitant pregnancy complications  i e   maternal hypertension or intractable labor  and with the absence of severe fetal structural abnormalities  procedural complications occurred in three of eight pregnancies  37 5   managed with serial amniocenteses and was attributed as a cause of fetal death in one case  two of 11 survivors  18   had complications after serial amniocenteses including brain infarction and renal tubular necrosis  serial amniocenteses may significantly improve the survival rate of twin gestations affected by the stuck twin phenomenon but may be associated with complications among survivors  
class10	pregnancy in a patient with treated wilson s disease  a case report  pregnancy should have a successful outcome in a patient with treated wilson s disease if complications are excluded before conception  chelating treatment must be maintained  although there is some concern about its teratogenicity  we describe the course of pregnancy in a patient followed up in our department  
class10	prenatal diagnosis of fetal intracranial calcifications  a case is presented wherein fetal intracranial calcifications as a result of intrauterine cytomegalovirus infection were visualized by computed tomography and magnetic resonance imaging at 36 weeks  gestation  diagnosis of in utero cytomegalovirus infection was made by isolation of the virus from amniotic fluid  no symptomatic abnormality has been noted in the neonatal period except periventricular calcifications  
class10	practical aspects of pulsatile gonadotropin releasing hormone administration  pulsatile administration of gonadotropin releasing hormone represents a major advance in the treatment of anovulation in women who fail to ovulate with clomiphene citrate and is an alternative for many women who currently receive human menopausal gonadotropin  four issues must be addressed before administering pulsatile gonadotropin releasing hormone   1  safety   2  efficacy   3  convenience  and  4  cost  each of these issues will be affected by the three major decisions a physician makes with gonadotropin releasing hormone therapy   1  patient selection   2  route of administration  and  3  dose of gonadotropin releasing hormone  the ideal candidate for gonadotropin releasing hormone therapy is a patient with an absence of endogenous pulsatile gonadotropin releasing hormone  as seen in hypothalamic amenorrhea  although women with polycystic ovarian disease can be treated with pulsatile gonadotropin releasing hormone  a decreased ovulation rate should be expected  the route of administration  intravenous or subcutaneous  and the degree of monitoring can be tailored by the physician to fit each patient s needs  pulsatile gonadotropin releasing hormone therapy is a safe  effective  convenient  and economical alternative to human menopausal gonadotropin for ovulation induction in women resistant to clomiphene  
class10	orbital intramuscular schwannoma  in an 8 year old girl with asymptomatic proptosis  computed tomographic scans showed a large medial orbital mass that contoured the globe anteriorly  bowed the optic nerve laterally  and extended posteriorly to the orbital apex  t1 weighted coronal magnetic resonance images showed the mass to be a diffusely enlarged medial rectus muscle  histopathologic examination of a medial rectus muscle biopsy specimen disclosed a multinodular  intramuscular schwannoma  separating and infiltrating normal skeletal muscle fibers  the intramuscular location and multinodular configuration of this tumor  together with its occurrence in a child  distinguish it from previous orbital schwannomas  
class10	south american blastomycosis  ophthalmic and oculomotor nerve lesions  a case of south american blastomycosis began with an oropharyngeal lesion which was followed by a granulomatous uveitis  the patient was treated with amphotericin b and showed a clinical regression  four months later  he developed a right 3rd cranial nerve palsy  aggravating the clinical aspect with a severe generalized involvement of the central nervous system and death  necropsy showed blastomycotic meningoencephalitis  
class10	attenuation of suxamethonium myalgias  effect of midazolam and vecuronium  we studied the incidence of fasciculations and postoperative myalgias in 100 female outpatients who had laparoscopy under thiopentone  n2o  isoflurane anaesthesia  four groups of 20 patients each were pretreated with saline  group 1   tubocurarine 0 05 mg kg  group 2   vecuronium 0 006 mg kg  group 3   or midazolam 0 025 mg kg  group 4   followed by suxamethonium 1 5 mg kg  group 5 received only vecuronium 0 1 mg kg as relaxant  no suxamethonium   fasciculations were graded  and postoperative myalgias rated on the first and third postoperative days  in groups 1 5 the incidence of fasciculations was 95  15  25  95 and 0   the incidence of myalgias on the first day after operation was 70  45  65  75 and 60   and on the third day after operation 20  5  20  20  and 5   respectively  we conclude that pretreatment with vecuronium  but not midazolam  decreases the incidence of fasciculations after suxamethonium  p less than 0 05  and that in this patient population  postoperative myalgias appear to be unrelated to the use of suxamethonium  
class10	spinal catheter anaesthesia for caesarean section in a patient with spina bifida  a patient with grossly deformed vertebral anatomy  scheduled for elective caesarean section  expressed her wish to stay fully awake during the procedure  epidural anaesthesia was considered to be impracticable  while dural puncture appeared possible only at thoracic level  spinal anaesthesia using a subarachnoid catheter placed at t7 8 was employed successfully  
class10	the woolley and roe case  a reassessment  in 1953  two patients  cecil roe and albert woolley  sued their anaesthetist for alleged negligence because they had developed painful spastic paraparesis after spinal anaesthesia  the court found that phenol  which was used to sterilise the outside of the ampoules of local anaesthetic  had percolated the glass through invisible cracks  contaminating the solution  but that the anaesthetist could not have been aware of this risk  the case was important  despite the fact that judgement was in favour of the anaesthetist  because of the fears that it generated over the incidence of paralysis after spinal anaesthesia  the  invisible crack  theory has been the subject of much scepticism  new information has been obtained  and the case re examined objectively  the most probable source of contamination  which led to paralysis in the two patients  and in a third who received spinal anaesthesia on the same day  has been identified  a similar explanation may lie behind a number of other episodes of paralysis associated with spinal anaesthesia  
class10	autonomic dysfunction and guillain barre syndrome  the use of esmolol in its management  a 17 year old girl with guillain barre syndrome and autonomic dysfunction was treated successfully with esmolol  esmolol may be an appropriate drug for the rapid assessment and control of tachyarrhythmias in critically ill patients  
class10	loss of consciousness after emergence from anaesthesia  a case of suspected micturition syncope  a case of postanaesthesia micturition syncope with respiratory arrest is described  if syncope occurs  the temporary myocardial ischaemia and cerebral hypoperfusion may increase anaesthetic risk in the marginally compensated patient  the loss of airway protection during the syncopal period is also a cause of concern  we recommend the use of an indwelling bladder catheter during any prolonged surgical procedure  
class10	an evaluation of a 30 gauge needle for spinal anaesthesia for caesarean section  a 30 gauge spinal needle was evaluated for caesarean section  using a combined epidural spinal technique  in 50 mothers  spinal anaesthesia failed in six mothers and was inadequate in another six  general anaesthesia was required on one occasion  a 25  overall failure rate suggests that a 30 gauge needle is not a practical proposition for routine clinical practice  
class10	intrathecal anaesthesia for day care surgery  a retrospective study of 160 cases using 25  and 26 gauge spinal needles  the records of 160 day care surgical patients who received intrathecal anaesthesia were reviewed  no major complications were recorded  the incidence of postspinal headache after puncture with a 25 gauge spinal needle was nearly four times more frequent compared to a 26 gauge needle  the occurrence of postspinal headache in patients over the age of 45 years was significantly less frequent  p less than 0 05  than in younger patients  intrathecal anaesthesia was acceptable to 91  of outpatients in this group  
class10	relief of injection pain in adults  emla cream for 5 minutes before venepuncture  the effectiveness of skin anaesthesia after 5 minutes  topical application of a lignocaine prilocaine cream was evaluated  one hundred and twenty patients estimated the pain of antecubital venepuncture both on a linear scale and verbally after use of the cream for either 5 or 60 minutes  a placebo cream or no treatment  reported pain was significantly less after only 5 minutes of the lignocaine prilocaine cream  p   0 002   the cream can be used to relieve the pain of all routine injections  
class10	resistance to atracurium induced neuromuscular blockade in patients with intractable seizure disorders treated with anticonvulsants  previous studies have demonstrated that  with the exception of atracurium  resistance to the neuromuscular blocking effects of various muscle relaxants develops in patients receiving anticonvulsant therapy  we studied the effects of 0 5 mg kg iv atracurium in 53 neurosurgical patients  21 nonepileptic patients receiving no anticonvulsant therapy  med   0   14 epileptic patients treated with carbamazepine for years  med   1   and 18 epileptic patients treated with carbamazepine plus either phenytoin or valproic acid for years  med   2   the evoked compound electromyogram of the adductor pollicis brevis was recorded  and results were analyzed using analysis of covariance  with weight and age as covariables  the onset time was not significantly different among the three groups  times for recovery of baseline and train of four responses to stimuli were significantly shorter in the med   1 and med   2 groups than in control patients  med   0   the recovery index  time between 25  and 75  recovery of baseline electromyogram values  was progressively shorter in the three groups  med   0  8 02 min  med   1  5 93 min  med   2  1 96 min  p less than 0 001   this study demonstrates that atracurium  when used on epileptic patients requiring long term  that is  years of  anticonvulsant therapy  has a shorter duration of action than when used in nonepileptic patients  
class10	infection during chronic epidural catheterization  diagnosis and treatment  a potentially serious complication of long term epidural catheterization in cancer patients is infection  the early signs of infection were studied in 350 patients in whom long term epidural catheters were inserted  three areas of the catheter track were found to be involved  exit site and superficial catheter track infection  and epidural space infection  the authors identified the early signs of infection in each area and the progress of the infection from the deep track to include the epidural space in four of these patients  all 19 patients who developed deep track or epidural infections were successfully treated with antibiotics and catheter removal  none of the patients required surgery for spinal cord decompression  catheters were replaced in 15 of the 19 treated patients who requested them after treatment with no recurrent infections  it was concluded that use of long term epidural catheterization is associated with a definable epidural infection rate  the use of epidural opioid analgesia is an effective and safe means of obtaining pain relief for terminally ill patients when patients are monitored for possible infection and receive prompt treatment when the diagnosis is established  
class10	differential effect of oncotic pressure on cerebral and extracerebral water content during cardiopulmonary bypass in rabbits  to study the effect of oncotic pressure on brain water content during cardiopulmonary bypass  cpb   14 anesthetized new zealand white rabbits underwent 60 min of nonpulsatile cpb at normothermia  animals were grouped according to the composition of the circuit priming fluid  group 1 animals  n   7  received a priming fluid  6 5  hydroxyethyl starch in 0 72 n nacl  323     13 mosm kg  mean     sd   that maintained normal colloid oncotic pressure  cop  during cpb  19 0     1 5 mmhg   group 2 animals  n   7  received a priming fluid  0 9 n nacl  324     23 mosm kg  that led to a hypooncotic state  cop   6 2     1 2 mmhg   blood chemistries and hemodynamics were recorded every 15 min during cpb  animals were given additional priming fluid and sodium bicarbonate during cpb to maintain a circuit flow of 85 ml kg 1 min 1 and arterial ph greater than 7 35  there were no significant differences between groups 1 and 2 with respect to temperature  central venous pressure  mean arterial pressure  pao2  paco2  plasma sodium concentration  or osmolality at any time during cpb  although osmolality increased in both groups  after 60 min of bypass  animals were killed and organ water contents were determined by wet dry weight ratios  a separate group of nine similarly prepared and anesthetized animals that did not undergo cannulation or cpb also underwent measurement of plasma chemistries and tissue water contents and served as nonbypass controls  group 3   brain and kidney water contents were unaffected by oncotic pressure  whereas duodenum and skeletal muscle had significantly greater water content  p   0 003 and p   0 008  respectively  after hypooncotic cpb  
class10	buffered versus plain lidocaine as a local anesthetic for simple laceration repair  study objective  buffered lidocaine was compared with plain lidocaine as a local anesthetic for simple lacerations  design  randomized  double blind  prospective clinical trial  setting  urban emergency department  type of participants  ninety one adult patients with simple linear lacerations were enrolled  patients with allergy to lidocaine and patients with an abnormal mental status were excluded  interventions  each wound edge was anesthetized with either plain or buffered lidocaine using a randomized  double blind protocol  the pain of infiltration was measured with a previously validated visual analog pain scale  measurements and main results  analysis of pooled data and paired data  using patients as their own controls  revealed that infiltrating buffered lidocaine was significantly less painful than plain lidocaine  p    03 and p    02  respectively   there was no significant difference in the anesthetic effectiveness of the two agents during suturing  conclusion  buffered lidocaine is preferable to plain lidocaine as a local anesthetic agent for the repair of simple lacerations  
class10	neurologic complications of cocaine abuse  the neurologic complications of cocaine toxicity are responsible for a major portion of the morbidity and mortality associated with cocaine  most of the complications appear to be related to the hyperadrenergic state induced by cocaine and may be treated symptomatically  diazepam is the most effective drug for cocaine induced seizures  
class10	occipital condyle fracture presenting as retropharyngeal hematoma  reported is the case of a 30 year old male motorcycle accident victim who was found on plain cervical spine radiography to have prevertebral soft tissue swelling  although subsequent computed tomography demonstrated no cervical spine fracture  it did reveal a fracture of one occipital condyle  the mechanism  diagnosis  and treatment of occipital condyle fractures are reviewed  as is the ligamentous and fascial anatomy of the cervicocranium  dissection of fracture hematoma inferiorly along vertically oriented tissue planes is hypothesized as the pathogenesis of our patient s retropharyngeal hematoma  in addition to being a sign of potential cervical spine injury  post traumatic prevertebral soft tissue swelling may also indicate occipital condyle fracture  to avoid overlooking such fractures  computed tomography undertaken to investigate upper cervical spine prevertebral soft tissue swelling should always include slices up to the level of the basal skull so as to visualize the condyles  
class10	erythromycin failure with subsequent pasteurella multocida meningitis and septic arthritis in a cat bite victim  we report the case of a 75 year old woman who developed pasteurella multocida meningitis and septic arthritis while being treated for a cat bite wound infection with erythromycin  review of the literature revealed that erythromycin has poor in vitro activity against this bacterium and has been associated with serious clinical failures  we recommend that erythromycin not be prescribed for empiric therapy of established animal bite infections  suggestions for optimal empiric therapy of animal bite infections and the differential diagnosis of severe cat bite associated sepsis are discussed  
class10	distinguishable types of dyspnea in patients with shortness of breath  dyspnea frequently accompanies a variety of cardiopulmonary abnormalities  although dyspnea is often considered a single sensation  alternatively it may encompass multiple sensations that are not well explained by a single physiologic mechanism  to investigate whether breathlessness experienced by patients represents more than one sensation  we studied 53 patients with one of the following seven conditions  pulmonary vascular disease  neuromuscular and chest wall disease  congestive heart failure  pregnancy  interstitial lung disease  asthma  and chronic obstructive pulmonary disease  patients were asked to choose descriptions of their sensation s  of breathlessness from a dyspnea questionnaire listing 19 descriptors  cluster analysis was used to identify natural groupings among the chosen descriptors  we found that patients could distinguish different sensations of breathlessness  in addition  we found an association between certain groups of descriptors and specific conditions producing dyspnea  these findings concur with those in an earlier study in normal volunteers in whom dyspnea was induced by various stimuli  we conclude that different types of dyspnea exist in patients with a variety of cardiopulmonary abnormalities  furthermore  different mechanisms may mediate these various sensations  
class10	carotid endarterectomy for elderly patients  predicting complications objective  to determine whether the complication or death rate from carotid endarterectomy can be predicted from hospital and physician structural variables  such as the hospital s teaching status or the number of endarterectomies done by the surgeon per year  design  survey of medical records  after controlling for the severity of the patient s condition on the basis of data in the medical record at the time of the endarterectomy  regression analyses were used to predict the postoperative stroke  heart attack  and 30 day death rate as a function of patient  physician  and hospital characteristics  setting  three geographic areas  states or large parts of states  average population  3 million  in the united states  patients  random sample of 1302 patients 65 years of age or older having carotid endarterectomy in 1981  intervention  carotid endarterectomy  measurements and main results  of 1302 patients  11 3  had a postoperative stroke or heart attack or died within 30 days of the operation  patient age  race  income  and gender  physician volume  board certification status  and age  and hospital size  for profit status  ownership  and teaching status were not significantly related to the postoperative complication or death rate  if the surgeon was a graduate of a foreign  but not a western european or canadian  medical school  however  the average complication or death rate rose from 10 4  to 19 6   p less than 0 05   conclusions  the effectiveness of carotid endarterectomy depends heavily on its complication rate  because complications after surgery cannot  in general  be predicted from structural variables  referring physicians cannot rely solely on the surgeon s experience and qualifications when recommending a carotid endarterectomy  the surgeon s and the hospital s actual postoperative complication and death rate should be considered  
class10	emergence of recreational drug abuse as a major risk factor for stroke in young adults objective  to investigate the clinical and epidemiologic relations between recreational drug abuse and stroke in young persons  design  a case control study based on medical records  setting  san francisco general hospital  a 400 bed municipal hospital  patients  consecutive sample of 214 patients aged 15 to 44 years  admitted between 1979 and 1988 with a diagnosis of ischemic or hemorrhagic stroke  an equal number of control patients admitted with diagnoses of status asthmaticus  acute appendicitis  or acute cholecystitis were matched to stroke patients by age  sex  and year of hospitalization  measurements and main results  seventy three patients with stroke  34   were drug abusers compared with 18  8   of the controls  in 47 patients with stroke  temporal proximity of drug administration  n   34  or infectious endocarditis  n   13  suggested a direct association between drug abuse and stroke  after controlling for other identifiable stroke risk factors  the estimated relative risk for stroke among drug abusers compared with that among non drug abusers was 6 5  95  ci  3 1 to 13 6   and this increased to 49 4  ci  6 4 to 379 0  for those patients whose symptoms began within 6 hours of drug administration  among patients less than 35 years of age  drug abuse was the most commonly identified potential predisposing condition  47    and it was the only condition with a significantly elevated relative risk for stroke  11 7  ci  3 2 to 42 5   further  a substantial rise in the proportion of drug related strokes was observed in the last 3 years of the study  31  in 1986 to 1988  compared with 15  in 1979 to 1985  p   0 008   cocaine  especially recently  was the drug used most frequently in drug related strokes  conclusion  in an urban population such as ours  recreational drug abuse appears to be a prominent and growing risk factor for strokes in young adults  
class10	improving outcomes of analgesic treatment  is education enough  frequent undertreatment of analgesic responsive acute pain and chronic cancer pain persists  despite intensive efforts to provide clinicians with information about analgesics  a set of background factors must be addressed in interventions to improve pain treatment  traditional patterns of clinician and patient interaction on the ward  quality assurance  and drug regulatory practices do not support prompt recognition and treatment of pain  possible interventions to modify these patterns of daily practice include monitoring and displaying patient pain ratings routinely  making available educational tools to assist optimal drug ordering  encouraging patients to communicate about unrelieved pain  reviewing quality assurance of pain treatment regimens  increasing behavioral research into analgesic prescribing  and selectively modifying narcotics regulatory practices  
class10	clarifying confusion  the confusion assessment method  a new method for detection of delirium objective  to develop and validate a new standardized confusion assessment method  cam  that enables nonpsychiatric clinicians to detect delirium quickly in high risk settings  design  prospective validation study  setting  conducted in general medicine wards and in an outpatient geriatric assessment center at yale university  site 1  and in general medicine wards at the university of chicago  site 2   patients  the study included 56 subjects  ranging in age from 65 to 98 years  at site 1  10 patients with and 20 without delirium participated  at site 2  16 patients with and 10 without delirium participated  measurements and main results  an expert panel developed the cam through a consensus building process  the cam instrument  which can be completed in less than 5 minutes  consists of nine operationalized criteria from the diagnostic and statistical manual of mental disorders  dsm iii r   an a priori hypothesis was established for the diagnostic value of four criteria  acute onset and fluctuating course  inattention  disorganized thinking  and altered level of consciousness  the cam algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion  at both sites  the diagnoses made by the cam were concurrently validated against the diagnoses made by psychiatrists  at sites 1 and 2 values for sensitivity were 100  and 94   respectively  values for specificity were 95  and 90   values for positive predictive accuracy were 91  and 94   and values for negative predictive accuracy were 100  and 90   the cam algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium  the cam was shown to have convergent agreement with four other mental status tests  including the mini mental state examination  the interobserver reliability of the cam was high  kappa   0 81   1 0   conclusions  the cam is sensitive  specific  reliable  and easy to use for identification of delirium  
class10	stroke in pediatric acquired immunodeficiency syndrome  in a 4 1 2 year period  4 of 68 children in a longitudinal study of neurological complications of human immunodeficiency virus  hiv  infection had clinical and or neuroradiological evidence of stroke  yielding a clinical incidence of stroke in this population of 1 3  per year  during this period  32 subjects died  and permission for autopsy was granted in 18 of the patients  including 3 of 4 who had clinical evidence of stroke  the prevalence of cerebrovascular pathological features in our consecutive autopsy series was higher than the clinical incidence  at autopsy cerebrovascular disease was documented in 6  24   of 25 children with hiv infection  including all 3 children who had clinical evidence of stroke  four patients had intracerebral hemorrhages  6 patients had nonhemorrhagic infarcts  and 3 had both  hemorrhage was catastrophic in 1 child and clinically silent in 3 children  all of whom had immune thrombocytopenia  one child had an arteriopathy that affected meningocerebral arteries  in another child  the arteries of the circle of willis were aneurysmally dilated  two children had coexisting cardiomyopathy and subacute necrotizing encephalomyelopathy with vascular proliferation  these results suggest that stroke should be considered when children with hiv infection develop focal neurological signs  
class10	myasthenic thymus and thymoma are selectively enriched in acetylcholine receptor reactive t cells  we compared t cell proliferative responses to acetylcholine receptor  achr  and to purified protein derivative  ppd   of tuberculin  of hyperplastic thymus  thymoma  and blood cells from patients with myasthenia gravis  mg   hyperplastic mg thymus cells gave significantly higher and more consistent responses to achr than parallel cultures of autologous blood cells  whereas responses to ppd showed an opposite trend  thus there was a preferential localization of achr reactive t cells in the hyperplastic mg thymus  furthermore  there was a strong correlation between blood and thymus cell responses to ppd  but not to achr   arguing that the hyperplastic mg thymus contains a sample of sensitized peripheral t cells  by contrast  both achr  and ppd responsive t cells were almost undetectable in thymus from nonmyasthenic patients  which is evidently much less receptive to circulating t cells  cells from mg thymomas showed the highest stimulations by achr but did not consistently react to ppd  however  the uninvolved thymus adjacent to these thymomas behaved almost identically to the hyperplastic samples described above  our interpretation is that achr specific t cells are initially sensitized in the mg thymoma but are selectively trapped in the hyperplastic thymus after being primed elsewhere  
class10	auras and subclinical seizures  characteristics and prognostic significance  the characteristics and prognostic significance of subclinical seizures and independent auras were studied in 40 patients with partial epilepsy who had long term electroencephalographic  eeg  monitoring with intracranial electrodes  focal  restricted subclinical seizures were noted in 23 patients  and 11 patients experienced auras that were accompanied by ictal eeg discharges  auras and subclinical seizures usually were identical in eeg appearance  but were distributed differently among patients  the subclinical seizures and auras usually had the same origin as complex partial seizures  but did not always reliably indicate complex partial seizure origin  subclinical seizures and auras were of favorable prognostic significance for patients undergoing temporal lobectomy  a majority  greater than 80   of individuals with subclinical seizures and auras were free of complex partial seizures after surgery  whereas a minority  29   of patients without subclinical seizures and auras became free of complex partial seizures  
class10	increased mepp frequency as an early sign of experimental immune mediated motoneuron disease  intracellular recordings of miniature end plate potentials were performed in extensor digitorum longus muscles from guinea pigs with experimental immune mediated motoneuron destruction  in the early stages of the disease  the miniature end plate potential frequency was elevated compared to that in control and normal animals  the amplitude and time course of the miniature end plate potentials as well as the resting potential of the muscle fibers were not altered  which implies integrity of the postjunctional membrane  the increase in frequency of miniature end plate potential reflects an increase of basal acetylcholine release and documents dysfunction of the presynaptic terminal of the neuromuscular junction  the increased frequency was associated with high levels of antimotoneuronal igg in the blood and the presence of igg at motor end plates  these data suggest that the presynaptic terminal of the neuromuscular junction may be involved in the immune attack in animal models of motoneuron degeneration  
class10	anoxic injury of mammalian central white matter  decreased susceptibility in myelin deficient optic nerve  the rat optic nerve  a typical central nervous system white matter tract  rapidly loses excitability when it is exposed to anoxia and is irreversibly damaged by prolonged anoxia  neonatal optic nerve is extremely resistant to anoxia induced dysfunction and injury  the adult pattern of response to anoxia appears between 10 and 20 days postnatal  that is  during the period of oligodendroglial proliferation and myelination  to test the hypothesis that myelination  or associated events  confer anoxic susceptibility on developing white matter  we analyzed the effects of anoxia on the myelin deficient  md  strain of rat  acutely isolated optic nerves from 19  to 21 day old md rats and control optic nerves from unaffected male littermates were maintained in vitro at 37 degrees c  and exposed to a standard 60 minute period of anoxia  the supramaximal compound action potential was recorded and amplitude of the compound action potential  expressed as   of amplitude before anoxic exposure  was determined  the compound action potential was nearly abolished within 3 to 6 minutes after onset of anoxia in control optic nerves  while optic nerves from md rats displayed a slower decrease in compound action potential amplitude during anoxia  with a distinct action potential present even after 60 minutes of anoxia  optic nerves from md rats showed significantly greater recovery of compound action potential  71     25   than did control optic nerves  33     21   p less than 0 02  after 60 minutes of anoxia  these findings support the hypothesis that myelination  or changes associated with it  may be important in the development of anoxic susceptibility in central white matter  
class10	substantia nigra  a site of action of muscle relaxant drugs  sites of action of centrally active muscle relaxant drugs are not well defined  clinical experience with such drugs suggests that the spinal cord may be one of the important regions from which pathologically increased muscle tone may be relieved  supraspinal centers that may also be involved in the expression of muscle relaxant action have not yet been defined  we report here that microinjections of therapeutically relevant muscle relaxants into the midbrain tegmentum of genetically spastic rats decrease muscle tone  the substantia nigra is the region from which midazolam  baclofen  and tizanidine  drugs used clinically in the treatment of spasticity   or gamma vinyl gaba      2 amino 7 phosphonoheptanoate  and  d pro2 d phe7 d trp9  substance p  experimental drugs active in animal models of spasticity   reduce muscle tone in genetically spastic rats and hoffmann reflexes in normal rats  the effects of muscle relaxant drugs are topographically restricted to the substantia nigra pars reticulata and are receptor specific  these observations disclose a previously unknown function of the substantia nigra in mediating muscle relaxation  
class10	polyneuropathy  ophthalmoplegia  leukoencephalopathy  and intestinal pseudo obstruction  polip syndrome  we describe 5 individuals  from three separate families  with a progressive neurological disorder characterized by sensorimotor peripheral polyneuropathy  cranial neuropathies  external ophthalmoplegia  deafness   and the syndrome of chronic intestinal pseudo obstruction  magnetic resonance imaging showed widespread abnormality of the cerebral and cerebellar white matter in the 2 patients studied  autopsy examination in 3 revealed widespread endoneurial fibrosis and demyelination in the peripheral nervous system  possibly secondary to axonal atrophy  and poorly defined changes in cerebral white matter  leukoencephalopathy   the cranial nerves and spinal roots were less severely involved and the neurons in the brainstem and spinal cord were intact  the fatal gastrointestinal dysmotility was due to a severe visceral neuropathy  we suggest that these patients manifested a hereditary disorder with distinctive clinical  radiological  and neuropathological features  and propose the acronym polip to emphasize the distinctive tetrad of polyneuropathy  ophthalmoplegia  leukoencephalopathy  and intestinal pseudo obstruction  
class10	major histocompatibility complex antigen expression in the affected tissues in amyotrophic lateral sclerosis  monoclonal antibody immunocytochemistry was used to examine spinal cord and muscle in amyotrophic lateral sclerosis for changes that would indicate ongoing or potential immune activity  increased expression of class i and ii major histocompatibility complex  mhc  antigens was seen in the affected areas of spinal cord  new mhc expression was concentrated in phagocytes  particularly in degenerating white matter in which they were dispersed in the tissue and also packed around blood vessels  mhc antigen was not revealed in motor neurons or skeletal muscle fibers  an anti pan t cell monoclonal revealed small numbers of t cells in degenerating white matter  similar changes have been seen in other neurodegenerative disorders  they suggest a potential for  secondary  cell mediated activity in the affected areas rather than an ongoing mhc restricted t cell response  vessel associated phagocytes may be a source of antigen to peripheral lymphoid tissue  stimulating production of the autoantibodies that have been described  
class10	igm deposits at nodes of ranvier in a patient with amyotrophic lateral sclerosis  anti gm1 antibodies  and multifocal motor conduction block  we studied a patient with amyotrophic lateral sclerosis  multifocal motor conduction block  and igm anti gm1 antibodies  a sural nerve biopsy demonstrated deposits of igm at nodes of ranvier by direct immunofluorescence  the deposits were granular and located in the nodal gap between adjacent myelin internodes  and in some instances  they extended along the surface of the paranodal myelin sheath  when injected into rat sciatic nerve  the serum igm bound to the nodes of ranvier  and the binding activity was removed by preincubation with gm1  these observations suggest that anti gm1 antibodies may have caused motor dysfunction by binding to the nodal and paranodal regions of peripheral nerve  
class10	spinal cord compression with paraplegia in xanthomatosis due to normocholesterolemic sitosterolemia  a 48 year old woman with a 30 year history of tendinous xanthomatosis developed paraplegia  the magnetic resonance image revealed extramedullary tumors  the analysis of her sera and tumors revealed increased amount of plant sterols  especially sitosterol  and the diagnosis of sitosterolemia was made  this is the first reported case of a patient with sitosterolemia who had the neurological complication of spinal cord compression due to extramedullary sitosterolemic xanthomas  
class10	ichthyosis  mental retardation  and asymptomatic spasticity  a new neurocutaneous syndrome with normal fatty alcohol nad  oxidoreductase activity  a number of inherited disorders of cornification have been related to abnormal lipid metabolism  in the recessively inherited sjogren larsson syndrome  defined by the triad of ichthyosis  mental retardation  and spasticity  fatty alcohol nad  oxidoreductase deficiency has recently been reported  these patients accumulate fatty alcohol in the plasma and cultured fibroblasts  a 19 year old woman with ichthyosis  mental retardation  and mild spasticity is described in whom fatty alcohol metabolism was normal  as determined by plasma octadecanol level and fibroblast fatty alcohol nad  oxidoreductase activity  ultrastructural studies on skin from the patient revealed morphologically abnormal epidermal lamellar bodies  not unlike those seen in neutral lipid storage disease with ichthyosis  we postulate that this patient has a novel neurocutaneous syndrome that may be secondary to abnormal lipid metabolism  
class10	ischaemic brain lesions diagnosed at birth in preterm infants  clinical events and developmental outcome  in 232 newborn babies of less than 32 weeks  gestational age ultrasound brain scans were carried out shortly after birth  daily for the first week of life  and at least twice weekly thereafter  periventricular echogenicity associated with or progressing to periventricular leukomalacia  ischaemic brain lesions  was present in nine babies within two hours of birth  early onset   30 other babies subsequently developed similar lesions  late onset   babies with early onset lesions were more likely to have a history of intrauterine growth retardation and to have recurrent apnoea in the first few hours after birth  by contrast  late onset lesions were associated with hyaline membrane disease  in later childhood four of six survivors with early onset periventricular leukomalacia  and seven of 14 survivors with late onset periventricular leukomalacia  had various disabilities including spastic diplegia  impaired vision  squints  sensorineural hearing loss  and developmental delay  in a third of the children with disabilities ischaemic brain lesions were noted within two hours of birth  raising the possibility that some of this damage had taken place before or during birth  
class10	area of lateral ventricles measured on cranial ultrasonography in preterm infants  association with outcome  the association between measurements of lateral ventricle area  determined by serial ultrasound scans  and outcome was studied in 70 preterm neonates of 33 weeks  gestation or less  the study group was subdivided into four groups according to cranial ultrasonographic findings at 2 weeks postnatal age  group a  n   15  had isolated periventricular intraventricular haemorrhage  group b  n   20  had periventricular intraventricular haemorrhage and dilated ventricles  group c  n   24  had periventricular intraventricular haemorrhage and periventricular leukomalacia with or without dilated ventricles  and group d  n   11  had isolated periventricular leukomalacia  eighty seven preterm infants with no evidence of intracranial disease and good neurodevelopmental outcomes at 2 years formed the control group  a poor outcome was observed in infants in group b  c  and d  particularly in those who had persistent dilated ventricles at 6 weeks postnatal age and extensive periventricular leukomalacia  there was no difference in outcome between group a and controls  during the first six weeks of life ventricular area growth velocities were significantly higher in groups b  c  d  compared with normal controls and group a  we suggest that persistent ventricular dilatation at this early stage carries a bad prognosis  which is the result of atrophy of the brain  
class10	skin conductance and arousal in the newborn  we measured skin conductance continuously from the sole of a foot in babies of different conceptional ages before  during  and for 10 minutes after a  heel prick  carried out for routine blood sampling  we studied 82 healthy babies whose gestational and postnatal ages ranged from 25 42 weeks  and 1 73 days  the median skin conductance level  preheel prick  in babies of 40 43 weeks  conceptional age was 0 6 micros  microsiemens  and differed significantly between awake babies  1 2 micros  and those who were asleep  0 5 micros   in contrast babies less than 40 weeks had a significantly lower median skin conductive level  0 3 micros  which was identical in awake and asleep babies  in response to the heel prick all babies became aroused and skin conductance rose sharply and immediately in 21 out of 22  95   babies 40 43 weeks  conceptional age  and in seven out of 23  30   babies 36 39 weeks  the median rise at one minute in babies of 40 43 weeks was significantly higher than those 36 39 weeks  2 7 micros compared with 0 5 micros   no babies less than 36 weeks had a change in their skin conductance after the heel prick  these results are consistent with the notion that  emotional sweating  is a function of maturity and does not develop until 36 weeks  conceptional age  
class10	the acutely affected abdomen in paraplegic spinal cord injury patients  the records of 145 paraplegic or quadriplegic patients were reviewed to identify those factors useful in the correct diagnosis of the acute abdomen in this population  twenty one patients had 22 episodes of acute or subacute abdominal problems  presenting complaints  physical findings  and laboratory results were useful in various ways  however appropriate radiographic studies led to the correct diagnosis in 77  of patients  although paraplegic and quadriplegic patients are predisposed to a distinct constellation of medical problems  including urinary tract infection and calculi  they also may present with other abdominal conditions that cause significant morbidity and mortality if not promptly recognized  
class10	does carotid restenosis predict an increased risk of late symptoms  stroke  or death  the identification of carotid restenosis as an unexpected late complication of carotid endarterectomy has prompted concerns regarding its importance as a source of new cerebral symptoms  stroke  and death  to investigate these concerns  we analyzed a consecutive series of 507 patients undergoing 566 carotid endarterectomies  each documented as technically satisfactory  post operative duplex doppler examination data at 3 days  1  3  6  12 months  and annually thereafter in 484 arteries  85 5   permitted classification of these arteries according to the most severe degree of postoperative stenosis  normal  n   306   1  to 19   n   89   20  to 50   n   40   more than 50   n   49  including 8 occluded   the incidence of more than 50  restenosis was 14 5  in female and 7 7  in male patients  p   0 003   life table analyses to 10 years revealed a significantly greater life expectancy among those with restenosis  p   0 05   stroke was also less likely in patients with restenosis  although this difference did not reach statistical significance  when survival and stroke were both endpoints  the likelihood of patients with more than 50  restenosis remaining alive and stroke free was also greater than the less than 20  stenotic group  p   0 03   thus patients with carotid restenosis were less likely than patients with normal postoperative scans to have late symptoms  stroke  or early death  
class10	choreoathetosis after deep hypothermia without circulatory arrest in 8 of 758 patients undergoing an intracardiac operation under cardiopulmonary bypass and hypothermia  choreoathetosis developed 3 to 7 days postoperatively  before the onset of choreoathetosis  varying degrees of neurological dysfunction were noted  electroencephalography and neuroimaging failed to detect any responsible functional or structural changes  six patients are alive 1 to 3 years postoperatively  and their condition is improving  two patients died of aspiration or sepsis  all patients were grouped based on factors identified as being possibly causative  depth of hypothermia  cooling time  flow rate  and repeated hypothermia  the incidence of choreoathetosis was significantly different in group a  rectal temperature greater than 25 degrees c  compared with group b  rectal temperature less than or equal to 25 degrees c   0 295 versus 8 463  p   0 02   based on cooling time  the incidence of choreoathetosis was significantly different in group b1  cooling time less than 1 hour  compared with group b2  cooling time greater than or equal to 1 hour   1 220 versus 7 243  p   0 05   based on flow rate during cooling  group b2 was further divided into the low flow group  less than 1 500 ml min 1 m 2  and the high flow group  greater than or equal to 1 500 ml min 1 m 2   although not significant  the incidence of choreoathetosis was higher in the high flow group  6 153 versus 1 90  p   0 22   in group b patients having reoperation  the incidence of choreoathetosis was higher than in patients operated on for the first time  5 54 versus 3 409  p less than or equal to 0 0001   
class10	vagal schwannoma  a patient with a benign encapsulated intrathoracic vagal schwannoma is presented and the literature is reviewed  the right paratracheal tumor was identified incidentally on a chest film and excised using a right thoracotomy  although rare  vagal schwannomas should be considered for any mediastinal mass along the vagus nerves especially when the paratracheal tumor produces minimal or no respiratory symptoms suggesting a slow growing  encapsulated process  
class10	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  
class10	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  
class10	syncope and presyncope associated with probable adverse drug reactions  the purpose of this study was to determine whether syncope and presyncope were associated with drug therapy in 70 patients referred to a tertiary care ambulatory clinic  drug use information was obtained  validated  and classified by its potential to cause syncope and presyncope  utilizing a standardized adverse drug reaction algorithm  nine  13   of the 70 patients were rated as having probable drug induced syncope and presyncope events  overall  12 medications were implicated  patients with probable adverse drug reactions were older  and taking more medications  or taking an antihypertensive  seven of the nine patients with probable adverse drug reactions were previously classified as having syncope of unknown origin after their initial clinic evaluation  syncope and presyncope are commonly associated with adverse drug reactions  especially in the elderly and those taking multiple medications  
class10	epidemiologic features of asymptomatic cerebral infarction in patients with nonvalvular atrial fibrillation  we performed unenhanced computed tomographic scans on 141 asymptomatic patients with nonvalvular atrial fibrillation  thirty six patients  26   had hypodense areas consistent with cerebral infarction  the majority of these were small deep infarcts  seen in 29 patients  21    but 13 patients  9   had cortical or large deep infarctions  twelve patients had more than one infarct on computed tomographic scan  increasing age and increased left atrial diameter were the only clinical features associated with asymptomatic infarction  patients older than 65 years with a left atrial diameter greater than 5 0 cm  n   23  had a 52  prevalence of asymptomatic infarction  patients younger than 65 years with a left atrial diameter less than 5 0 cm  n   38  had an 11  prevalence of silent infarction  patients with only one of these risk factors  n   72  had a 24  prevalence of silent infarction  infarction was more common in those with chronic  34   as opposed to intermittent  22   nonvalvular atrial fibrillation  but this difference was not significant  hypertension  diabetes  duration of atrial fibrillation  congestive heart failure  history of myocardial infarction  and echocardiographic evidence of left ventricular dysfunction were not associated with asymptomatic infarction  a history of hypertension was present in only 35  of our patients with small deep asymptomatic infarction  similar to the percentage in patients without stroke  asymptomatic cerebral infarction is common in nonvalvular atrial fibrillation  the association with enlarged left atria and the lack of correlation with major cerebrovascular risk factors suggests a cardioembolic mechanism  further study is needed to determine the functional and prognostic significance of these strokes  
class10	acute autonomic neuropathy  two cases and a clinical review  acute autonomic neuropathy is an uncommon syndrome  usually affecting healthy young people  presentation is often dramatic and initial misdiagnosis is common  we describe two young women with acute autonomic neuropathy who presented with gastrointestinal involvement heralding widespread dysautonomia and review 26 additional cases of acute autonomic neuropathy from the english language literature  acute autonomic neuropathy can be primarily cholinergic without orthostatic hypotension  26   or pandysautonomic  74   involving sympathetic adrenergic functions  onset has been temporally related to viral syndromes in 20  of cases  with autonomic deficits usually evolving over 1 to 3 weeks  gastroparesis  69   and syncope  12   are frequent presenting complaints  spinal fluid protein levels are often  75   elevated in pandysautonomic subtypes  prolonged and incomplete recovery is the rule  60    with persistent gastroparesis and orthostatic hypotension  other specific diseases that occasionally mimic acute autonomic neuropathy include botulism  porphyria  amyloidosis  and paracarcinomatous neuropathies  acute autonomic neuropathy shares several clinical features with acute idiopathic polyneuropathy  guillain barre syndrome   suggesting an immune mediated pathogenesis  
class10	recurrent meningitis in a patient with congenital deficiency of the c9 component of complement  first case of c9 deficiency in europe  we describe the first cases  to our knowledge  of c9 deficiency in europe that were detected in a swiss family  of which two members  one with a complete deficiency and the other with approximately half normal c9 levels  experienced bacterial meningitis  the index patient  a 56 year old white man with a history of purulent meningitis at the age of 23 years  presented with an acute meningococcal meningitis  no impairment of cellular immunity or immunoglobulin deficiency could be found  complement assays showed a complete deficiency of the c9 component  while the other individual component levels were normal and the hemolytic activity  measured using the ch50 assay  was only slightly reduced  a family study revealed complete c9 deficiency in the patient s healthy brother and half normal c9 concentrations in his sister  his son  who also had experienced an episode of bacterial meningitis   and his niece  consistent with an inherited c9 deficiency  this first case of recurrent meningitis in a white patient with complete c9 deficiency suggests that this complement defect may also be a risk factor for bacterial  especially neisserial  infections  
class10	gilles de la tourette syndrome is not linked to d2 dopamine receptor  gilles de la tourette syndrome has an important genetic component  the pathophysiology of this disorder may involve the dopamine system  we tested a d2 dopamine receptor  locus drd2  recognized by probe hd2g1  for genetic linkage with gilles de la tourette syndrome  using a genetic linkage map of the region of drd2 on the long arm of chromosome 11 and restriction fragment length polymorphism data from a total of four markers  drd2 itself  d11s84  d11s29  and pbgd   we were able to exclude linkage of this candidate gene and gilles de la tourette syndrome in two extended kindreds segregating for gilles de la tourette syndrome  this rules out causation of gilles de la tourette syndrome by mutation in drd2 in the kindreds studied under the genetic assumptions we employed  use of the map and multipoint linkage analyses also allowed us to exclude a gilles de la tourette syndrome susceptibility locus from a larger genetic region  
class10	quantitative evaluation of sway as an indicator of functional balance in post traumatic brain injury  the test of sway  using different conditions of stance with measurements of the average radial deviation of the center of pressure and its path length of sway per unit of time  has been shown to be a useful clinical tool in determining balance problems in traumatic brain injury  tbi  patients  normative values were established to determine if an individual patient s sway values fell within the normal range  mean     2sd   the tests have shown good test retest reliability for tbi patients  in addition  it has been shown that the sensitivity of the test is sufficient to identify changes in patients  performances as their clinical conditions change  it has been demonstrated that the different stance conditions of the battery of tests become progressively more difficult to perform  from comfortable stance  eyes open and eyes closed  through narrow stance  eyes open and eyes closed  to tandem stance with right or left foot forward  eyes open and eyes closed   by using these subtests  it is easy to distinguish between the performances of able bodied patients and tbi patients with very mild balance problems  the validity of the measure has been documented by correlating the sway performance with clinical functional performance tests  the test performance also correlates with the patient s own assessment of his or her gait difficulties  the limited data available suggest that the test of sway relates difficulties in static balance to the frequency of falls  finally  subtests permit identification of specific problems in maintaining balance as a basis for therapeutic intervention  
class10	asymptomatic ulnar neuropathy in carpal tunnel syndrome  quantitative assessment of the vibration threshold of the second and fifth fingertips at 125hz was performed on 28 affected limbs of 17 patients with carpal tunnel syndrome  cts  together with a median and ulnar sensory nerve conduction velocity  sncv  study  twenty six limbs of 26 age matched healthy subjects were used as controls  both the vibration threshold elevation of the second finger and the delay of median sncv were significant in cts patients as compared with controls  p less than  001   although the ulnar sncvs of all affected limbs were within the normal range  ten affected limbs  36   were found to have a concomitant vibration threshold elevation of the fifth finger  and eight of those limbs were found to be exposed to chronic occupational mechanical stimulation at the wrist  these findings appear to support the presence of subclinical traumatic damage to the ulnar nerve at the wrist  in summary  digital vibration measurement can elucidate subclinical ulnar neuropathy in cts which cannot be detected by sncv studies  
class10	postoperative complications in patients with disabling psychiatric illnesses or intellectual handicaps  a case controlled  retrospective analysis  the purpose of this study was to quantitate the operative risk and costs encountered in the surgical treatment of institutionalized patients  operative complications and duration of hospitalization for 200 institutionalized patients were compared with those in a control group of patients matched for age  sex  and type of operation drawn from the general hospital population  postoperative complications occurred in 53  26 5   of the patients in the study group compared with 15  7 5   of the patients in the control group  elective laparotomy was followed by a complication in 48  of institutionalized patients compared with 11 6  of matched controls  emergency celiotomy carried a 75  complication rate in the study group  atelectasis and pneumonia accounted for 50  of the postoperative complications and occurred with greatest frequency following intra abdominal procedures  the median hospital stay for all institutionalized patients was 3 days more than for matched controls  a strategy for postoperative treatment is presented  with particular emphasis on prevention of pulmonary complications  
class10	the influence of hyperglycemia and diabetes mellitus on immediate and 3 month morbidity and mortality after acute stroke  fasting serum glucose  glycosylated hemoglobin  and fructosamine concentrations were determined in 304 consecutive subjects admitted with acute stroke  within 48 hours of ictus  based on the medical history and these results  subjects were divided into known diabetics  newly diagnosed diabetics  subjects with stress hyperglycemia  and nondiabetics  the type of stroke was classified as lacunar infarct  cerebral infarct  or intracerebral hemorrhage  based on clinical examination by a neurologist and computed tomographic brain scan and or autopsy  immediate and 3 month outcomes were examined in relation to  1  fasting glucose  glycosylated hemoglobin  and fructosamine levels by stroke subtypes  and  2  glucose tolerance categories by stroke subtypes  a high fasting glucose level was associated with an increased mortality  but this was observed only among patients with intracerebral hemorrhage  patients with stress hyperglycemia  but not diabetics  had increased mortality  in spite of having similar glucose concentrations to those patients with stress hyperglycemia  diabetics did not have a worse outcome compared with nondiabetics  it is concluded that the association between glucose concentration and outcome is a reflection of stress relating to stroke severity  rather than a direct harmful effect of glucose on damaged neurons  
class10	screening for early dementia using memory complaints from patients and relatives  this study examined whether the subjective impression of memory function might differentiate healthy elderly subjects from patients with memory complaints  and whether memory complaints differed between patients with and without a dementing illness  both self assessment and relatives  responses on a new memory questionnaire differentiated patient groups from control subjects  the relatives  form measuring deterioration in memory function over time identified dementing individuals from those with non dementing causes for their memory complaints  factor analysis indicated that patients  memory complaints correlated with depression rather than objective memory performance  while relatives  ratings correlated with objective memory scores  not depression  stepwise discriminant function analyses showed that objective memory testing greatly improved specificity but not sensitivity of the subjective memory questionnaire alone  
class10	cerebrospinal fluid as a reflector of central cholinergic and amino acid neurotransmitter activity in cerebellar ataxia  cerebrospinal fluid  csf  amino acid neurotransmitters  related compounds  and their precursors  choline levels  and acetylcholinesterase activity were measured in the csf of patients with cerebellar ataxia during a randomized  double blind  crossover  placebo controlled clinical trial of physostigmine salicylate  the csf gamma aminobutyric acid  methionine  and choline levels  adjusted for age  were significantly lower in patients with cerebellar ataxia compared with controls  physostigmine selectively reduced the level of csf isoleucine and elevated the levels of phosphoethanolamine  no change occurred in csf acetylcholinesterase activity and in the levels of plasma amino compounds in patients with cerebellar ataxia when compared with controls  median ataxia scores did not statistically differ between placebo and physostigmine nor did functional improvement occur in any of the patients  
class10	asthma and eczema in children born to women with migraine  migraine and asthma have been reported to occur in the same person more commonly than would be expected if they are independent  the large collaborative perinatal project provided an opportunity to see if children born to women with migraine or with the group of disorders characterized by asthma and or allergies were more likely to manifest asthma or eczema in the first 7 years of life  among children whose mothers had neither migraine nor asthma allergies  3 2  had asthma  of children whose mothers had migraine  but not asthma allergies  more than 6  had asthma  the risk of asthma among children born to women who had both migraine and asthma allergies was greater than the risk associated with each maternal disease  the risk of eczema in children was not appreciably influenced by the mother s propensity to migraine or asthma allergies  the results of this first study of migraine in one generation and asthma in the next lead to the conclusion that the two disorders are probably related  
class10	temporoparietal cortex in aphasia  evidence from positron emission tomography  forty four aphasic patients were examined with  f18  fluorodeoxyglucose positron emission tomography in a resting state to determine whether consistent glucose metabolic abnormalities were present  ninety seven percent of subjects showed metabolic abnormalities in the angular gyrus  89  in the supramarginal gyrus  and 87  in the lateral and transverse superior temporal gyrus  pearson product moment correlations were calculated between regional metabolic measures and performance on the western aphasia battery  no significant correlations were found between the western aphasia battery scores and right hemisphere metabolic measures  most left hemisphere regions correlated with more than one score from the western aphasia battery  temporal but not frontal regions had significant correlations to the comprehension score  the left temporoparietal region was consistently affected in these subjects  suggesting that common features in the aphasias were caused by left temporoparietal dysfunction  while behavioral differences resulted from  1  the extent of temporoparietal changes  and  2  dysfunction elsewhere in the brain  particularly the left frontal and subcortical areas  
class10	nontropical pyomyositis as a cause of subacute  multifocal myalgia in the acquired immunodeficiency syndrome  we report a case of nontropical pyomyositis in a patient with acquired immunodeficiency syndrome and disseminated mycobacterium avium infection  in which severe myalgia was the presenting symptom over several weeks  multifocal muscle lesions were identified by gallium scanning and magnetic resonance imaging techniques  the epidemiology  possible pathogenesis  clinical features  diagnostic imaging  and therapy are reviewed  early suspicion of nontropical pyomyositis in severely immunocompromised patients with  cryptic  myalgia is recommended  
class10	neurodevelopmental outcome of children with evidence of periventricular leukomalacia on late mri  fifteen children  8 months of age or older  from a neonatal follow up program underwent magnetic resonance imaging and neurologic  cognitive  and language evaluations  magnetic resonance imaging findings in all children included increased white matter signal on t2 weighted images and ventricular enlargement adjacent to regions of abnormal white matter  the extent of degree of abnormal white matter signal and the degree of sulcal prominence were variable  twelve children had cerebral palsy  5 children  4 of whom had cerebral palsy  manifested significant sensory impairments  the median score on cognitive testing was 89  only 2 children exhibited severe to profound cognitive disability  cognitive scores were stable on retesting  the degree of motor disability was correlated with the extent of white matter signal abnormality  however  cognitive outcome was not related to the extent and degree of white matter signal abnormality or to the degree of sulcal prominence  despite the association of a major handicapping condition and periventricular leukomalacia  cognitive and language functioning may be relatively spared  
class10	rett syndrome  cerebellar pathology  the cerebellar pathology at autopsy of 5 patients with rett syndrome is described  the patients ranged in age from 7 30 years  all had markedly reduced brain weights with proportionately small cerebella  microscopic examination revealed loss of purkinje cells  atrophy  astrocytic gliosis of the molecular and granular cell layers  and gliosis and loss of myelin in the white matter  cortical atrophy occurred focally along the folia and was often more marked in the tips of the folia  the 2 oldest patients had been treated with phenytoin which may have contributed to the morphologic changes  atrophy and gliosis increased with age or in patients without phenytoin treatment  the youngest patient demonstrated only minor microscopic changes  in addition to the generalized alterations  1 patient had several adjacent folia with severe atrophy  the results indicate that cerebellar changes in rett syndrome consist of general hypoplasia with the addition of atrophy beginning in childhood and progressing over many years  
class10	recurrent lateral rectus palsy in childhood  five patients with recurrent  lateral rectus palsy in childhood  examined at the university of iowa hospitals over a period of 22 years  are reported  during the same period  131 abducens nerve palsy patients  younger than 18 years of age  were evaluated  eighteen similar patients  most single case reports  are reviewed from the literature  all reported patients  including our own  shared the following features  spontaneous recovery within 6 months in the majority of patients  ipsilateral recurrence  and painless palsy  there is female and left sided preponderance  etiology is undetermined  hypotheses include viral etiology  neurovascular compression by aberrant artery  and migraine  
class10	ultrasonography and magnetic resonance imaging in leigh disease  an infant with leigh disease  who was the younger sister of a similarly affected infant  had been examined before the onset of the disease  ultrasonography revealed hyperechoic lesions in the putamen and caudate nucleus during the preclinical stage  at onset  these changes extended into the cerebral cortex and medulla  these lesions were also detected by t2 weighted magnetic resonance imaging  mri  as areas of increased signal intensity  her brother demonstrated the same ultrasonographic results  cranial computed tomography disclosed low density areas in the basal ganglia which were detected as hyperechoic lesions by ultrasonography  these findings suggest that ultrasonography is useful in detecting early intracranial lesions in leigh disease  
class10	rett syndrome  findings suggesting axonopathy and mitochondrial abnormalities  we report the histopathologic findings of 3 sural nerve biopsies and 1 muscle biopsy from 3 patients with rett syndrome  the 3 sural nerve biopsies demonstrated a few ultrastructural abnormalities  including the presence of many pi granules and mitochondrial changes in the cytoplasm of schwann cells  occasional bands of bungner and onion bulb formations  and mitochondrial alterations in myelinated axons  morphometric analysis disclosed reduction in the number of large myelinated fibers with normal densities in comparison to those of an age matched normal control  light microscopic examination of the biopsied muscle from a 6 year old patient with rett syndrome revealed the existence of many small  dark  angulated fibers with nadh tr staining  ultrastructural investigation of the muscle confirmed the presence of the dumbbell shaped mitochondria  peripheral nerve involvement and the possibility of mitochondrial abnormalities in rett syndrome were suggested by the results  
class10	west syndrome associated with hyperlexia  two patients are reported with west syndrome associated with hyperlexia  they had peculiar linguistic and psychosocial development and autistic behavior  yet began to read japanese and chinese characters  numbers  roman alphabet letters  and trademark letters at 3 years of age  neuropsychologic  electroencephalographic  and radiologic studies were performed at 11 years of age in patient 1 and at 10 years of age in patient 2  although they were able to read fluently with correct intonation  their comprehension was significantly impaired  the neuropsychologic evaluation of both patients demonstrated selective  excellent ability in auditory memory in contrast to impairment of associational abilities  visual retention  and visual constructional abilities  these findings suggest that the functions in the nondominant hemisphere were also impaired  although children with west syndrome frequently have associated mental retardation  patients with west syndrome associated with hyperlexia have never been reported  a neuropsychologic investigation of epileptic children with mental retardation is necessary for the detection of hyperlexia  
class10	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  
class10	the use of obstetric analgesia in sweden 1983 1986 the use of obstetric analgesia was investigated in a swedish population based prospective study of 335 207 births  which represents almost all women who had vaginal deliveries in sweden between 1983 and 1986  lumbar epidural analgesia  eda  was used in 16   paracervical block  pcb  in 12   pethidine or morphine in 49  and pudendal block in 62   all four types of analgesia were much more commonly used by nulliparae than multiparae  variables such as maternal age  smoking  nationality  relationship with the infant s father and gestational age had only moderate influence on the rates of different types of analgesia  eda and pcb were more frequently used in larger than in smaller hospitals and in the daytime than at night  no such differences were found for pethidine or morphine  or pudendal block  which were administered routinely by midwives  
class10	choroid plexus cysts and chromosomal defects during a 4 year period  83 pregnant women with fetal choroid plexus cysts were investigated in our unit  abnormal karyotypes were found in 20 fetuses  including trisomy 18  n   16   trisomy 13  n   1   triploidy  n   1  and translocation down s syndrome  n   2   all fetuses with chromosomal defects had structural malformations in addition to the choroid plexus cysts  
class10	neurologic complications in chronic renal failure  a retrospective study  we have retrospectively examined 324 patients with chronic renal failure and evaluated the probable underlying causes of neurologic complications  laboratory data and therapeutic interventions  the common neurologic problems in our patients were alterations in consciousness  40 7   and convulsions  35 1    when bun concentration was above 135 mg dl and creatinine clearance was below 8 m min 1 73 m2  alteration of consciousness was observed and when bun concentration was 200 mg dl and creatinine clearance was below 7 m min 1 73 m2  abnormal convulsives appeared  changes in deep tendon reflexes and pathologic reflexes were associated with hypertension  all of the patients with cortical atrophy using computerized cranial tomography aluminum hydroxide at least for 18 months  and six of them had hemodialysis  fourteen patients who underwent dialysis developed convulsions and were thought to have disequilibrium syndrome  these findings are consistent with the suggestion that the metabolic and biochemical derangements associated with crf may be particularly detrimental to the still developing cns of the child  
class10	evaluation and treatment of mental disorders in patients with aids  mental symptoms are common in patients with aids  optimal management involves the identification and treatment of underlying mental disorders rather than symptomatic treatment alone  organic mental disorders are very frequent in aids  particularly with seriously ill patients who are medical inpatients  there is a high priori probability that such common symptoms as agitation  irritability  and insomnia will be caused by an organic mental disorder  psychopharmacology in the patient with aids requires considerable caution  lower doses and careful surveillance for subtle neuropsychiatric side effects are necessary  routine medical contact with a compassionate physician may be of inestimable value to the patient in coping with the fear and dread that surround the illness  
class10	schindler disease  the molecular lesion in the alpha n acetylgalactosaminidase gene that causes an infantile neuroaxonal dystrophy  schindler disease is a recently recognized infantile neuroaxonal dystrophy resulting from the deficient activity of the lysosomal hydrolase  alpha n acetylgalctosaminidase  alpha galnac   the recent isolation and expression of the full length cdna encoding alpha galnac facilitated the identification of the molecular lesions in the affected brothers from family d  the first cases described with this autosomal recessive disease  southern and northern hybridization analyses of dna and rna from the affected homozygotes revealed a grossly normal alpha galnac gene structure and normal transcript sizes and amounts  therefore  the alpha galnac transcript from an affected homozygote was reverse transcribed  amplified by the polymerase chain reaction  pcr   and sequenced  a single g to a transition at nucleotide 973 was detected in multiple subclones containing the pcr products  this point mutation resulted in a glutamic acid to lysine substitution in residue 325  e325k  of the alpha galnac polypeptide  the base substitution was confirmed by dot blot hybridization analyses of pcr amplified genomic dna from family members with allele specific oligonucleotides  furthermore  transient expression of an alpha galnac construct containing the e325k mutation resulted in the expression of an immunoreactive polypeptide which had no detectable alpha galnac activity  
class10	effect of normal msafp screening on maternal age for genetic amniocentesis  routine maternal serum alpha fetoprotein  msafp  screening for neural tube defects is considered by many to be standard obstetrical care  and recently many have encouraged this test to screen for trisomy 21  down s syndrome   we questioned whether  after a normal msafp screen  the risk of trisomy 21 decreases enough to warrant modifying the recommended age for genetic amniocentesis for down s syndrome  a logistic regression was developed which  using reported values for sensitivity and specificity for msafp detection of trisomy 21 and assuming a constant threshold risk in opting for amniocentesis  indicates that genetic amniocentesis for trisomy 21 may be deferred in some women who have a normal msafp screening  sensitivity analysis of varying thresholds for a normal msafp demonstrates that a 37 year old woman with a median msafp level has the same risk for trisomy 21 as an unscreened women who is 4 5 years younger  an abnormal msafp is useful in screening for neural tube defects and possibly for trisomy 21  a normal msafp may allow for delaying the potentially risky amniocentesis in otherwise low risk pregnancies  
class10	acupuncture and chronic pain  a criteria based meta analysis  a literature search revealed 51 controlled clinical studies on the effectiveness of acupuncture in chronic pain  these studies were reviewed using a list of 18 predefined methodological criteria  a maximum of 100 points for study design could be earned in four main categories   a  comparability of prognosis   b  adequate intervention   c  adequate effect measurement and  d  data presentation  the quality of even the better studies proved to be mediocre  no study earned more than 62  of the maximum score  the results from the better studies  greater than or equal to 50  of the maximum score  are highly contradictory  the efficacy of acupuncture in the treatment of chronic pain remains doubtful  
class10	the role of carotid screening before coronary artery bypass  five hundred thirty nine patients with no symptoms of cerebral ischemia undergoing coronary artery bypass were preoperatively evaluated for presence of carotid stenosis by noninvasive methods  duplex scanning and ocular pneumoplethysmography gee   overall prevalence of carotid stenosis greater than 75  was higher  8 7   than that generally reported  age greater than 60 years was significantly related to presence of carotid stenosis greater than 75   11 3  vs 3 8   p   0 003   risk factors such as hypercholesterolemia  hypertension  diabetes mellitus  and smoking were not predictive for carotid stenosis  postoperative stroke  or death  carotid stenosis greater than 75   odds ratio 9 87  p less than 0 005  and coronary artery bypass redo  odds ratio 5 26  p less than 0 05  were both independent predictors of stroke risk  patients were divided into four groups  group 1  minimal or mild degree of carotid stenosis  less than 50    not submitted to prophylactic carotid endarterectomy  432 patients  80 1    group 2  moderate degree of stenosis  50  to 75    no prophylactic carotid endarterectomy  60 patients  11 2    group 3  severe carotid stenosis   greater than 75    submitted to prophylactic carotid endarterectomy  19 patients  3 5    group 4  severe carotid stenosis  greater than 75   no prophylactic carotid endarterectomy  28 patients  5 2    patients in group 4 had significantly higher stroke rate  14 3   compared to the other three groups  1 1    p   0 0019   the finding of carotid stenosis greater than 75  in patients over 60 years of age was associated with occurrence of stroke in 15  of cases  carotid screening is helpful to determine patients at increased risk of stroke and should be performed in patients greater than 60 years  
class10	a single cholesterol measurement underestimates the risk of coronary heart disease  an empirical example from the lipid research clinics mortality follow up study  in prospective epidemiologic studies of coronary heart disease  a single measurement of cholesterol is made to assess its relationship to the risk of coronary disease  statistical theory states that if this measurement is subject to within individual variability  the strength of the relationship will be underestimated  this is empirically shown for the example of plasma cholesterol  for the lipid research clinics follow up study population  comprising 2170 white men over 30 years of age   the age adjusted coronary heart disease mortality regression coefficient increases from  453 to  496 if the average of two cholesterol measurements is used instead of a single measurement  since the correlation between the two repeated cholesterol measurements is  815  an increase in the regression coefficient up to  556 would be expected if the true cholesterol values were available  thus  epidemiologic studies have substantially underestimated the strength of the relationship between cholesterol levels and the risk of coronary disease by calculating the relationship on the basis of a single cholesterol determination  
class10	acute syphilitic posterior placoid chorioretinitis  six patients with evidence of secondary syphilis presented with visual loss in both eyes caused by large  placoid  yellowish lesions with faded centers at the level of the pigment epithelium in the macula and juxtapapillary areas  all eyes had vitreitis  all of the lesions showed a similar fluorescein angiographic pattern of early hypofluorescence and late staining  five patients had mucocutaneous lesions typical of secondary syphilis  all five patients treated with antibiotics had prompt improvement in visual function and resolution of the fundus lesions  the ophthalmoscopic and angiographic appearance of these posterior fundus lesions was sufficiently characteristic to suggest a diagnosis of secondary syphilis  modification of the host response to syphilis by human immune deficiency virus  hiv  infection may be partly responsible for this peculiar fundus picture  three of the four patients tested positive for hiv  
class10	repetitive strain injuries  how to deal with  the epidemic of the 1990s   occupational trends  especially the mushrooming of computer use in the united states  have brought with them a virtual epidemic of repetitive strain injury of the upper limb  what can you as a primary care physician do to stem the tide  in this article  the authors fill you in on treatment of the most common injuries as well as remark on the ramifications for business and industry  
class10	treating systemic fungal infections in aids patients  prolonging life against the odds  fungal infections have become one of the major causes of death among immunocompromised patients  particularly patients with aids  accurate and quick diagnosis is difficult  therefore  empirical therapy is often necessary  this scenario is complicated by the fact that most antifungal agents are toxic at the doses used or relatively ineffective against deep seated mycoses  because the population of aids patients is increasing  physicians will be faced more often with the management of systemic fungal infections  despite the current bleak prognosis for these patients  several new antigen detection tests are being developed and triazole agents are proving to be effective and less toxic than their predecessors  many cases of systemic mycoses do result in mortality  but appropriate treatment can both prolong life and improve its quality  
class10	rigid fixation of internal orbital fractures  when large portions of the internal orbit are destroyed  two to four walls   standard bone grafting techniques for immediate and late orbital reconstruction may not yield predictable eye position  critical bone support is most often deficient inferomedially  ct analysis of orbital volume in cases where eye position was unsatisfactory reveals that displacement of bone grafts is one mechanism of the unsatisfactory result  other mechanisms include undercorrection and bone graft resorption  in order to minimize postoperative bone graft displacement  titanium implants were used to span large defects in the internal orbit to provide a platform for bone graft support  twenty six implants were placed in immediate and 12 were placed in late orbital reconstructions  more reliable bone graft position resulted  two late infections have occurred resulting in implant removal in a 3 year period  
class10	early cerebral infarction  gadopentetate dimeglumine enhancement gadopentetate dimeglumine was administered prospectively to 50 patients who presented for magnetic resonance  mr  imaging within 2 weeks after a cortical cerebral infarction  twenty two patients  44   were imaged within 3 days after clinical ictus  abnormalities detected with gadopentetate dimeglumine enhancement were observed in 46  92   of 50 patients  classic parenchymal enhancement was a late finding  observed in all patients  17 of 17  imaged at 7 14 days after infarction  before this time  three additional phases of contrast material related abnormalities were observed  enhancement of vessels supplying the infarct   intravascular enhancement sign   was the earliest finding  seen in 17  77   of 22 infarcts aged 1 3 days  from day 2 to day 6  abnormal enhancement of meninges adjacent to the infarct was frequently noted   meningeal enhancement sign    finally  a transition phase that combined intravascular or meningeal enhancement with early parenchymal enhancement was seen from day 3 to day 6  gadopentetate dimeglumine enhanced mr imaging in early stroke reveals evidence of vascular engorgement and sluggish flow  which precede the development of classic parenchymal enhancement  
class10	embolization with particles in thoracic intramedullary arteriovenous malformations  long term angiographic and clinical results  to evaluate the long term results of endovascular treatment with particles in the management of thoracic intramedullary arteriovenous malformations  avms   the authors retrospectively reviewed the angiographic and clinical findings in 35 patients  follow up was 1 15 years  mean  6 years  in 28 patients and 6 10 months  mean  7 months  in seven  a total of 158 embolization procedures were performed in 35 patients  revascularization occurred frequently  necessitating multiple endovascular sessions  long term clinical evaluation showed clinical improvement  compared with the initial status before treatment  in 63  of the patients  clinical aggravation due to embolization was observed in seven patients  20   after 12 of the 158 endovascular sessions  8    these results are better than those reported after surgery and indicate that embolization with particles is an efficient and safe tool in the treatment of thoracic intramedullary avms  
class10	graves orbitopathy  correlation of ct and clinical findings  the clinical and high resolution computed tomographic  ct  findings in 71 patients  142 orbits  with graves orbitopathy and 20 healthy patients  40 orbits  were retrospectively reviewed  the orbits with orbitopathy were subgrouped at clinical examination into those with  n   18  and those without  n   124  optic neuropathy  mean extraocular muscle diameters and the calculated muscle diameter index were significantly increased in all orbits with ophthalmopathy  particularly in those with optic neuropathy  graves orbitopathy affected the superior muscle group  63 4   more than the medial  61 3   or inferior  57   recti  the most common pattern of muscle involvement involved all five measured extraocular muscles  solitary muscle involvement most frequently involved the superior muscle group  6 3    significant enlargements of the retrobulbar optic nerve sheath and superior ophthalmic vein were noted only in orbits with optic neuropathy  anterior displacement of the lacrimal gland at ct correlated with clinical palpability and occurred more frequently in patients with optic neuropathy  severe apical crowding was the most sensitive indication of optic neuropathy at ct  
class10	neuromuscular diseases  evaluation with high frequency sonography  forty four patients with clinically suspected neuromuscular disease and 12 healthy volunteers underwent high frequency ultrasound examination of the rectus femoris  vastus medialis  vastus lateralis  and biceps brachii muscles  and the number of perimysial septa was determined  these numbers and muscle soft tissue ratios of the lower extremity were compared  findings were correlated with results of muscle biopsy in all patients with suspected disease  using the number of perimysial septa in the lower extremity  the authors found significant differences between the muscles of healthy volunteers and those of patients with duchenne muscular dystrophies  other muscular dystrophies  and spinal muscular atrophies  the receiver operating characteristic curve showed that an average of 12 perimysial septa within 1 cm of muscle is the ideal cutoff value to differentiate subjects without morphologic changes from those with pathologic findings  the authors conclude that this measurement is useful for differentiation of neuromuscular diseases and may be a noninvasive  reproducible means with which to evaluate disease progression  
class10	emergency portosystemic shunt in patients with variceal bleeding  thirty five patients for whom emergency sclerotherapy or conservative treatment  or both  failed to arrest variceal bleeding  or who had early rebleeding and required emergency portosystemic shunts  epss  were studied  epss permanently controlled the variceal bleeding in all but one patient  in this patient  the shunt was patent as demonstrated by angiography  esophageal varices disappeared in 18 patients and were reduced in 14  three patients died before the endoscopic examination could be performed  the causes of death were hepatic failure in two and bleeding ulcerations of the gastric fundus in the other patient  one patient was classified in child s category b and two in child s category c  thirty two patients submitted to epss and were discharged alive  twelve of these patients subsequently died  at an average of 11 2 months after undergoing the shunt procedure  four of 12 patients died of hepatic failure  two patients died of hepatomas  two  other neoplasia  three  hemorrhaging duodenal ulcers  and one patient  renal failure  analysis of actuarial survival rates showed that the five year survival rate was 43 per cent  the long term survival rates were fewer for patients with child s category c than for those with combined child s categories a and b  five year survival rates were 21 versus 55 per cent  p less than 0 05   during the follow up period  none of the patients had variceal bleeding  chronic encephalopathy developed in six  which was mild in three  moderate in one instance and severe in two  it developed soon after epss  with onset in the first month after discharge in three  thus  when conservative treatment fails to arrest variceal bleeding  epss should be performed to guarantee definitive control of hemorrhage and prolong the survival period  
class10	vancomycin pharmacokinetics in hydrocephalic shunt prophylaxis and relationship to ventricular volume  vancomycin pharmacokinetics were determined in 25 patients receiving ventriculoperitoneal shunts for hydrocephalus  computed tomography scan derived ventricular brain ratio as an expression of hydrocephalus varied between 9 3  and 15 4   12 9      1 7    one hour prior to surgery each patient received 1 g of vancomycin infused intravenously over 60 minutes  samples of cerebrospinal fluid and venous blood were obtained 1 hour later and vancomycin levels assayed by fluorescence polarization immunoassay  there were 11 females and 14 males  with a mean age of 44 5     10 3 years and a mean weight of 72 0     11 4 kg  all had normal renal function  levels of vancomycin in the cerebrospinal fluid at 1 hour ranged from 0 1 to 1 5 micrograms ml  0 9     0 3   weight did not affect these values  p greater than 0 1   simultaneous blood vancomycin levels varied between 9 1 and 38 7 micrograms ml  22 3     8 3   ventricular volume  expressed as the ventricular brain ratio  did not correlate with cerebrospinal fluid vancomycin levels  p greater than 0 5   there was no significant increase in concentrations of vancomycin in csf as cerebrospinal fluid protein concentration increased  nor when blood vancomycin concentration was greater than 20 mg dl  therapeutic range   p greater than 0 1   no patient had evidence of infection at 6 months follow up  these results indicate minimal cerebrospinal fluid penetrance of vancomycin when administered systemically 1 hour prior to shunt surgery  in addition concentrations of vancomycin in cerebrospinal fluid bear no relationship to weight  ventricular volume  meningeal inflammation  or blood levels in the therapeutic range  the minimum inhibitory concentration of vancomycin for staphylococci is 1 5 to 3 1  and as bactericidal levels of 5 to 8 minimum inhibitory concentration are needed to kill organisms  a combination of both systemic and intraventricular vancomycin may be needed to ensure adequate cerebrospinal fluid and tissue concentration of antibiotic during shunt prophylaxis  
class10	cerebral blood flow velocities in the anterior cerebral arteries and basilar artery in hydrocephalus before and after treatment  we studied pourcelot s index  pi   which shows cerebral vascular resistance  in the anterior cerebral arteries and basilar artery  and the pi ratio  pourcelot s index in the anterior cerebral artery pourcelot s index in the basilar artery  in 11 measurements of hydrocephalus  the mean values of pi in the anterior cerebral artery  basilar artery  and the pi ratio before treatment were significantly higher than those after treatment and those in normal infants  before treatment  the mean pi in the anterior cerebral arteries was significantly higher than the mean pi in the basilar artery  all pi ratios increased to 1 00 or more  after treatment and in normal infants  the mean pi in the anterior cerebral arteries was significantly lower than the mean pi in the basilar artery  all pi ratios decreased to less than 1 00  we believe that the pi ratio is useful to evaluate the need or effect of treatment in hydrocephalus  
class10	brain stem tuberculoma in adult patients  diagnosis and treatment  a consecutive series of six adult patients ranging in age from 29 to 53 years is presented  the clinical and radiological features in each patient are described  attention is drawn to the features demonstrated on computed axial tomography  in only one patient  the first encountered  was surgical excision undertaken and histological verification obtained  one patient died before any form of treatment could be instituted  the remaining four patients were treated with antituberculous chemotherapy alone and their progress monitored by sequential computed tomography  the excellent response and good outcome in this conservatively treated group are documented  
class10	cerebral hemodynamics in patients with normal pressure hydrocephalus  correlation between cerebral circulation time and dementia  regional cerebral blood flow and regional cerebral circulation time were measured in 13 demented patients with chronic hydrocephalus  mostly normal pressure hydrocephalus  the average hemispheric  frontal  and temporal cerebral blood flows were significantly reduced  the average regional cerebral circulation time values were significantly prolonged in the frontal  temporal  and thalamic regions  most markedly in the frontal white matter  where periventricular lucency was observed on computed tomography  clinical improvement was obtained in all patients after operation  while postoperative regional cerebral blood flow values did not change compared with preoperative ones  postoperative regional cerebral circulation time values were significantly reduced in all the regions measured  and most markedly in the frontal white matter  the present results suggest that microcirculation in the frontal lobe is closely correlated with dementia in association with pressure exerted on the nerve fibers in the frontal white matter in patients with normal pressure hydrocephalus  
class10	aqueductal  pencil  glioma presenting as neurogenic pulmonary edema  a case report  a case of neurogenic pulmonary edema due to hydrocephalus  without initial neurological deficit  is described  computed tomography demonstrated a ring enhancing lesion in the tectum of the mesencephalon obstructing the aqueduct of sylvius  the lesion  on autopsy  was a rare mesencephalic glioma described in the literature as a  pencil glioma  of the aqueduct  
class10	metoprolol for aggressive behavior in persons with mental retardation  persons with mental retardation sometimes exhibit behaviors that are difficult to control  use of neuroleptic medications may be limited by side effects or ineffectiveness  beta blockers such as propranolol and metoprolol have been shown to decrease aggressive and impulsive behaviors in some patients with mental retardation  
class10	concomitant neurocysticercosis and brucellosis  a young mexican woman had headache and left arm weakness develop shortly after immigrating to the united states  a solitary cerebral cysticercus was found at surgery  but  instead of the expected finding of clear fluid  the cyst contained pus from which brucella melitensis was cultured  although the patient had no signs or symptoms suggestive of brucellosis  agglutination studies revealed igm and igg antibodies consistent with active brucellosis  clinicians should be alert to the possibility of multiple infections in immigrants from countries where parasites and bacteria that are uncommon in the united states are endemic  
class10	the deja vu experience  remembrance of things past  the deja vu experience is a common phenomenon  occurring in pathological as well as nonpathological conditions  it has been defined as any subjectively inappropriate impression of familiarity of a present experience with an undefined past  the authors discuss the epidemiologic data  clinical features  and etiology of the phenomenon of deja vu  they also review the different hypotheses on the psychopathogenesis of the deja vu experience and introduce an explanation based on the hologram as a mnestic model  
class10	brainstem auditory evoked response and subcortical abnormalities in autism  previous studies of the neurobiology of autism that have used the brainstem auditory evoked response have given contradictory results  the authors of this study considered two supplementary aspects  they added an ipsilateral masking procedure  and they compared the results for every subject to the values  corrected for age and sex  of a large number of normal children  twenty autistic  according to dsm iii r criteria  and 13 mentally retarded  nonverbal iq less than 75  subjects were assessed  eighty percent of the autistic subjects had abnormal interpeak latencies  compared to 15  of the mentally retarded subjects  the i v and iii v prolonged interpeak latency values were seen only in the autistic subjects  the ipsilateral masking procedure doubled the rate of detection of higher brainstem abnormalities in the autistic children  
class10	the ucla university of utah epidemiologic survey of autism  the etiologic role of rare diseases  twelve rare diseases known to cause cns pathology were found in 26  11   of 233 autistic probands identified during a recent epidemiologic survey of utah  these 26 probands had significantly lower mean iqs than the remaining patients  43 versus 60  but similar sex distribution and prevalence of abnormal eegs and seizures  the rarity and diversity of these 12 diseases make it highly unlikely that they randomly occurred with autism  their presence in this epidemiologic survey is the most compelling evidence to date to support the hypothesis that different diseases producing different types of cns pathology can play an etiologic role in autism  
class10	pharmacologic treatment of noncognitive behavioral disturbances in elderly demented patients  fifty nine elderly residents of long term care facilities who had dsm iii diagnoses of dementia were studied in an 8 week randomized  double blind comparison trial of haloperidol  oxazepam  and diphenhydramine to test the efficacy of these agents in the treatment of clinically significant behavioral disturbances in patients with dementia  all three agents demonstrated modest but significant efficacy as measured by clinician ratings of agitated behavior and activities of daily living  the absolute magnitude of improvement was greater for haloperidol and diphenhydramine than for oxazepam  but differences among groups did not approach statistical significance  frequencies of acute adverse events during the trial were similar across the drug treatment groups  although these drugs may differ in terms of long term safety and efficacy  they appear to be equivalent for short term management of agitated behavior in severely demented patients  
class10	steroid anabolic drugs and arterial complications in an athlete  a case history  serious side effects and complications have been attributed to anabolic and androgenic steroids when used for medical reasons or when taken in sports in hopes of increasing strength and  hence  performance  the author presents a case of an athlete who experienced two metachronous arterial complications after taking these drugs  a cerebrovascular accident caused by a carotid artery thrombus that partially embolized to the brain and  later  a severe ischemic episode in a lower limb caused by a diffused distal arterial thrombosis  this patient represents the first reported case of vascular events in an otherwise healthy athlete taking androgens to increase his skeletal muscle mass  
class10	type i hypersensitivity to rubber  seven patients with type i hypersensitivity reactions to rubber are reported  radioallergosorbent testing with crude latex antigen was positive in 6 7 patients  five patients had coexisting spina bifida  and all had undergone surgery before the development of rubber allergy  rubber allergy is a new phenomenon that should be in the differential diagnosis of idiopathic anaphylaxis and urticaria  
class10	cystocerebral syndrome  acute urinary retention presenting as confusion in elderly patients  the diagnosis of acute mental status changes in the elderly patient is often very difficult  many causes are possible  and there is often little history obtainable  the physical examination occasionally provides the essential clues needed to discover the source of the sudden deterioration  we have recently evaluated four episodes of acute delirium in three elderly patients who presented with no readily apparent cause for these changes  on further evaluation  the patients were found to have marked bladder distention associated with acute urinary retention  none of these patients complained of discomfort  and none had any awareness or recollection of their deterioration  each patient had rapid resolution of symptoms on bladder decompression  to our knowledge  this  cystocerebral syndrome  has not been previously described  and we suggest that it be considered in the evaluation of acute confusional states in elderly men  
class10	rapid eye movement sleep deprivation as a probe in elderly subjects  the effects of a 2 night rapid eye movement  rem  sleep deprivation  rsd  procedure on electroencephalographic sleep and mood were examined in 15 healthy elderly control subjects  14 elderly patients with endogenous depression  and 15 patients with primary degenerative dementia  compared with control subjects  both patient groups maintained a higher amount of rem sleep time and rem activity during rsd  unexpectedly  depressed patients showed little rebound in visually scored or automated rem sleep measures following rsd  and they showed stability of rem activity temporal distribution from baseline to recovery conditions  this contrasted with the rebound in rem sleep activity seen in control subjects  and the more modest increase in demented patients  the rsd was fairly specific  with some impact on delta sleep during the procedure but not during recovery sleep  mood ratings were unaffected by rsd  these findings demonstrated a greater plasticity of rem sleep regulation in the healthy elderly control subjects and suggested a higher rem  pressure  with a  ceiling effect  in depressed patients  patients with dementia appeared to have an impaired capacity to respond to the challenge of rsd  
class10	altered waveform of plasma nocturnal melatonin secretion in premenstrual depression  the nocturnal secretion of plasma melatonin was determined under dim to dark conditions in eight patients with prospectively confirmed premenstrual syndrome and in eight age  and menstrual cycle phase matched normal control subjects  plasma samples for melatonin were collected every 30 minutes from 6 pm to 9 am during the early follicular  late follicular  midluteal and late luteal phases of the menstrual cycle  compared with normal controls  patients with premenstrual syndrome had an earlier  phase advanced  offset of melatonin secretion  which contributed to a shorter secretion duration and a decreased area under the curve  no statistically significant differences were found between women with premenstrual syndrome and normal controls for melatonin onset or peak concentration  or for estradiol or progesterone levels  the data demonstrate that women with premenstrual syndrome have chronobiological abnormalities of melatonin secretion  the fact that these patients respond to treatments that affect circadian physiology  such as sleep deprivation and phototherapy  suggests that circadian abnormalities may contribute to the pathogenesis of premenstrual syndrome  
class10	a study of immunoglobulin g in the cerebrospinal fluid of 1007 patients with suspected neurological disease using isoelectric focusing and the log igg index  a comparison and diagnostic applications  cerebrospinal fluid and serum immunoglobulin g from 1007 patients with suspected neurological disease were analysed by 2 methods  isoelectric focusing for the detection of oligoclonal banding  and quantitative measurement of igg and albumin for the formulation of a log igg index  a comparison of the 2 methods in the detection of local synthesis of igg showed that isoelectric focusing not only gave a much higher yield overall  with 282 patients showing local synthesis versus 225 for the log igg index  but also a higher specificity  with a false positive rate of 0  versus 3 5   in addition  of the 282 patients positive by isoelectric focusing only 163  58   were positive by the log igg index  of the 1007 patients studied  206 had multiple sclerosis  ms   and isoelectric focusing showed local synthesis in 95  of clinically definite cases  with a 90  detection rate overall  the log igg index was positive in only 67  of clinically definite cases  with an overall 59  detection rate  thus with the exceptions noted above  local synthesis of igg as defined by isoelectric focusing is confined to demyelinating  inflammatory  infectious and postinfectious disorders  our results compare very favourably with the published sensitivities of magnetic resonance imaging in the detection of abnormalities in multiple sclerosis  and better than those for evoked potentials  where both these investigations are readily available isoelectric focusing provides a useful adjunct  for the majority of physicians and neurologists who do not have ready access to magnetic resonance imaging  isoelectric focusing is an excellent alternative  we would also recommend that it become the standard for the measurement of igg abnormalities in the cerebrospinal fluid and that the use of quantitative data be abandoned for routine purposes  
class10	congenital myasthenia associated with facial malformations in iraqi and iranian jews  a new genetic syndrome  fourteen jewish patients from 10 families of either iraqi or iranian origin with congenital myasthenia had associated facial malformations which included an elongated face  mandibular prognathism with class iii malocclusion and a high arched palate  other common features were muscle weakness restricted predominantly to ptosis  weakness of facial and masticatory muscles  and fatigable speech  mild and nonprogressive course  response to cholinesterase inhibitors  absence of antibodies to acetylcholine receptor  decremental response on repetitive stimulation at 3 hz but no repetitive compound muscle action potential in response to a single nerve stimulus  this newly recognized form of congenital myasthenia with distinctive ethnic clustering and associated facial malformations is transmitted as an autosomal recessive disorder  the facial abnormalities may be secondary to the neuromuscular defect or may be primary and unrelated  further studies are needed to elucidate the defect in neuromuscular transmission responsible for the pathogenesis of this syndrome  
class10	myelopathy associated with human t cell lymphotropic virus type i  htlv i  in natal  south africa  a clinical and investigative study in 24 patients  unexplained spastic myelopathy in black  zulu  patients  similar to that seen in the tropics  has previously been described from natal  south africa  following reports linking the human t cell lymphotropic virus type i  htlv i  to spastic myelopathy  we undertook a prospective and retrospective search for htlv i antibodies in 36 patients who were labelled as having unexplained myelopathy  24  66   were positive and htlv i was isolated from 4 out of the 6 patients whose peripheral blood lymphocytes were cultured  eighteen  75   gave a short history  less than 6 months   there was a female preponderance  71    spinothalamic dysfunction was common  55   and as many as half were severely disabled  50  wheelchair bound   routine laboratory studies showed no specific trends apart from hypergammaglobulinaemia and csf pleocytosis  greater than 5 cells microliter in 66  of patients   the total csf protein was raised  greater than 0 4 g l  in 45  of patients  the igg index was greater than 0 7 in 15 of 19 patients  conventional myelography did not show any specific abnormalities  computer assisted myelography was undertaken in 22 patients  3 showed arachnoiditis and 2 spinal cord atrophy  periventricular lucencies were seen in 1 of 10 patients who had computed tomography of the head  nerve conduction studies demonstrated abnormalities in 46  of the patients indicating that subclinical peripheral nerve dysfunction was common  visual evoked responses were abnormal in only 1 patient but brainstem auditory evoked response studies showed some abnormality in 42  of the patients  the finding of htlv i antibodies in a significant number  and the isolation of htlv i from the blood in 6 of our black patients with noncompressive myelopathy  represents a substantial clinical advance  future studies should define more clearly the role of the virus in this disorder  
class10	heterogeneity in progressive aphasia due to focal cortical atrophy  a clinical and pet study  six patients with a slowly progressive aphasic disorder due to degenerative cortical disease are reported  the length of history varied from 18 months to 6 years  in 5 patients  there was a naming deficit  associated in 4 of these with some abnormalities in comprehension  one patient had a progressive history of reduced speech output  which was associated with an orofacial dyspraxia  all patients were studied neuropsychologically  and in addition regional cerebral metabolism was measured using position emission tomography  a localized left hemisphere deficit was found in all patients except 1  who had the longest history and the most profound clinical deficit  and who also had right hemisphere hypometabolism  the major brunt of the deficit was in the anterior portion of the left temporal lobe in all but 1 case  the patient with poor speech output who had a more severe left posterior frontal deficit  these findings suggest that in progressive aphasia due to focal cortical atrophy there is heterogeneity in the clinical presentation and anatomical site of the deficit  with possible implications for the underlying aetiology  
class10	developmental dysmnesia in a poor reader  a 22 yr old subject with moderate developmental dyslexia experienced poor memory from an early age  in spite of normal intelligence he had great difficulty in learning historical and geographical names  mathematical formulae  poems and songs  and verbal series such as the letters of the alphabet and the months of the year  his recognition of familiar faces was also faulty at times  a battery of memory tests confirmed a moderate deficit of verbal as well as visual memory  whereas spatial memory was preserved  other cognitive functions were intact  except for a mild reading disability  no evidence of brain pathology was provided by his history  neurological examination and ct scanning  
class10	familial paroxysmal kinesigenic ataxia and continuous myokymia  a large family with paroxysmal ataxia and continuous myokymic discharges is described  the disorder is of autosomal dominant inheritance  during attacks coordination of movements and balance are disturbed  often a postural tremor of the head and the hands and fine twitching in some of the facial and hand muscles are present  the attacks usually last a few minutes and may occur several times per day  they first appear in childhood and tend to abate after early adulthood  the attacks are frequently precipitated by kinesigenic stimuli similar to those in paroxysmal kinesigenic choreoathetosis  their occurrence can be reduced or prevented by carbonic anhydrase inhibitors  between attacks a slight postural tremor and ataxia was found in a few of the elderly affected members  fine rippling myokymia was obvious in a few and could be detected on close inspection in about half of the adults  electromyography  emg  showed myokymic discharges in all affected members  the characteristics and reactivity of this myokymic activity suggest multiple impulse generation in the peripheral nerves  
class10	the comportmental learning disabilities of early frontal lobe damage  two adult patients are described who suffered bilateral prefrontal damage early in life and who subsequently came to psychiatric attention because of severely aberrant behaviour  a battery of developmental psychology paradigms  not previously used to assess neurologically impaired individuals  showed that social and moral development of these 2 patients was arrested at an immature stage  in comparison with other types of brain damage which disrupt cognitive development  frontal damage acquired early in life appears to provide the neurological substrate for a special type of learning disability in the realms of insight  foresight  social judgement  empathy  and complex reasoning  
class10	cerebral blood flow in progressive aphasia without dementia  case report  using 133xenon inhalation  technetium 99m hexamethylpropyleneamine oxime and single photon emission computerized tomography  we report a case of progressive aphasia without clinical signs of intellectual or behavioral impairment  satisfying mesulam s clinical criteria of primary progressive aphasia  as 4 yrs of extensive psychometric testing and radiological imaging  comprising ct and mri  failed to detect evidence of relevant involvement outside the left perisylvian regions  cranial ct was normal but mri showed multiple bilateral lesions in the deep white matter  cerebral blood flow  cbf  studies by single photon emission computerized tomography  however  showed an initial frontotemporal focus of hypoperfusion that progressively extended to include most of the ipsilateral hemisphere and the contralateral frontal lobe  this suggests that cbf imaging may yet be the most sensitive technique in revealing subclinical injury in the degenerative brain diseases of focal onset  
class10	the anatomical basis of the caecocentral scotoma  new observations and a review  it is shown that the  papillomacular bundle  of optic nerve fibres  although a concept discussed frequently in the clinical literature  lacks a clear anatomical definition  it is suggested that the explanation for this is that the  bundle  was originally described in autopsy studies of toxic amblyopia  not normal anatomy  the optic nerve fibre projection and vascular architecture of the caecocentral region of the retina is described  these anatomical features are discussed in relation to a number of possible anatomical explanations for the fact that a caecocentral scotoma is the characteristic field defect found in toxic amblyopia  we have been unable to identify a distinct anatomical feature which might explain this vulnerability but suggest that the problem has not as yet been clearly addressed by anatomists  
class10	the distribution of muscle weakness in upper motoneuron lesions affecting the lower limb  to determine the distribution of weakness in the lower limb after upper motoneuron lesions the strength of 8 muscle groups was measured  four groups of patients were studied  22 control subjects  16 patients with unilateral leg paresis  4 patients with severe unilateral paralysis and 5 patients with paraparesis  in the testing posture  seated   patients with cerebral upper motoneuron lesions showed no selective loss of power in flexors or extensors on the contralateral side  gravitational torques were included in the measurements  however  proximal muscles  acting at hip and knee  were significantly less severely affected than more distal muscles  acting at ankle and hallux   at any particular joint  physiological flexors and extensors were affected equally in both the hemiparetic and paraparetic subjects  as in the upper limb  colebatch and gandevia  1989   the strength of muscles on the clinically unaffected side was reduced compared with control subjects  although no muscle groups were especially affected  
class10	innervation territories for touch and pain afferents of single fascicles of the human ulnar nerve  mapping through intraneural microrecording and microstimulation  the peripheral distribution of the fibre content of individual ulnar nerve fascicles supplying skin and muscles of the hand in human volunteers was indirectly mapped by tracing the fields of projected sensation evoked by intraneural electrical microstimulation  inms  and by tracing receptive fields delineated through intraneural recording of afferent impulse activity elicited by natural stimulation of end organs  moderate intensity suprathreshold inms  delivered in cutaneous fascicles  induced nonpainful sensations projecting to stereotyped and coherent areas of skin  the fascicular projected fields  fpfs   fascicular receptive fields  frfs  were mapped during microneurographic recording by determining the area of skin which  when activated by light tactile stimuli  elicited afferent neural discharges recorded intraneurally  it was found that at a given electrode position in a skin nerve fascicle  moderate intensity inms induced nonpainful sensations projecting to a cutaneous field  fpf  that coincides with the frf  while high intensity inms induced painful sensations projecting within the cutaneous field of nonpainful sensations  pain induced by inms in muscle nerve fascicles was projected to the muscles innervated by that fascicle and  in most instances  to areas beyond the muscular receptive field  the study demonstrates that individual ulnar nerve fascicles  at wrist levels  subserve well defined cutaneous territories in the hand  and that the area of skin covered by the sum of all ulnar fascicular receptive or projected fields matches the maximal possible cutaneous distribution of the ulnar nerve  insights of practical relevance regarding clinical expression of fascicular nerve injuries are also brought up by this study  
class10	volume conduction of the parietal n20 potential to the prerolandic frontal area  somatosensory evoked potentials were recorded from the frontal and parietal areas in patients with various lesions in the central nervous system on stimulation of the median nerve  five representative cases who showed a selective loss of the positive potential from the frontal area are reported  in each case  the parietal n20 potential was relatively well preserved  and the midposition between the frontal and central areas  fc area  showed a negative potential following p14  the peak of this negative potential was synchronous with that of the parietal n20 potential  this negativity on the fc area is considered to be a volume conducted potential from the parietal n20 to the prerolandic frontal area  such an anterior volume conduction of the parietal n20 would not be explained by the concept of a tangentially oriented dipole generated in the posterior bank of the central sulcus  instead  for the generator of the parietal n20 potential  a radically oriented dipole generated mainly in the parietal area is postulated  
class10	selective spatial attention in patients with visual extinction  the present study was designed to verify the attentional performance of patients with parietal lesions in the experimental condition in which they had to pay attention to 3 spatial positions located on the left  on the right and directly above the fixation stimulus  experiment 1  and to only 1 of the 3 spatial positions at a time  experiment 2   twelve patients  6 subjects with right parietal lesions and 6 subjects without neurological deficits  participated in the experiment  the results of experiment 1 showed that in patients with right parietal lesions the speed and accuracy of response to horizontally aligned stimuli increased gradually from right to left  whereas the control group showed only the effect due to the different retinal eccentricities of the 3 stimuli  that is  responses to central stimuli were faster and more accurate than responses to left and right stimuli  the results of experiment 2 showed that both the neurological and control groups were faster to respond to central than to left and right stimuli  and that the neurological group was faster to respond to right than left stimuli  whereas no difference in rts between two visual fields was obtained in the control group  furthermore  when the patients had to respond to 3 spatial locations aligned horizontally  experiment 1   the speed and accuracy of response to the right stimulus were the same as when they had to focus attention on it  experiment 2   these results showed that the focus of attention in patients with visual extinction is on the rightmost stimulus and that the increased attention to the right is accompanied by a decreased attention to the left  
class10	osseointegration of titanium implants in total hip arthroplasty  osseointegration is defined as direct contact on the light microscopic level between living bone tissue and the implant  using titanium screw dental implants in the jaw  a lasting interface under loaded conditions extending over a 20 year follow up period has been demonstrated  this demonstration brings up the question whether a similar interface can be achieved in total hip arthroplasty  tha  between living bone and a titanium alloy implant under necessitated conditions of immediate loading  two series of cases are reported  the first series used a femoral  press fit  titanium alloy component and the second used a press fit titanium acetabular component and redesigned femoral  press fit  titanium alloy component  both demonstrated a high percentage of good to excellent results  roentgenograms showed that the geometrical changes in the redesigned femoral component gave early indications of a better fixation with loading in valgus  less subsidence  and less evidence of distal stress transfer  a two and one half year postoperative anatomic specimen study confirmed osseointegration to the press fit titanium alloy femoral component  multiple areas of contact between bone and metal without fibrous interposition were seen  examination by electron microscopy supported the light microscopic findings  these findings support further use of smooth  press fit titanium components in thas without the need for porous coating  mesh  or other surface modifications  
class10	intraoperative dexamethasone irrigation in lumbar microdiskectomy  in 45 lumbar hemilaminectomy microdiskectomy patients  a control group of 23 patients had the standard operative procedure  the remaining 22 patients were treated with intraoperative irrigation of long acting dexamethasone before incision closure  age  weight  gender ratio  mean postoperative hospital stay  mean in hospital narcotics usage  and incidence of perioperative complications among the two groups were compared  age and gender ratios were comparable  although the control group was significantly heavier in body weight than the steroid irrigated group  the steroid irrigated group had a significant reduction in hospitalization and a marked reduction in narcotics usage compared with the control group  postoperative fever occurred in one patient in the steroid group  the control group had three postoperative complications  these preliminary observations suggest that dexamethasone irrigation during lumbar diskectomy is a safe and effective adjunct to surgical management  
class10	continuous removal of middle molecules by hemofiltration in patients with acute liver failure  in patients with acute liver failure and hepatic coma  an increase in the abnormal  middle molecules  seen on the chromatograms of the sera is suspected of playing an etiologic role in the coma  a pilot study of continuous hemofiltration using a high performance membrane was conducted in 16 such patients in an attempt to decrease the serum levels of the middle molecules  the procedure was used alternately with plasma exchange  high performance liquid chromatography showed a notable removal of the substances in the filtrates and a sequential removal from the serum by hemofiltration  eight  50   of the 16 patients had amelioration in level of consciousness and were weaned successfully from hemofiltration  although only three of the 16 patients survived the acute illness  13 others lived an average of 15 days and five patients survived greater than 3 wk  while the continuous removal of middle molecules from the serum may not reverse liver failure  this procedure used in conjunction with plasma exchange may provide a means of life support  e g   for patients awaiting a liver transplant  
class10	a limited diagnostic investigation for obstructive sleep apnea syndrome  oximetry and static charge sensitive bed  a simplified sleep apnea investigation consisting of combined oximetry and respiration movement monitoring was compared with conventional polysomnography  these two types of recordings were performed simultaneously during one night in 77 patients with suspected obstructive sleep apnea syndrome  osas   a static charge sensitive bed  scsb  was used in the simplified recording because it provides a comfortable and reliable means of recording respiration movements  periods of obstructive apneas gave a diamond shaped periodic respiration movement pattern in the scsb  usually accompanied by repetitive oxygen desaturations  the average number of desaturations greater than or equal to 4 percent per sleeping hour was termed the oxygen desaturation index  odi  and compared with the apnea index  ai   in the whole population they were well correlated  p less than 0 0001  r2   0 41   but in individual cases there were considerable discrepancies  patients with periodic respiration movements less than 18 percent of total sleeping time and odi less than 2 never had ai greater than or equal to 5  whereas patients with periodic respiration greater than 45 percent and odi greater than 6 always had ai greater than or equal to 5  fifty one of the 77 patients fulfilled these criteria  a bradycardia response to apneas was absent in 29 percent of patients with ai greater than or equal to 5  a combination of respiration movement and oximetry recording thus seems to give sufficient information to confirm or negate a diagnosis of osas in a majority of patients with clinical symptoms  in borderline patients  further investigations should be performed  
class10	systemic hypertension in sleep apnea syndrome  relationship with sleep architecture and breathing abnormalities  to examine the possible relationship between systemic ht and sas we compared 21 hypertensive  ht   and 29 normotensive  ht   patients for morphologic characteristics  sleep disturbances and respiratory events monitored during a full night polysomnography  there was no significant difference between ht  and ht  patients with respect to age  weight  bmi  sleep stage distribution and disorganization  apnea hypopnea index  number of episodes per hour of sleep  and duration  minutes per hour of sleep  nor o2 saturation indices  mean nocturnal and minimum o2 saturation  we conclude therefore that ht in sas patients is not directly related to morphologic characteristics  sleep disturbances and breathing abnormalities  
class10	clinical dysautonomia in patients with bronchial asthma  study with seven autonomic function tests  fifty asthmatic patients and 20 healthy control subjects  carefully age  and sex matched  were subjected to seven standardized tests to evaluate their autonomic status  due care was taken to remove factors which could interfere with results  of the tests concerned with the parasympathetic system  the intravenous atropine test  p greater than 0 10  and heart rate response to standing  p greater than 0 01  which measured the basal parasympathetic tone  did not show a significant difference  tests requiring stimulation of the parasympathetic system  ie  deep breathing test  p less than 0 001   valsalva maneuver  p less than 0 001   and carotid sinus massage  p less than 0 001  showed significantly heightened response  postural fall of blood pressure  p greater than 0 10  and sustained hand grip test  p greater than 0 10   chiefly concerned with the sympathetic system  did not show a significant difference  of the 50 asthmatic patients  nine were atopic and 41 nonatopic  when the results were compared in the two groups separately  we found that there was no alteration in the measurements except the intravenous atropine test which showed heightened response with atopic subjects  p less than 0 05   these results suggest that hyperresponsiveness of the parasympathetic system is an important factor in producing bronchial spasm in asthmatic patients  and atopic and nonatopic subjects do not differ much in their autonomic status  
class10	maxillofacial surgery and nasal cpap  a comparison of treatment for obstructive sleep apnea syndrome nasal continuous positive airway pressure  cpap  is the primary therapy for obstructive sleep apnea syndrome  osas   recent reports have indicated  however  that there is a small but significant number of failures related to patient compliance  primary surgical treatment  which has been uvulopalatopharyngoplasty  uppp   has declined because of poor results  a reviewed of uppp failures has shown that while uppp eliminated palatal obstruction  it failed to eliminate base of tongue obstruction  maxillofacial surgery has been reported as treatment of osas by correcting base of tongue obstruction  thirty patients with severe osas were evaluated to compare nasal cpap and maxillofacial surgery  the goal was to determine if our surgical protocol was as effective as nasal cpap  all patients initially underwent baseline diagnostic polysomnography to document osas  a nasal cpap study was performed to determine the appropriate positive end expiratory pressure  the patients in this study were using nasal cpap  but they found it unacceptable as long term treatment and elected surgery  maxillofacial surgery consisted of maxillary  mandibular  and hyoid advancement  polysomnography was performed six months following surgery and compared with the night 2 cpap results  the parameters included in the investigation were the respiratory disturbance index  rdi   lowest sao2  number of sao2 falls below 90 percent  total sleep time  tst   rem sleep percent  stage 3 4 sleep percent  and wake after sleep onset  the mean rdi before treatment was 72 0  sd 25 7   after completing therapy  the rdi from surgery and cpap was 8 8  sd 6 0  and 8 6  sd 4 1   respectively  the mean low sao2 prior to treatment was 61 0  sd 13 5   and the cpap results and postsurgical results were 86 2  sd 5 5  and 86 1  sd 4 2   respectively  an analysis of variance was used to examine the results  and there was no statistical difference between nasal cpap and surgery for all respiratory variables  
class10	lack of change in neurochemical markers during the postepileptic phase of intrahippocampal tetanus toxin syndrome in rats  the chronic epileptic syndrome induced by injecting tetanus toxin into rat hippocampus causes functional changes that essentially are permanent  outlasting the period of active seizures by at least 1 year  these long term changes have been characterized by an impaired performance on a range of behavioral tasks  which in turn have been associated with a physiologic depression of hippocampal evoked responses but not with any discernible histopathology  in the present study  we examined the hippocampi of rats in the postseizure phase of the tetanus toxin model and observed no significant changes in the concentration of neurochemical markers for six neurotransmitters  therefore  the long term reduction in hippocampal excitability cannot be attributed to any major loss of afferents or hippocampal neurons using aspartate  acetylcholine  gamma aminobutyric acid  gaba   glutamate  norepinephrine  ne   or serotonin as their transmitters  
class10	some endorphin derivatives and hydrocortisone prevent eeg limbic seizures induced by corticotropin releasing factor in rabbits  corticotropin releasing factor  crf  injected into the cerebral ventricles of small mammals induces eeg limbic seizures  behavioral excitability  stereotyped behavior  and tardive enhancement of hippocampal theta voltage and frequency  because we addressed this phenomenon when we explained the pathogenesis of infantile spasms in children  we wished to study the interference exerted by some gamma endorphin fragments on eeg epileptiform and behavioral symptoms induced by crf in the rabbit  animals were implanted intracerebroventricularly  i c v   with semichronic cortical and hippocampal electrodes  together with a cannula into the left lateral ventricle  when some gamma endorphin derivatives  dt gamma e  de gamma e  were injected intravenously  i v   for 4 days  or hydrocortisone once   they prevented the eeg ictal seizures induced in the hippocampus of rabbits by crf injected i c v  hydrocortisone and de gamma e also prevented the appearance of scattered spiking and partially prevented tardive enhancement of theta voltage in the hippocampal eeg  finally  de gamma e also prevented stereotyped behavior and excitability induced by crf  these results confirm the regulatory role exerted by crf in limbic structure excitability and suggest that the above peptides may be involved in a regulatory feedback mechanism of crf metabolism or activity  the possibility that these peptides may also have interesting antiepileptogenic properties should be considered  
class10	neonatal monosodium glutamate abolishes corticotropin releasing factor induced epileptogenic activity in rats  intracerebroventricular  i c v   injection of rat corticotropin releasing factor  rcrf  at doses of 5 20 micrograms in rats induces epileptogenic activity characterized by pacemaker like spikes localized in the hippocampal leads  such an effect was still present in rats neonatally treated with saline but was absent in those neonatally treated with monosodium glutamate  msg   a treatment that caused marked changes in the concentration of several brain neurotransmitters and neuropeptides in hypothalamic nuclei where crf is highly concentrated and is believed to induce endocrinologic and behavioral effects  the present results suggest the rcrf induced spiking activity is mediated by activation of neuronal pathways sensitive to msg neurotoxic effect  
class10	triiodothyronine and brain excitability  we investigated mechanisms involved in thyroid hormone action on brain excitability  the effect of acute exposure of triiodothyronine  t3  to rat hippocampal slices in vitro was studied  no significant changes could be detected in prevolley  field excitatory postsynaptic potentials  fepsp  and population spike amplitude  while there was a minor  nonsignificant trend toward shortening of the population spike latency time  t3 had no effect on penicillin induced epileptiform activity  there was  however  an active accumulation of radioactively labeled t3 in the slices  a rat cervaux isole preparation was used to determine focal seizure thresholds in the visual cortex  and no acute  2 4 h  effects were demonstrated  no significant acute effects of t3 on brain excitability in the hippocampus and visual cortex was observed  despite an active accumulation of t3  thus  the effect of t3 on brain excitability most likely is due to delayed effects  
class10	epidemiology of epilepsy in guaymi indians from bocas del toro province  republic of panama  this cross sectional study was conducted to describe the epidemiology of epilepsy in guaymi indians residing in changuinola  a small town on panama s caribbean coast near costa rica  we randomly selected households and attempted to enroll all residents aged less than or equal to 1 year  337 eligible subjects agreed to participate  93  response rate   we administered a standard neurologic disease screening examination to all subjects and  if any abnormality was found  we administered a standard neurologic evaluation  we detected 19 cases of active epilepsy  the mean age at onset was 12 years  and generalized tonic clonic seizures were the most common diagnosis  10 of 19  53    the prevalence of active epilepsy among caribbean coastal guaymi  57 1000  is considerably greater than that in lower class panama city populations  22 1000  or in other parts of the world  to identify risk factors for epilepsy  we collected epidemiologic data and serum  for cysticercus antibody  from subjects with active epilepsy and from 44 age sex matched controls  significantly more cases  47   than controls  6   had other family members with epilepsy  relative risk  rr   14   44  of cases and 13  of controls reported a history of febrile seizures during childhood  rr   6   
class10	electrocorticographic confirmation of focal positron emission tomographic abnormalities in children with intractable epilepsy  the relationship between focal disturbances of glucose utilization demonstrated by positron emission tomography  pet  and electrophysiologic abnormalities defined by intraoperative electrocorticography  ecog  was studied in eight children  aged 13 months to 12 years  who underwent cortical resection because of intractable seizures  none of the children had pure temporal lobe epilepsy  computed tomography  ct  and or magnetic resonance imaging  mri  were normal in four of the eight children  the scalp electroencephalogram  eeg  showed lateralized interictal epileptiform abnormalities in all eight and lateralized ictal onset in five of eight  in seven children  interictal pet showed focal hypometabolism  the eighth child had focal  ictal hypermetabolism  ecog at the time of surgery showed epileptiform spiking  slowing  and or suppression of normal background activity that in every case corresponded to the focus on pet scan  the ecog findings support the notion that in children with epilepsy focal metabolic abnormalities on pet correspond to electrophysiologically abnormal areas of cortex  which are presumably also the epileptogenic regions  such areas can appear normal on anatomic imaging studies  ct and mri   when ictal scalp eeg data are ambiguous or contradictory  pet provides a less invasive means than chronic grid or depth electrode recording for evaluating whether a localized epileptogenic area exists  
class10	lateralized effects of subclinical epileptiform eeg discharges on scholastic performance in children  the interaction between lateralization of subclinical epileptiform discharges and cognitive tasks was investigated in 21 children  12 girls and 9 boys  mean age 10 6 years   seventeen had a diagnosis of epilepsy  partial or secondarily generalized   testing was by reading  arithmetic  and intelligence subtests during continuous telemetric eeg and video monitoring  children with left sided discharges had significantly lower reading performance than children with right sided discharges  during reading  epileptiform discharges occurred relatively less frequently and with a shorter total duration over the left hemisphere than the right  this supports the view that cognitive tasks suppress epileptiform discharges when they activate a region of the brain within the epileptogenic zone  discharges from other epileptogenic zones not directly activated by the tasks are increased  however  
class10	topographic comparative study of magnetic resonance imaging and electroencephalography in 34 children with tuberous sclerosis  a series of 34 children with confirmed tuberous sclerosis  ts  were studied prospectively by both eeg and magnetic resonance imaging  mri  at ages ranging from 5 months to 18 years  size and topography of the cortical tubers were analyzed on axial and coronal views  in t2 sequences  and the large tubers greater than 10 mm were studied  in addition  eeg follow up data were reviewed retrospectively  twenty six patients  76   had both mri large cortical tubers and eeg foci  3 had normal eeg  2 had normal mri  and the remaining 3 had only small tubers  the number of large tubers was significantly related to eeg foci  a topographic mri eeg correspondence was observed for at least one tuber in 25 of the 26 patients  and correspondence was complete in 10 patients  large cortical tubers without corresponding eeg foci were observed in 11 patients  these tubers mainly involved the frontal regions and were found before the patients were 2 years old  eeg foci without corresponding tubers were observed in 4 patients  in addition  secondary bilateral synchrony was preferentially observed in patients with frontal lesions and after the age of 2 years  these data confirm that the cortical tubers are epileptogenic and that their expression may be influenced by regional cortical maturation  
class10	landau kleffner syndrome  a clinical and eeg study of five cases  in five children with normal initial psychomotor development  a landau kleffner syndrome appeared at age 3 7 years  no neuroanatomic lesions were noted  aphasia and hyperkinesia were isolated in three patients and associated with global regression of higher cortical functions in one patient  massive intellectual deterioration and psychotic behavior were associated with transient aphasia in one patient  the epilepsy  focal motor and generalized tonic clonic seizures  subclinical eeg focal seizures during sleep  and atypical absences  always regressed spontaneously or with antiepileptic drug  aed  treatment  the eeg in waking patients showed focal and generalized spike wave discharges on a normal background rhythm  discharge topography and pattern changed frequently  during sleep  discharges always increased  at some time during syndrome development  all patients had bilateral spike waves for greater than 85  of the sleep period  while at other times the discharges were discontinuous or continuous but focal or unilaterally hemispheric  discharge topography and abundance changed from night to night  the abnormal eeg and the impaired higher functions developed and regressed together  but not with strict temporal correlation  our own experience suggests that the landau kleffner syndrome and epilepsy with continuous spike wave activity in slow wave sleep cannot be clearly differentiated  they may be different points on the spectrum of a single syndrome  
class10	landau kleffner syndrome  a pharmacologic study of five cases  five children with landau kleffner syndrome  epilepsy  acquired aphasia  and continuous spike wave discharges during sleep   were treated with antiepileptic drugs  aeds   sleep modifying drugs  and corticosteroids  the pharmacologic profiles differed from those observed in focal epilepsies  resembling instead those of certain generalized epilepsies  such as west or lennox gastaut syndromes  phenobarbital  pb   carbamazepine  cbz   and phenytoin  pht  were ineffective or worsened the eeg and neuropsychological symptoms  whereas valproate  vpa   ethosuximide  esm   and benzodiazepines were partially or transiently efficacious  dextroamphetamine produced a dramatic but transient improvement in waking and sleep eeg in one of two children  aphasia did not change  corticosteroid treatment resulted in improved speech  suppression of seizures  and normalization of the eeg in three of three children  our own experience and data from the literature suggest that corticosteroids should be given in high doses as soon as the diagnosis is firmly established and should be continued in maintenance dose for several months or years to avoid escape  early diagnosis  before mutism or global deterioration develops  appears to be essential for effective therapy with minimal neuropsychological sequelae  
class10	cerebral glucose utilization during sleep in landau kleffner syndrome  a pet study  three right handed male children  aged 5  6  and 11 years  with signs  symptoms and or history of the syndrome of acquired aphasia epilepsy  landau kleffner syndrome  were studied during drug induced  electroencephalographically  eeg  monitored sleep by positron emission tomography  pet  and the  18f fluorodeoxyglucose  fdg  method  our data demonstrate that in landau kleffner syndrome  cerebral glucose utilization is not normal during sleep  the metabolic pattern varied between the children but the metabolic disturbances always predominated over the temporal lobes  they were right sided  left sided  or bilateral  in the two first patients  eeg recordings showed continuous spike and wave discharges during sleep and a right greater than left asymmetry was observed in temporal areas  in patient 1  the asymmetry was associated with a relative increase of glucose utilization of the right posterior temporal region  in patient 2  the glucose utilization was relatively decreased in the left anterotemporal and left perisylvian regions  in patient 3  the sleep eeg showed no discharge and no significant asymmetry was observed  however  glucose utilization of both temporal lobes was decreased  lower metabolic rates in subcortical structures than in cortex were also noted in the three children  this metabolic pattern may be related to the maturation of the central nervous system  cns   
class10	gastrointestinal motor dysfunction in acquired selective cholinergic dysautonomia associated with infectious mononucleosis  this report documents the disturbance in gastrointestinal motor function in a patient with selective cholinergic dysautonomia that occurred following acute infectious mononucleosis  apart from the gut  other organs affected included the pupils  sweat glands  lacrimal and salivary glands  and urinary bladder  autonomic function tests showed the preservation of sympathetic adrenergic functions in contrast to the generalized involvement of postganglionic parasympathetic and sympathetic cholinergic nerves  including denervation hypersensitivity of the pupil and urinary bladder to exogenous cholinergic agonists  cardiac and abdominal vagal responses were abnormal  colon myenteric plexus ganglion cells were normal by morphological and immunohistochemical studies  suggesting that the selective cholinergic dysautonomia was the most likely pathophysiologic process responsible for the observed motility disorder  this study documents the occurrence of selective cholinergic dysautonomia following a viral illness  the importance of the extrinsic neural control on the motor function of the gastrointestinal tract  and the usefulness of combined motility and autonomic function testing in the evaluation of patients with symptoms suggestive of gut dysmotility  
class10	silent cerebrovascular disease in the elderly  correlation with ambulatory pressure  does the average daily blood pressure correlate with hypertensive cerebrovascular disease better than the casual pressure  as has been reported in other target organ involvement  we investigated the associations of two abnormal findings on brain magnetic resonance imaging suggestive of a vascular etiology  low intense foci  lacunae   and periventricular hyperintense lesions on t1  and t2 weighted images  with both office and average daily blood pressure values in a population of 73 healthy normotensive and hypertensive elderly individuals  70     6 years old   lacunae were detected in 34 subjects  47    the number per subject ranged from 0 to 19 and was significantly correlated with advancing age  furthermore  these changes were supposedly related to the average of noninvasive ambulatory  24 hour and during awake and asleep periods  pressure recordings but not to office pressures  the grade of periventricular hyperintensity was also significantly associated with advancing age and the average of ambulatory systolic pressure recordings  particularly during sleep  but not with office blood pressure  in comparisons of normotensive   office hypertensive   and hypertensive subgroups  abnormalities on magnetic resonance imaging were appropriate to the level of the 24 hour blood pressure measurements but not to that of clinic pressure  in hypertensive patients  the presence of electrocardiographic evidence of left ventricular hypertrophy was also associated with greater abnormalities on magnetic resonance imaging  we conclude that ambulatory blood pressure monitoring is superior to casual pressure measurements in predicting latent cerebrovascular disease  which is unexpectedly common in apparently healthy elderly subjects  
class10	effect of age on the efficacy of blood pressure treatment strategies  to study whether the proportion of excess cardiovascular events attributable to various levels of systolic blood pressure varies with age  we calculated the population attributable risk of all cause mortality  fatal and nonfatal cardiovascular events  stroke  coronary heart disease  angina  congestive heart failure  and peripheral vascular disease   and stroke incidence due to systolic blood pressure in men and women 45 years of age or older in the united states during 1980  our estimates are based on us census counts  blood pressure prevalence distributions from the second national health and nutrition examination survey  and the annual risk of cardiovascular complications during 18 years of follow up in the framingham cohort  we then determined the impact of age on the relative efficacy of mass treatment and case finding strategies in preventing systolic blood pressure related events  at 45 54 years of age  only 30 40  of systolic blood pressure related excess events occur in hypertensive individuals  systolic blood pressure greater than or equal to 160 mm hg   with increasing age  however  the percentage of systolic blood pressure related events that occur in hypertensive individuals rose substantially  in the older age group  greater than or equal to 75 years   65 70  of fatal and nonfatal cardiovascular disease events occur in hypertensive persons  the pattern is similar for men and women  the potential impact of a mass treatment strategy designed to shift the distribution of blood pressure downward by a small amount is greater in younger than in older groups  whereas an opposite trend is seen for a high risk  hypertensive case finding and treatment approach  
class10	glucocorticoid induced muscle atrophy prevention by exercise in fast twitch fibers  exercise has been shown to be effective in preventing glucocorticoid induced atrophy in muscles containing high proportions of type ii or fast twitch fibers  this investigation was undertaken to further evaluate this response in type iia and iib fibers  determined by histochemical staining for myofibrillar adenosinetriphosphatase with alkaline and acid preincubation  steroid  cortisol acetate  ca   100 mg kg body wt  and exercise  running 90 min day  29 m min  treatments were initiated simultaneously for 11 consecutive days in female rats  fiber distribution and area measurements were performed in a deep and superficial region of plantaris muscle  the exercise regimen spared approximately 40  of the ca induced plantaris muscle atrophy  in the deep region  the fiber population  which contained approximately 13  type i  slow twitch   24  type iia  and 63  iib fibers  was not affected by either treatment  in the superficial section  which consisted solely of type ii fibers  the proportion of type iia fibers was higher  27 vs  9   p less than 0 01  in the steroid  than in the vehicle treated groups  within each region  type iia fibers were less susceptible to atrophy than type iib fibers  and within each fiber type  the deep region had less atrophy than the superficial region  type i fibers were unchanged by steroid treatment  for type iia fibers  exercise prevented 100  of the atrophy in the deep region and 50  in the superficial region  for type iib fibers  the activity spared 67 and 40  of the atrophy in these same regions  respectively  these results show that glucocorticoids are capable of changing the myosin phenotype  
class10	failed acromioplasty for impingement syndrome  we evaluated 67 shoulders in 65 patients who had pain and dysfunction for more than two years after an initial acromioplasty for impingement syndrome without a rotator cuff tear  in addition to a thorough history  physical examination  local anaesthesia injection and any other necessary investigations all patients had arthroscopic evaluation of the shoulder  in 27 shoulders there had been diagnostic errors  and in 28 operative errors  only in 12 had the diagnosis and the operative procedure both been correct  subsequent operative intervention in patients not receiving worker s compensation benefit had a 75  success rate  whereas in those receiving such benefits the success rate was only 46   
class10	effect of the topical anesthetic emla on the efficacy of pulsed dye laser treatment of port wine stains  emla cream  eutectic mixture of local anesthetics  is a new topical anesthetic composed of 25 mg lidocaine and 25 mg prilocaine in an oil in water emulsion cream  it has been found to be very effective for local anesthesia prior to venepuncture  minor surgical procedures  and pulsed dye laser  pdl  therapy for port wine stains  pws  in children  however  since emla may cause vasoconstriction of cutaneous vessels  we tried to determine whether pretreatment with emla decreases the efficacy of subsequent pdl treatment  we report eight patients between the ages of 4 and 32 years with pws who received two test site treatments prior to pdl treatment  one site was pretreated with emla cream under occlusion for 60 minutes and then left unoccluded for 15 minutes prior to pdl test treatment  the other site  in the same area of the pws and patient s body  was not pretreated with emla  the test sites were compared 6 8 weeks later to determine whether emla decreased the degree of lightening of the pws compared to the non emla treated site  we conclude that emla is an effective topical anesthetic for pdl treatment of pws and does not adversely affect the efficacy of the treatment  
class10	disturbance in daily sleep wake patterns in patients with cognitive impairment and decreased daily activity  the sleep wake patterns of 121 chronically ill  mentally and physically handicapped patients were visually monitored hourly for 14 consecutive days  four types of sleep wake patterns were found  in order to investigate how cognitive and physical functions correlated with sleep disorders  patients were classified based on a scale of mental function and the grading of daily activity  the percent of total sleep hours and the sleep rating  showing disturbances in sleep wake pattern  were evaluated  we found a high degree of individuality in sleep wake patterns  sleep disturbance was associated with daily activity as well as with cognitive impairment  this monitoring system provides medical personnel with valuable information for clinical management  
class10	what practicing physicians in north carolina rate as their most challenging geriatric medicine concerns  we recently surveyed a random sample of 500 physicians in family practice  general practice  and internal medicine in north carolina  to discover their most challenging geriatric concerns  using a three stage survey technique  respondents were asked to answer two open ended questions about the most challenging geriatric problems they face and what specific geriatric content areas would attract their participation in an educational program  they were then asked to rank 34 topics on which they would like more information  a total of 242 responses were received for a 55  response rate  63 of the 500 were undeliverable   responses indicated that physicians are more concerned with management than diagnosis and revealed considerable evidence of empathy and concern  the top three topics had to do with the management of dementia  multiple problems  and depression  approximately 25  of physicians consider problems of financing health care as among the most challenging problems  
class10	delirium  masquerades and misdiagnosis in elderly inpatients  delirium is an organic mental disorder defined as transient  fluctuating global dysfunction of cognition  it is common in elderly medical inpatients  yet its varied presentation is often missed or misdiagnosed  
class10	primary intratemporal tumours of the facial nerve  diagnosis and treatment  benign primary tumours of the facial nerve are uncommon  a slowly progressive facial palsy should be considered the result of a nerve tumour until proven otherwise  improvements in diagnostic imaging techniques of the temporal bone have increased the possibility of a correct pre operative diagnosis but facial nerve tumours remain a frequently ignored or misdiagnosed entity as a consequence of their subtle and protean clinical manifestations  a series of 12 cases of primary facial nerve tumours is presented  the clinical features  diagnostic modalities and treatment are discussed in relation to a review of the literature  
class10	parapharyngeal abscess and torticollis  the combination of a parapharyngeal abscess and torticollis in an adult  due to a spastic contraction of the sterno cleido mastoid muscle is an extremely rare condition  we have recently been exposed to such case  in which it was very difficult to make the diagnosis and where ct of the neck gave us the answers without any difficulty  the indication for ct at an early stage in unexplained neck infections is stressed  
class10	outcome of pregnancies experienced during residency  to investigate potential adverse effects of residency training on pregnancy outcome  a cohort study was conducted among 45 university affiliated residency programs  outcomes of the first pregnancy experienced during residency were compared between 92 female residents and 144 spouses of male residents  despite long hours  sleep deprivation  and an increase in perceived stress  the female residents were as likely to give birth to a live  full term newborn as the spouses of male residents  for white cohort members  an increased risk of premature labor without delivery was identified  rr   12 3  95  confidence interval 2 4 61 6   no significant differences were found in prematurity  spontaneous and therapeutic abortions  or presence of congenital abnormalities in the infants  method of delivery and use of anesthetics and of other medications were similar in both groups  pregnancy outcomes between the two groups were similar  however  the increased risk for premature labor among female residents is a cause for concern and should be further investigated  
class10	immunopathology and viral reactivation  a general theory of schizophrenia  a theory is proposed that explains a broad range of clinical manifestations in schizophrenia  it is a heuristic device for organizing research in the neuroimmunology and virology of schizophrenia  this approach is different from other immune and viral theories of schizophrenia and defines testable hypotheses for further theory refinement or rejection  defective alpha interferon  aifn  regulation resulting in excessive effect is postulated to cause schizophrenia  the role of aifn in the regulation of development and its induction within the brain by the reactivation of viruses that are commonly present in the normal central nervous system  cns  are the primary pathophysiological mechanisms  biological properties of aifn include neural excitation  opiate and adrenocorticotropic hormone activity  and inhibition of cellular proliferation and differentiation  psychosis results from in situ viral stimulation of aifn production in the cns of a vulnerable host having defective regulation of either sensitivity or production  negative symptoms result from aifn effects on cns development and the behavioral toxicity of aifn  biological developmental abnormalities  gender differences in severity  and decline in psychotic symptoms with age are discussed in the context of the theory  research strategies and specific testable hypotheses are presented  
class10	multiple muscle enzyme release with psychiatric illness  associations  p less than  001  between serum concentrations of lactate dehydrogenase  ldh  and glutamic oxaloacetic transaminase  sgot  were observed in physically well patients with mania  n   100  r    70   depression  n   138  r    51   chronic schizophrenia  n   85  r    68   and schizoaffective or atypical psychosis  n   39  r    52  discharged from 1978 through 1981  in contrast  there was a negligible association between these enzymes in 90 nonpsychiatric inpatient control subjects  patients with mania  229 0     106 1 iu l  showed significantly  t   3 16  p less than  002  two tailed  higher lactate dehydrogenase  ldh  levels than control subjects  191     41 7 iu l  and a 14  incidence of abnormally high serum ldh levels vs  1  among control subjects  results were unchanged when patients taking neuroleptics were excluded  these results indicate that psychiatric illness  especially mania  induces release of ldh and sgot  occasionally to unusually high levels  this is similar to previous reports of muscle creatine phosphokinase release in psychiatric patients  presumably  these enzymes are released from skeletal muscle in association with agitation  with muscle tension  or with blood stasis and local tissue hypoxia consequent to hypoactivity  
class10	infarction in the territory of the medial branch of the posterior inferior cerebellar artery  we report 10 cases of cerebellar infarction in the territory of the medial branch of the posterior inferior cerebellar artery  mpica   axial sections on mri through the middle of the medulla and the cerebellum showed the infarction as a triangular area with a dorsal base and a ventral apex directed towards the fourth ventricle  the infarct also involved the lateral and dorsal medulla when the mpica supplied all or part of these regions  three clinical patterns were observed  1  pseudolabyrinthine signs with or without dysmetria and ataxia when the medulla was spared  marked axial lateropulsion was present in most cases  2  complete or incomplete wallenberg s syndrome  when the medulla was involved  3  silent infarction  these syndromes are precisely those previously attributed to pica occlusion without distinction of the branch involved  no alteration of consciousness was recorded and spontaneous recovery was the rule  cerebellar infarction in the distribution of the mpica can be regarded as a benign condition with a good prognosis  
class10	transcranial electrical motor evoked potentials as a prognostic indicator for motor recovery in stroke patients  transcranial electrical motor evoked potentials  mep  were examined in 33 patients within three days after stroke  normal values for mep and motor central conduction time  cct  were obtained in 46 healthy controls whose meps were evaluated during slight voluntary muscle contraction and at rest  two months later 23 patients were re examined clinically and electrophysiologically  motor function change was correlated with mep results  two months after stroke the patients with normal or prolonged cct had an improved motor function compared with those with absent cct  mep may be a valuable prognostic indicator in the acute stage of paralytic stroke for recovery of motor function  
class10	parkinsonian tremor loses its alternating aspect during non rem sleep and is inhibited by rem sleep  non rem sleep transforms the waking alternating parkinsonian tremor into subclinical repetitive muscle contractions whose amplitude and duration decrease as non rem sleep progresses from stages i to iv  during rem sleep parkinsonian tremor disappears while the isolated muscle events increase significantly  
class10	the effects of cyproheptadine on locomotion and on spasticity in patients with spinal cord injuries  the effects of cyproheptadine  a serotonergic antagonist  were studied in seven patients with spastic paresis of spinal origin  six patients were included in a double blind crossover trial  maximal dose 24 mg day   the patients were evaluated on both their spasticity and locomotor function  four of the patients also participated in an open trial in which cyproheptadine was administered for a minimum of six months at optimal dose  patients walked on a treadmill at full weight bearing when possible  or with 40  of their body weight externally supported  as required  by an overhead harness system  cyproheptadine considerably decreased the sustained ankle clonus and episodes of spontaneous spasms observed in all the patients who previously presented these manifestations of spasticity  two patients who required body weight support  bws  during locomotion could walk at full weight bearing during cyproheptadine therapy  a more normal timing of emg patterns in these patients during cyproheptadine therapy was associated with temporal distance changes and marked improvement of joint angular displacement  in contrast  the other patients showed marginal changes in the emg and the kinematic pattern but eventually managed to walk at a higher speed  these preliminary results suggest that cyproheptadine can reduce spasticity and enhance locomotor function in spinal cord injured patients  
class10	motor unit discharge characteristics and short term synchrony in paraplegic humans  frequency of firing and regularity of discharge of human motor units  and short term synchrony between pairs of motor units  have been assessed in extensor digitorum communis  edc  and tibialis anterior  ta  muscles in control subjects and in clinically complete paraplegic subjects  the discharge pattern of ta motor units in paraplegia ranged from extremely regular to very irregular for different motor units whereas in the control population  and in edc of both groups  there was a narrow  but intermediate  range of regularity  there was little difference in the incidence and degree of short term synchrony  sts  in edc between paraplegic and normal subjects  in contrast  virtually no sts of motor units was observed in the ta muscles of the paraplegic group whereas control subjects exhibited approximately the same amount of sts in their ta and edc muscles  it is concluded that the extra burden placed on arm muscles in paraplegia does not change the amount of synchronisation between motor units  furthermore  section of the spinal cord does not increase sts as predicted from lesions of the reticulospinal tract in cats  this may reflect the coincidental removal of supraspinal synchronising inputs of motoneurons or the reorganisation of synaptic inputs in chronic paraplegia  
class10	magnetic and electrical stimulation of cervical motor roots  technique  site and mechanisms of excitation  cervical motor roots and the brachial plexus were excited transcutaneously with magnetic  magstim  and electrical stimulation  elstim  applied dorsally over the spine and over the supraclavicular fossa  erb s point   the compound muscle action potentials  cmaps  from the abductor digiti minimi  adm  and the biceps muscles  biceps  could be evoked with either stimulating technique in all 52 subjects tested  with magstim over the spinous process c7  greater cmaps were obtained from adm  p less than or equal to 0 0001  paired t test  and biceps  p less than or equal to 0 005  when the inducing current in the coil as viewed from behind was clockwise for the right arm and vice versa  elstim with the cathode over c7 t1 and the anode directed cranially provided greater cmaps from the adm  p less than or equal to 0 0001  and smaller cmaps from the biceps  p less than or equal to 0 01  than with the inverse polarity  magstim of the cervical roots provided cmaps which were smaller from adm  p less than or equal to 0 0001   and greater from biceps  p less than or equal to 0 0001   than elstim  cathode c7 t1   whereas latencies did not differ significantly  p less than or equal to 0 3   when comparing elstim and magstim applied over erb s point  the former yielded greater cmaps and 0 5 ms longer latencies from both the adm and biceps  p less than or equal to 0 001   from these data and additional studies in four patients  including direct intraoperative root stimulation in one of them  it is concluded that elstim and magstim over the spine excite the motor roots at a similar site  that is  within a few cm outside the intervertebral foramina  
class10	eosinophilic meningitis  cause of a chronic pain syndrome  three tourists developed eosinophilic meningitis after visiting the fijian islands  two had a severe and long lasting illness with chronic intractable pain  in one patient electrophysiological studies and mri scan of the brain were abnormal and provided evidence of both radicular and cerebral parenchymal involvement by the most likely causative agent  angiostrongylus cantonensis  
class10	rigid spine syndrome with respiratory failure  the pathogenesis and therapy of respiratory failure in the rigid spine syndrome are discussed in two cases who improved with respiratory assistance  in both cases  the partial pressures of oxygen and carbon dioxide were reversed in arterial blood gas analysis and  vc was less than 30   remission from respiratory failure has been obtained by the use of a ventilator during the night  the cause of the respiratory failure in both cases was severe restrictive respiratory dysfunction due to extreme flattening of the chest and fixation of the thorax during respiration as a result of contracture of costovertebral joints  all the previously reported cases of the rigid spine syndrome with respiratory failure died  appropriate use of the ventilator can improve the prognosis  
class10	learning a unimanual motor skill by partial commissurotomy patients  a series of motor tests on four chinese partial commissurotomy patients is reported  the single stage commissurotomy in all four patients included the anterior commissures and two thirds or four fifths section of the corpus callosum with sparing of the splenium  there was no demonstrable ability to transfer hand posture in these patients  this was the major evidence for functional deconnexion  a newly learned task of one hand knotting revealed right hand impairment in all four patients  there was no dyspraxia in the right hand for over learned object handling tasks in these patients  it is suggested that there might be right hemisphere specialisation for the initial acquisition of unimanual object handling skills and that the spared callosal fibres in the splenium alone are insufficient to mediate task control under these conditions  this is supported by the finding that one of these patients  who was the only one who had a right parietal lesion  was unable to perform the newly learned task with either hand  
class10	involvement of the central nervous system in chronic inflammatory demyelinating polyneuropathy  a clinical  electrophysiological and magnetic resonance imaging study  in a consecutive series of 30 patients with chronic inflammatory demyelinating polyneuropathy  cidp  minor clinical evidence of cns involvement was found in five  cranial magnetic resonance imaging  mri  was performed in 28 and revealed abnormalities consistent with demyelination in nine patients aged less than 50 years and abnormalities in five aged 50 years or over  measurements of central motor conduction time  cmct  were obtained in 18 and showed unilateral or bilateral abnormalities in six  it is concluded that subclinical evidence of central nervous system  cns  involvement is common  at least in patients with cidp in the united kingdom  but that clinically evident signs of cns disease are infrequent  the association of a multiple sclerosis like syndrome with cidp is rare  
class10	hip pain in late pregnancy  hip pain in late pregnancy is quite common  and its etiology is rarely established unless acute demineralization occurs  we measured the bone mineral content of both hips in 26 women within 48 hours of delivery  twelve of 36 densities  33   were decreased in a group with severe pain when compared to 12 of 120 decreased densities  10   in the remaining patients  p less than  05   those data suggest that severe hip pain may be related to a decrease in bone mineral content  
class10	non vesicular release of glutamate from glial cells by reversed electrogenic glutamate uptake  glutamate uptake into nerve and glial cells usually functions to keep the extracellular glutamate concentration low in the central nervous system  but one component of glutamate release from neurons is calcium independent  suggesting a non vesicular release that may be due to a reversal of glutamate uptake  the activity of the electrogenic glutamate uptake carrier can be monitored by measuring the membrane current it produces  and uptake is activated by intracellular potassium ions  here we report that raising the potassium concentration around glial cells evokes an outward current component produced by reversed glutamate uptake  this current is activated by intracellular glutamate and sodium  inhibited by extracellular glutamate and sodium  and increased by membrane depolarization  these results demonstrate a non vesicular mechanism for the release of glutamate from glial cells and neurons  this mechanism may contribute to the neurotoxic rise in extracellular glutamate concentration during brain anoxia  
class10	long term potentiation of electrotonic coupling at mixed synapses  long term potentiation of chemical synapses is closely related to memory and learning  studies of this process have concentrated on chemically mediated excitatory synapses  by contrast  activity dependent modification of gap junctions  which also widely exist in higher structures such as hippocampus and neocortex  has not been described  here we report that at mixed synapses between sensory afferents and an identified reticulospinal neuron  the electrotonic coupling potential can be potentiated  as well as the chemically mediated excitatory postsynaptic potential  for a prolonged time period using a stimulation paradigm like that which produces long term potentiation in hippocampus  the effect on coupling is due to an increase in gap junctional conductance  our data indicate that the potentiation of both synaptic components requires an increase in intracellular calcium  involves activation of nmda  n methyl d aspartate  receptors  and is specific to the tetanized pathway  
class10	indications for thymectomy in myasthenia gravis  fifty six board certified neurologists with interest and expertise in myasthenia completed a survey of indications for thymectomy in myasthenia gravis  thymectomy was advocated for virtually all patients with thymoma  for a variable subset of patients with generalized myasthenia without thymoma  and occasionally for selected patients with disabling ocular myasthenia  
class10	phenotypic heterogeneity of spinal muscular atrophy mapping to chromosome 5q11 2 13 3  sma 5q   we made phenotypic analysis of 14 families with spinal muscular atrophy  sma  linking to chromosome 5q11 2 13 3  sma 5q   and 2 that may not map to this locus  to assess clinical symptoms among sma families known to result from mutation at the identical gene locus  although the current number of families is still small  the correlation of clinical phenotype and molecular genotype supports 2 observations  first  sma mutations at the 5q locus present with a broad continuum of clinical abnormalities  and 2nd  the single clearly unlinked family presents with an unusual phenotype characterized by relatively late onset and early death  thus  there are as yet no unambiguous cases of typical sma families that are clearly unlinked to the locus at 5q ie  no clear cases of nonallelic heterogeneity  analysis of sma 5q families supports the view that  with certain exceptions  there is little phenotypic intrafamilial variability  when families were ranked by severity of disease there was a strong correlation with age of onset  onset within the 1st few months was associated with early death  but not in all cases  with rare exception  onset after 1 year of age was associated with less severe disease and greater longevity  
class10	routine and quantitative eeg analysis in gilles de la tourette s syndrome  gilles de la tourette s syndrome  gdlt  is a neurobehavioral disorder  with a reportedly high frequency of eeg abnormalities  we performed eegs on 48 consecutive patients with gdlt  and frequency analysis in 26 patients  17 males   and compared the results with those from age  and sex matched normal controls  routine 18 channel eeg revealed minimal diffuse nonspecific slowing in only 3 of 48 patients  6   and in 2 of 26 controls  7 7    the frequency analysis of the eeg of the 26 gdlt patients and their normal controls showed similar brain activity  we conclude that no significant differences exist between the eeg activity in gdlt patients as compared with that in sex  and age matched controls in routine as well as in quantitative eeg  
class10	internuclear ophthalmoplegia in the chiari type ii malformation  we describe 3 cases of chiari type ii malformation presenting with bilateral internuclear ophthalmoplegia  ino   although prominent  the ino was not an isolated sign in any of the patients  superimposed abduction paresis was present in 2  and deficits in smooth pursuit  optokinetic nystagmus  and vestibulo ocular responses were present in 3  two had hydrocephalus  1 was clinically unchanged without therapy after 5 years  the other did not improve with shunting  findings in our 3 patients  along with the 4 previously reported  confirm that ino is 1 manifestation of widespread brainstem or cerebellar dysfunction  its origin is probably multifactorial  related to hydrocephalus  vascular compromise  direct neuronal distortion  or congenital neural malformation  
class10	sensory visual testing in idiopathic intracranial hypertension  measures sensitive to change  management decisions in idiopathic intracranial hypertension  iih  pseudotumor cerebri  are based on the presence and change of visual loss  to study this change  we evaluated tests of sensory visual function over time  we used the results of the right eye of 19 patients whose clinical status improved  decrease in papilledema grade   and compared the outcome measures of the initial and final examinations  contrast sensitivity testing showed significant improvement in the middle and high spatial frequency targets  snellen acuity and color tests did not change significantly over the same period  both goldmann and automated visual field grade significantly improved from the initial to the final visit  while the presence of a defect on confrontation visual fields did not  numerical analyses of automated perimetry thresholds also showed significant improvement  generalized loss  most pronounced on the nasal side of the visual field  was present on the initial examination  generalized improvement followed  least in the central and inferior paracentral areas  patients with iih should be followed with contrast sensitivity testing and perimetry using a disease specific strategy  
class10	deteriorating ischemic stroke  risk factors and prognosis  to determine a risk profile of deterioration in cerebral infarction of less than 8 hours  duration  we studied prospectively a series of clinical and radiologic data in 98 patients  we evaluated the canadian neurological scale score and barthel index during a follow up period of 3 months  there was deterioration in the 1st 48 hours in 40 8  of the patients  high systolic blood pressure  elevated blood sugar concentration at admission  and carotid territory involvement were independently related with deterioration in the logistic regression analysis  death occurred in 35  of the patients with deteriorating infarcts and in 8 6  of those with stable infarcts  at the end of the study  functional capacity was lower in those with deteriorating infarcts  but the 2 groups improved in parallel from the 4th day onward  
class10	infantile cns spongy degeneration  14 cases  clinical update  we studied 14 arab infants with infantile spongy degeneration  13 of whom were products of consanguineous marriages  they presented in infancy with macrocephaly  poor visual behavior or blindness  and axial hypotonia with appendicular spasticity  brain ct and mri showed diffuse symmetric leukoencephalopathy  even before neurologic symptoms  there were relatively normal eegs  the visual evoked responses  p100  were either absent or delayed early in the course  the brainstem auditory evoked responses showed milder abnormalities  with loss of later components before the earlier ones  deficient aspartoacylase activity in cultured fibroblasts or brain biopsy confirmed the diagnosis in all patients  
class10	dominantly inherited apathy  central hypoventilation  and parkinson s syndrome  clinical  biochemical  and neuropathologic studies of 2 new cases  we describe 2 new patients from a family in which 10 persons in 3 successive generations had a dominant neuropsychiatric disorder characterized by apathy  central hypoventilation  and parkinsonism  neuropathologically  both patients showed severe neuronal loss and reactive gliosis in the substantia nigra  neurochemical studies showed a marked depletion of dopamine in substantia nigra  putamen  and caudate nucleus  as well as reduction in serotonin content in the substantia nigra  glutamate contents were low in frontal cortex and thalamus  and gamma aminobutyric acid  gaba  contents were low in thalamus and substantia nigra of both patients  in addition  phosphoethanolamine contents were reduced in all brain regions of both patients  especially in the substantia nigra  one patient with severe symptoms had low levels of homovanillic acid  5 hydroxyindoleacetic acid  and gaba in his csf repeatedly for 3 years before death  aged 58   while the 2nd patient died  aged 51  of an unrelated cause before developing any symptoms of the familial disorder  because brain deficiencies of multiple neurotransmitters appear to be involved  this disorder is unlikely to respond to treatment  however  neurochemical studies of csf may make presymptomatic diagnosis feasible  
class10	sensorineural hearing loss  a reversible effect of valproic acid  we report 2 patients over the age of 70 who  while on valproate  vpa  for complex partial seizures  developed sensorineural hearing loss  following discontinuation of vpa for nonaudiologic reasons  the patients reported improved hearing which was confirmed by audiometry  these findings represent vpa induced sensorineural hearing loss  possibly in preexisting presbycusis  
class10	large cystic optic glioma  a 5 1 2 year old boy developed a huge cyst in his chiasmal glioma 4 years after radiation therapy  the cyst produced obtundation but was successfully treated  
class10	study of verbal description in neuropathic pain  the aim of this paper is to study the quality of verbal description and its diagnostic value in neuropathic pain  the verbal description of pain as assessed by a french adjective list questionnaire  qdsa  is compared between a group of 100 patients with neuropathic pain and a mixed group of 97 chronic benign and cancer non neuropathic pain patients  seventeen descriptors of the 61 qdsa descriptors have a significant intergroup frequency difference  by principal component analysis and varimax rotation of the intercorrelation matrix of descriptors in the neuropathic group  7 factors accounting for 66 0  of the total variance are derived  six factors reflect purely sensory or affective aspects of the pain experience  seven descriptors from the discriminant analysis function correctly assign 77  of neuropathic pain patients and 81  of the non neuropathic pain patients  in a second neuropathic pain group of 32 patients  the discriminant function coefficient permits correct diagnostic categorization in 66  of the cases  implications for clinical practice and trials are discussed  
class10	quantification of biomedical findings of chronic pain patients  development of an index of pathology  difficulties in assessing and quantifying the biomedical signs and symptoms that may be related to patients  reports of pain are well recognized  although there appears to be some consensus among physicians as to the potential utility of examination and diagnostic tests frequently used to evaluate chronic pain patients  little attention has been paid to the reliability of interpreting the results of these procedures  moreover  the integration of biomedical findings to form a general index of pathology associated with chronic pain has been a difficult problem to solve because not all biomedical procedures used to evaluate pain patients are necessarily relevant or indicated for a specific patient  two studies are presented that were designed to evaluate the reliability of 23 biomedical procedures commonly used to evaluate chronic pain patients and to determine if findings on these procedures can effectively be combined to form a reliable index of physical pathology  the results of study 1 suggest that 17 of the 23 procedures can be applied in clinical setting with acceptable levels of reliability  study 2 provides evidence that an innovative weighted scoring approach  based on current medical consensus  can be used to produce a reliable  general index of pathology that is independent of the number of procedures used to evaluate patients  the utility of this quantification approach to biomedical findings for clinical and research purposes is discussed  
class10	is emotional disturbance a precipitator or a consequence of chronic pain  the present study examined the relationship between psychological factors and pain in order to assess the contribution of emotional disturbance to the perpetuation of pain  a group of 163 chronic pain suffers in multiple settings was compared with 81 control subjects on measures of personal history antecedent to pain onset  as well as on measures of current emotional disturbance  in addition  these psychological variables were examined for their associations with subjectively rated pain intensity  overall  pain was found to be related to more current depression and less current life satisfaction  but was not associated with most of the personal history variables examined  these results suggests that emotional disturbance in pain patients is more likely to be a consequence than a cause of chronic pain  the dangers of routinely ascribing intractable pain to psychological causation are discussed in the light of these findings  
class10	epidural haematoma requiring surgical decompression following repeated cervical epidural steroid injections for chronic pain  we report a case of epidural haematoma following a steroid injection into the cervical epidural space  the complication occurred on the seventh such injection over a 2 year period for chronic spinal pain  surgical decompression over the seventh cervical and the upper 3 thoracic vertebrae was required to alleviate the symptoms of paralysis and anaesthesia  the patient subsequently required skin grafting to the surgical site and two trans urethral resections of the prostate gland during his 6 week hospital admission  he made a full recovery  
class10	quantitative evaluation of hypnotically suggested hyperaesthesia and analgesia by painful laser stimulation  the ability to reduce both clinically and experimentally induced pain by hypnotic suggestion of analgesia is well known  however  the nature of hypnotic analgesia still remains uncertain  attempts to demonstrate and identify specific psychophysiological mechanisms have  so far  been unsatisfactory  methodological problems in inducing pain and monitoring physiological responses may be the reason for this lack of success  in the present study  we have attempted to eliminate some of these methodological problems  the sensory and pain thresholds to laser stimulation were determined  and the laser evoked brain potentials were measured for 8 highly hypnotically susceptible subjects in 3 conditions   1  waking state   2  suggestion of hyperaesthesia   3  suggestion of analgesia  the thresholds were reduced during induced hyperaesthesia and increased during analgesia  during hyperaesthesia sensations could be evoked by laser intensities which were below intensities that could be perceived in the awake state  the amplitude of the evoked brain potentials increased during hyperaesthesia and decreased during analgesia  the latency of the potential remained constant  the perception of pain during hypnosis can change very fast  indicating that slow endogenous mechanisms may play only a minor role in suggested hyperaesthesia analgesia  
class10	cytoreductive hepatic surgery for neuroendocrine tumors  we retrospectively reviewed 37 patients who underwent hepatic resection between 1970 and 1989 to evaluate the role of cytoreductive hepatic surgery in patients with metastatic neuroendocrine tumors  carcinoid  24  islet cell  13   seventeen resections were curative  no gross residual tumor   nine patients had symptomatic endocrinopathies and seven patients had symptoms caused by the primary tumor  eight of nine patients with symptomatic endorcrinopathies obtained complete relief of symptoms  five are alive with no evidence of disease at 2 to 82 months  mean  26 months   six of seven patients with symptoms caused by the primary tumor obtained complete relief  five are alive with no evidence of disease at 5 to 28 months  mean  14 months   one symptom free patient underwent curative hepatic resection 5 years after abdominoperineal resection for a rectal carcinoid  twenty resections were palliative  gross residual tumor   16 patients had symptomatic endocrinopathies and 4 patients had symptoms caused by the primary tumor  eight of 16 patients with symptomatic endocrinopathies obtained complete relief  five are alive at 2 to 30 months  mean  11 months   with a mean duration of complete relief of 6 months  3 to 12 months   all four patients who underwent resection for symptoms caused by the primary tumor obtained complete relief  two are alive and symptom free at 10 and 101 months  our experience suggests that curative surgery should be considered in all patients with completely resectable metastatic disease and that palliative surgery  despite the short duration of complete relief  should be considered in selected patients because it delays and may reduce the subsequent need for medical therapy  
class10	pharyngeal shape and dimensions in healthy subjects  snorers  and patients with obstructive sleep apnoea  to characterise the relation between pharyngeal anatomy and sleep related disordered breathing  17 men with complaints of snoring were studied by all night polysomnography  ten of them had obstructive sleep apnoea  mean  sd  apnoea hypopnoea index 56 3  41 7   age 52  10  years  body mass index 31 4  5 3  kg m2   whereas seven were simple snorers  apnoea hypopnoea index 6 7  4 6   age 40  17  years  body mass index 25 9  4 3  kg m2   the pharynx was studied by magnetic resonance imaging in all patients and in a group of eight healthy subjects  age 27  6  years  body mass index 21 8  2 2  kg m2  both significantly lower than in the patients  p less than 0 05   on the midsagittal section and six transverse sections equally spaced between the nasopharynx and the hypopharynx several anatomical measurements were performed  results showed that there was no difference between groups in most magnetic resonance imaging measurements  but that on transverse sections the pharyngeal cross section had an elliptic shape with the long axis oriented in the coronal plane in normal subjects  whereas in apnoeic and snoring patients the pharynx was circular or had an elliptic shape but with the long axis oriented in the sagittal plane  it is suggested that the change in pharyngeal cross sectional shape  secondary to a reduction in pharyngeal transverse diameter  may be related to the risk of developing sleep related disordered breathing  
class10	role of serum prolactin determination in evaluation of impotent patient  hyperprolactinemia is a recognized cause of impotence  the discovery of elevated prolactin levels in impotent men is very important since pharmacotherapy in this instance is highly successful  we review our experience with prolactin determinations in impotent men  and a population is defined that may benefit from routine prolactin determination  in our experience  the predominant symptom associated with hyperprolactinemia in men is loss of libido  
class10	retrograde transurethral balloon dilation of prostate  innovative management of abacterial chronic prostatitis and prostatodynia  retrograde transurethral balloon dilatation  rtbd  of the prostate recently has been suggested as alternative therapy for patients with benign prostatic hyperplasia  bph   seven patients with documented functional urinary outlet obstruction at the level of the bladder neck or prostatic urethra underwent rtbd of prostate  each patient had a classic diagnosis of abacterial chronic prostatitis or prostatodynia based on history  physical examination  and localization cultures  prior to rtbd of prostate  patients underwent cystoscopy  voiding cystourethrogram  urodynamic and uroflow studies  rtbd of prostate was done as an outpatient procedure requiring intravenous sedation or general anesthesia  dilation was performed with a 25 mm urethroplasty balloon catheter inflated at 3 5 atm of pressure for twenty minutes  improvement in voiding symptomatology was noted in all patients and graded numerically  0 10 scale   with ten indicating normal voiding  follow up to date ranges from one to five months  this technique may have promise as a treatment option in patients with abacterial chronic prostatitis and prostatodynia  
class10	protecting the vasculature  an eye toward the future  although calcium antagonists were originally developed for use in the management of patients with angina pectoris  they are now used in the management of other cardiovascular disorders  including hypertension  more recently  the calcium antagonists have been under investigation for their potential protective role in atherosclerosis  coupled with these new possibilities for therapeutic use are the development of new  long acting  tissue specific calcium antagonists  amlodipine belongs to this group  and although it is a dihydropyridine based calcium antagonist  its pharmacologic profile differs from that of other dihydropyridine based calcium antagonists  differences include  different ph optimum for receptor binding  different rates of association and dissociation  and differences in allosteric interaction with the diltiazem and verapamil binding sites  amlodipine  when given orally to rabbits receiving a high cholesterol diet  reduces atheroma formation  evidence of its ability to protect the vasculature is provided by its ability to significantly increase  p less than 0 001  survival in stroke prone hypertensive rats  
class10	anisocoria in the pigmentary dispersion syndrome we studied four patients with anisocoria and the pigmentary dispersion syndrome  in all patients  the larger pupil was on the side of the greater iris transillumination  the amount of anisocoria was between 0 5 and 1 5 mm and was the same in both the light and dark  there was no blepharoptosis  and all pupils dilated normally with cocaine  all of the patients were young men with myopia  and one patient had increased intraocular pressure  
class10	laser placement in noncontact nd yag cyclophotocoagulation  we treated 40 eyes of 40 patients by using noncontact transscleral nd yag cyclophotocoagulation to determine whether treatment 1 5 or 3 0 mm posterior to the corneoscleral lumbus was preferable  patients were randomly assigned to one of the treatment groups  and all other variables  including power  number  and distribution of laser applications  were kept constant  six months postoperatively  those treated 1 5 mm posterior to the corneoscleral limbus had a lower intraocular pressure  p    0047  than those treated 3 0 mm from the corneoscleral limbus  the 1 5 mm group also required fewer retreatment  p    017  and had a slightly lower occurrence of visual acuity loss after this procedure  we believe it may be advantageous to locate the laser application approximately 1 5 mm posterior to the corneoscleral limbus  rather than further posteriorly  when performing noncontact transscleral nd yag cyclophotocoagulation  
class10	antinociceptive interaction between opioids and medetomidine  systemic additivity and spinal synergy  the antinociceptive interaction on the tail flick  tf  and hot plate  hp  tests between opioid analgesics and medetomidine after intravenous  iv  or intrathecal administration were examined by isobolographic analysis  male sprague dawley rats received fixed ratios of medetomidine to morphine  fentanyl  and meperidine of 1 10 and 1 30  10 1  and 1 3  respectively  by iv administration or 10 1  3 1 and 10 1  and 1 3 by intrathecal administration  respectively  data were expressed as the percentage maximal possible effect   mpe   the a50  dose producing 50  mpe  for each drug or drug combination was determined from the dose response curve  isobolographic analysis revealed that the effect of medetomidine combined with fentanyl  morphine  or meperidine was additive after iv administration  the intrathecal administration of combinations of medetomidine with the opioids produced a synergistic antinociceptive effect in the tf but not hp test  these data confirmed that the interaction between medetomidine and opioids in producing antinociception may be additive or synergistic  depending on the route of administration  drug ratio administered  and level of processing of the nociceptive input  i e   spinal vs  supraspinal   moreover  these results were consistent with a spinal role for alpha 2 adrenoceptors in mediating antinociception  the authors suggest that the interaction between the opioid and alpha 2 adrenergic receptors occurs within the spinal cord  
class10	calcium antagonists in the management of patients with aneurysmal subarachnoid hemorrhage  a review  cerebral arterial vasospasm and infarction is the leading cause of death and disability among patients who reach a major medical center after aneurysmal subarachnoid hemorrhage  sah   recent evidence suggests that two calcium antagonists  nimodipine or nicardipine  may be useful in preventing this important complication of sah  this paper reviews the current status of these two calcium antagonists in the management of sah  
class10	sudden blindness after thermocoagulation of the trigeminal ganglion  sudden blindness during percutaneous thermocoagulation of the gasserian ganglion occurred in a 72 year old woman with trigeminal neuralgia  considered a safe procedure  we highlight the possibility of this serious complication which was probably due to direct damage of the optic nerve  
class10	short stature  mental retardation  and hypoparathyroidism  a new syndrome  eight children  four boys and four girls  with extreme failure to thrive  dysmorphic features  developmental delay  hypoparathyroidism  and abnormal skeletal survey were studied  they were the products of seven consanguinous marriages  two of the patients being brothers  in the remaining six families  a further four children had affected siblings who had died in infancy  when assessed the children were aged 0 47 12 8 years  sd scores were less than  2 for height  weight  and head circumference in all patients  the children had identical facies with deep set eyes  depressed nasal bridge with beaked nose  long philtrum  thin upper lip  micrognathia  and large floppy earlobes  they were all developmentally retarded  the following abnormalities were found on investigation  hypocalcaemia in all  of whom six of seven had hypoparathyroidism   medullary stenosis and other skeletal survey defects in seven of the eight children  and reduced numbers of t cell subsets in four of four tested  we believe that these children represent a new  as yet undescribed genetically determined syndrome  
class10	survey of adolescents with severe intellectual handicap  a diagnostic survey was undertaken of children aged 11 to 19 years in tameside with severe learning difficulties  intelligence quotient less than or equal to 50   eighty two children were identified and their medical records reviewed  a specific diagnosis for the retardation was documented in 25  30   of the children  18 of whom had down s syndrome  a probable aetiology or a disorder of unknown aetiology had been identified in a further 21  26   children  to confirm the existing diagnosis  identify new diagnoses  and offer genetic counselling  the parents of 63 children were offered detailed reassessment of their child  fifty three children were reviewed  and a specific disorder identified in 25 out of 31 previously undiagnosed children  the most frequent diagnoses made were fragile x syndrome and rett s syndrome  on completion of the survey  61 of the 82 children  74   had a specific diagnosis or probable aetiology identified  12  15   had associated disorders such as cerebral palsy  and in only nine of the 82 children  11   were there no clues at all to the cause of their retardation  
class10	continuous papaveretum infusion for the control of pain in painful sickling crisis  we describe our experience of using continuous papaveretum infusions to control pain in 24 children admitted on 45 occasions with painful sickling crisis  the children were aged from 1 7 to 14 3 years  infusion duration ranged from one to nine days  median three days   total dose from 0 3 to 21 mg kg  median 2 4 mg kg   with a pronounced tendency for dosage to increase with increasing age  no respiratory depression was observed  one infusion was discontinued because of cerebral toxicity  
class10	benign intracranial hypertension after ciprofloxacin administration  many drugs  including antibiotics  have been implicated in the aetiology of benign intracranial hypertension  we report the development of benign intracranial hypertension after the use of ciprofloxacin in a teenager with cystic fibrosis  
class10	endocrine function and morphological findings in patients with disorders of the hypothalamo pituitary area  a study with magnetic resonance  evaluation of the sellar area was performed with magnetic resonance imaging in 101 patients  age range 0 8 27 years  with hypopituitarism  isolated diabetes insipidus  hypogonadotrophic hypogonadism  and central precocious puberty  the hypopituitary patients  n   70  included multiple pituitary deficiency  n   23   pituitary deficiency with diabetes insipidus  n   5   and isolated growth hormone deficiency  n   42   the patients with multiple pituitary deficiency showed pathological morphological findings in all cases  with stalk and posterior lobe always involved  the group with associated diabetes insipidus had abnormal stalk in four of five cases and posterior lobe not visible in all cases  only five of 42  12   patients with isolated growth hormone deficiency had abnormalities of the sellar area  in two out of four patients with isolated diabetes insipidus posterior lobe was not seen  all patients with hypogonadotrophic hypogonadism  three with kallmann s syndrome  one prader willi syndrome  and two idiopathic hypogonadism  appeared normal  in precocious puberty  n   21  the three patients with onset of symptoms before age 2 years exhibited a hypothalamic hamartoma  whereas in the others with onset of puberty between age 2 and 7 the magnetic resonance image was normal in 17 of 18 patients  the probability of finding a pathological magnetic resonance image was considerably high in our patients with multiple pituitary deficiency  isolated diabetes insipidus  and precocious puberty with very early onset of symptoms  on the contrary  purely functional abnormality is suggested in most patients with isolated growth hormone deficiency  hypogonadotrophic hypogonadism  and precocious puberty with later onset of symptoms  
class10	central nervous system vasculitis after chickenpox  cause or coincidence  a 7 5 year old boy  known to have a seizure disorder  presented with an infarct in the left middle cerebral artery territory  10 weeks after severe chickenpox  immunofluorescent antibody titre to the varicella zoster virus in the cerebrospinal fluid was 1 32  cerebral angiography showed evidence of focal vasculitis  he presented again seven months later with an acute exacerbation of seizures  magnetic resonance imaging of the brain showed an old posterior extension of the infarct  but a repeated angiography demonstrated an improvement in the vasculitic process  cerebrospinal fluid antibody titre was again 1 32  although this may have been an unfortunate coincidence  a possible association between chickenpox and vasculitis  similar to that reported with herpes zoster  and with potentially significant clinical implications  should be considered  as a definite proof can be obtained only by a brain biopsy  however  which is generally not indicated in such cases  only additional clinical reports can lead to delineation of this association as a definite entity  
class10	pneumocephalus secondary to a high pressure water injury to the nose  we report a case of pneumocephalus following a water jet injury to the nose incurred during a water skiing fall  pneumocephalus due to this type of injury has not been previously reported  to our knowledge  since this unusual injury may be associated with serious complications  it must be promptly recognized and treated  
class10	quantitative assessment of extradural bupivacaine analgesia  bupivacaine  0 5   20 ml was administered extradurally to six healthy volunteers  it was found that simultaneous application of 10 needles to the skin could evoke pain when analgesia was obtained to one needle stimulation  in addition  a laser beam was used as a quantitative technique to activate simultaneously many cutaneous nociceptors  for 7 h  thresholds  sensory and pain  and pain evoked brain potentials  amplitude and latency  to laser stimulation were monitored and used for quantitative assessment of onset  efficacy and duration of analgesia at various dermatomes  c7  t8  t10  t12  l1  l3  s1   the onset time of analgesia was shortest and conduction delay longest at the dermatome related to the site of injection  l3   full analgesia was obtained at l1  l3 and s1  although the peak efficacy at s1 was delayed for 120 180 min after injection  a minor effect was found at dermatome c7 approximately 60 min after injection  
class10	onset phase of spinal bupivacaine analgesia assessed quantitatively by laser stimulation  analgesia was assessed quantitatively at various dermatomes  c7  t8  t10  t12  l1  l3  s1  for the first 30 min after subarachnoid administration of 0 5  bupivacaine 3 5 ml  stimulation with 10 needles and laser stimulation could evoke pain in dermatomes with adequate analgesia to single needle stimulation  analgesia was assessed by thresholds  sensory and pain  and by pain related brain potentials  amplitude and latency  to laser stimulation  little analgesia was found at t10  but it increased gradually towards caudal segments  the dermatome related to the site of the injection  l3  was not blocked to a greater extent than the surrounding dermatomes  conduction time  the latency of the evoked brain potential  was increased relatively more from the s1 dermatome compared with l1  
class10	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  
class10	7th nerve palsy after extradural blood patch  we describe a patient who developed a 7th cranial nerve palsy following an extradural blood patch  full recovery followed  the likely aetiology is discussed  
class10	bladder function in the mentally retarded  a group of 21 mentally retarded patients with severe  long standing urinary symptoms underwent urodynamical investigation  the most common abnormalities were detrusor areflexia and detrusor hyper reflexia  of 11 patients treated surgically  10 derived marked benefit  drugs were successful in reducing micturition problems in 3 6 patients  severely retarded patients with spastic quadriplegia are difficult to investigate and if this is associated with detrusor hyper reflexia it is impossible to treat them in any way  severely retarded patients with detrusor areflexia and infrequent voiding can benefit from bladder outlet surgery  patients with moderate  especially mild  retardation can be investigated and treated in the same way as non retarded people  
class10	lens opacity as a predictor of visual field impairment due to cataract  the contribution of cataract to the decrease of visual field in patients with glaucoma is difficult to ascertain  to attempt to quantitate the change in visual field due to cataract  we examined 27 eyes of 26 patients before and after cataract extraction  the examination consisted of measurement of best refraction with visual acuity  visual field testing with the pupil dilated  measurement of lens opacity  determination of the intraocular pressure  and evaluation of the character of the cataract before surgery and of the posterior capsule after surgery  the results reaffirmed the detrimental effect that cataract may have on the visual field but also showed that the heterogeneity of cataracts limits the usefulness of the lens opacity meter in quantitating the extent of visual field loss due to cataract  
class10	choroid plexus tumors in the breast cancer sarcoma syndrome  choroid plexus neoplasms are rare epithelial tumors of the central nervous system  a carcinoma of the choroid plexus occurred in a child from a family with the breast cancer sarcoma syndrome  li fraumeni or sbla syndrome   an inherited condition characterized by the development of diverse neoplasms  sarcoma  breast cancer  brain tumors  leukemia  adrenal cortical carcinoma  and others   choroid plexus carcinomas were identified in two kindreds previously reported with the syndrome  the literature contains reports of choroid plexus neoplasms occurring in families and in individuals with multiple primary tumors  choroid plexus neoplasm may be a manifestation of the inherited proclivity to tumor development in the breast cancer sarcoma syndrome  
class10	codeine increases pain thresholds to copper vapor laser stimuli in extensive but not poor metabolizers of sparteine  the analgesic efficacy and kinetics of a single oral dose of 75 mg codeine was investigated in 12 extensive metabolizers and 12 poor metabolizers of sparteine in a double blind  placebo controlled crossover study  the cosegregation of the o demethylation of codeine to morphine with the sparteine oxidation polymorphism was confirmed  hence morphine could not be detected in the plasma of any of the poor metabolizers  whereas detectable morphine plasma levels were found in 10 of 12 extensive metabolizers  pain thresholds to laser stimuli were determined before drug intake and 90  150  and 210 minutes after drug intake  codeine significantly increased the pricking pain thresholds in the extensive metabolizers  p less than 0 05   whereas there were no significant changes in the poor metabolizers  no change in pain thresholds occurred with placebo in any of the two phenotypes  in the extensive metabolizers there was a significant positive correlation between the increase in pain threshold and plasma concentration of codeine  the study supports the hypothesis that morphine formation is essential for achievement of analgesia during codeine treatment  
class10	effects of a multidisciplinary management program on neurologically impaired patients with dysphagia  dysphagia is a major problem in patients with neurologic disorders  aspiration pneumonia and impaired nutritional status are consequences of dysphagia that result in high morbidity and mortality rates  assessment and treatment of the dysphagic patient by a multidisciplinary team have been advocated but to date the effects of such an approach have not been demonstrated quantitatively  this prospective study was conducted to determine if a dysphagia program would improve patients  caloric intake and body weight  decrease the instances of aspiration pneumonia  or improve patients  feeding ability  patients were referred from a 26 bed neurology neurosurgery unit  a time series design was utilized  the control group consisted of 15 patients  mean age   46 1 years   managed according to the existing ward routine  subsequently  nursing staff attended a dysphagia training program  following this  the treated group of 16 patients   mean age   49 3 years  was assessed by the dysphagia team  using bedside and videofluoroscopic examinations to determine the specific swallowing disorder  an individualized treatment program was designed for each patient  the groups were compared on the basis of deviation from their baseline weight  deviation from ideal energy intake  and the incidence of aspiration pneumonia  statistical analysis revealed that the groups were comparable in age  number of days on the study  and glasgow coma scale score  and that a significant weight gain and increase in caloric intake occurred in the treated group  no incidence of aspiration pneumonia was reported in either group  we speculate that this may have been influenced by the meticulousness of the care delivered in an acute unit as well as greater attention to prevention given in both groups  
class10	changes in thermal and mechanical pain thresholds in hand amputees  a clinical and physiological long term follow up  in a previous study  allodynia to cold and vibratory stimuli was found in the finger stumps of 24 patients with amputations  control values being obtained from fingers of the intact contralateral hand  when treated with regional intravenous guanethidine block  rgb   some of the patients only had short lasting relief of symptoms  whereas others experienced a more long lasting beneficial effect  in the present long term follow up study the patients were re examined 6 years after the rgb treatment  the aim was to investigate whether the earlier symptoms and signs persisted  and whether there were any differences in these respects  between patients with long lasting  group 1  and short lasting relief of symptoms after rgb  group 2   all 24 patients were asked to answer a questionnaire concerning their clinical symptoms  in addition  14 of them visited the laboratory for determination of thermal and vibration induced pain thresholds  comparisons were made with values obtained at the first examination before rgb treatment and with values from 14 healthy subjects tested in a similar way on 2 occasions with an interval of 8 years  twenty of 23 patients reported that cold exposure still evoked stump pain  however  the threshold measurements showed that with time the patients had become more tolerant to thermal stimuli not only in the injured but also in the uninjured hand  a rise in pain threshold was also observed when vibration induced pain was tested in the injured hand  there was no significant difference between groups 1 and 2  similar changes in pain thresholds with time were not observed in the group of healthy control subjects  
class10	recurrent pain  illness intrusiveness  and quality of life in end stage renal disease  repeated episodes of headache and muscle cramp were hypothesized to contribute to increased patient perceptions of illness intrusiveness and to compromised quality of life  standard measures of pain  illness intrusiveness  and quality of life were obtained on 2 occasions  each 6 weeks apart  from 100 end stage renal disease patients  the impact of recurrent muscle cramps on perceptions of illness intrusiveness was conditional upon the occurrence of headache symptoms  perceptions of illness intrusiveness were significantly higher when both muscle cramp and headache symptoms occurred during one or more assessment intervals as compared to when muscle cramps or headaches  only  occurred  illness related concerns and general feelings of pessimism were also significantly higher among patients who experienced recurrent episodes of muscle cramp  although no direct relations were observed between pain and other quality of life indicators  previous research has documented a relation between illness intrusiveness and quality of life  recurrent pain problems  thus  appear to contribute to increased illness intrusiveness and to reduced quality of life in end stage renal disease patients  
class10	health locus of control  gender differences and adjustment to persistent pain  locus of control  loc  beliefs  long thought important in adjustment to persistent pain  were studied among 160 subjects  67 males and 93 females  referred to a comprehensive pain rehabilitation program  the subscale structure of the multidimensional health locus of control  mhlc  was factorially replicated in our sample  three unique mhlc profile clusters were identified for both males and females  among men  cluster assignment was related to age only  the younger male patients reported a stronger internal attributional style  older male patients relied more heavily on both chance and powerful other factors  among women  cluster assignment was related to the use of coping strategies  for example  patients with high internal scores only  reflecting a strong internal orientation towards self management of health care needs  were more likely to utilize information seeking  self blame  and threat minimization coping strategies than patients with high scores on both the internal and powerful other factors  it appears that the presence of both internal and powerful other health attributional styles is associated with less frequent use of cognitive self management techniques  in understanding the loc scores it is important to rely on pattern analysis of scores  implications for clinical treatment are discussed  
class10	neonatal facial and cry responses to invasive and non invasive procedures  evaluation of pain in neonates is difficult due to their limited means of communication  the aim was to determine whether behavioural reactions of cry and facial activity provoked by an invasive procedure could be discriminated from responses to non invasive tactile events  thirty six healthy full term infants  mean age 2 2 h  received 3 procedures in counterbalanced order  intramuscular injection  application of triple dye to the umbilical stub  and rubbing thigh with alcohol  significant effects of procedure were found for total face activity and latency to face movement  a cluster of facial actions comprised of brow bulging  eyes squeezed shut  deepening of the naso labial furrow and open mouth was associated most frequently with the invasive procedure  comparisons between the 2 non invasive procedures showed more facial activity to thigh swabbing and least to application of triple dye to the umbilical cord  acoustic analysis of cry showed statistically significant differences across procedures only for latency to cry and cry duration for the group as a whole  however  babies who cried to two procedures showed higher pitch and greater intensity to the injection  there were no significant differences in melody  dysphonation  or jitter  methodological difficulties for investigators in this area were examined  including criteria for the selection of cries for analysis  and the logical and statistical challenges of contrasting cries induced by different conditions when some babies do not always cry  it was concluded that facial expression  in combination with short latency to onset of cry and long duration of first cry cycle typifies reaction to acute invasive procedures  
class10	treatment of reflex sympathetic dystrophy with topical capsaicin  case report  a 31 year old woman with intractable reflex sympathetic dystrophy experienced nearly complete  though temporary  resolution of pain following 3 weeks of topical capsaicin  we propose that capsaicin may be a useful treatment for reflex sympathetic dystrophy  either by depleting substance p from primary afferent neurons that mediate allodynia  or by modulating sympathetic efferent activity  
class10	receptor changes in the spinal cord of sheep associated with exposure to chronic pain  there is evidence that post injury hypersensitivity is partly due to changes in the central nervous system  sheep with foot rot were used to investigate the effect of chronic pain on some receptors thought to be involved in spinal nociceptive processing systems  alpha 2 adrenoceptor and mu and delta opioid receptors   saturation binding studies showed a variable distribution of  3h  clonidine  alpha 2 adrenoceptor agonist  in the spinal cord of normal sheep  the number of receptors  bmax  present in areas thought to be involved in nociceptive processing  laminae i and ii and lamina x  increased to 131  and 169  of control sheep values respectively in animals exposed to chronic pain  the affinity of the receptors  kd   however  remained unchanged at approximately 2 nm  there was less  3h dago  mu opioid agonist  and  3h dpdpe  delta opioid agonist  binding in the sheep spinal cord  both opioid receptor types being mainly located in the superficial dorsal horn  the  3h dpdpe binding was unchanged in the sheep with foot rot  whilst the number  bmax   but not the affinity  of the  3h dago binding sites increased in laminae i and ii in lame animals to 130  of the control sheep values  hence  in animals in chronic pain  the number of alpha 2 adrenoceptors and mu opioid receptors increased mainly in areas of the sheep spinal cord associated with nociception  
class10	characterization of descending inhibition and facilitation from the nuclei reticularis gigantocellularis and gigantocellularis pars alpha in the rat  descending influences on the spinal nociceptive tail flick  tf  reflex produced by focal electrical stimulation and glutamate microinjection in the nuclei reticularis gigantocellularis  ngc  and gigantocellularis pars alpha  ngc alpha  were examined and characterized in rats lightly anesthetized with pentobarbital  both inhibition and facilitation of the tf reflex were produced by electrical stimulation at identical sites in the ngc ngc alpha  glutamate microinjection only inhibited the tf reflex  the chronaxie of stimulation for inhibition of the tf reflex was 169     28 microseconds  inhibition of the tf reflex by stimulation was produced throughout the ngc and ngc alpha  intensities of stimulation for inhibition were least in the ventral ngc and in the ngc alpha  at threshold intensities of stimulation  inhibition of the tf reflex did not outlast the period of stimulation  facilitation of the tf reflex was produced at many of the same sites at which stimulation inhibited the tf reflex  but always at lesser intensities of stimulation  mean  10 microa vs  43 microa for inhibition  n   25   stimulation in the ngc ngc alpha at threshold intensities for facilitation or inhibition of the tf reflex did not significantly affect blood pressure  strength duration characterization of electrical stimulation and microinjection of glutamate into identical sites in the ngc and ngc alpha suggest that descending inhibition of the tf reflex results from activation of cell bodies in the ngc and ngc alpha  
class10	transcranial electrical stimulation with high frequency intermittent current  limoge s  potentiates opiate induced analgesia  blind studies  transcutaneous cranial electrical stimulation  tces  with high frequency  166 khz  intermittent current  100 hz  limoge current  has been used for several years in cardiac  thoracic  abdominal  urological and micro surgery  the main benefits are a reduced requirement for analgesic drugs  especially opiates  and a long lasting postoperative analgesia  we have confirmed these clinical observations in rats using the tail flick latency  tfl  test to measure pain threshold  tces was not found to modify the pain threshold in drug free rats  but it potentiated morphine induced analgesia  systemic injection   to obtain a maximal effect  the stimulation must be initiated 3 h before the drug injection and be maintained throughout the duration of its pharmacological action  tces potentitation was found to depend on the dose of the drug  the intensity of the current and the polarity of electrodes  these findings were confirmed by blind tests of the efficiency of tces on several opiate analgesic drugs currently used in human surgery  morphine  fentanyl  alfentanil and dextromoramide   the analgesic effect of these 4 opiates  tfl as   of baseline without or with tces  were respectively  174   306   176   336   160   215   and 267   392   the results were obtained not only after systemic opiate treatment  but also after intracerebroventricular injection of morphine  10 micrograms  analgesic effect 152   207  with tces  suggesting that tces potentiation of opiate induced analgesia is centrally mediated  
class10	induction  blockade and restoration of a persistent hypersensitive state  a new model of chronic hypersensitivity was developed in the rat by daily intraplantar administration of either prostaglandin e2 dopamine or isoprenaline  for a period of 2 weeks  like other hyperalgesic mediators  dibutyryl camp  when applied to the paws  caused an acute effect but did not produce persistent hypersensitivity  the persistent hypersensitive state was not affected by a typical non steroidal anti inflammatory drug  indomethacin   was temporarily inhibited by a centrally acting analgesic  morphine   was partially inhibited by a protein synthesis inhibitor  cycloheximide  and abolished by a single dose of peripherally acting analgesics such as dipyrone or n methyl morphine  once the residual hypersensitivity had been abolished with dipyrone or n methyl morphine  a small dose of prostaglandin e2  dopamine or interleukin 1 beta  which in normal animals causes a mild and short lived effect  restored the persistent hypersensitive state  this ability to restore the persistent effect was not observed with intraplantar administration of dibutyryl camp  our results suggest the existence of a peripheral trace of inflammatory pain  a phenomenon which may be associated with stimulation of neuronal adenylate cyclase and protein synthesis  this concept may explain part of the puzzle of chronic inflammatory pain and lead to the development of new analgesics  
class10	the influence of warning signal timing and cognitive preparation on the aversiveness of electric shock  many medical and dental procedures are noxious  finding an optimal way of warning patients concerning the aversive procedures could help them to cope better  a model for the effective use of a warning signal in coping with pain posited that a person needs enough time to be able to react and should possess the skills necessary to utilize the time effectively  it was felt that a very short warning period  e g   5 sec  could not be long enough  while a 180 sec warning period would in and of itself become aversive  reactions to electric shock were obtained from 36 paid  volunteer subjects who were each tested on a within subject  counterbalanced order at 4 different warning periods  5  30  60  and 180 sec  the subjects were divided into 3 groups   1  the experimental group was provided with a pretested self instructional booklet to learn a variety of pain control techniques   2  the placebo group was provided with a self instructional booklet on citizenship   3  the control group waited quietly for 13 min  no significant results were obtained for the different pain coping conditions  significant differences  however  were obtained for the various warning periods  maximum skin resistance changes  higher ratings of pain and of anxiety were obtained for the 60 and 180 compared to the 5 and 30 sec warning periods  maximum heart rate was obtained for the 30 sec warning  results were discussed in terms of the psychological meaning of the various measures as well as their clinical implications  
class10	efficacy of methylphenidate among mentally retarded children with attention deficit hyperactivity disorder  twelve children with iq scores of 50 to 74  educable mental retardation  who met rigorous diagnostic criteria for attention deficit hyperactivity disorder participated in a double blind crossover study of the efficacy of two doses of methylphenidate compared with placebo  dependent measures included behavioral ratings  classroom work output  laboratory measures of attention and learning  and direct observations of social behavior  improvement with medication on the conners hyperactivity index was observed in 75  of subjects  significant increases in work output  on task behavior  and attentional skills were associated with methylphenidate  however  gains in measures of attention were not associated with improvement in learning  as measured by a paired associate learning task  additionally  no significant increases in appropriate social interactions during free play were associated with methylphenidate  the results suggest that mentally retarded children with attention deficit hyperactivity disorder respond to methylphenidate at similar rates and in similar domains to that of the nonretarded population  
class10	quantifying language development from birth to 3 years using the early language milestone scale  a point scoring technique for the early language milestone scale is described  normative data based on the original 1982 cross sectional sample and validation data based on a separate longitudinal sample are presented  mean early language milestone scale point scores  standard deviations  and percentile equivalents for raw point scores are presented for all ages from birth to 36 months  correlations between point scores on the early language milestone scale and scores on other standardized developmental tests such as the stanford binet intelligence scale  the peabody picture vocabulary test  and the illinois test of psycholinguistic abilities are presented  the clinical and research advantages of this point scoring technique are presented and compared with the original pass fail scoring method  
class10	unilateral hydrocephalus in adults  the authors report 14 cases of unilateral hydrocephalus in adults  headache was the most common presenting symptom  unilateral hydrocephalus was documented in each patient with computed tomography scans  magnetic resonance imaging was also used in seven patients in the latter part of the series  unilateral hydrocephalus was caused by tumor  seven patients   venous angioma  one patient   ependymal cyst  one patient   postinflammatory gliosis  one patient   and was idiopathic in four patients  the primary surgical treatment was craniotomy with fenestration of the septum pellucidum  which relieved symptoms in eight of nine patients for whom long term follow up data were available  
class10	cerebrospinal fluid endothelin 1 and endothelin 3 levels in normal and neurosurgical patients  a clinical study and literature review  endothelins are a family of structurally related  potent  long lasting vasoconstrictor peptides  there are no established normal human levels of endothelin 1 or endothelin 3 in the cerebrospinal fluid  we measured cerebrospinal fluid endothelin 1 and endothelin 3 levels in five groups of patients  normal controls  patients with subarachnoid hemorrhage and cerebral vasospasm  patients with severe head injuries  patients undergoing temporal lobectomy for intractable epilepsy  and a patient with a gunshot injury to the thoracic spine  endothelin 3 levels were significantly elevated in patients with subarachnoid hemorrhage and may participate in cerebral vasospasm and subsequent neurologic deterioration  
class10	familial trigeminal neuralgia and charcot marie tooth neuropathy  report of two families and review  typical trigeminal neuralgia has occasionally occurred in multiple members of the same family over several generations  the clinical features of such cases  including the increased incidence in females  and the absence of other apparent hereditary  neurologic  metabolic  or structural abnormalities were identical to those of sporadic cases  more rarely  familial trigeminal neuralgia has been described in the setting of hereditary peripheral neuropathy  especially charcot marie tooth disease  we describe patients from two different families with charcot marie tooth disease and medically intractable trigeminal neuralgia  both patients were successfully treated by percutaneous retrogasserian glycerol rhizolysis  the occurrence of cranial nerve symptoms in patients with demyelinating peripheral neuropathies is discussed in light of the current hypotheses regarding the etiology of trigeminal neuralgia  
class10	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  
class10	surgical correction of the snapping iliopsoas tendon  eighteen patients with 20 symptomatic hips underwent lengthening of the iliopsoas tendon for persistent painful snapping of this  internal  variety of snapping hip  we referred to the pathologic  painful snapping of the iliopsoas in the deep anterior groin as the  internal  snapping hip  this is in contrast to the more common and better known  external  snapping that involves the greater trochanter and its overlying soft tissues  the results of our iliopsoas lengthening procedure are presented here  lengthening of the iliopsoas tendon was accomplished by step cutting of the tendinous portion of the iliopsoas  the pathoanatomy of this poorly understood symptom complex was described in 1984 paper from this institution and is reviewed here  iliopsoas bursography demonstrated a sudden jerking movement of the iliopsoas tendon between the anterior inferior iliac spine and iliopectineal eminence  synchronous with the patient s pain and often accompanied by an audible snap  the average preoperative duration of symptoms was 2 9 years  and the average length of postoperative followup was 25 months  all patients  except one  had a marked reduction in the frequency of snapping after tendon lengthening  and 14 of 20 hips had no snapping postoperatively  of the six patients who had recurrence of snapping  all but one stated that this occurred much less frequently and was much less painful compared to the preoperative state  two hips required reoperation  postoperatively  only three patients complained of subjective weakness  and most patients were unlimited in physical activity with return to activities such as competitive football  pole vaulting  and long distance running  
class10	anteromedial tibial tubercle transfer without bone graft  we followed 30 patients for more than 2 years after anteromedial tibial tubercle transfer for persistent patellofemoral pain associated with patellar articular degeneration  twelve of these patients were followed more than 5 years  we report 93  good and excellent results subjectively and 89  good and excellent results objectively  the quality of improvement was sustained in all 12 of the patients who were evaluated again after more than 5 years from surgery  when examined separately  75  of those patients with advanced patellar arthrosis achieved a good result  none of these patients achieved an excellent result  postoperative continuous passive motion has markedly reduced the incidence of stiffness  serious complications such as compartment syndrome  infection  and skin slough were avoided completely in 51 consecutive cases  patellofemoral contact pressure studies in five cadaver knees have shown that anteromedial tibial tubercle transfer can provide substantial reduction of patellofemoral contact stress while helping to balance medial and lateral facet pressures  this surgical procedure is mechanically and clinically successful for alleviating intractable pain related to patellar malalignment and articular degeneration  this procedure enables the majority of appropriately selected patients with malalignment and patellar articular degeneration to resume increased levels of activity with substantially diminished pain  
class10	arterial abnormalities of the hand in athletes  vascular lesions of the hand may be seen in athletes exposed to repetitive blunt trauma  thirteen athletes seen from 1983 to 1988 experienced symptoms related to hand ischemia  nine were professional baseball catchers  the majority of patients complained of chronic symptoms  including cold hypersensitivity  four patients   finger numbness  one   finger coolness  three   and finger blanching  three   two patients had acute symptoms with sudden posttraumatic hand ischemia with finger and palmar pain  diagnosis was established by history and physical examination and confirmed by noninvasive testing  testing included use of doppler examination and cold tolerance examination with thermistors  two athletes required angiographic evaluation because of severe ischemia and continuous pain  all patients in this group were managed nonoperatively  those with chronic complaints were counseled regarding cold avoidance and instructed to increase their glove padding  the two patients with acute symptoms required vasodilator  papaverine chloride  infusion  followed by intravenous heparin and dextran  all baseball catchers returned to their sport with dissipation of symptoms  
class10	community hospital carotid endarterectomy in patients over age 75  we compared the prevalence of stroke and death in 133 patients aged 75 and older in whom 170 carotid endarterectomies were performed with that in 501 patients less than age 75 in whom 640 carotid endarterectomies were performed  there were three strokes  2   in patients aged 75 and older and nine strokes  1   in younger patients  p   0 7   there were 8 deaths  5   in patients aged 75 and older and 14 deaths  2   in younger patients  p   0 1   after controlling for the possible confounding effects of diabetes  prior stroke  history of angina  prior carotid artery disease  previous vascular surgery  history of myocardial infarction  preoperative hypertension requiring medication  and female gender  a logistic regression model showed that patients aged 75 and older were no more likely to have a stroke or death than patients under age 75  we conclude that age alone is not a contraindication to the safe performance of carotid endarterectomy in the community hospital  
class10	alkalinisation of prilocaine for intravenous regional anaesthesia  suitability for clinical use  eighty unpremedicated patients undergoing day case hand surgery under intravenous regional anaesthesia were randomly allocated to receive  in a double blind study  either 40 ml 0 75  prilocaine hydrochloride  with 5 ml 8 4  sodium bicarbonate or 5 ml 0 9  saline  the alkalinised group had significantly less pain on injection  p   0 0045   during surgery  p   0 0074  and 5 minutes after the tourniquet was deflated  p   0 0027   the time elapsed between insertion of the block and commencement of surgery was not affected  
class10	ph adjustment and discomfort caused by the intradermal injection of lignocaine  published erratum appears in anaesthesia 1991 mar 46 3  242  one hundred adult day case patients who required intravenous access had cannulae inserted using local anaesthesia with 1  lignocaine  1  lignocaine with adrenaline or the corresponding ph adjusted solutions  the local anaesthetic solutions were modified by the addition of 1 ml 8 4  sodium bicarbonate to 10 ml lignocaine  pain scores at different stages of cannulation were noted and showed a significant reduction after use of ph adjusted solutions  p less than 0 02 for the plain lignocaine  and less than 0 001 for the lignocaine with adrenaline   modification of the ph of lignocaine solutions by the addition of sodium bicarbonate is a simple method significantly to reduce the discomfort caused by the infiltration of the local anaesthetic  
class10	nasal and oral flow volume loops in normal subjects and patients with obstructive sleep apnea  because flow volume loops  fvls  are clinically useful in evaluating upper airway  ua  obstruction and the fact that patency of the nasopharyngeal ventilatory pathway is important to the prevention of obstructive sleep apnea  osa   the present study examined the role of nasal compared with oral fvls in evaluating patients with osa  fourteen obese male patients 56     3 yr of age with a mean apnea plus hypopnea index  ahi  of 51     9 h were studied along with 14 nonobese  healthy  age  and sex matched control subjects whose mean ahi was 6     1 h  nasal and oral fvls obtained in the normal subjects indicated the nose behaved like a variable resistor  with flow limitation during inspiration but not during expiration  in the patient group  flow limitation was observed during expiration as well as inspiration indicating nondistensibility of the nasopharyngeal ventilatory pathway in the patients compared to the control subjects  a change in body position from upright to supine in the osa group was associated with small reductions in expiratory but not inspiratory flow rates  the area under the nasal supine flow volume loop  fvlanasup  was found to be highly correlated with awake resting pao2  r   0 80  and paco2  r    0 83  in the patient group  in addition  multiple linear regression analysis revealed that pao2 and the area under the nasal fvls independently contributed to the prediction of ahi with a multiple r of 0 89  these results suggest that limitations to ventilation via the nasopharynx may significantly influence both gas exchange and the frequency of sleep disordered breathing in patients with osa  
class10	the south karelia air pollution study  the effects of malodorous sulfur compounds from pulp mills on respiratory and other symptoms  the paper mills in south karelia  the southeast part of finland  are responsible for releasing a substantial amount of malodorous sulfur compounds such as hydrogen sulfide  h2s   methyl mercaptan  ch3sh   and methyl sulfides   ch3 2s and  ch3 2s2   into ambient air  in the most polluted residential area the annual mean concentrations of hydrogen sulfide and methyl mercaptan are estimated to be 8 and 2 to 5 micrograms m3 and the highest daily average concentration 100 and 50 micrograms m3  the annual mean and highest daily concentrations of sulfur dioxide  so2  are very low  we studied the effects of malodorous sulfur compounds on eye  nasal and respiratory symptoms  and headache in adults  a cross sectional self administered questionnaire was distributed in february 1987 and responded to by 488 adults living in a severely  n   198   a moderately  n   204   and a nonpolluted community  n   86   this included questions about occurrence of the symptoms of interest during the previous 4 wk and 12 months and individual  behavioral  and other environmental determinants of the symptoms  the response rate was 83   the odds ratios  or  for symptoms experienced often or constantly in severely versus nonpolluted and moderately versus nonpolluted communities were estimated in logistic regression analysis controlling potential confounders  the odds ratios for eye  moderate exposure or 11 70  cl95  2 33 to 58 65  severe exposure or 11 78  cl95  2 35 to 59 09  and nasal symptoms  or 2 01  cl95  0 97 to 4 15  or 2 19  cl95  1 06 to 4 55  and cough  or 1 89  cl95  0 61 to 5 86  or 3 06  cl95  1 02 to 9 29  during the previous 12 months were increased  with a dose response pattern  
class10	brain microemboli during cardiac surgery or aortography we have observed many focal dilatations or very small aneurysms in terminal arterioles and capillaries of 4 of 5 patients and 6 dogs who had recently undergone cardiopulmonary bypass  a smaller number of sausagelike dilatations distended medium sized arterioles  two other patients had a small number of the same microvascular changes following proximal aortography  thirty four patients and 6 dogs not undergoing cardiopulmonary bypass had none   a 35th patient who had not undergone cardiopulmonary bypass or aortography showed a small number of dilatations  mediastinal air was a suggested source   some of the dilatations exhibited various forms of birefringence  because most of the dilatations appear empty  we speculate that they are the sites of gas bubbles or fat emboli that have been removed by the solvents used in processing  these microvascular events  occurring only in conjunction with major arterial interventions  may be the anatomical correlate of the neurological deficits or moderate to severe intellectual dysfunction seen in at least 24  of patients after cardiac surgical procedures assisted by cardiopulmonary bypass  
class10	synaptic transmission in human neocortex removed for treatment of intractable epilepsy in children  synaptic transmission to pyramidal cells was studied in slices of neocortex resected from infants and children  n   10  age 8 months to 13 years  undergoing surgical treatment for intractable epilepsy  most specimens were from the least abnormal area of the resection  stable intracellular recordings could be obtained for up to 8 hours  most of the recorded neurons had electrophysiological characteristics similar to those of regular firing pyramidal cells and were in layers iii to v  which was confirmed by intracellular staining with lucifer yellow  local extracellular stimulation evoked a sequence of excitatory and inhibitory postsynaptic potentials  after application of the gamma aminobutyric acid antagonist  bicuculline  10 30 microm   extracellular stimulation induced large excitatory postsynaptic potentials and epileptiform bursts  spontaneous bursts occasionally occurred in bicuculline  this effect of bicuculline was observed in all the tissue samples  even those from infant patients  n   4  age 8 16 months   kynurenic acid depressed or abolished both spontaneous and stimulation induced bursts  the competitive antagonist for n methyl d aspartate receptors  dl 2 amino 5 phosphonopentanoic acid decreased the duration of bicuculline induced bursts  these data provide evidence that  similar to rat and cat neocortex  excitatory and inhibitory amino acids are important transmitters to pyramidal cells in immature human neocortex  
class10	treatment of spasticity with botulinum toxin  a double blind study  we studied the effect of botulinum a toxin on spasticity of the leg adductors in 9 patients who were either chair bound or bed bound with chronic stable multiple sclerosis  we injected botulinum toxin  400 mouse units  or placebo into the adductor muscles in a randomized  crossover  double blind design  two physicians  who were unaware of the treatment order  used an objective rating scale and independently assessed the patients  interobserver correlation was excellent  r   0 93 0 81   we found that botulinum toxin produced a significant reduction in spasticity  p   0 009  and a significant improvement in the ease of nursing care  p   0 009   there were no adverse effects during this short term trial  this is the first demonstration of the beneficial effect of botulinum toxin on focal spastic muscle contractions  
class10	peripheral neuropathy associated with eosinophilia myalgia syndrome  in 1989  the centers for disease control recognized the existence of an epidemic illness characterized by myalgia and eosinophilia in individuals taking preparations containing l tryptophan  we evaluated 3 patients with eosinophilia myalgia syndrome who presented with subacute progressive neuropathies  the neuropathies were predominantly motor and maximal in the lower extremities  two patients were confined to a wheelchair and one was ventilator dependent and bedridden  sensory loss predominantly involved small fiber modalities  electrophysiological studies showed multifocal marked conduction slowing and conduction block indicating segmental demyelination  with associated axonal degeneration that was accentuated distally  examination of sural nerve biopsy specimens demonstrated axonal degeneration in all 3 patients and perivascular infiltrates in 2  levels of quinolinic acid  a neurotoxic metabolite of l tryptophan  were elevated in the cerebrospinal fluid in the 2 patients in whom it was measured  the cause of the neuropathy is unknown but may include immune mechanisms or toxicity of eosinophils  l tryptophan  its metabolic products  or contaminants within l tryptophan preparations  
class10	adult phosphorylase b kinase deficiency  phosphorylase b kinase deficiency affecting muscle has been observed infrequently in children with weakness and hepatomegaly  and in 2 adults with cramps on exertion  we observed 2 additional adults with phosphorylase b kinase deficiency  patient 1  aged 58  had progressive  predominantly distal weakness since age 46 but no cramps on exertion  patient 2  aged 26  had cramps on exertion since age 6 but no weakness  lactate production on ischemic exercise was impaired only in patient 1  the serum creatine kinase level was elevated in both  muscle specimens showed focal glycogen excess in both  and a necrotizing myopathy and mild denervation atrophy in patient 1  muscle phosphorylase b kinase activity was 0 5  and 8 9  of the lowest control value in patients 1 and 2  respectively  erythrocyte phosphorylase b kinase activity was normal in both  liver phosphorylase b kinase activity  measured in patient 1  was also normal  other glycolytic enzymes in muscle were preserved in both  
class10	nmda antagonists potentiate antiparkinsonian actions of l dopa in monoamine depleted rats  systemically administered n methyl d aspartate  nmda  antagonists  mk 801     5 methyl 10 11 dihydro 5h dibenzo a d cyclohepten 5 10 imine maleate  and cpp  3       2 carboxypiperazin 4 yl  propyl 1 phosphonate   potentiate the ability of l dopa  l 3 4 dihydroxyphenylalanine  to reverse akinesia and to alleviate muscular rigidity in monoamine depleted rats  on the basis of these findings  it is proposed that nmda antagonists may be beneficial as adjunctive treatment in the therapy of parkinson s disease  cpp locally injected into the subthalamic nucleus  entopeduncular nucleus  the rat homologue of the internal pallidal segment  or substantia nigra pars reticulata of monoamine depleted rats stimulates locomotor activity and alleviates rigidity  whereas local microinjection of cpp into the neostriatum is ineffective  these results make it unlikely that the neostriatum is the site of the antiparkinsonian action of nmda antagonists in monoamine depleted rats  whereas the subthalamic nucleus  internal pallidal segment  and substantia nigra pars reticulata appear to be important for the effects of nmda antagonists  
class10	cerebrospinal fluid neopterin in human immunodeficiency virus type 1 infection  we evaluated cerebrospinal fluid  csf  concentrations of neopterin  a putative marker of activated macrophages  in 97 subjects infected with human immunodeficiency virus type 1 who had a spectrum of neurological complications  the highest csf neopterin concentrations occurred in those with neurological opportunistic infections  primary central nervous systems lymphoma  and acquired immunodeficiency syndrome  aids  dementia complex  in general  the csf concentration of neopterin was independent of csf cell count and blood brain barrier disruption to albumin  in the patients with aids dementia complex  csf neopterin concentrations correlated with severity of disease and decreased in conjunction with clinical improvement following treatment with zidovudine  these results suggest that csf neopterin  although not disease specific  may be useful as a surrogate marker for the presence of aids dementia complex and its response to antiviral therapy  
class10	alpha 1 antichymotrypsin as a possible biochemical marker for alzheimer type dementia  we measured serum alpha 1 antichymotrypsin levels in 38 patients with alzheimer type dementia  89 control subjects  2 subjects with down s syndrome  20 with vascular dementia  18 with parkinson s disease  14 with spinocerebellar degeneration  15 with cerebrovascular disease without dementia  and 14 with duchenne muscular dystrophy  cerebrospinal fluid  csf  levels of alpha 1 antichymotrypsin were also measured in 15 patients with alzheimer type dementia  26 control subjects  6 with vascular dementia  7 with cerebrovascular disorder  and 11 with degenerative disorders  in control subjects  there were no age related changes or sex differences  serum and csf levels were significantly and specifically higher in patients with alzheimer type dementia than in other subjects  serum  p less than 0 001  csf  p less than 0 05   serum levels of alpha 1 antichymotrypsin were significantly elevated in the early stage of alzheimer type dementia  whereas there was no definite correlation between serum levels and the degree of dementia  csf levels of alpha 1 antichymotrypsin tended to parallel the severity of dementia  serum levels were not correlated with csf levels  these data indicate that serum and csf levels of alpha 1 antichymotrypsin might be independently upregulated in alzheimer type dementia  we concluded that the measurement of serum levels of alpha 1 antichymotrypsin could be useful as a screening marker for alzheimer type dementia  in addition  csf levels also could be a useful marker for alzheimer type dementia  because they might reflect the state of dementia  
class10	failure of nine month phenobarbital administration to reverse amygdaloid kindled seizure susceptibility in cats  upon completion of left amygdaloid kindling  4 cats underwent long term phenobarbital administration during the subsequent 5  to 9 month rest period  plasma phenobarbital levels were maintained above 15 to 20 micrograms ml and were restimulated following plasma phenobarbital washout  three cats served as nonmedicated controls  all 7 cats were subjected to repeated 6 hour sleep monitoring for observation of interictal discharges  which were observed most often in the immediate postictal period  their frequency decreased gradually throughout the experiment in both the medicated and control animals  but they never completely disappeared except from the contralateral amygdala in 1 medicated animal  upon primary site restimulation  all of the medicated animals responded with a generalized convulsion once the afterdischarge was induced  when these animals underwent secondary site amygdaloid kindling  3 showed a positive transfer effect  the findings suggest that although phenobarbital is a potent anticonvulsant  it has little effect on the acquired seizure susceptibility of previously amygdaloid kindled cats  
class10	aggravation of myasthenia gravis by erythromycin  erythromycin is not currently recognized as causing clinical aggravation of myasthenia gravis  we report the case of a patient who experienced exacerbations of myasthenia gravis subsequent to each of several doses of intravenous erythromycin  we suggest that erythromycin can cause clinical worsening in patients with disease of the neuromuscular junction  
class10	familial creutzfeldt jakob disease without periodic eeg activity  four members of a kindred with creutzfeldt jakob disease are reported  in whom myoclonus did not develop and in whom serial electroencephalograms performed late in their illness failed to show periodic sharp wave complexes  otherwise  the patients  disease duration  clinical features  and neuropathological findings were similar to those described in sporadic cases of creutzfeldt jakob disease  our findings and those reported by others suggest that periodic electroencephalographic activity may be rare in familial forms of creutzfeldt jakob disease  as it is in other slow transmissible encephalopathies  
class10	fetal homotransplants  ventral mesencephalon and adrenal tissue  to the striatum of parkinsonian subjects  fetal ventral mesencephalon and fetal adrenal tissue grafted to the caudate nucleus of four and three parkinsonian patients  respectively  have been shown to be an alternative treatment for the amelioration of the signs of the disease  the ventral mesencephalon patients had a significant amelioration of rigidity  bradykinesia  postural imbalance  gait disturbance  and facial expression  three of these four patients have returned to work  the fatal adrenal group only showed amelioration of rigidity and bradykinesia  though these patients are now able to perform their basic daily living activities  and one of them has renewed her household tasks  the other two have not yet been able to return to work  the differences observed between the ventral mesencephalon  and the fetal adrenal transplanted patients may be related to the heterogeneity of their disease and or the type of graft implanted  however encouraging our results may be  this experimental procedure obviously requires further studies  and should not be practiced outside of highly qualified clinical research centers  
class10	autologous transplantation of adrenal medulla in parkinson s disease  18 month results  eighteen of 19 patients who underwent autologous adrenal medullary transplantation to the right caudate nucleus have been followed up for 18 months  during the course of this study  a statistically significant improvement was noted in percent  on  time  percent  on  time without dyskinesia  activity of daily living  adl  scores during the  on  stages  and adl  motor  and schwab england scores during the  off  stages  benefits tended to be maximal at 6 months and to gradually lessen thereafter  although statistically significant improvement in comparison with baseline was still present at 18 months for adl  motor  and hoehn yahr scores during the  off  stages  almost all parameters had deteriorated by 18 months compared with 12 months  including those remaining significantly improved in comparison with baseline  these patterns were similar for each of the three participating centers  complications were largely restricted to the perioperative period  
class10	white matter hyperintensities in dementia of alzheimer s type and in healthy subjects without cerebrovascular risk factors  a magnetic resonance imaging study  t2 weighted  0 5 t  magnetic resonance images were used to study the prevalence of subcortical white matter hyperintensities  wmhis  in 22 patients with dementia of alzheimer s type  dat   20 age matched older healthy control subjects  and 10 younger healthy control subjects  exclusionary criteria for all groups included cerebrovascular risk factors  all subjects had hachinski ischemic index scores of less than 2 and computed tomographic scans showing no infarct  the wmhis were classified as periventricular wmhis or deep wmhis and graded 0 through 3  0 indicated absent  and 3  severe   for the group with dat and older control subjects  periventricular wmhis and deep wmhis were graded 2 or 3 in fewer than 17  and 27  of subjects  respectively  whereas in the younger control subjects  all ratings were grade 1 or less  serum cholesterol and systolic blood pressure values  although within the normal range  were elevated significantly in older control subjects when compared with those in younger control subjects  no significant differences in wmhi ratings  blood pressure  cholesterol  or triglyceride levels were found between patients with dat and age matched control subjects  systolic blood pressure levels correlated with the severity of periventricular wmhis only in older control subjects  age correlated with periventricular wmhis and deep wmhis within both the older control subjects and the patients with dat  there was no significant correlation between wmhis and the severity of dementia in the group with dat  these results suggest that  in subjects screened for cerebrovascular risk factors  wmhis are rare and occur with identical frequency in patients with dat as in age matched healthy control subjects  
class10	clinical and positron emission tomographic studies in the  extrapyramidal syndrome  of dementia of the alzheimer type  extrapyramidal signs  particularly rigidity and tremor  have been reported in a proportion of patients with dementia of the alzheimer type  to test the hypothesis that these extrapyramidal signs are similar clinically and neurochemically to the extrapyramidal signs of parkinson s disease  a group of 20 patients satisfying clinical criteria for probable alzheimer s disease were studied and assessed clinically for the presence of rigidity  tremor  and bradykinesia  in those patients with extrapyramidal signs  qualitative differences were observed between the signs in these patients and in subjects with parkinson s disease  fifteen of 20 patients underwent fluoro 18 dopa scans  which showed no significant difference in fluoro 18 dopa uptake into the caudate and putamen between normal subjects and the rigid and nonrigid patients with alzheimer s disease  in contrast to the marked reduction in fluoro 18 dopa uptake into the putamen that is observed in parkinson s disease  this provides clinical and in vivo neurochemical support for the hypothesis that extranigral factors may be involved in the pathogenesis of rigidity in alzheimer s disease  
class10	acquired childhood aphasia  outcome 1 year after onset  the effects of the variables age at onset  cause  severity and bilaterality of lesion  and type of aphasia on course and outcome were investigated in a group of 28 aphasic children  analysis of spontaneous speech and tests of auditory verbal comprehension were used to determine the presence of aphasia  the severity of the cerebral lesion was assessed using a rating scale for computed tomographic scans  most of the children had not recovered completely 1 year after onset  recovery was significantly different according to etiological categories  complete recovery was seen in the majority of traumatic cases  
class10	primary progressive aphasia  longitudinal course  neuropsychological profile  and language features  four patients with the clinical syndrome of primary progressive aphasia and a nonfluent aphasia profile were followed up over a period of 3 to 5 years  extensive neuropsychological data for three patients revealed a progressive  quantitative decline of language with relative stability of memory  visuospatial skills  and reasoning  comportment and most activities of daily living were preserved even when speech was unintelligible  although several aphasia types may be associated with primary progressive aphasia  a nonfluent aphasia profile and phonemic paraphasic errors are most useful in differentiating it from the much more common clinical syndrome   probable alzheimer s disease   the clinicopathological correlates of probable alzheimer s disease differ from those associated with primary progressive aphasia  therefore  the clinical distinction between the two syndromes may be important for predicting the underlying pathophysiologic changes during the life of the patient  
class10	plasticity in the aging brain  reversibility of anatomic  metabolic  and cognitive deficits in normal pressure hydrocephalus following shunt surgery  the course of idiopathic normal pressure hydrocephalus was studied in a 78 year old woman with a 4 year history of progressive dementia who underwent neuropsychologic testing  quantitative x ray computed tomography  magnetic resonance imaging  and positron emission tomography with fludeoxyglucose f 18 to measure rates of regional cerebral glucose utilization  preshunt cognitive testing demonstrated progressive deterioration during 2 years  and positron emission tomography showed significant reductions in regional cerebral glucose utilization of 34  to 49  as compared with age  and sex matched control subjects in frontal  temporal  parietal  and whole brain regions  periodic testing  carried out during a 2 year period after shunt surgery  showed steady improvement in clinical status  parallel to the clinical changes  there was a significant reversal in neuropsychologic test scores with increased brain volume and increased regional cerebral glucose utilization in several brain regions  these results documented the considerable potential for recovery of compromised brain function in older subjects even after 4 years of progressive brain disease  
class10	effects of physostigmine on spatial attention in patients with progressive supranuclear palsy  we tested patients with progressive supranuclear palsy and control subjects on a task of visuopatial attention  targets preceded by cues on the same side were termed validly cued  and those on the opposite side  invalidly cued  for all subjects  validly cued targets were responded to faster than those that were invalidly cued  the difference between reaction times for invalidly and validly cued targets  which is hypothesized to measure attentional movement  was significantly increased for the patients  the performance of the controls on certain neuropsychological tests was correlated with their attentional ability  these correlations were altered by progressive supranuclear palsy  physostigmine treatment of the patients induced a speeding of responses to invalidly cued targets as a function of the duration of the disease  these studies show defects in cognition and attention in patients with progressive supranuclear palsy and demonstrate that physostigmine reduces some of the abnormal visual attentional performance  
class10	cumulative aids incidence and altered mortality from bacterial infections  to determine whether populations with high cumulative incidence of acquired immunodeficiency syndrome  aids  experienced increased deaths from sepsis  central nervous system abscess  or endocarditis  new jersey aids patients were grouped according to their age  sex  race  and residence specific cumulative incidence of aids since the onset of the aids epidemic  between 1980 and 1986  among 25 44 year olds in the highest cumulative incidence group for aids  sepsis mortality increased from 3 3 to 15 2 deaths 100 000 year  an increase of 11 9 deaths 100 000 year  95  confidence interval  6 9  17 0  deaths 100 000 year   mortality from central nervous system abscesses increased from zero to 1 7  0 1  3 2  deaths 100 000 year  and mortality from endocarditis increased from 0 8 deaths 100 000 year to 2 4 deaths 100 000 year  an increase of 1 6   0 5  3 7  deaths 100 000 year  age matched new jersey patient populations with low cumulative incidence of aids did not sustain a similar increase  the hiv disease associated increase in sepsis mortality among young populations represents a new component of the substantial increase in u s  sepsis mortality that occurred over the last two decades  but was previously limited to older populations  
class10	safety  stability  and effectiveness of immunoadsorption under membrane plasmapheresis treatment for myasthenia gravis  nine patients  five women and four men  average age 50 4 years  with refractory myasthenia gravis  mg  underwent thymectomy and were then treated with immunoadsorption under membrane plasmaphersis  iap   thymic histology showed hyperplasia in nine patients  an immunoadsorption column  asahi  med  co  was made with tryptophan  a plasouto 1 000  asahi  med  co  was used as the machine  the plasma separator was a first filter  asahi  med  co   and immunoadsorption columns were used for plasma perfusion  iap treatment was performed three times weekly for a total of six times  after which iap was done every 3 weeks  the removal rate of anti ach r titer was 54     12   igg  iga  and igm levels improved in nine of nine patients after iap treatment  and improvement of gait disturbances were seen in two of two  muscle strength improved in all nine patients  whereas speech disturbances improved in two of three  eye ptosis improved in nine of nine patients  subjective improvement was reported by nine of nine patients  and none had severe side effects with iap  in conclusion  iap is a safe  stable  effective  and clinically useful treatment  for mg  
class10	an extracorporeal perfusion system to bridge pediatric liver transplant candidates  an extracorporeal liver perfusion system was designed to maintain cadaver livers in an oxygenated  normothermic state for bridging procedures for hepatic transplantation  nonpulsatile high flow and pulsatile low flow blood are supplied to the portal venous  pv  and hepatic arterial  ha  circulations  controlled low blood flow  5 10 cc kg  patient  min  is exchanged between the high flow extracorporeal perfusion circuit  1 cc g  liver  min  and the patient  the system was evaluated in perfusions of fresh  excised pig livers  n   5   the average oxygen consumption was 9     3 microliters g min  and bile production averaged 4 7 microliters g hr  perfusion pressures and flows were normal in both the ha and pv circulations for about 4 hr  pressures then gradually rose  especially in the ha circulation  causing flow to decrease  with subsequent mottling and discoloration of the liver  red blood cell  platelet  and white blood cell counts fell continuously  maintenance of liver function was assessed by clearance of an 80 mg taurocholic acid challenge  an average of 56  of injected acid was cleared from the perfused livers  n   5  in the first half hour  compared with 90  and 25  for the in situ  n   3  and unperfused  n   3  control livers  respectively  the system consistently maintained livers in a moderately well functioning state through the first 4 hr of perfusion  adequate support of animals with induced hepatic failure must now be demonstrated  
class10	aids for visual impairment  this article provides only a flavour of the type and range of aids available to the visually impaired person  many other aids for leisure  learning  and daily living are illustrated in the rnib equipment and games catalogue  
class10	gallbladder surgery following cholecystlithotripsy  suggested guidelines for treatment twenty three of 229 symptomatic patients undergoing cholecystlithotripsy underwent surgical intervention  22 of the patients had cholecystectomy performed  five also undergoing choledochotomy  and one patient had a cholecystostomy  of these 23 patients  five were lithotripsy failures  five developed acute pancreatitis  one had acute cholecystitis  and one had cholangitis  one patient had her gallbladder removed incidentally at the time of surgery for a bleeding gastric ulcer  ten patients underwent surgery for recurrent biliary pain  probably related to fragment passage via the cystic duct  we suggest that up to 16 of these 23 patients did not necessarily require cholecystectomy  i e  five patients with pancreatitis  one patient with cholangitis and ten patients with recurrent biliary colic  conservative and or endoscopic management may be successful in the first instance to allow further treatment with lithotripsy in the majority of patients  if  however  the expertise to perform endoscopic sphincterotomy is not available or the patient declines further lithotripsy  then resort to surgery may be necessary  we propose that it is the responsibility of the management team in charge of the lithotripsy unit to inform both the patient and the referring clinicians of the possible side effects and outcome of treatment in an attempt to avoid unnecessary surgical procedures  
class10	cerebrospinal norepinephrine concentrations and the duration of epidural analgesia this study was performed to determine whether the addition of norepinephrine to local anaesthetics prolongs epidural analgesia in man  in addition  cerebrospinal fluid norepinephrine  ne  concentrations were measured  in the first part of the study  epidural catheters were inserted in 14 patients before herniotomy  mepivacaine  1 5 per cent  0 35 ml kg 1   was administered and norepinephrine  5 micrograms ml 1  was added in seven patients  the duration of anaesthesia was prolonged from 54     11 min to 83     12 min  p less than 0 05  and csf ne concentrations increased from 68     12 pg ml 1 to 336     85 pg ml 1 in the ne group  p less than 0 01   in the second part  eight patients with herpetic neuralgia received epidural analgesia at the fourth to eighth thoracic interspace  using bupivacaine 0 25 per cent  with and without ne  the csf ne concentrations in this group were greater than in the surgical patients before operation and increased from 254     58 to 406     58 pg ml 1 30 min after administration of bupivacaine with ne  the duration of pain relief was prolonged with ne  these results suggest that adding ne to local anaesthetics prolongs epidural analgesia  moreover  ne concentrations in surgical patients increased to levels similar to those found in patients suffering from herpetic analgesia  this suggests that the increase of csf ne in chronic pain states has an antinociceptive effect  
class10	crico tracheal disruption and common carotid artery occlusion  a case of blunt trauma  a case of blunt trauma to the neck is presented  while driving an all terrain vehicle  atv   a 20 yr old male was struck across the anterior neck by a cord suspended between two poles  initial findings were suggestive of an isolated laryngeal injury  48 hours later  however  a dense left hemiplegia became manifest  a ct scan demonstrated a large right frontoparietal cerebral infarct  and an angiogram confirmed occlusion of the right common carotid artery  intractable cerebral oedema developed  and the patient died five days after the initial insult  such injuries should alert the clinician to the possibility of major vascular injury  and if suspected  angiography is warranted  
class10	from disease to delirium  managing the declining elderly patient  many geriatric patients have concurrent physical and psychiatric illnesses  but at times it may be difficult to determine which is primary  delirium  a transient syndrome that presents with psychiatric symptoms  is usually the manifestation of an organic disorder and  if undetected and untreated  can be fatal  clinicians  therefore  must learn to recognize the syndrome  search diligently for the underlying etiology  and treat accordingly  
class10	evidence for motor neuropathy and reduced filling of the rectum in chronic intractable constipation  subtotal colectomy with ileorectal anastomosis is now frequently offered to patients with slow transit constipation who have severe symptoms and no response to more conventional medical treatment  if this operation is to be successful  the underlying problem should be delay in the progress of contents through the colon but no mechanical or functional obstruction in the small bowel or rectum  we have used a recently described technique of prolonged ambulant manometry and electromyography to investigate anorectal function in these patients  pressure data were collected using a 2 mm diameter intrarectal probe carrying microtransducers  and external anal sphincter activity was assessed by a pair of silver silver chloride surface electrodes  fourteen control subjects and eight patients with colonic inertia were studied  sampling reflexes  indicative of rectal filling  occurred at mean  sem  rates of 7 4  2 0  hour in controls but were significantly reduced in patients  2 4  0 3  hour  p less than 0 01   recurrent rectal motor complexes were seen to occur in both groups at intervals of 76  1 8  minutes in controls and 64 9  7 2  minutes in patients  p less than 0 1   and with amplitudes of 42 4  2 1  mmhg and 9 2  0 7  mmhg  p less than 0 001   respectively  external sphincter electromyographic spike activity did not differ between groups  our results support the concept of reduced transit of faeces to the rectum from the colon over a 24 hour period in slow transit constipation and suggest that a motor neuropathy may also be present in the rectum  
class10	phenotypic and functional characterization of t cells from patients with myasthenia gravis  a study of cell surface phenotypes of pbl of myasthenia gravis  mg  patients showed that their t cells had a significantly higher percentage of 4b4  t cells  the helper inducer subset  than age  and sex matched controls  the pbl of mg patients proliferated significantly higher than those of normal subjects  ns  in response to the purified alpha chain of the acetylcholine receptor  achr   anti achr antibody was present in sera of 88  of mg and none of the ns  the pbl b cells from mg only  when cultured with autologous t cells and stimulated with either pokeweed mitogen  69    or achr alpha chain  38    secreted antibody to achr alpha chain  whereas t and b cells alone secreted no antibody  t cells from pbl of mg patients were more readily cloned than t cells of ns  by limiting dilution  in the presence of recombinant il 2 and in the absence of achr alpha chain  about 50  of t cell clones from mg patients  compared to none from ns  proliferated to achr alpha chain  this response was hla dr restricted  mg t cell clones did not display significant cytotoxic activity  as compared to control t cell clones  our results indicate that in mg  4b4  regulatory t cells play their role in the pathogenesis of mg  not by cytotoxicity  but more likely by their ability to stimulate specific antibody production by b cells  
class10	causes of death in the elderly and their changing pattern in hisayama  a japanese community  results from a long term and autopsy based study  the causes of death for the elderly were prospectively studied in hisayama  japan  a rural community  we compared 1 621 subjects  aged 40 years or over  recruited in 1961  and 2 053 subjects recruited in 1974  each cohort was studied in a follow up that lasted 10 years  they had autopsy rates of 82 1  and 86 1  during each 10 year period  respectively  the most common causes of death for those aged 70 years or over were cerebrovascular disease  malignant neoplasms  and pneumonia  deaths due to cerebrovascular disease tended to decrease in the recent cohort  but the proportion of decline was more prominent in cases aged 40 to 69 years  there was a sex difference in the changing pattern of mortality from heart diseases including ischemic heart disease  deaths by both heart diseases and ischemic heart disease increased in the more recent cohort of aged women  whereas they decreased in the aged men  pneumonia was an important cause of death for the elderly in both cohorts  deaths due to  senility  were rare  being only 1  of the deceased aged 70 or over  with prolonged lifespan  especially for women  the impact of atherosclerosis and its related disorders on the recent japanese aged population appears to have increased  
class10	sphenoid sinusitis  a cause of debilitating headache  we present a case of sphenoid sinusitis resulting in a debilitating headache refractory to both oral and intramuscular analgesics  despite an aggressive evaluation in the emergency department  the correct diagnosis and appropriate treatment were delayed  recognition of sphenoid sinusitis  the complications associated with it  and the need for aggressive management are addressed  
class10	blepharospasm oromandibular dystonia associated with a left cerebellopontine angle meningioma  blepharospasm oromandibular dystonia is characterized by the presence of spasms of the orbicularis oculi  blepharospasm  and of the lower facial or oromandibular muscles  a patient with this syndrome is presented in which a left cerebellopontine angle meningioma appeared to act as a triggering mechanism for the development of this disorder  on the basis of this report  we recommend that physicians search for this tumor in patients with this disorder  
class10	reliability of death certificate diagnoses  consistency between death certificates and clinical records from 5 general hospitals in kuwait was studied for 470 deaths with the following underlying or associated causes  hypertensive  hyp   ischaemic heart diseases  ihd   cerebrovascular diseases  cvd  and diabetes mellitus  dm   direct causes were not considered since they are of little interest analytically  only deaths with definite or most probable ascertainment were included  one cardiologist  who was provided with the who criteria and relevant documents on death certification  independently reviewed the records  to test the reviewer s bias and the reliability of his judgement  an adjudication process was effected by having one senior cardiologist re review a random subsample of 140 records  the two reviewers showed good agreement  specific diagnoses criteria for deciding the underlying cause of death in multiple morbid conditions by the reviewer were followed  due to possible reviewer bias  we aimed at measuring the difference between initial certifiers and the reviewer rather than measuring the diagnostic accuracy of initial certifiers in reference to the reviewer  the agreement index kappa showed poor agreement between original and revised certificates  the original certificates under estimated cvd as an underlying cause of death by 69 2   dm by 60   ihd by 33 5  and hyp by 31 8  in our sample  associated causes were also consistently under estimated by initial certifiers as compared with the reviewer  this bias calls for basing mortality statistics in kuwait on hospital death committees  reports rather than on initial certifier death certificates  use of multiple causes of death instead of one underlying cause and adequate training of the medical profession on the value and process of death certification  
class10	sensitivity of effect variables in rheumatoid arthritis  a meta analysis of 130 placebo controlled nsaid trials  published erratum appears in j clin epidemiol 1991 44 6  613  in a meta analysis of placebo controlled nsaid trials  the sensitivity of the effect variables was calculated as the correlation coefficient and as the difference between drug and placebo  divided by the placebo group standard deviation  the patient s global evaluation was the most sensitive variable overall  pain was more sensitive than ritchie s index  several variables may be omitted from clinical trials  especially if two active drugs are being compared  for example  the best maximum estimate for the difference in esr between nsaids and placebo was 1 0 mm hr  95  confidence interval  1 5 to 3 4 mm hr   and for joint size 0 44    1 0 to 1 9    corresponding to a quarter of a millimeter for each of the 10 joints usually measured  it is suggested to record only the patient s global evaluation  pain  and morning stiffness  
class10	examination by logistic regression modelling of the variables which increase the relative risk of elderly women falling compared to elderly men  in a community based  prospective study to determine risk factors for falls  465 women and 296 men 70 years and over were followed for 1 year and 507 falls were documented  a greater proportion of women  32 7   than men  23 0   experienced at least one fall in which there was no or minimal external contribution  using unconditional logistic regression models we investigated the effect of physical and sociological variables on the sex difference in fall rate  controlling for the variables age  use of psychotropic drugs  inability to rise from a chair without using arms  going outdoors less than daily and living alone decreased the relative risk of women falling compared to men from 2 02  95  ci  1 40 2 92  to 1 55  95  ci 1 04 2 31   some of the increased risk of falling associated with being a women was able to be explained and is potentially correctable  but even after controlling for the physical and social variables which we had assessed  women compared to men still had a significantly increased relative risk of falling  
class10	restricted dose and duration of corticosteroid treatment in patients with polymyalgia rheumatica and temporal arteritis  to analyze whether corticosteroids in low doses during limited time periods could be safely used in the treatment of patients with polymyalgia rheumatica  pmr  or temporal arteritis  ta  the records of 91 patients diagnosed between 1980 and 1987 were reviewed  the mean initial prednisolone dose was in patients with pmr 18 mg day and the mean duration of treatment was 17 months  in patients with ta the mean initial dose was 31 mg day and the mean duration of treatment 16 months  and in all the corticosteroid treatment was terminated within 24 months  patients with coexisting ta and pmr demanded longer treatment compared to patients with either ta or pmr and thus 18 91 patients were treated for more than 2 years  no visual or neurological complications occurred after treatment with corticosteroids had been initiated  our study indicates that most patients with pmr or ta can be treated safely with an initial prednisolone dose of 10 mg given twice daily  with few exceptions corticosteroid treatment can be terminated within 24 months  
class10	psychological stress and the fibrositis fibromyalgia syndrome  the relationship of stress and social support to the fibrositis fibromyalgia syndrome  fs  was investigated by administration of 4 questionnaire instruments to 28 patients with fs  20 patients with rheumatoid arthritis  ra  and 28 pain free normal controls  fs showed higher levels of stress as measured by daily  hassles  than did ra or controls  however  on a measure of major life stress  they reported lower levels  no differences were found between groups with regard to daily  uplifts  or social support  correlations between those measures of stress and social support with their scores on the arthritis impact measurement scale showed that the hassles scale was significantly related to the aims psychological component  
class10	diagnostic criteria for neuropsychiatric systemic lupus erythematosus  the results of a consensus meeting  the ad hoc neuropsychiatric lupus workshop group  definitions and classifications proposed for the neuropsychiatric complications of systemic lupus erythematosus  np sle  indicate a wide range of approaches taken by different researchers and clinicians  a meeting of investigators was convened to begin a consensus process for standardizing its classification  we found that the level of agreement among raters on the importance of elements to the diagnosis of np sle increased significantly as indicated by an intraclass correlation coefficient of 0 05 before the conference to 0 60 after the conference  the results of such studies can be used to generate and test the utility of diagnostic criteria for np sle in multicenter trials  
class10	severe cerebral and systemic necrotizing vasculitis developing during pregnancy in a case of systemic lupus erythematosus  we describe a fatal case of systemic lupus erythematosus  sle  developing cerebral and systemic necrotizing vasculitis during pregnancy  the patient was discovered to have sle at 14 weeks  gestation  although the symptoms disappeared without treatment with corticosteroid in the 2nd trimester  she presented with meningoencephalitis due to vasculitis in the 3rd trimester  polyarteritis nodosa  pan  like necrotizing vasculitis of the small muscular arteries and arterioles  with acute and healing lesions in the leptomeninges  brain parenchyma and visceral organs was observed at postpartum autopsy  pan like vasculitis in the central nervous system is quite rare in sle  this case is also suggestive in terms of the influence of pregnancy on the activity of sle  
