Hypercalcemia associated with gynecologic malignancies: biochemical characterization

Fasting calcium excretion, renal phosphorus threshold, plasma 1,25 dihydroxyvitamin D, immunoreactive PTH, nephrogenous cyclic AMP excretion, and tumor burden were assessed in nine patients with gynecologic neoplasms and hypercalcemia. Gynecologic neoplasms were responsible for hypercalcemia in seven of 34 (20.5%) consecutive patients with malignancy-associated hypercalcemia. The tumor burden in each patient was large. Three of four endometrial carcinomas contained squamous elements. All patients displayed biochemical evidence of nonparathyroid humorally mediated hypercalcemia (bone resorption). Treatment of hypercalcemia did not appear to diminish production of the humoral calcemic factor but eradication of tumor eliminated biochemical evidence of the humoral syndrome. It can be concluded that (1) gynecologic neoplasms are a frequent cause of malignancy-associated hypercalcemia, (2) humoral mechanisms appeared to be responsible for the hypercalcemia in 100% of the patients in this series, (3) squamous features occur with unexpected frequency in hypercalcemic endometrial carcinoma, (4) the presence of hypercalcemia connotes a large tumor burden, and (5) treatment directed at the neoplasm (but not treatment directed at hypercalcemia) may eliminate evidence of ectopic calcemic hormone production.

The timing of a repeat ultrasound examination in the evaluation for ectopic pregnancy

A method is described for timing a repeat ultrasound examination in patients evaluated for ectopic pregnancy in whom the findings are initially non-diagnostic. This method is based on measuring the serum hCG at the time of the initial ultrasound examination, which allows the time interval required for the serum hCG to exceed 6500 mIU/ml to be calculated. When the serum hCG is above this level, the gestational sac of an intrauterine pregnancy can be reliably identified, and failure to do so signifies ectopic gestation. Seven patients referred for ultrasound to rule out ectopic pregnancy had initially nondiagnostic findings. In each case, a correctly-timed repeat examination, demonstrating a gestational sac, enabled the diagnosis to be excluded.

Receiver operating characteristic (ROC) curve analysis of the relative efficacy of single and serial chorionic gonadotropin determinations in the early diagnosis of ectopic pregnancy

A study was undertaken of 36 patients with viable intrauterine pregnancies who presented in the first trimester with abdominal pain and/or vaginal bleeding, and of 15 patients with ectopic pregnancies, all of whom had at least two human chorionic gonadotropin (hCG) determinations in the same gestation. The mean and lower 25%, 20%, 15%, 5%, and 1% limits of the rate of hCG increase in serum and of the serum hCG at different periods of gestation were determined for intrauterine pregnancy with the use of linear regression analysis, and each was used as a basis for identifying ectopic gestation. It was found that for any given false-positive rate, subnormal rates of hCG increase were more sensitive in identifying ectopic gestations than single "low for date" hCG values. It is suggested that the explanation for this may be that hCG production in many patients with ectopic pregnancies is normal until symptoms develop and falls thereafter as the functional trophoblastic mass is reduced by the shearing off the trophoblast from the tubal wall, which takes place with the development of the pregnancy and of symptoms.

A method of screening for ectopic pregnancy and its indications

The possibility of distinguishing between normal intrauterine and ectopic pregnancies by determining the lower limit of the rate of human chorionic gonadotropin (hCG) increased in early pregnancy was investigated. This can be expressed as the slope of the log hCG-time curve or as the percent increase in hCG over a given sampling interval. For practical purposes, the rate is most easily determined from 2 samples drawn 48 hours apart. The differences between the 2 hCG values obtained is expressed as a percentage of the initial value, and should be 66% or greater for this sampling interval. Approximately 15% of normal intrauterine pregnancies screened in this way will appear abnormal, and the diagnosis in 13% of ectopic pregnancies will be delayed beyond 48 hours.

Discriminatory hCG zone: its use in the sonographic evaluation for ectopic pregnancy

The most reliable ultrasonographic criteria for diagnosing ectopic pregnancy are based on the appearance of the uterus in the presence of a positive urine pregnancy test. The absence of an intrauterine sac signifies ectopic pregnancy, whereas its presence indicates intrauterine gestation. These criteria cannot be applied when serum pregnancy tests are used unless the serum human chorionic gonadotropin (hCG) level at which the sac of an intrauterine pregnancy becomes visible on ultrasound is known, because these tests are far more sensitive and identify pregnancy at an earlier stage than does sonar. In this study, the hCG level that distinguishes patients with intrauterine pregnancies in whom a gestational sac can be seen from those in whom it cannot be seen was determined and designated the discriminatory hCG zone. This zone lies between 6000 and 65000 mIU/ml. The absence of an intrauterine sac in conjunction with hCG values above this level signifies ectopic pregnancy; however, the absence of an intrauterine sac has no diagnostic significance when associated with hCG values below the discriminatory zone. An intrauterine sac associated with hCG levels above the discriminatory zone reliably indicates an intrauterine pregnancy, but at hCG values below the zone, it is suggestive of an abnormal pregnancy-either a missed abortion or an ectopic gestation.

Familial hypocomplementemic hemolytic uremic syndrome with HLA-A3,B7 haplotype

We describe a familial, relapsing type of hemolytic uremic syndrome (HUS) that has a possible genetic origin. Three members of a family, aged between 15 months and 34 years, evidenced HUS. Histological examination disclosed thrombotic microangiopathy. Recurrences, persistent hypocomplementemia, and the HLA haplotype A3,B7 were a common factor. We studied 17 members of this family and found a low C3 level from activation of the alternative pathway in the haplotype A3,B7 carriers. These three patients with HUS probably had a congenital and hereditary condition in which immunologic factors played a role in its pathogenesis.

Surgical management of unruptured ectopic pregnancy

There is an increasing frequency of early diagnosis of unruptured tubal ectopic pregnancy. This is due primarily to better diagnostic testing, such as the use of ultrasound and radioimmunoassay for the beta-subunit of human chorionic gonadotropin. The more stable conditions of the patients at the time of surgery caused us to reconsider the need for laparotomy in these cases. Therefore, an attempt was made to definitively treat 18 patients with ectopic pregnancy utilizing laparoscopic techniques. Eighteen patients had signs, symptoms, and diagnostic test results suggestive of unruptured ectopic pregnancy. Laparoscopy was employed to confirm the diagnosis. If the tubal swelling was less than 3 cm in diameter, a linear salpingostomy was carried out on the antimesenteric side of the fallopian tube, utilizing a cutting current. The contents were expressed and removed through a second puncture site. Vigorous lavage was used to cleanse the abdomen, and bleeding was controlled with electrocautery. All tubes which were operated upon were patent at the time of postoperative hysterosalpingography. Fifty per cent of those patients actively trying to conceive have achieved pregnancy. There were not repeat ectopic pregnancies or abortions. There were no immediate or long-term postoperative complications. This method represents an alternative to the treatment of unruptured tubal ectopic pregnancies in early gestation.

[The use of microcomputers in the processing of complex hemodynamic data]

The use of a low-cost microcomputer in the clinical study of left ventricular diastolic function is described. Both left ventricular filling and compliance were studied by means of the simultaneous recording of left ventricular pressure and an echocardiogram displaying ventricular dimensions. A program was written to calculate ventricular volume every 40 msec and a volume-time diagram was obtained. The raw curve was smoothed with a second degree polinomial. The rate of change of ventricular volume (dV/dt) was obtained. Simultaneous left ventricular volume and pressure were plotted. The diastolic, exponential portion of the pressure-volume loop was used to calculate an index of ventricular stiffness at zero volume. It is concluded that a simple microcomputer, when conveniently programed, is able to perform the time-consuming mathematical operations involved in the clinical assessment of left ventricular diastolic function.

Oculomotor and oculovestibular functions in a hemispherectomy patient

Oculomotor and oculovestibular functions in a patient who had undergone a left hemispherectomy were examined under a variety of visual and vestibular stimuli. The main findings were an inability to hold left eccentric gaze, resulting in gaze-evoked nystagmus to that side; inaccurate saccades to the right; defective smooth pursuit to the left; asymmetrical vestibulo-ocular responses (VOR) in the dark due to the interaction of the VOR with the "spasticity of conjugate gaze", decreased gain of the visuo-vestibulo-ocular reflexes to both sides, more marked to the right, when rotated fixating on a stationary wall target or the environment, due to abnormal smooth and optokinetic systems; and failure to inhibit the VOR when rotated to the left with visual fixation.

[Preliminary results of indirect isotopic lymphography with colloidal rhenium marked with Tc 99m in urinary tract pathology]

The authors have carried out a study of a new method for studying the lymphatic system in patients with a neoplastic, urological pathology, by using lymphogammagraphy with radionuclids. It involves the comparative analysis of the lymphatic ganglion chains. This method consists in the subcutaneous injection into the interdigital space of a radionuclid, Colloidal, Rhenium Sulphide, marked with Tc-99m and with external detection by means of a gammacamera and with lymphatic channeling not being necessary.

[Hypokalemic periodic paralysis. Report of two cases (author's transl)]

The familial periodic hypokalemic paralysis is an infrequent disease characterized by paralytic attacks of sudden appearance affecting the muscles of the trunk and limbs. There is a marked hypokalemia during the paralytic episodes of the disease, and a family history in 80 percent of the cases. The differential diagnosis includes hyperthyroidism with periodic paralysis, congenital paramyotony and adynamia episodica hereditaria. Two typical cases of hypokalemic periodic paralysis are presented, with biological, electrophysiological, clinical, and ultrastructural pictures characteristics of the disease. The clinical manifestations of both patients are discussed, stressing the diagnostic importance of the electrophysiological study during the insulin test, and the interest of the histologic and ultrastructural studies. The spectacular response during the acute episodes to the intravenous perfusion of potassium salts, and the usefulness of the acetazolamide administration to prevent the paralytic episodes are emphasized.

Effects of cerebellectomy on eye movements in man

A patient with a right hemicerebellectomy and recurrence of a tumor on the left cerebellar hemisphere was examined regarding oculomotor and vestibuloocular functions. The findings were as follows: inability to maintain eccentric gaze; defective smooth pursuit system; failure to suppress by visual fixation the nystagmus induced by sinusoidal horizontal rotations; moderate increase of the vestibulo-ocular reflex gain when rotated in the dark; relative preservation of the slow phases of the optokinetic nystagmus, as compared to the slow phases induced by tracking a pendulum; decreased gain of the vestibulo-ocular reflex when rotated with the lights on fixating the environment; square wave jerks; and no saccadic dysmetria.

Liver tissue lecithin: cholesterol acyltransferase activity in patients with liver disease

Lecithin: Cholesterol acyltransferase (LCAT) activity was measured in serum and liver tissue from patients with parenchymal liver disease. Serum LCAT activity was within normal limits and it was probably related to the absence of clinical and laboratory evidence of a decompensated liver function. Liver tissue LCAT activity is about tenfold lower than that in serum. The relative proportion of cholesterol esters in liver tissue was much higher that could be expected according the low tissue LCAT activity. This findings suggest that LCAT is a "plasma specific" enzyme and that cholesterol esters in parenchyma may be considered as a storage form of cholesterol esterified in plasma pool.

Synthesis and biological activity of some antitumor benzophenanthridinium salts

A facil synthesis of benzophenanthridinium salts has been developed and used for preparing a number of these compounds. The antitumor activities in mouse leukemia L1210 (LE) and P388 (PS) were determined as well as some selected antimicrobial activities. Although antitumor activity was exhibited by several of the derivatives, none was as active as the naturally occurring alkaloid fagaronine. Fagaronine was made available as a synthetic by an improved procedure. Some structure-activity relationships among antitumor benzophenanthridinium salts are discussed.

Identification of group B streptococci by immunofluorescence staining

Gamma globulin fractions of rabbit antisera prepared with whole cell vaccines of group B types Ia, Ib, II, and III and labeled with fluorescein isothiocyanate stained group B streptococci type specifically. Type Ic cells, which contain the Ia polysaccharide antigen of type Ia and the Ic protein antigen of type Ib, were specifically stained by both Ia and Ib conjugates. A group B conjugate pool (B pool) that contained one conjugate specific for each group B type at its predetermined titer gave positive fluorescent-antibody (FA) reactions (4+ intensity) with group B stock strains and negative FA reactions (less than 2+ intensity) with stock strains of streptococcal groups A, C through H, and K through U, viridans streptococci, Streptococcus pneumoniae, Staphylococcus aureus, Neisseria gonorrhoeae, and representative Enterobacteriaceae. Examination of 883 clinical isolates submitted to the Streptococcus Laboratory (Center for Disease Control, Atlanta, Ga.) for identification revealed a 99.1% agreement between FA and culture-precipitin methods. All 305 group B streptococci identified by culture-precipitin and six nonhemolytic group B streptococci missed initially by culture tests were identified correctly by FA. Results of cultural and FA methods in a double-blind study of 99 vaginal swabs agreed on 96 of 99 strains. Three nonhemolytic group B streptococci were identified first by FA and later confirmed by culture-precipitin tests.