Tumors of the adrenogenital syndrome: an aggressive conservative approach

PURPOSE

Testicular masses in male individuals with the adrenogenital syndrome are a clinical and pathological diagnostic dilemma. The major differential diagnosis of gonadal nodules in this setting includes interstitial Leydig cell tumors and secondary benign tumors of possible adrenal rest origin. Management of these 2 entities obviously differs. We report clinical, biochemical and pathological features in 3 children with rare bilateral testicular masses and the adrenogenital syndrome in an attempt to define better the natural history of these entities and formulate recommendations for management.

MATERIALS AND METHODS

All 3 patients had a history of precocious puberty. Two boys were diagnosed with the adrenogenital syndrome at birth, and presented with bilateral testicular masses at ages 5 and 17 years, respectively. The remaining patient was diagnosed at age 15 years after testicular and adrenal masses developed. All 3 cases were classified as 21-hydroxylase deficiency with markedly elevated levels of 17-hydroxyprogesterone, dehydroepiandrosterone, adrenocorticotropic hormone and androstenedione. Testosterone levels were mildly elevated above normal age matched values. Testicular biopsies were done in each case.

RESULTS

Two cases were initially interpreted as bilateral Leydig cell tumors but they were histologically reclassified as tumors of the adrenogenital syndrome. The other case was diagnosed as interstitial cell hyperplasia. Although corticosteroid therapy corrected each steroid abnormality, in no case did tumors resolve, but there was gradual regression in 1. Each patient has been followed conservatively for 4 years. There has been no increase in tumor size or evidence of metastatic disease.

CONCLUSIONS

Bilateral testicular masses in children with the adrenogenital syndrome may mimic Leydig cell tumors, which also commonly cause precocious puberty. Orchiectomy for Leydig cell tumors in boys with precocious puberty is contraindicated without a complete endocrinological profile. When congenital adrenal hyperplasia is diagnosed, these tumors appear to be derived from cells of possible adrenal origin stimulated by adrenocorticotropic hormone and they may be followed conservatively.

Completion rates and feasibility of outcome measures: experience in a multicenter clinical trial of systemic hypothermia for severe head injury

The National Acute Brain Injury Study: Hypothermia (NABIS:H) is an ongoing multicenter trial of systemic hypothermia for the treatment of severe head injury. Follow-up rates for the study's 3-and 6-month outcome assessments have been maintained at high levels by establishing close contact with family members, by reimbursing cost of travel, and by sending examiners to the subject's location whenever necessary. Two years into the study, global disability data (e.g., Glasgow Outcome Scale) have been obtained on 86% of patients due for 3-month assessment (n = 131) and for all subjects due at 6 months (n = 100). Over half of the patients have completed neuropsychological testing with high reliability ratings. These preliminary findings suggest that the procedures used to document data quality and increase follow-up and completion rates are being successful.

Role of electron microscopy of sperm in the evaluation of male infertility during the era of assisted reproduction

OBJECTIVES

To determine whether there are indications for and benefits from electron microscopy (EM) of sperm during the era of assisted reproductive technology.

METHODS

The medical history, semen analyses, and EM findings of 55 patients with pure male-factor infertility were reviewed to determine: (1) which semen characteristics (seminal volume, sperm concentration, percent motility, and percent normal morphology) were associated with normal or abnormal ultrastructure as determined by EM, (2) whether EM findings correlated with success or failure of in vitro fertilization (IVF), and (3) whether EM could screen for potentially inheritable genetic disorders.

RESULTS

Principal EM diagnoses were normal sperm ultrastructure (11 of 55; 20%), tail abnormalities (21 of 55; 38%), necrospermia (12 of 55; 22%), acrosomal defects (9 of 55; 16%), neck abnormalities (1 of 55; 2%), and incomplete maturation (1 of 55; 2%). Every patient with an abnormal EM study had impaired motility (33% or below) and abnormal morphology (13% or lower normal forms by World Health Organization criteria). The percentage of normal sperm morphology differed significantly across EM diagnoses (P < 0.0001). Differences in motility across the groups could not be detected because EM was only performed on patients with impaired motility. Although the partner of 1 patient with a normal EM study who underwent IVF achieved pregnancy, 11 with abnormal EM studies failed to establish a pregnancy by IVF. Finally, 5 (11%) of 44 patients with abnormal EM findings were diagnosed with primary ciliary dyskinesia directly as a result of EM. In addition, 3 (6.8%) of the 44 patients with abnormal EM findings were diagnosed with complete acrosomal loss.

CONCLUSIONS

Patients with severely abnormal motility and morphology on routine semen analysis may benefit from EM study of sperm. Our data indicate that EM findings correlate with success or failure of IVF, and that EM can screen for potentially inheritable genetic disorders.

Initial dissection of the lateral fascia reduces the positive margin rate in radical prostatectomy

OBJECTIVES

Positive margins predict an adverse outcome after radical retropubic prostatectomy (RRP). The effect of initial incision of the lateral pelvic fascia prior to urethral transection on positive margins rates is assessed.

METHODS

The rate of positive margins in 350 consecutive RRPs is compared in two groups without hormonal pretreatment. In group 1 (n = 198), RRP was performed in standard fashion with apical dissection and urethral transection preceding dissection of the lateral pelvic fascia and mobilization of the prostate from the anterior rectal surface. In group 2 (n = 1 52), the initial step consisted of incision of the lateral pelvic fascia along the perirectal surface with prostatic mobilization off the rectum prior to urethral transection. The bladder neck and seminal vesicle dissection was identical in both groups. Specimens were step-sectioned for histologic analysis. Differences in rates of positive margins were analyzed by Fisher's exact test and logistic regression.

RESULTS

The rate of positive margins was reduced from 37.4% in group 1 to 15.8% in group 2. In the logistic regression model, surgical technique, Gleason sum, serum prostate-specific antigen (PSA), and the presence of extracapsular extension were independent predictors of margin status, with group 1 being more than twice as likely to have positive margins than group 2 (P = 0.0076; odds ratio 2.198; 95% confidence interval 1.23 to 3.92). The rate of positive margins was reduced from 45.5% in group 1 to 16.7% in group 2 (P = 0.0046) for non-nerve-sparing RRP and from 33.3% to 15.5% (P = 0.0012) for nerve-sparing RRP. There were no differences in functional outcomes between groups and no rectal injuries in group 2.

CONCLUSIONS

Initial dissection of the lateral pelvic fascia during RRP results in a lower rate of positive margins independent of tumor grade, clinical stage, extracapsular extension, and preoperative PSA level.

Identification of spermatozoa and round spermatids in the ejaculates of men with spermatogenic failure

OBJECTIVES

As many as 10% of infertile men have azoospermia caused by spermatogenic failure or ductal obstruction. The histologic diagnoses associated with spermatogenic failure--Sertoli cell-only syndrome, maturation arrest, and hypospermatogenesis--do not necessarily represent global changes in the affected testis, as occasional seminiferous tubules may still produce mature germ cells. Intracytoplasmic sperm injection (ICSI) allows individual sperm that have been isolated from testicular tissue to fertilize oocytes. This study assessed whether mature germ cells (either round spermatids or spermatozoa) were present in the ejaculates of patients with spermatogenic failure.

METHODS

All semen analyses performed at our tertiary care institution from January 1993 through December 1995 were reviewed to identify azoospermic men with spermatogenic failure. During this period, our laboratory employed Nuclear-Fast Red and picroindigocarmine staining (NF-PICS) of cytospin slides to identify rare spermatozoa and spermatids in otherwise azoospermic ejaculates.

RESULTS

Of 3005 analyses reviewed, 20 azoospermic men whose infertility was solely attributable to spermatogenic failure were identified. The histologic diagnoses were germinal cell aplasia (n = 7), complete maturation arrest (n = 6), incomplete maturation arrest (n = 3), and hypospermatogenesis (n = 4). Using the NF-PICS technique, mature germ cells were identified in the ejaculates of 15 men (75%), and 9 men (45%) had fully formed spermatozoa present.

CONCLUSIONS

In the clinical management of azoospermic infertile men, the NF-PICS technique may be used to identify men who have some degree of testicular spermatogenesis. This might obviate the need for the purely diagnostic testis biopsy that is performed before therapeutic biopsy for testicular sperm extraction in conjunction with ICSI.

Combined nested RT-PCR assay for prostate-specific antigen and prostate-specific membrane antigen in prostate cancer patients: correlation with pathological stage

Nested reverse transcription (RT)-PCR for prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSM) can detect circulating prostatic cells in patients with prostate cancer. We evaluated the role of a combined screening approach for PSA and PSM in prostate cancer staging. We examined the peripheral blood samples from 136 patients with adenocarcinoma of the prostate (PCA), 15 patients with benign prostatic hyperplasia, 15 normal male subjects, and 5 female subjects. The controls (benign prostatic hyperplasias, normal males, and normal females) were negative for both PSA and PSM. In patients with metastatic PCA (n = 11), 100% were positive by combined PSA/PSM (64% by PSA and 91% by PSM). In biochemical failure PCA patients (n = 18), 39% were positive by PSM, compared to only 6% by PSA. In patients with clinically localized PCA (n = 107), 48% were positive by combined PSA/PSM approach (43% by PSM and 14% by PSA). These results show that PSM is a more sensitive marker than PSA in detecting circulating prostatic cells (P < 0.0001). We correlated preoperative RT-PCR results with final pathological stages in 67 prostatectomy patients. RT-PCR positivity was 81.5% in patients with non-organ-confined disease versus 37.5% in organ-confined disease (P = 0.001). PSA/PSM RT-PCR had an odds ratio of 7.3 (95% confidence interval, 2.3-23.4; P = 0.001) in predicting tumor extracapsular extension. PSA/PSM RT-PCR was a better predictor of tumor extracapsular extension than initial serum PSA, clinical stage, and biopsy Gleason score. Our data show that PSA/PSM nested RT-PCR may provide the staging information unavailable from the current modalities. The ultimate impact of this technique in the management of patients with prostate cancer will require continued investigation.

Discourse after closed head injury in young children

This study examined narrative discourse in 23 children, ages 6 to 8 years, who sustained a severe closed head injury (CHI) at least 1 year prior to assessment. Narratives were analyzed at multiple levels using language and information structure measures. Results revealed significant discourse impairments in the CHI group on all measures of information structure, whereas differences in the linguistic domain failed to reach significance. In addition, effects of age at injury and lateralization of lesion on discourse were considered. Although no significant differences were found according to age at injury, a consistent pattern of generally poorer discourse scores was found for the early injured group (< 5 years). With regard to lesion focus, the group findings were unimpressive. However, preliminary examination of individual CHI cases with relatively large lateralized lesions suggested that the late injured children may show the language-brain patterns reported in brain-injured adults, whereas early injured children may not.

Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury

OBJECTIVE

To assess which social activities were still impaired 5 years after a traumatic brain injury (TBI) in adults, and which neuropsychological impairments were associated with this loss of social autonomy.

DESIGN

Cross-sectional study of 79 patients selected from the follow-up cohort of an epidemiologic survey of 2,116 TBI patients.

SETTING

The present study was of ambulatory patients seen at hospital or at their homes. The inception cohort was from the trauma center of a university hospital and from a general hospital that is representative of level II trauma centers in Aquitaine, France.

PATIENTS

Seventy-nine patients selected from a representative sample of 407 patients who were included in the 5-year follow-up study of the initial cohort (convenience sample).

MAIN OUTCOME MEASURES

Glasgow Outcome Scale (GOS) and loss of social autonomy as assessed by the European Brain Injury Society's European Head Injury Evaluation Chart; assessment of neurobehavioral impairments by means of the Neurobehavioral Rating Scale-Revised.

RESULTS

Up to 16 patients suffered disability for at least one social skill because of cognitive/behavioral reasons. Seven needed full-time supervision. Performing administrative tasks and financial management, writing letters and calculating, driving, planning the week, and using public transport were the most impaired social abilities. Loss of social autonomy was mainly observed in severely injured patients. Univariate analysis showed that mental fatigability, motor slowing, memory difficulties, and disorders of executive function were associated with low scores on the GOS, unemployment, and difficulties in shopping, using public transport, and performing financial management and administrative tasks.

CONCLUSION

Persistent impairments of executive functions and speed of psychomotor processing are major factors associated with loss of social autonomy and inability to return to work long after TBI in adults. Improving these impairments in concrete social situations represents a major challenge for cognitive rehabilitation.

Concept formation and problem-solving following closed head injury in children

To further investigate the usefulness of 3 purported measures of executive function (EF) in head injured children, we administered the Twenty Questions Test (TQT), Tower of London (TOL), and the Wisconsin Card Sorting Test (WCST) to 151 children who had sustained a closed head injury (CHI) of varying severity about 3 years earlier. In addition, we tested 89 normal controls. Fifty-seven of the patients were included in a longitudinal study that compared performance at 3 months and 36 months. All of the head injured children underwent magnetic resonance imaging for investigational purposes. Severity of CHI, as defined by the lowest Glasgow Coma Scale (GCS) score, affected performance on all 3 EF measures. Focal lesion volume incremented prediction of performance on TOL and WCST, but not TQT. Moderate intercorrelations of the test variables were obtained. Although all three EF measures depicted changes in performance over 3 years, a ceiling effect detracted from the sensitivity of the TOL to the impact of CHI on development. Implications of the findings for clinical applications are discussed.

Longitudinal neuropsychological outcome in infants and preschoolers with traumatic brain injury

Neuropsychological outcome was evaluated in a prospective, longitudinal follow-up study of children age 4 months to 7 years at injury with either mild-to-moderate (N = 35) or severe (N = 44) traumatic brain injury (TBI). Age-appropriate tests were administered at baseline, 6 months, 12 months, and 24 months after the injury. Performance was compared on (1) Composite IQ and motor, (2) Receptive and expressive language, and (3) Verbal and Perceptual-Performance IQ scores. In comparison to mild-to-moderate TBI, severe TBI in infants and preschoolers produced deficits in all areas. Interactions between task and severity of injury were obtained. Motor scores were lower than IQ scores, particularly after severe TBI. Both receptive and expressive scores were reduced following severe TBI. Expressive language scores were lower than receptive language scores for children sustaining mild-to-moderate TBI. While severe TBI lowered both Verbal and Perceptual-Performance IQ scores, Verbal IQ scores were significantly lower than Perceptual-Performance IQ scores after mild-to-moderate TBI. Mild injuries may produce subtle linguistic changes adversely impacting estimates of Verbal IQ and expressive language. Within the limited age range evaluated within this study, age at injury was unrelated to test scores: The impact of TBI was comparable in children ages 4 to 41 months versus 42 to 72 months at the time of injury. All neuropsychological scores improved significantly from baseline to the 6-month follow-up. However, no further change in scores was observed from 6 to 24 months after the injury. The persistent deficits and lack of catch-up over time suggest a reduction in the rate of acquisition of new skills after severe TBI. Methodological issues in longitudinal studies of young children were discussed.

Fibrin-glue assisted vasoepididymostomy: a comparison to standard end-to-side microsurgical vasoepididymostomy in the rat model

PURPOSE

The use of fibrin glue for vasovasostomy has produced high patency rates in animal models. Vasoepididymostomy is a microsurgical technique that might be made easier if fibrin glue could substitute for microsutures. We evaluated the efficacy of a new vasoepididymostomy technique using fibrin glue.

MATERIALS AND METHODS

Bilateral vasoepididymostomies were performed in 24 male Sprague-Dawley rats using a conventional microsurgical technique on one side and a fibrin-glue assisted technique on the other. The rats were sacrificed 30 days after surgery and anastomotic patency was assessed by examining the vasal fluid for sperm, injecting methylene blue dye into the vas deferens and observing backflow into the epididymis by gross inspection and histological studies. Additionally, the incidence of granuloma formation was compared between the two techniques.

RESULTS

Fibrin-glue anastomoses showed a patency rate of 79% (n = 19), compared with 63% (n = 15) for the conventional suture anastomoses (p = 0.29). Among the patent anastomoses, the incidence of sperm granuloma formation between the sutured (12, 50%) and the fibrin glue anastomoses (16, 67%) did not differ significantly (p = 0.36). Morphological tissue changes were similar for the two techniques. The time required for anastomosis using fibrin glue was significantly shorter than the conventional suture technique (p < 0.001).

CONCLUSIONS

Conventional suturing techniques for vasoepididymostomy require advanced microsurgical skills. The use of fibrin glue simplifies this procedure and provides patency rates comparable to microsutured, end-to-side anastomoses.

Stage T1-2 prostate cancer with pretreatment prostate-specific antigen level < or = 10 ng/ml: radiation therapy or surgery?

PURPOSE

To detect differences in biochemical failure rates by treatment modality (radiation therapy or radical prostatectomy) in patients with early-stage prostate cancer presenting with pretreatment prostatic-specific antigen (PSA) levels < or = 10.0 ng/ml.

METHODS AND MATERIALS

A total of 1467 consecutive patients with prostate carcinoma were treated with either radiotherapy (RT) or radical prostatectomy (RP) between January 1987 and June 1996. Patients with the following were excluded from the present study: initial PSA (iPSA) level > 10 ng/ml (n = 444), clinical Stage T3 disease (n = 73), adjuvant or neoadjuvant treatment (n = 173), no available iPSA level (n = 31), no available biopsy Gleason score (GS) (n = 33), incomplete pathologic information (n = 16), and no available follow-up PSA levels (n = 90). The analysis was performed on 607 cases: 354 treated with RP and 253 with RT (median dose 68.4 Gy). The outcome of interest was biochemical relapse-free survival (bRFS), with biochemical relapse being defined as either a detectable PSA level after RP or elevation in PSA levels of > or = 1.0 ng/ml above the nadir after RT. Proportional hazards were used to analyze the effect of treatment modality and confounding variables (i.e., age, stage, biopsy GS, iPSA levels) on treatment outcome.

RESULTS

Seventy-nine percent of patients (n = 478) had clinical Stage T1 or T2A disease at presentation (RP vs. RT: 84% vs. 71%, p < 0.001). Twenty-one percent of patients (n = 127) had iPSA levels < or = 4 ng/ml (RP vs. RT: 24% vs. 17%, p = 0.027). Seventy-six percent of patients (n = 460) had biopsy GS < or = 6 (RP vs. RT: 79% vs. 71%, p = 0.014). The median follow-up time was 24 months (range 3-110). For the 607 patients, the 5-year bRFS rate was 76%. The 5-year RFS rates for RP versus RT were 76% versus 75%, respectively (p = 0.09). After adjustment for all confounding variables, iPSA levels (p < 0.001) and biopsy GS (p = 0.001) were the only independent predictors of relapse, whereas age, clinical stage, and treatment modality were not (p = 0.20; p = 0.09; and p = 0.10, respectively).

CONCLUSION

In patients with clinical Stage T1-2 prostate cancer and pretreatment PSA < or = 10 ng/ml, there is no difference in biochemical failure rates between those treated with radiation and those treated with surgery.

Prospective evaluation of fine needle aspiration of small, solid renal masses: accuracy and morbidity

OBJECTIVES

To determine the accuracy and clinical utility of fine needle aspiration (FNA) of small, solid renal masses.

METHODS

A total of 25 patients with small (less than 5.0 cm), solid, clinically localized renal masses were prospectively identified and evaluated with computed tomography guided FNA with analysis for presence of malignant cells and determination of nuclear grade. The final pathologic findings were used for comparison in each case. All patients had renal cell carcinoma and were managed with radical or partial nephrectomy; 3 had low-grade lesions (Fuhrman's grade 1/4), 2 had high-grade lesions (Fuhrman's grade 4/4), and all other patients had intermediate-grade lesions (Fuhrman's grade 2/4 or 3/4) on final histopathologic assessment.

RESULTS

Overall, 10 aspirations yielded diagnostic malignant cells, and 9 were read as rare as rare atypical cells suspicious for malignancy. The remainder were negative (n = 6). Correlation with final nuclear grade was observed in eight instances and discordance in two instances. Subcapsular hematomas were observed at the time of surgery in 10 patients, but in no instance was the operation adversely affected.

CONCLUSIONS

The diagnostic yield of FNA of small, solid renal masses appears to be too low to justify the potential morbidity of the procedure.

Isolated splenic metastases from colon cancer

Metastatic tumors of the spleen are rare and usually occur in the presence of disseminated visceral metastases. The liver is the most common site of metastatic spread from colon cancer. We report a case of isolated intrasplenic metastasis from sigmoid colon cancer and review the possible reasons for the rarity of splenic metastasis. This represents the fifth reported case of isolated splenic metastasis from colon cancer. Splenectomy may be justified in presence of isolated metastatic disease, since it is an operation with a low complication rate and may provide potential long-term survival in colon cancer.

Ureteroscopic diagnosis of intraluminal metastatic rectal carcinoma

Ureteral obstruction resulting from metastatic adenocarcinoma is almost always extrinsic in nature. In contrast, true intraluminal metastases are extremely rare. With this report, we document the videoendoscopic appearance of true intraluminal ureteral metastases from metastatic rectal cancer confirmed with histopathologic examination. The value of transureteroscopic biopsy for accurate diagnosis is also demonstrated.

The psychological construct of word fluency

Measures of word fluency have been convincingly linked in the literature to damage in the left prefrontal lobe region. Yet, a reduction in word fluency has also been reported with diffuse, multifocal and nonfrontal lobe damage. Despite the undisputed neuropsychological application of multiple word fluency measures, the psychological construct underlying this measure is not well understood. In a sample of 360 normal adults stratified by age, gender, and level of education, we found that auditory attention and word knowledge were among the most important determinants. With respect to memory, short-term memory was not significantly correlated, but long-term memory was. Despite these three determinants, a large share of the variance of the multiple regression was still not accounted for, which underscores the partial independence of word fluency per se. Thus, we propose a distinction between (1) poor word fluency secondary to deficient verbal attention, word knowledge, and/or verbal long-term memory and (2) impaired word fluency without these three areas concurrently affected. Based on a review of the literature, it seems likely that in the latter condition, the profile is more associated with prefrontal lobe impairment, versus in the former condition, diffuse multifocal or nonfrontal lobe factors can play a role.

Stage T1-2 prostate cancer: a multivariate analysis of factors affecting biochemical and clinical failures after radical prostatectomy

PURPOSE

Prostate-specific antigen (PSA) is extensively used in case selection and outcome evaluation after treatment of clinically localized prostate cancer. Careful case selection can have a profound impact on pathologic findings and ultimate outcome. In addition, salvage treatment is frequently initiated at the time of biochemical relapse rather than clinical recurrence. Consequently, patterns of failure can be significantly altered compared to previous times when PSA was not available. To better understand the impact of PSA on pathologic findings, outcome, and salvage treatment, we reviewed our experience in the PSA era with clinical Stage T1-2 prostate cancer treated with radical prostatectomy.

METHODS AND MATERIALS

Between 1987 and 1993, 423 cases could be identified with clinical Stage T1-2 prostate cancer treated with radical prostatectomy. The distribution of cases by pretreatment PSA levels was as follows: < or = 4 ng/ml (18%), 4-10 ng/ml (42%), 10-20 ng/ml (21%), > 20 ng/ml (14%), and unknown (5%). The median pretreatment PSA level for the entire group was 8.0 ng/ml. Sixteen patients received adjuvant or neoadjuvant androgen suppression and 13 received postoperative radiotherapy. Only 31 patients (7%) had pathologically positive pelvic lymph nodes. The overall margin involvement rate was 46%. Fifty-three percent of patients had surgical Gleason scores > or = 7, and 65% had extracapsular extension. The median follow-up time was 41 months.

RESULTS

The projected overall survival at 7 years after surgery was 90%. The 5-year clinical relapse-free survival rate was 84%. At 5 years, the local control and distant failure rates were 92% and 91%, respectively. Biochemical relapse was defined as a detectable or rising PSA level after prostatectomy. The 5-year biochemical relapse-free survival (bRFS) rate was 59%. The 5-year RFS was 88% in patients with preoperative PSA levels < or = 4, 62% for 4-10, 48% for 10-20, and 31% for > 20. Combining the two independent preoperative variables, iPSA and biopsy GS (bGS), two risks groups were defined: low risk [initial PSA (iPSA) levels < or = 10.0 and bGS < or = 6] and high risk (iPSA levels > 10.0 ng/ml or bGS > or = 7). The 5-year bRFS rate for the low-risk cases was 81% vs. 40% for high-risk cases (p < 0.001). On multivariate analysis, three factors independently predicted biochemical relapse: iPSA levels (p = 0.005), Gleason score from the surgical specimen (sGS) (p = 0.002), and positive surgical margins (p < or = 0.001). The 5-year bRFS rates for margin positive vs. margin negative patients were 37% vs. 78%, respectively. The 5-year bRFS rates for GS > or = 7 vs. GS > or = 6 were 42% vs. 80%, respectively. All clinical relapses were accompanied by a rise in PSA. In patients who manifested biochemical failure followed by a clinical failure, the median interval between the PSA rise and clinical failure was 19 months (range 7-71). Margin involvement was the only independent predictor of local failure (p = 0.019). The 5-year local failure-free survival for negative margin cases was 96% vs. 87% for positive margin cases (p = 0.012). Lymph node (LN) involvement and high-risk group were the two independent predictors of distant failure. The 5-year distant failure-free survival for negative LN cases was 94% vs. 67% for positive LN cases (p < 0.001). The 5-year distant failure-free survival for low-risk cases was 97% vs. 85% for high-risk cases (p = 0.005). For the 124 patients failing biochemically, 85 were observed and 39 were treated either with radiation or androgen deprivation. With a median follow-up of 32 months, the clinical disease relapse-free survival was 79% for the treated patients vs. only 32% for the patients observed (p < 0.001).

CONCLUSION

Pretreatment PSA is the most potent clinical factor independently predicting biochemical relapse, thereby allowing markedly better case selection. Achieving negative margins, even in relatively advanced disease, provides excellent lon

Magnetic resonance imaging in relation to functional outcome of pediatric closed head injury: a test of the Ommaya-Gennarelli model

OBJECTIVE

To characterize late neuropathological findings of pediatric closed head injury (CHI), to assess depth of brain lesion in relation to acute severity, and to assess long-term outcome to test the Ommaya-Gennarelli model.

METHODS

Magnetic resonance imaging (MRI) at least 3 months postinjury in a prospective sample (n 5 169) and at least 3 years after CHI in a retrospective sample (n 5 82) was studied. Lesion volume was measured by planimetry. Acute CHI severity was measured by the Glasgow Coma Scale. Patients were classified according to the depth of the deepest parenchymal lesion into no lesion, subcortical, and deep central gray/brain stem groups. The outcomes were assessed by the Glasgow Outcome Scale and the Vineland Adaptive Behavior Scale, which were performed at the time of the MRI in the retrospective sample and up to 3 years postinjury in the prospective sample.

RESULTS

Focal brain lesions were present in 55.4% of the total sample. Depth of brain lesion was directly related to severity of acute impairment of consciousness and inversely related to outcome, as measured by both the Glasgow Outcome Scale and the Vineland Adaptive Behavior Scale. A rostrocaudal gradient of hemispheric lesion frequency was observed, whereas the posterior lesions of the corpus callosum were particularly common. Total lesion volume could not explain the depth of lesion effect.

CONCLUSION

Our findings extend support for the Ommaya-Gennarelli model to pediatric CHI, indicating that depth of brain lesion is related to functional outcome. The relative frequency of focal brain lesions revealed by late MRI is higher than that of previous findings using acute computed tomography. Future investigations could explore whether depth of lesion observed using late MRI is sensitive to neuroprotective interventions.

Adenomatoid tumor of the adrenal gland: a report of four new cases and a review of the literature

Adenomatoid tumors of the adrenal gland are rare, benign, asymptomatic neoplasms that are usually found incidentally. Previously reported cases occurred only in men and only on the left side. We report four cases, including two from the right adrenal gland, one from a woman, and one with a cystic component. The average age of our patients was 49 years, compared with the average age of 34 years in previously reported cases. Our immunohistochemical stains and electron microscopic analysis support the presumed mesothelial derivation of these tumors. The differential diagnosis of adenomatoid tumors of the adrenal gland includes a variety of solid and cystic tumors. It is important to recognize these rare tumors to avoid misclassifying them, especially as metastatic or primary malignant vascular tumors.

Semantic memory following pediatric head injury: relationship to age, severity of injury, and MRI

The effects of closed head injury (CHI) severity (mild vs. severe) and age at injury were analyzed in a longitudinal study (3. 12 months postinjury) of semantic memory which used magnetic resonance imaging (MRI) to characterize focal brain lesions. Semantic memory was evaluated by word and category fluency, semantic verification, semantic clustering in word list recall, and vocabulary. Episodic memory was assessed by word list recall. Comparison of normal control (n = 104) data with the patients' data (n = 77) at 3 months postinjury disclosed semantic and episodic memory deficits in the severe CHI patients. Analysis of the longitudinal data revealed significant effects of age at injury for all of the semantic memory measures. The effects of injury severity were confined to the latency of verifying correct statements. Volume of left frontal and extrafrontal lesions was predictive of performance on several semantic memory measures, but less robust for right hemisphere lesions.

Posttraumatic Amnesia as a predictor of outcome after severe closed head injury. Prospective assessment

OBJECTIVES

To identify the demographic and clinical variables related to the duration of posttraumatic amnesia after severe closed head injury; to evaluate the usefulness of posttraumatic amnesia duration in predicting outcome at the time of hospital discharge and at 6 months after injury.

SETTING

Four clinical centers located in primary care hospitals.

PATIENTS

Three hundred fourteen severely injured subjects aged 16 years or older who did not have trauma as a result of a penetrating injury and came out of coma before hospital discharge.

INTERVENTIONS

Approximately half of the subjects were administered phenytoin sodium for some period after termination of coma; 17% were administered dexamethasone and 41% morphine sulfate.

MAIN OUTCOME MEASURES

Galveston Orientation and Amnesia Test scores defined the duration of posttraumatic amnesia. The Glasgow Outcome Scale was used to grade outcome at the time of hospital discharge and at 6 months.

RESULTS

Older age, low initial Glasgow Coma Scale score, nonreactive pupil(s), coma duration, and use of phenytoin were associated with a longer duration of posttraumatic amnesia. Poor pupillary response, time in coma, and duration of posttraumatic amnesia and use of phenytoin was predictive of the 6-month outcome.

CONCLUSIONS

The results support the prognostic usefulness of prospectively measuring duration of posttraumatic amnesia after termination of coma. Pending replication, our findings suggest that posttraumatic amnesia duration may be a useful surrogate outcome measure for clinical trials involving interventions for acute head injury.

Behavioral outcomes after pediatric closed head injury: relationships with age, severity, and lesion size

This study investigated the behavioral outcomes and adaptive functioning of 138 children with mild to severe closed head injury in the 6- to 16-year age range. Each child was evaluated with the Personality Inventory for Children-Revised. A subset of this sample (n = 77) received the Vineland Adaptive Behavior Scales. Results revealed little evidence for group differences based on severity of closed head injury on scales associated with psychopathology on the Personality Inventory for Children-Revised. However, children with severe closed head injury were viewed as experiencing more difficulties than children with mild-moderate closed head injury on those components of the Personality Inventory for Children-Revised most closely associated with cognitive functions. In addition, on the Vineland Adaptive Behavior Scales, severely injured children had lower scores on the Communication and Socialization scales than children with mild-moderate injury. Relationships between the size of frontal and extrafrontal lesions from concurrent magnetic resonance imaging and behavioral outcomes were not apparent. This study suggests that outcome measures assessing adaptive behavior and cognitive functions are more sensitive to severity of closed head injury than parent-based scales of internalizing and externalizing psychopathology.

Subacute methylphenidate treatment for moderate to moderately severe traumatic brain injury: a preliminary double-blind placebo-controlled study

OBJECTIVE

To determine the effect of subacute administration of methylphenidate on recovery from moderate to moderately severe closed head injury.

DESIGN

Double-blind placebo-controlled with random assignment. Patients were enrolled when their Galveston Orientation and Amnesia Test score was at least 65. Drug/placebo treatment began the day following baseline cognitive assessment and continued for 30 consecutive days. Follow-up evaluations were conducted at 30 and 90 days after baseline, after discontinuation of drug/placebo.

SETTING

A level I trauma center.

PATIENTS

Twenty-three patients ranging in age from 16 to 64 years. Head injury severity ranged from moderately severe (Glasgow Coma Score [GCS] < or = 8, no intracranial pressure monitor) to "complicated mild" (GCS from 13 to 15 with positive computed tomography brain scan). Thirty-day follow-up was based on 12 patients, whereas 90-day evaluation was based on 9 patients, with complicated mild head injuries excluded from the analyses.

INTERVENTIONS

Methylphenidate administered twice daily at a dose of .30 mg/kg; placebo administered according to the same schedule in identical pill form.

MAIN OUTCOME MEASURES

The Disability Rating Scale (DRS) and tests of attention, memory, and vigilance.

RESULTS

The methylphenidate group was significantly better at 30 days on the DRS (p < .02), and on tests of attention (p < .03) and motor performance (p, .05). No significant differences were noted between groups at 90 days.

CONCLUSIONS

Subacute administration of methylphenidate after moderately severe head injury appeared to enhance the rate but not the ultimate level of recovery as measured by the DRS and tests of vigilance. Problems with possible selection bias and small sample size limit generalization of results.

Intraoperative evaluation of renal cell carcinoma: a prospective study of the role of ultrasonography and histopathological frozen sections

PURPOSE

Nephron sparing surgery is being performed increasingly for treatment of renal cell carcinoma, including in select patients with a normal contralateral kidney. The number of tumors in the involved kidney (single versus multiple) and presence or absence of perinephric fat involvement (pathological stage T1 to 2 versus T3A) are important prognostic factors. In a prospective study we evaluated the accuracy of intraoperative histopathological frozen section analysis of renal capsular biopsies for assessing local tumor stage, and the accuracy of intraoperative ultrasonography for assessing tumor focality.

MATERIALS AND METHODS

Intraoperative frozen section biopsies and ultrasonography were compared with information obtained from preoperative computerized tomography (CT), intraoperative inspection of the kidney by the surgeon and permanent histopathological specimens.

RESULTS

We evaluated 99 patients (102 kidneys) with localized sold renal masses undergoing either radical nephrectomy (48) or nephron sparing surgery (54). Final pathological analysis revealed 95 renal cell carcinomas (stage T3A in 24), 6 oncocytomas and 1 angiomyolipoma. Multiple tumors were detected in 18 of 102 kidneys overall. Frozen section analysis identified 87% of the stage T3A lesions with no false-positive results, compared to CT, which only identified 67%. Ultrasonography identified 14 of 18 multifocal tumors (78%) and was not more accurate than the combination of CT and intraoperative inspection. However, during nephron sparing surgery ultrasonography was useful to localize the intrarenal extent of tumors (17 cases).

CONCLUSIONS

Our results clarify the role of intraoperative ultrasonography and frozen section analysis in patients undergoing nephron sparing surgery for renal cell carcinoma. Frozen section analysis may be useful in select patients with small peripheral tumors who are under consideration for elective nephron sparing surgery.

Testicular cancer in association with developmental renal anomalies and hypospadias

OBJECTIVES

To characterize the clinical, pathologic, and genetic aspects of patients with a previously undescribed phenotype of testicular germ cell tumors associated with renal hypoplasia or agenesis and urethral hypospadias.

METHODS

Review of clinical and pathologic findings and genetic analysis of constitutional and tumor DNA for mutations of the Wilms' tumor suppressor gene (WT1).

RESULTS

Clinical findings suggest that this phenotype is distinct from other syndromes associated with renal anomalies and that the associated testicular tumors are histologically and clinically similar to those that occur sporadically. No karyotypic abnormalities, loss of heterozygosity, or mutations in the zinc finger domains (exons 7-10) of WT1 were observed in 5 patients with this phenotype.

CONCLUSIONS

The phenotype of testicular germ cell tumor, developmental renal anomalies, and urethral hypospadias constitutes a discrete syndrome caused by a gene distinct from WT1.

Benton Controlled Oral Word Association Test: reliability and updated norms

The aim of this paper is to update the over 20-year-old normative data for the Benton Controlled Word Association (COWA) Test. In a sample of 360 normal volunteers, the age ranged between 16-70 years, and the educational level ranged from 7-22 years. Care was taken to ensure that the population was heterogeneous, yet the two stratifications of gender, four age, and three educational groups led to 24 cells with 15 individuals in each. Test-retest reliability was established by testing 30% of the sample after a 6-month delay, which represents a typical follow up duration between testings in a clinical setting. The two forms of the COWA revealed significant test-retest reliability. Generally, our updated values fall above the original normative values, which were derived from a less well-educated and rural sample. No major gender or age trends were noted, but the COWA test performances were influenced by education, i.e., as the level of education increased, the performance on the COWA increased. The only gender differences that were found were for the women in the highest educational group ( > 16 years), who performed significantly better that men in the highest educational group. An error analysis of repetitions or perseverations is provided, with cut-off scores according to age levels. Finally, the updated COWA norms are compared to the original norms as well as to other measures of word fluency.

Dyscalculia and dyslexia after right hemisphere injury in infancy

OBJECTIVE

To use the findings from neuropsychological evaluation and functional magnetic resonance imaging (fMRI) to assess interhemispheric reorganization of function after early unilateral brain injury.

DESIGN AND METHODS

The study focused on one case of early brain injury that resulted in both dyscalculia and dyslexia. Brain injury was studied using both structural and fMRI. Intellectual function was evaluated using the Wechsler Intelligence Scale for Children, Third Edition, while visuospatial skills were assessed using the Block Design subtest of the Wechsler Intelligence Scale for Children, Third Edition, and Judgment of Line Orientation subtest. The Selective Reminding Test and the Recurring Figures Test were used to evaluate memory and orientation; language and speech skills were evaluated using the Boston Naming Test, Controlled Oral Word Association, Gates-MacGinitie Reading Test, and color naming. Various methods were used to study arithmetic skills, including the Wide Range Achievement Test-Revised and the Peabody Individual Achievement Test. The control group for fMRI consisted of nine normal subjects.

SETTING

Neuropsychological laboratory in primary care hospital.

PATIENT

A 17-year-old boy who had sustained a closed head injury associated with a partially depressed, right parietal skull fracture, and right temporal hemorrhage in a motor vehicle crash at age 7 months (November 9, 1977). Subsequent social behavior was normal, but the patient had difficulty throughout school in mathematics and spelling and was characterized as having a "short attention span."

INTERVENTION

None.

MAIN OUTCOME MEASURES

Standardized tests of arithmetic and reading supplemented by an assessment of calculation and quantitative skills. While performing calculations, fMRI disclosed predominantly left hemisphere activation involving the frontal and posterior parietal regions, whereas this task produced bilateral activation of the supramarginal gyrus in seven of nine normal subjects.

RESULTS

Neuropsychological findings confirmed the presence of dyscalculia and dyslexia despite normal intellectual functioning. Visuospatial skills ranged from the low normal to average level. The fMRI findings were consistent with early interhemispheric transfer of visuospatial skills normally committed to the right parietal area to the left parietal region. The patient's dyscalculia and reading ability raise a question of acquired left parietal dysfunction as a consequence of the competition between verbal and visuospatial functions for left hemisphere representation.

CONCLUSION

Interhemispheric reorganization of function may be bidirectional rather than a feature unique to the left hemisphere substrate for language.

Prediction of recovery from traumatic brain injury

This paper encompasses the prediction of early and late recovery from traumatic brain injury (TBI). Predictors of the duration of coma and the utilization of posttraumatic amnesia duration to predict residual memory function are discussed. The issues surrounding prediction of long-term neurobehavioral recovery from TBI are considered, particularly the patient and clinical variables that are related to intellectual recovery. Findings from the NIH Traumatic Coma Data are reviewed pertaining to testability as a criterion for outcome. In addition to discussing the relationship of specific neurologic indices of TBI as predictors, the results obtained using a regression model are summarized. Finally, the relationship of neuroimaging findings to neurobehavioral outcome is discussed including directions for future research.

Frontal lobe changes after severe diffuse closed head injury in children: a volumetric study of magnetic resonance imaging

In view of the pathophysiology and biomechanics of severe closed head injury (CHI) in children, we postulated that the frontal lobes sustain diffuse injury, even in the absence of focal brain lesions detected by magnetic resonance imaging (MRI). This study quantitated the morphological effects of CHI on the frontal lobes in children who sustained head trauma of varying severity. The MRI findings of 14 children who had sustained severe CHIs (Glasgow Coma Scale score of < or = 8) were compared with the findings in a matched group of 14 children having sustained mild head injuries (Glasgow Coma Scale score of 13-15). The patients ranged in age from 5 to 15 years at the time of their MRIs, which were acquired at least 3 months postinjury. MRI findings revealed no focal areas of abnormal signal in the frontal lobes. Volumetric analysis disclosed that the total prefrontal cerebrospinal fluid increased and the gray matter volume decreased in the patients with severe CHI, relative to the mildly injured comparison group. Gray matter volume was also reduced in the orbitofrontal and dorsolateral regions of the brains of children with severe CHI, relative to the children who sustained mild head trauma. These volumetric findings indicate that prefrontal tissue loss occurs after severe CHI in children, even in the absence of focal brain lesions in this area. Nearly two-thirds of the children who sustained severe CHIs were moderately disabled after an average postinjury interval of 3 years or more, whereas 12 of the 14 patients with mild CHIs attained a good recovery (2 were moderately disabled) by the time of study.(ABSTRACT TRUNCATED AT 250 WORDS)

Open pelvic lymph node dissection for prostate cancer: a reassessment

OBJECTIVES

To provide a risk-to-benefit analysis of open staging pelvic lymph node dissection (PLND) for prostate cancer.

METHODS

The medical records of all patients presenting with prostate cancer from July 1989 to April 1994 were reviewed. A total of 245 patients with clinically localized disease were selected to undergo radical retropubic prostatectomy (RRP) preceded by open PLND. Univariate and multivariate analyses were performed to evaluate the predictive value of the preoperative serum prostate-specific antigen (PSA) concentration, clinical stage, and Gleason score with regard to final nodal status. The cost and morbidity associated with PLND in the setting of RRP was also defined.

RESULTS

Overall, only 16 patients (6.5%) had lymph node metastases. Lymph node involvement correlated significantly with elevated serum PSA values (P = 0.0001), high Gleason score (P = 0.0022), and advanced clinical stage (P = 0.0001). Lymph node metastases were particularly uncommon in patients with nonpalpable tumors (1 of 67 [1.5%]), PSA values less than 10 (2 of 154 [1.3%]), and Gleason score less than 6 (1 of 26 [3.8%]). Overall, 179 patients (73.1%) presented with at least one or more of these favorable characteristics, and only 4 (2.2%) had lymph node involvement. Complications related to the lymphadenectomy occurred in 10 patients (4.1%). The cost per metastasis diagnosed in patients with low-risk characteristics was approximatley $43,600.

CONCLUSIONS

An open staging PLND may no longer be justified on a routine basis in patients undergoing radical retropubic prostatectomy.

Neurobehavioral outcome of closed head injury: implications for clinical trials

This review encompasses the neurobehavioral sequelae of moderate to severe closed head injury (CHI). Following a discussion of posttraumatic amnesia and its measurement, the paper discusses assessment of the global outcome of CHI using the Glasgow Outcome Scale. Domains of residual neurobehavioral sequelae that are reviewed include attention/information processing speed, memory, language, intellectual ability, executive functions, and motor speed. The contribution of behavioral disturbance and psychosocial maladjustment to overall outcome is reviewed, as is the impact on the family. Finally, the neurobehavioral outcome measures for clinical trials involving moderate to severe head-injured patients are presented. Caveats for completing clinical trials that involve assessment of neurobehavioral functioning are provided.

Reversible amnesia associated with a left temporal hematoma in a case of right temporal complex partial seizures

We report the case of a 44-year-old woman with complex partial seizures (CPS) of right frontotemporal origin who developed generalized amnesia after undergoing intracranial electrode implantation complicated by left hippocampal hemorrhage. Serial memory testing disclosed recovery from the amnesic disorder, while repeated magnetic resonance imaging (MRI) showed resolution of her left hippocampal hemorrhage in a 2-month period. A second intracarotid amytal procedure confirmed the capability of her left temporal region to support memory. Consequently, a right orbitofrontotemporal lobectomy was performed without complication.

Neurobehavioural consequences of closed head injury in older adults

This study examined the neurobehavioural effects of closed head injury (CHI) in adults aged 50 years and older. Twenty two mild to moderate CHI patients who were within seven months of the injury were administered measures of language, memory, attention, and executive functioning. Compared with demographically similar normal controls, the patients exhibited significantly poorer functioning on the cognitive domains. Naming and word fluency under timed conditions, verbal and visual memory, and the ability to infer similarities were especially vulnerable. These initial findings indicate that CHI in older adults produces considerable cognitive deficits in the early stages of recovery. Future research should characterise long term outcome and the potential links between head injury and the development of progressive dementia.

Visual information processing after severe closed head injury: effects of forward and backward masking

Three tachistoscopic tasks were employed to assess whether survivors of severe closed head injury (CHI) exhibit a disturbance of information processing within peripheral and/or central visual pathways. Twelve survivors of severe CHI and 12 individually matched control subjects completed a recognition threshold (no mask) task, a monoptic, forward masking by visual noise task (to assess processing within relatively peripheral pathways), and a dichoptic, backward masking by pattern task (to assess processing within central pathways). For each experimental procedure, the minimum exposure durations required by subjects to identify correctly single consonants and triple consonants were determined. Survivors of severe CHI showed deficits on all three visual tasks. Both groups also had higher threshold durations for the more complex stimuli (triple v single consonants), but differences in threshold were greater in the patients with CHI. The degree of perceptual impairment exhibited by patients with CHI was highly variable and not consistently related to injury characteristics or residual motor or speech and language impairment.

Sleep apnea and vigilance performance in a community-dwelling older sample

Impaired vigilance performance has been reported in older subjects with sleep apnea syndrome (SAS). The current study is an attempt to extend these findings and to investigate additional factors that might have implications for vigilance in the older adult. Fifty-nine older adults [age: 62 +/- 5 (mean +/- SD), range 54-75 years; respiratory disturbance index (RDI): 8.8 +/- 14.4 (mean +/- SD), range 0-67.5] were categorized as SAS or NotSAS, based on various classification criteria [i.e. apnea index (AI) > or = 5, and 10, RDI > or = 5, 10 and 15], and were compared on their vigilance performance as assessed by the computer program "Steer Clear". Vigilance performance did not discriminate the groups, independent of how they were formed. Groups were then formed based on vigilance performance (HiVig vs. LowVig) and compared on assorted sleep variables, periodic leg movements, and self-reported hypersomnolence and depression. Only age discriminated vigilance performance (an inverse relationship), accounting for 31% of the observed variance. Our findings suggest that subject selection may unintentionally bias findings regarding the neuropsychological functioning of individuals with SAS, that vigilance may be impaired only in relatively more "severe" SAS, and that severity of SAS in older adults may not be well characterized by current classification standards. Age clearly impacted vigilance performance, despite the constricted age range sampled, and should be taken into account in future research.

Dissociation between delayed alternation and memory after pediatric head injury: relationship to MRI findings

This study investigated the usefulness of a delayed alternation task in characterizing the cognitive sequelae of closed head injury in children and adolescents. Verbal learning and memory (California Verbal Learning Test) were also studied for comparison. Sixty-two closed head injury patients (mean age, 9.6 years), who were studied after an average postinjury interval of 20 months, were divided according to both their lowest postresuscitation Glasgow Coma Scale score (3 to 8 versus 9 to 15) and age range (5 to 7 years versus 8 to 16 years) at the time of testing. Magnetic resonance imaging was performed to evaluate the relationship of focal brain lesions to cognitive and memory performance. Fifty-six neurologically normal children (mean age, 9.9 years) were tested on the same measures. The results disclosed no relationship between delayed alternation performance and severity of injury. In contrast, verbal memory was impaired in the severely-injured patients, relative to both controls and less severely-injured patients. Frontal lobe (but not extrafrontal) lesion size incremented the Glasgow Coma Scale score in predicting verbal memory, but there was no relationship between focal brain lesions and delayed alternation performance. In contrast to the tendency for more efficient delayed alternation performance in the 5- to 7-year-old subjects than in the 8- to 16-year-old subjects, verbal memory significantly improved with age in the closed head injury and control groups. Notwithstanding our essentially negative findings for delayed alternation, it is possible that this task may be useful for assessing frontal lobe injury in younger children or infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Head trauma

Progress in research includes studies concerning the pathophysiology and outcome of pediatric head injury, the pathology of the hippocampus in fatal injury, and the use of multivariate statistics to predict outcome in survivors. Recent research has confirmed and extended findings regarding the differential effects of closed head injury, depending on the age of the individual. These studies indicate that the consequences of head injury are more severe in older adults and in children younger than 2 years. Neuroimaging findings include evidence for delayed brain injury as a major cause of mortality and disability. Functional brain imaging provides evidence for cerebral dysfunction that is not appreciated by structural brain imaging techniques and may have a stronger relationship to neurobehavioral sequelae. The neurobehavioral sequelae frequently implicate frontal dysfunction, even in the absence of structural findings on computed tomography or magnetic resonance imaging. Studies of mild head injury have expanded our knowledge concerning the pathogenesis of postconcussional symptoms, including a preinjury vulnerability based on recent life events. Persistent postconcussional symptoms after mild head injury are frequently associated with emotional disturbance of clinical proportions.

A comparison of psychiatric symptoms in vascular dementia and Alzheimer's disease

OBJECTIVE

Psychiatric symptoms account for much of the morbidity of vascular dementia and Alzheimer's disease. The goals of this study were to extend previous observations of the psychopathology and behavioral problems associated with vascular dementia and to compare the profile of symptoms in patients with vascular dementia to that in patients with Alzheimer's disease.

METHOD

Twenty-eight pairs of patients (one with vascular dementia and one with Alzheimer's disease) were matched with respect to education, age, and severity of dementia. Their psychiatric symptoms were assessed with the Neurobehavioral Rating Scale, a 28-item observer-rated instrument, and the Hamilton Depression Rating Scale, and the symptoms in the two diagnostic groups were compared.

RESULTS

Blunted affect, depressed mood, emotional withdrawal, motor retardation, low motivation, anxiety, unusual thoughts, and somatic concerns occurred in more than one-third of the patients with vascular dementia. There was no significant relation between severity of cognitive impairment and severity of these noncognitive symptoms. The patients with vascular dementia had more impairment than the patients with Alzheimer's disease, as indicated by the Neurobehavioral Rating Scale total scores and scores on the behavioral retardation, anxiety/depression, and verbal output disturbance factors. They also had a higher total score on the Hamilton depression scale and higher scores on 14 of the 17 Hamilton depression items.

CONCLUSIONS

Patients with vascular dementia have more severe behavioral retardation, depression, and anxiety than those with Alzheimer's disease when the groups have similar levels of cognitive impairment. This probably reflects the contrasting brain regions typically involved in the two disorders.

Renal oncocytoma: clinical and biological correlates

We treated 31 patients with renal oncocytoma. Renal cell carcinoma was found existing separately within the same or contralateral kidney in 10 patients (32%). Followup of 29 patients revealed 24 alive with no evidence of disease and 1 alive with recurrent oncocytoma, while 1 with coexistent tumors died of progressive renal cell carcinoma and 3 tumor-free patients died of unrelated diseases. Quantitative deoxyribonucleic acid analysis was performed on cell suspensions of fresh tumor by flow cytometry or by image cytometry on touch preparations from frozen tissue in 16 patients with renal oncocytoma. Ploidy analysis revealed all oncocytomas to be diploid. Frozen tissue immunohistology was performed using murine monoclonal antibody against human HLA-A, B and C (class I) antigens with the avidin-biotin peroxidase technique in 11 patients with renal oncocytoma. Ten oncocytomas did not express these self-recognition antigens and 1 was only weakly positive for antigen expression. In contrast, renal cell carcinomas strongly expressed HLA class I antigens. The high incidence of coexistence of renal oncocytoma and renal cell carcinoma has important clinical implications. Loss of HLA class I antigen expression by renal oncocytomas may provide an additional method for differentiating this lesion from renal cell carcinoma.

Attentional disturbance after pediatric closed head injury

The influence of severity of closed head injury and age on attentional functioning was prospectively investigated in 36 children (age range, 7 to 16 years) 6 months after injury. Children were placed into mild, moderate, and severe injury groups using established neurologic criteria. Each child received the Wechsler Intelligence Scale for Children-Revised Digit Span subtest and a continuous performance test. Children with severe closed head injury demonstrated significantly poorer continuous performance test scores than mildly or moderately injured children. Injury severity had no effect on Digit Span scores. Younger children exhibited more pronounced impairment on the continuous performance test relative to uninjured age peers. These results extend the persistence of attentional impairments beyond those of previous reports. Closed head injury is not associated with preferential sparing of sustained attention in younger children 6 months after injury. Brain injury earlier in life may result in delayed vulnerability of information processing skills.

Cognition in relation to magnetic resonance imaging in head-injured children and adolescents

To investigate the relationship between cognitive sequelae and magnetic resonance imaging (MRI) findings following closed head injury of varying severity in the pediatric age range, 76 head-injured children and adolescents were studied at least 3 months after trauma and compared with 57 normal controls. Problem solving, planning, verbal and design fluency, memory, and response modulation were assessed. Significant effects of injury were obtained on all of the cognitive measures. Cognitive impairment was more consistently present on the various outcome measures in children who were 6 to 10 years old at the time of the study than in the older children and adolescents. Magnetic resonance imaging disclosed areas of abnormal signal in the frontal lobes of 42 patients, whereas focal lesions restricted to the extrafrontal region were found in 15 children. Regression analyses disclosed that taking into account the size of frontal lobe lesion enhanced the relationship between cognitive performance and the severity of injury.

Effects of transcallosal surgery on interhemispheric transfer of information

The effects of transcallosal surgery on interhemispheric transfer of information were investigated in five patients who underwent partial section of the corpus callosum for evacuation of a brain tumor. In comparison with normal controls, postoperative findings indicated subtle motor and/or sensory manifestations of hemispheric disconnection which tended to resolve overtime. However, in no case were the disconnection effects disabling in the performance of daily activities.

Predictors of outcome following severe head trauma: follow-up data from the Traumatic Coma Data Bank

Outcome as a function of employment status or return to school was evaluated in severely head-injured patients. A priori we selected the most salient demographic, physiological, neuropsychological and psychosocial outcome predictors with the aim of identifying which of there variables captured at baseline or 6 months would best predict employability at 6 or 12 months. Based on the patients evaluated at 6 months, 18% of former workers had returned to gainful employment and 62% of former students had returned to school. For those not back to work or school at 6 months, 31% of the former workers and 66% of the former students had returned by 12 months. Age, length of coma, speed for both attending and motor movements, spatial integration, and intact vocabulary were all significantly related to returning to work or school. The three most potent predictors for returning to work or school were intactness of the patient's verbal intellectual power, speed of information processing and age.

Prognostic features of primary and metastatic testis germ-cell tumors

Careful pathologic analysis of a germ-cell tumor provides important prognostic data. The author describes the histopathologic features of the various types of germ-cell tumors that have prognostic implications and discusses the pitfalls in the sampling and examination of tissue specimens.

Fibrotic lesions of the testicle: sonographic patterns mimicking malignancy

All testicular sonograms performed over a 2.5-year period were retrospectively reviewed, yielding eight patients with pathologically proven lesions consisting primarily of tubular sclerosis and interstitial fibrosis. Only two patients (25%) had a palpable abnormality. A variety of sonographic patterns was found, including focal hypoechoic or hyperechoic lesions and diffuse heterogeneity of the testicular parenchyma. The clinical and sonographic findings prompted open biopsy or orchiectomy in all cases. In the same time period, nine pathologically proven testicular malignancies were evaluated sonographically and displayed either well-defined hypoechoic or diffusely heterogeneous echo patterns. All but two of these patients (78%) had palpable abnormalities. This study demonstrates a significant overlap in the sonographic appearance of benign fibrotic lesions and testicular malignancies. When careful palpation of a sonographically heterogeneous or focal hypoechoic lesion fails to reveal a mass and serum tumor markers are negative, an open biopsy with frozen section analysis should be considered rather than proceeding directly to orchiectomy. Homogeneously hyperechoic masses can be considered benign and do not require surgery.

Reversibility of cerebral atrophy after head injury in children

Reversible cerebral atrophy in humans has been documented by computed tomography in alcoholics and has been described as an incidental finding after head injury in children. Two children were studied who had sustained a severe closed head injury, 1 and 5 years previously, after which cerebral atrophy had developed, according to subacute computed tomography. Reversible cerebral atrophy was seen on magnetic resonance images of both patients. Despite normal appearance on magnetic resonance images more than 1 year after injury, both patients exhibited residual neuropsychological impairment on a broad range of cognitive and memory tests.

Late MRI after head injury in children: relationship to clinical features and outcome

To characterize the brain pathology in relation to long-term outcome after pediatric head injury, 55 children were studied by magnetic resonance imaging (MRI) at least 3 months after sustaining moderate to severe closed head injury (CHI). Thirty-nine of the patients had abnormal signal intensity consistent with residual brain lesions, including 28 children with lesions involving the frontal lobes. The clinical features of children with frontal lesions, extrafrontal lesions, and diffuse injury were compared. The analysis disclosed that children with frontal lobe lesions were more frequently disabled than children who sustained diffuse injury. Our MRI findings indicate that residual brain lesions are more common after moderate to severe CHI in children than previously thought and that the frontal lobes are most frequently involved. Further investigation is indicated to elucidate whether distinctive cognitive and behavioral sequelae are associated with frontal lobe lesions in children.

Outcome measures for clinical trials involving traumatically brain-injured patients: report of a conference

A conference was held in Houston, Texas, on October 8-9, 1991, to develop recommendations for outcome measures for clinical trials in traumatic brain injury. Participants, all experts in this area, discussed and agreed on treatments for patients with severe brain injury (Glasgow Coma Score [GCS] < or = 8) and moderate brain injury (GCS, 9-12). A parallel trial design was recommended rather than a factorial, sequential, or crossover design. It was agreed that stratifying randomization based on motor score alone or on a combination of motor score and age would result in increased power. Acute stage measurements, such as cerebral blood flow, cerebrospinal fluid biochemistry, and evoked potentials, were recommended only when they satisfied a specific hypothesis. Functional outcome measures were recommended as the primary outcome measure for severe brain injury (GCS, 3-8). Either the Glasgow Outcome Scale or Disability Rating Scale, measured at 6 months after injury, were recommended as the primary outcome measure for severe brain injury (GCS, < or = 8). For patients with moderately severe brain injury (GCS, 9-12), the Disability Rating Scale at 3 months after injury was recommended as the primary outcome measure. The Neurobehavioral Rating Scale appears to be a satisfactory instrument for measuring behavioral changes. Specific neuropsychological measures were recommended as supplementary outcome measures for both severe and moderate brain injury, consistent with a 1.5-hour period available for testing.