Hormone replacement therapy in a postmenopausal woman with epilepsy

OBJECTIVE

To prospectively evaluate the effects of hormone replacement therapy (HRT) on seizure activity in a postmenopausal woman with epilepsy.

BACKGROUND

Postmenopausal women are at an increased risk for cardiovascular disease and osteoporosis secondary to a lack of estrogen's protective effects. As a result, women without known contraindications often take HRT to counteract this risk. Postmenopausal women with epilepsy are at a greater risk for osteoporosis because of the negative effects that certain antiepileptic drugs have on bone density. Clinical studies and experience have shown that hormonal variances across a woman's lifetime play a significant role in seizure activity, but the effects of HRT in postmenopausal women with epilepsy are unknown.

CASE SUMMARY

We report the case of a 51-year-old postmenopausal white woman with epilepsy who presented with frequent vasomotor flushing. To determine individual effects of HRT on seizure activity, therapy was initiated in two three-month phases, with monthly evaluation. A weekly transdermal patch of estradiol 0.1 mg/d was initiated for the first three months. During the second three months, the regimen was expanded to include oral medroxyprogesterone acetate 2.5 mg once daily. Antiepileptic medications and their dosages remained constant. HRT was associated with a decreased incidence of seizures, cessation of vasomotor flushing, improved sleep, and a positive impact on the lipid profile.

CONCLUSIONS

This case report describing the prospective addition of HRT in a postmenopausal woman with epilepsy suggests that HRT can be initiated in certain women to achieve therapeutic benefits without adversely affecting seizure activity.

Centromere-linked microsatellite markers for linkage groups 3, 4, 6, 7, 13, and 20 of zebrafish (Danio rerio)

A large number of interesting mutations affecting development and organogenesis have been identified through genetic screens in zebrafish. Mapping of these mutations to a chromosomal region can be rapidly accomplished using half-tetrad analysis. However, knowledge of centromere-linked markers on every chromosome is essential to this mapping method. Centromeres on all 25 linkage groups have been mapped on the RAPD zebrafish genetic map. However, species specificity and the lack of codominance make RAPD markers less practical for mapping than microsatellite-based markers. On the microsatellite-based genetic map, centromere-linked markers have been identified for 19 linkage groups. No direct evidence has been published linking microsatellite markers to the centromeres of linkage groups 3, 4, 6, 7, 13, and 20. Therefore, we compared the microsatellite-based genetic map with the RAPD map to identify markers most likely linked to the centromeres of these 6 linkage groups. These candidate markers were tested for potential centromere linkage using four panels of half-tetrad embryos derived by early-pressure treatment of eggs from four different female zebrafish. We have identified microsatellite markers for linkage groups 3, 4, 6, 7, 13, and 20 to within 1.7 cM of their centromeres. These markers will greatly facilitate the rapid mapping of mutations in zebrafish by half-tetrad analysis.

An assessment of epilepsy patients' knowledge of their disorder

PURPOSE

Patient education is an effective component of comprehensive care. Studies assessing patient's knowledge of their epilepsy are scarce. We report the first objective study evaluating knowledge of epilepsy patients referred to an American tertiary care center.

METHODS

Two hundred twenty epilepsy patients referred to an epilepsy center completed a knowledge questionnaire. The questionnaire included topics related to safety, compliance, and legal issues of driving and employment. Questionnaire scores were correlated with demographics, number of years with epilepsy, and educational background.

RESULTS

Of 220 patients, 175 were included in study analysis. Thirteen percent (n = 28) were excluded because of the diagnosis of nonepileptic seizures, and 8% (n = 17) were excluded because of having a diagnosis other than epilepsy. The average age and number of years with epilepsy was 34.7 +/- 13 and 14. 4 +/- 13.1, respectively. Neither age (r = 0.20, p </=0.01), number of years with epilepsy (r = 0.09, p = 0.2), nor years of education (r = 0.34, p </=0.01) correlated with questionnaire scores. Thirty percent believed that epilepsy is a mental disorder or contagious. Forty-one percent believed it is appropriate to place an object in a patient's mouth during a seizure to prevent injury. Two of the lowest scores, 13.6% and 47.5%, pertained to the legal issues of driving and employment, respectively.

CONCLUSIONS

Patients with epilepsy are not knowledgeable about their disorder. This is true regardless of age, educational background, or number of years with epilepsy. There is a need for educational intervention in this population, particularly related to injury prevention and the legalities of driving and employment.

Referral characteristics of primary care physicians for seizure patients

PURPOSE

To investigate primary care physicians' behavior with respect to referral patterns, antiepileptic drug (AED) initiation, and level of comfort in managing seizure patients.

METHODS

A cross-sectional descriptive study design was used for collecting and analyzing data. A 20-item survey was developed and mailed to 8,195 primary care physicians including family practitioners, internal medicine physicians, and obstetrics-gynecologists throughout the state of Ohio; 504 primary care physicians that interact regularly with epilepsy patients responded to the survey.

RESULTS

Two patterns of referral emerged. Data showed that the majority (n = 382) of physicians refer >/=50% of their patients, but a minority of physicians (n = 122) refer <50% of their patients. Differences between the two groups existed in three of the four research questions asked: who initiates AED therapy, comfort level, and percentage of patients referred to a neurologist. Influence of managed care on decision making was not different between the two groups.

CONCLUSIONS

A minority of primary care physicians rate themselves very comfortable with seizure patients. These same physicians refer a minority of their patients to a neurologist. As a whole, however, primary care physicians refer a majority of their seizure patients to a neurologist. Neurologists evaluate most seizure patients because most primary care physicians claim not to be extremely comfortable with evaluation and treatment of seizures. We conclude that neurologists play an essential role in the treatment of most seizure patients.

Ethylnitrosourea induces neoplasia in zebrafish (Danio rerio)

The zebrafish (Danio rerio) has been successfully used to discover hundreds of genes involved in development and organogenesis. To address the potential of zebrafish as a cancer model, it is important to determine the susceptibility of zebrafish to tumors. Germ line mutations are most commonly induced for zebrafish mutant screens by exposing adult male zebrafish to the alkylating agent, ethylnitrosourea (ENU). To determine whether ENU induces tumors, we compared the incidence of tumors in ENU-treated fish with untreated controls. Interestingly, 18 of 18 (100%) fish mutagenized with either 2.5 or 3.0 mM ENU developed epidermal papillomas, which numbered 1 to 22 per fish, within 1 year of treatment. The induced epidermal lesions included epidermal hyperplasia, flat papillomas (0.2 to 1.2 mm), and pedunculated papillomas (1.2 to 8 mm in greatest dimension), but no skin cancers. Angiogenesis was evident in papillomas larger than approximately 1 mm. All but two papillomas contained the three cell types (keratinocytes, club, and mucous cells) of normal zebrafish epidermis; histologic variants lacked either club cells or mucous cells. Two cavernous hemangiomas and a single malignant peripheral nerve sheath tumor were also found in the treated fish. None of five untreated controls developed tumors. These studies establish the feasibility of the zebrafish as an experimental model for the study of skin tumors.

Alternative medicine use by patients with epilepsy

Purpose. The objectives of this study were, first, to determine the prevalence, characteristics, and demographic patterns of alternative medicine (AM) use in patients with epilepsy, and second, to ascertain the extent to which these patients inform the neurologist of AM use. Methods. Surveys were distributed randomly to patients attending a tertiary care epilepsy clinic. The survey assessed use of specific herbal medicine/dietary supplements, along with other forms of AM. Results. Of 150 surveys distributed, 92 were used for analysis. Twenty-two patients with epilepsy (24%) used AM, and only 31% of AM users reported such to their neurologists. Massage and herbs/supplements were used the most, and only two patients used AM specifically for treatment related to epilepsy. Conclusions. A sizable minority of patients with epilepsy who visit our tertiary care clinic use AM. Health professionals should actively monitor therapies to ensure safety and effectiveness with combined traditional medicine and AM use.

Investigations of crashes involving pregnant occupants

Case reports of 16 crashes involving pregnant occupants are presented that illustrate the main conclusions of a crash-investigation program that includes 42 crashes investigated to date. Some unusual cases that are exceptions to the overall trends are also described. The study indicates a strong association between adverse fetal outcome and both crash severity and maternal injury. Proper restraint use, with and without airbag deployment, generally leads to acceptable fetal outcomes in lower severity crashes, while it does not affect fetal outcome in high-severity crashes. Compared to properly restrained pregnant occupants, improperly restrained occupants have a higher risk of adverse fetal outcome in lower severity crashes, which comprise the majority of all motor-vehicle collisions.

Hearing loss and automobile airbag deployments

In an on-going research program, on the causation of injuries in motor vehicle accidents, at the University of Michigan Transportation Research Institute, crashes with airbags have been, and are continuing to be, investigated. In order to determine the occurrence, if any, of 'hearing problems' associated with airbag deployments, drivers and passengers who had been involved in 'airbag' automobile crashes were interviewed by telephone. From the crashes investigated, 225 attempts were made to contact drivers who were exposed to airbag deployments. From these telephone interviews, contacts were made with 177 car occupants. Only three reported that they had experienced any type of hearing-related problems subsequent to their crash. One other case is reported of a driver who had pre-crash hearing loss. It appears that permanent hearing deficit due to airbag deployment, both in cars with the steering wheel airbag alone, and in those with a passenger side airbag, is an infrequent event (1.7%) from the data of this study.

Assessing the needs of pharmacists and physicians in caring for patients with epilepsy

OBJECTIVE

To obtain primary care physicians' and community pharmacists' opinions of the Pharmacist Note, a model epilepsy patient profile maintained by the pharmacist and transmitted to the physician as needed, and the information it contains.

DESIGN

A cross-sectional descriptive study design was used for collecting and analyzing data. Separate surveys were developed and mailed to physicians and pharmacists.

PARTICIPANTS

554 primary care physicians and 114 community pharmacists in Ohio who interact regularly with epilepsy patients.

MAIN OUTCOME MEASURES

Pharmacist and physician opinions on the Pharmacist Note program.

RESULTS

Physicians ranked seizure frequency as their most useful piece of information, followed by medication compliance and drug interaction screening. For medication profile and drug interaction screening, most physicians currently use themselves as their primary source of information, although a significant number would prefer to use pharmacists as information sources in these areas (p < .05). A majority (62%) would like to have pharmacists more involved in the care of their patients. Pharmacists identified lack of time and lack of appointments with patients, inadequate pharmacy staff, and insufficient reimbursement as barriers to implementing the Pharmacist Note program.

CONCLUSION

Physicians desire pharmacist involvement in specific areas of care for patients with epilepsy, and the feasibility of implementing the Pharmacist Note and similar programs appears promising. However, pharmacists identified barriers to implementation, and these barriers need to be addressed if this type of program is to be successful.

A descriptive analysis of "not aeronautically adaptable" dispositions in the U.S. Navy

BACKGROUND

All aviation personnel in the U.S. Navy are evaluated for aeronautical adaptability (AA) in both initial and periodic examinations and for daily aeromedical disposition. By definition, all aviation personnel with a diagnosed personality disorder or those with maladaptive personality traits that have had a documented effect on safety of flight, crew coordination, or mission completion, are determined to be Not Aeronautically Adapted (NAA).

METHODS

NAA dispositions were examined for demographic data, basis for disposition, and frequency of personality features.

RESULTS

NAA dispositions were made on the basis of personality disorders and maladaptive personality traits in 29% and 35% of the cases, respectively. The officer and enlisted NAA dispositions were distinctly different in terms of frequency of personality features. Obsessive-compulsive features were present in 58% of officer and 10% of enlisted NAA dispositions. Dependent and avoidant features were present in excess in comparison to psychologically healthy aviators, suggesting the incompatibility of these features with aviation.

Amnioinfusion-induced malpresentation

Amnioinfusion is a valuable and common intrapartum procedure for the relief of cord compression and to dilute thick meconium. Like most procedures, it is not without risk and we report a case of malpresentation following amnioinfusion. Intrapartum fetal demise occurred after malpresentation during amnioinfusion resulting in a change of fetal presentation from vertex to unrecognized shoulder presentation. Further study is needed regarding changes in volume of amniotic fluid and saline as well as intrauterine manipulation and the effect on fetal presentation. Careful attention must be paid to infused volumes during amnioinfusion.

Arachnoid cysts: how do postsurgical cyst size and seizure outcome correlate?

Arachnoid cysts (ACs) are congenital cystic brain malformations associated with epilepsy. The purpose of this study was to determine the effect of surgical intervention of ACs on cyst size and seizure outcome. We reviewed the world's medical literature dealing with surgically treated ACs in epilepsy patients. Our study included only cases, in which the relationship between pre-and postoperative CT-size of the AC and seizure outcome was described. We also included six patients with ACs and epilepsy treated surgically at the University of Mainz. We analyzed postoperative AC size and seizure outcome with respect to mode of operation, cyst location, and patients' age. A total of 76 patients was reviewed. Sixty (79%) patients had a smaller AC postoperatively. Forty-six of those 60 (76.6%) experienced seizure improvement. Thirteen patients (21.6%) remained unchanged and one patient (1.8%) worsened. In 16 of the 76 patients (21%) the postoperative AC size was unchanged. Eight of those 16 patients improved. Six patients (37.5%) remained unchanged and two (12.5%) worsened. A positive correlation between postoperative AC size and seizure outcome was well demonstrated among patients treated by cyst fenestration, needle aspiration, or internal shunting. Among patients treated by cystoperitoneal shunting this direct correlation was less clear. Seizure outcome correlates directly with postoperative AC size. Seizure reduction is associated with decreased AC size postoperatively and depends on the mode of operation. Based on these data we would expect that patients with epilepsy secondary to ACs would demonstrate improved seizure control with lower AC volume. Conversely, we might expect increasing AC size to correlate with worse seizure control. This relationship may guide physicians in efficacy and timely patient management.

Fenestration of porencephalic cysts to the lateral ventricle: experience with a new technique for treatment of seizures

BACKGROUND

Porencephalic cysts are brain cavities resulting from perinatal vascular occlusion and are commonly associated with severe neurological deficits and medically intractable epilepsy. Thirty-seven children presenting to the University of Münster with intractable seizures because of a porencephalic cyst were treated by uncapping and fenestration of these cysts to the lateral ventricle between 1978 and 1992. We conducted the following study to determine the efficacy and safety of the uncapping and fenestration procedure for the treatment of seizures.

METHODS

We reviewed all cases retrospectively and assessed the outcome of these patients with regard to seizures, paresis, and perioperative complications.

RESULTS

Of 37 children, 23 (62%) were seizure-free postoperatively. Nine patients (24%) had a reduction of seizures and five children (14%) remained unchanged. Of 30 patients with preoperative hemiparesis, 11 (30%) improved after the operation. The leading postoperative problem was a subcutaneous/subgaleal cushion of CSF, which affected 12 children (12 of 37). A dural patch covering the iatrogenic dural defect could not prevent or reduce postoperative CSF leakage, but prolonged the postoperative fever period. Postoperative fever occurred in 36 children (36 of 37) and was caused by an aseptic meningitis.

CONCLUSIONS

Children with intractable seizures and porencephalic cysts benefit from uncapping and cyst fenestration to the lateral ventricle. Concomitant perioperative complications are mild and are easily treated.

Genetic dissection of vertebrate processes in the zebrafish: a comparison of uniparental and two-generation screens

Genetic dissection is used to identify important genes in biological processes and is accomplished through the generation and study of mutations in model organisms. In diploid organisms, recessive mutations must be rendered hemizygous or homozygous for the mutant phenotype to be detected. In zebrafish (Danio rerio), this can be accomplished in two ways: (i) crosses between siblings who are potential carriers (in two-generation screens) and (ii) the generation of uniparental progeny. Two-generation screens have been the most productive to date but require substantial resources. However, uniparental screens involving haploids and half-tetrads (products of meiosis I) have also been productive, and require more modest resources. In genetic screens, the fraction of an average genome that is heterozygous (heterozygosity index) is inversely proportional to the likelihood that separate recessive mutations will be homozygous at the same time. Heterozygosity indices for haploid, half-tetrad, and two-generation screens are 0, 66, and 87.5%, respectively. Family sizes required to minimize bias in half-tetrad screens are also calculated. We conclude that gynogenetic half-tetrad screens are genetically robust and technically accessible to the independent researcher. The increasingly powerful genetic and experimental tools available for work with zebrafish can be used to address a broad range of questions in vertebrate biology.

Lifelong self-directed learning using a computer database of clinical questions

Physicians often have self-perceived knowledge gaps when they are seeing patients. Traditional continuing medical education is designed to meet the knowledge gaps of groups rather than individual physicians with specific patient problems. Physicians with clinical information needs are advised to critically evaluate high-quality original research in order to practice "evidence-based medicine." But this advice may be unrealistic for busy clinicians. We propose a system for documenting self-perceived information needs using a computer database. Concise answers to these needs are included in the database along with reference citations supporting the answers. The system tracks continuing education efforts, directs patient care decisions, and focuses lifelong learning on relevant topics. We emphasize the importance of being sensitive to personal information needs and the benefits of maintaining a record of these needs.

Activation of the focal adhesion kinase signal transduction pathway in cervical carcinoma cell lines and human genital epithelial cells immortalized with human papillomavirus type 18

The inappropriate activation of protein-tyrosine kinases (PTKs) has been associated with initiation and progression of several types of human cancers. We therefore postulated that immortalization by DNA tumor viruses results in the induction of PTKs fundamental to these processes. An RT-PCR-based screen was thus used to identify PTKs that were abundantly expressed in HPV-18-immortalized epithelial cells and HPV-containing carcinoma cell lines. One of the genes isolated in this screen was the focal adhesion kinase (FAK; pp125FAK), a cytoplasmic protein kinase that is activated in v-src transformed cells or by stimulation with mitogenic polypeptides. FAK also becomes catalytically active upon integrin engagement with extracellular matrix proteins, such as fibronectin. We found that FAK expression and activity were significantly elevated in HPV-18 E6/E7-immortalized human genital epithelial cells relative to their primary cell counterparts. Protein expression and tyrosine phosphorylation of the putative FAK substrate, paxillin, were also notably increased upon HPV-18 immortalization of genital epithelial cells and in HPV-containing cervical carcinoma cell lines. Most significantly, these cells expressed markedly higher levels of both intracellular and extracellular fibronectin, thus providing a mechanism for activation of FAK and increased tyrosine phosphorylation of paxillin. These findings suggest a role for the integrin/FAK-mediated signaling pathway in cervical carcinogenesis and represent one of the first demonstrations of a tyrosine kinase whose activity is elevated following viral immortalization.

Structure-activity relationships of N-hydroxyurea 5-lipoxygenase inhibitors

The discovery of second generation N-hydroxyurea 5-lipoxygenase inhibitors was accomplished through the development of a broad structure-activity relationship (SAR) study. This study identified requirements for improving potency and also extending duration by limiting metabolism. Potency could be maintained by the incorporation of heterocyclic templates substituted with selected lipophilic substituents. Duration of inhibition after oral administration was optimized by identification of structural features in the proximity of the N-hydroxyurea which correlated to low in vitro glucuronidation rates. Furthermore, the rate of in vitro glucuronidation was shown to be stereoselective for certain analogs. (R)-N-[3-[5-(4-Fluorophenoxy)-2-furyl]-1-methyl-2-propynyl]-N-hydroxyure a (17c) was identified and selected for clinical development.

Panic with a twist: an unusual presentation of combined psychiatric and neurologic symptoms in a tactical jet aviator

A 28-yr-old Naval F-14 aviator presented with complaints of flight-related anxiety occurring intermittently over an 18-mo period. Symptoms included sensation of strangeness, concern over the welfare of his radar intercept officer, flushing, nausea, and intense need to immediately land the aircraft. He also described a 6-mo history of episodes wherein he would see "shooting stars" in the periphery of his vision, accompanied by dizziness and disorientation. These latter attacks were always precipitated by head turning, usually in combination with positive Gz maneuvers, and were relieved by head straightening. The anxiety symptoms were consistent with a form of panic attack, but the neurological symptoms provoked further workup. Magnetic resonance cerebral angiogram demonstrated a dominant right vertebral artery and hypoplastic left vertebral artery. All symptoms resolved once the aviator was removed from flying the aircraft. After a year of follow-up with an aviation psychiatrist, he remained asymptomatic and was reassigned to maritime patrol aircraft. This case illustrates a difficult diagnostic, therapeutic, and disposition challenge. This aviator suffered from a complex interaction of neurologic and psychiatric manifestations having a common inciting stimulus, namely flying the F-14 Tomcat. A promising aviation career was preserved upon removal of that stimulus.

The efficacy of protoporphyrin as a predictive biomarker for lead exposure in canvasback ducks: Effect of sample storage time

We used 363 blood samples collected from wild canvasback dueks (Aythya valisineria) at Catahoula Lake, Louisiana, U.S.A. to evaluate the effect of sample storage time on the efficacy of erythrocytic protoporphyrin as an indicator of lead exposure. The protoporphyrin concentration of each sample was determined by hematofluorometry within 5 min of blood collection and after refrigeration at 4 °C for 24 and 48 h. All samples were analyzed for lead by atomic absorption spectrophotometry. Based on a blood lead concentration of ≥0.2 ppm wet weight as positive evidence for lead exposure, the protoporphyrin technique resulted in overall error rates of 29%, 20%, and 19% and false negative error rates of 47%, 29% and 25% when hematofluorometric determinations were made on blood at 5 min, 24 h, and 48 h, respectively. False positive error rates were less than 10% for all three measurement times. The accuracy of the 24-h erythrocytic protoporphyrin classification of blood samples as positive or negative for lead exposure was significantly greater than the 5-min classification, but no improvement in accuracy was gained when samples were tested at 48 h. The false negative errors were probably due, at least in part, to the lag time between lead exposure and the increase of blood protoporphyrin concentrations. False negatives resulted in an underestimation of the true number of canvasbacks exposed to lead, indicating that hematofluorometry provides a conservative estimate of lead exposure.

The rev-responsive element negatively regulates human immunodeficiency virus type 1 env mRNA expression in primate cells

The human immunodeficiency virus type 1 (HIV-1) Rev protein mediates the accumulation of unspliced and singly spliced viral transcripts within the cytoplasm of infected cells, late in the infection cycle, leading to the expression of the viral structural proteins, Gag, Pol, and Env. Rev binds to a complex RNA structure, the Rev-responsive element (RRE), present in all Rev-responsive viral transcripts, relieving their nuclear sequestration. The precise mechanism by which RRE-containing transcripts are retained within the nucleus in the absence of Rev protein is not well understood. We previously demonstrated that the RRE alone plays a crucial role in the nuclear retention of RRE-containing env transcripts in stably transfected Drosophila cells. Here we extend our previous observations and demonstrate that the RRE is a principal determinant of nuclear retention for envelope transcripts in primate cells and, in particular, human CD4+ T cells.

Effect of cAMP binding site mutations on the interaction of cAMP receptor protein with cyclic nucleoside monophosphate ligands and DNA

Although cAMP binding to wild type cAMP receptor protein (CRP) induces specific DNA binding and activates transcription, cyclic nucleoside monophosphate (cNMP) binding to the CRP mutant Ser128 --> Ala does not, whereas the double CRP mutant Thr127 --> Leu/Ser128 --> Ala activates transcription even in the absence of cNMP. Isothermal titration calorimetry measurements on the cNMP binding reactions to the S128A and T127L/S128A mutants show that the reactions are mainly entropically driven as is cAMP binding to CRP. In contrast to cAMP binding to CRP, the binding reactions are noncooperative and exothermic with binding enthalpies (DeltaHb) ranging from -23.4 +/- 0.9 kJ mol-1 for cAMP binding to S128A at 39 degrees C to -4.1 +/- 0.6 kJ mol-1 for cAMP binding to T127L/S128A at 24 degrees C and exhibit enthalpy-entropy compensation. To account for the inactivity of the S128A mutant, in vitro and in vivo DNA binding experiments were performed on the cAMP-ligated S128A mutant. The cAMP-ligated S128A mutant binds to the consensus DNA binding site with approximately the same affinity as that of cAMP-ligated CRP but forms a different type of complex, which may account for loss of transcriptional activity by the mutant. Energy minimization computations on the cAMP-ligated S128A mutant show that amino acid conformational differences between S128A and CRP occur at Ser179, Glu181, and Thr182 in the center of the DNA binding site, implying that these conformational changes may account for the difference in DNA binding.

Endometrial stromal sarcoma with focal smooth muscle differentiation: recurrence after 17 years: a follow-up report with discussion of the nomenclature

In 1977, a case report was published describing a 28-year-old women with an endometrial stromal tumor that showed foci of myogenic differentiation. The term "stromomyoma" was introduced to encompass both this type of neoplasm as well as "uterine neoplasms resembling ovarian sex-cord tumors" (UTROSCTs). More than 17 years later, the tumor recurred, involving the right ovary, sigmoid colon, small bowel, abdominal wall and omentum. The histologic and electron microscopic similarities between the recurrent tumor and the primary neoplasm were confirmed. Applying the recent classification and diagnostic criteria of endometrial mesenchymal neoplasms, we have concluded that this tumor was a low-grade endometrial stromal sarcoma (LGSS). The formerly proposed term "stromomyoma" implies a benign tumor, in contrast to the obviously malignant nature of this particular tumor. Focal myogenic differentiation of LGSS is not an uncommon finding and does not warrant a separate diagnostic or prognostic entity. UTROSCTs and endometrial stromal sarcomas are two separate diagnostic entities, and combining them under an inclusive terminology is not appropriate.

Recurrent granulosa cell tumor of the ovary 37 years after initial diagnosis: a case report and review of the literature

Granulosa cell tumors of the ovary (GCTs) are uncommon neoplasms that are characterized by late recurrence and high survival rates. A case of recurrent GCT presenting 37 years after initial diagnosis is reported with a review of the literature. This case illustrates an example of a very late recurrence and emphasizes the importance of the extended follow-up required for these patients.

A case of "eating disorder NOS": aeromedical implications of DSM-IV diagnostic criteria

The authors describe a case of intermittent fasting and self-induced vomiting in a student aviator whose symptoms do not meet the full criteria for either anorexia or bulimia. The range of symptomatology and differential diagnosis of eating disorders is discussed. New DSM-IV diagnostic criteria for eating disorders, including Eating Disorder Not Otherwise Specified (NOS), and associated therapeutic alternatives are reviewed. The case demonstrates the importance of comprehensive physical and psychiatric evaluation of those patients with complex or atypical presentations. Issues pertaining to the aeromedical disposition of such patients are discussed, with emphasis on the role of the flight surgeon in the early recognition of eating disorders.