Transient ischemic attack: review for the emergency physician

In the past few years, the approach to patients with transient ischemic attacks has undergone a transformation. To care for these patients, emergency physicians must understand these changes. They must be comfortable with the diagnosis and treatment of transient ischemic attacks in their emergency department. To this end, we ask and answer the following 6 important questions in this up-to-date review of transient ischemic attacks: (1) How is a transient ischemic attack defined? (2) Does this patient have a transient ischemic attack? (3) Once diagnosed, what diagnostic evaluation should be done (and when)? (4) What treatment should be instituted (and when)? (5) What is the correct disposition? and (6) What are the current medical guidelines?

Incidence of traumatic lumbar puncture

OBJECTIVE

To determine the incidence of traumatic lumbar puncture (LP).

METHODS

A retrospective study was conducted at an urban, university tertiary care referral center with 50000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics.

RESULTS

Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01).

CONCLUSIONS

The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital.

Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage

The lumbar puncture (LP) is a relatively simple diagnostic test. However, significant diagnostic ambiguity can arise when trauma from the needle causes bleeding into the subarachnoid space, especially when trying to make the diagnosis of subarachnoid hemorrhage (SAH). The purpose of this article is to assist emergency physicians in distinguishing traumatic LPs from SAH. To correctly interpret the findings of a traumatic tap, a few concepts must be understood. Timing of the LP in relation to the onset of the SAH affects the results of the cerebrospinal fluid (CFS) analysis; the typical findings will change with time. With a few caveats, xanthochromia, the yellow discoloration of the CSF resulting from hemoglobin catabolism, is often critical in making a diagnosis of SAH. A few of the most essential methods for distinguishing traumatic LP from true SAH include: the "three tube test," opening pressure, and inspection for visual xanthochromia.

Trauma in pregnancy: maternal and fetal outcomes

OBJECTIVE

Pregnancy imposes significant physiologic demands that may confuse and complicate the evaluation, resuscitation, and definitive management of pregnant women who sustain trauma. Accurate prediction of fetal outcome after trauma remains elusive. The objective of this study was to characterize patterns of injury in pregnant women, to determine if pregnancy affects maternal morbidity and mortality after trauma, and to identify predictors of fetal death.

METHODS

We performed a retrospective, case-control analysis of all injured pregnant patients admitted to the Trauma Service at the University of California San Diego Medical Center from 1985 to 1995.

RESULTS

We identified 114 injured pregnant patients. Motor vehicle crashes accounted for 70% of injuries, and of these, 46% of patients were not using seat belts or helmets. Violence accounted for 12% of injuries. Injured pregnant women with Injury Severity Scores > 8 demonstrated similar mortality, morbidity, and length of stay to matched nonpregnant control patients. Pregnant women were more likely to sustain serious abdominal injury and were less likely to sustain severe head injury. Identified risk factors for fetal loss include maternal death, overall maternal injury severity, the presence of severe abdominal injury, and the presence of hemorrhagic shock.

CONCLUSION

There appears to be a group of pregnant women in San Diego at high risk for traumatic injury who should be targeted for preventative strategies including improved seat belt use. Pregnancy does not increase mortality or morbidity after trauma but influences the pattern of injury. Maternal death, high Injury Severity Score, serious abdominal injury, and hemorrhagic shock are risk factors for fetal loss.

A comparison of single-dose and fractionated total-body irradiation on the development of pneumonitis following bone marrow transplantation

PURPOSE

A review of 132 consecutive patients who received bone marrow transplant for various malignancies was conducted to determine factors associated with increased risk in developing interstitial pneumonitis (IP) as the result of total body irradiation (TBI). Twenty-four patients were excluded because 22 did not receive TBI and two had insufficient records.

METHODS AND MATERIALS

Patients were conditioned with TBI and various drug regimens. Eighteen patients received a single 6.0 Gy dose of x-rays. The remaining 90 were treated with three doses of 3.33 Gy separated by 24 h. All patients were followed for at least 18 months for the purposes of determining the IP incidence.

RESULTS

Twenty-seven of these 108 (25%) patients developed IP; 19 (17.6%) died. The 2-year estimated incidence of IP was 24 and 18.6% for fatal IP. The etiology was determined to be idiopathic in 12 patients, the result of cytomegalovirus in 6 patients, and caused by a variety of other infectious organisms in 9 patients. We were unable to demonstrate a statistically significant increase in IP with age (adults vs. children), dose regimen, use of methotrexate for graft-vs.-host disease prophylaxis, the presence of acute graft-vs.-host disease, time from diagnosis to transplant, or transplant type (allogeneic vs. autologous).

CONCLUSIONS

The incidence of fatal IP reported here is similar to that reported by other institutions utilizing hyperfractionated TBI protocols. Our data do not support the need for hyperfractionation to reduce the risk of IP.

Cancer of the anal canal: treatment with chemotherapy and low-dose radiation therapy

PURPOSE

To determine the efficacy of a standardized protocol of chemotherapy and low-dose radiation therapy in treatment of patients with anal canal cancer.

MATERIALS AND METHODS

Forty-two consecutive patients with anal canal cancer were treated with 15 fractions of 30-Gy photon beam radiation therapy administered anteroposterior-posteroanterior in conjunction with chemotherapy with 5-fluorouracil and mitomycin C. Survival analysis was performed with the lifetest procedure.

RESULTS

In patients with stage T1 and T2 tumors, 26 of 29 (90%) were free of disease after chemotherapy and radiation therapy and had no recurrent tumors. In patients with stage T3 and T4 tumors, five of 13 (38%) were free of disease after therapy and had no recurrences.

CONCLUSION

This therapy is effective for epidermoid cancers of the anal canal that are smaller than 5 cm regardless of nodal status. Tumors larger than this or that invade adjacent structures are not adequately controlled with this protocol.

Baclofen in trigeminal neuralgia--a clinical trial

Baclofen is a new antineuralgic drug. A clinical trial with treatment by this drug on 20 patients of trigeminal neuralgia was done. The action of this drug is similar to that of carbamazepine, however the former gives less undesirable side-effects. Out of 20 patients under treatment by this drug, 45% were relieved completely from pain while in 20% intensity and/or number of attacks of pain was reduced to half and in 35% effectiveness of Baclofen could not be observed.

Osteosynthesis of mandibular fractures with N-butyl cyanoacrylate: a pilot study

Osteosynthesis with n-butyl cyanoacrylate was attempted in 10 cases. Maxillomandibular fixation was maintained for only 48-72 hours. No mobility of the fractured segments was found when tested by moderate manual force. Union took place uneventfully in all but one case. Cases were followed from one to six months with appropriate radiographs at regular intervals. Blood, urine, and serum analyses revealed no significant changes when compared pre- and postoperatively. Chromosomal study revealed no rise in the frequency of SCEs postoperatively.

The incidence of thyroid carcinoma in patients with Hashimoto's thyroiditis and solitary cold nodules

The reported incidence of thyroid carcinoma in Hashimoto's thyroiditis varies widely. For this reason the specific subpopulation of patients with Hashimoto's thyroiditis and a solitary cold nodule was analyzed. Between 1972 and 1984 we operated on 146 consecutive patients with solitary cold nodules and Hashimoto's thyroiditis. There were 47 carcinomas, for an incidence of 32%. The mean age of the 146 patients was 43 1/2 years (median 44 years), with 126 females and 20 males. There was a history of prior head and neck radiation exposure in 54 patients, with a 33% incidence of thyroid carcinoma. The 92 patients without a history of radiation exposure had a 31.5% incidence of carcinoma. The frequency of multicentricity (bilateralism) was 33% in the group that underwent radiation and 24% in the group that did not. To date, with a mean follow-up of 4.7 years, there have been no deaths and no evidence of recurrence. In conclusion, we report a 32% incidence of thyroid carcinoma in patients with Hashimoto's thyroiditis and a solitary cold nodule, with no apparent difference between the patients with or without a history of radiation exposure, although there was a higher incidence of bilateralism (33% versus 24%) in the carcinomas of the patients with a history of head and neck irradiation. We suggest that the operative management of these patients is total thyroidectomy for those with a history of head and neck radiation and thyroid lobectomy for patients with no history of radiation, followed by contralateral lobectomy if a carcinoma is demonstrated.

Total thyroidectomy in irradiated patients. A twenty-year experience in 206 patients

During a period of 20 years (1965-1985), 206 consecutive patients were operated on for radiation-associated nodular thyroids. The ages ranged between 8 and 76 years (mean 38.7). there were 136 women and 70 men. The average duration between radiation exposure and operation was 27 years. The operations performed were total thyroidectomy (192) or, in patients who had undergone a previous lobectomy in another institution, another lobectomy (14). In addition, 25 patients required a neck dissection for nodal metastases and 27 underwent simultaneous subtotal parathyroidectomy for coexistent hyperparathyroidism. The pathologic findings were: 87 (42.2%) carcinoma (73 papillary, 13 follicular, 1 undifferentiated); 92 (44.7%) follicular adenomas; and 27 (13.1%) thyroiditis. To date, with an average follow-up of 6 years (0.5-31 years), only two patients have expired from recurrent disease. A third died of unrelated cause. A comparison of the first 100 patients (12 years) with the last 106 patients (8 years) demonstrated that the incidence of carcinoma has dropped from 48 to 37%, the incidence of lymph node metastases has decreased from 35 to 26%, and the incidence of bilaterality has fallen from 75 to 54%. On the basis of this series, it was concluded that total thyroidectomy is still indicated for radiation-associated nodular thyroids. However, if the trend of decreasing incidence, bilaterality, and metastatic disease persists, this approach may have to be reevaluated in the near future.

Parathyroid cysts: a report of eleven cases including two associated with hyperparathyroid crisis

Eleven parathyroid cysts were found in 325 patients who underwent parathyroid operations. Ten cysts were located in the neck and one was located in the mediastinum. The cysts ranged in size from 1.6 to 10 cm with a mean of 3.9 cm. The patients who had cysts included six women and five men, and their ages ranged from 28 to 72 years with a mean of 51 years. In contrast to other reports that have suggested that most parathyroid cysts are nonfunctional, all but one of our patients had hyperparathyroidism, as evidenced by hypercalcemia, hypophosphatemia, and elevated parathyroid hormone level, which was corrected by cyst removal. The nonfunctional cyst first appeared to be an asymptomatic neck mass. Two patients had acute hyperparathyroid crises, which required emergency operations. It is postulated that the crises may have been the result of spontaneous necrosis of preexisting parathyroid adenomas. This is supported by the pathologic findings of degeneration and early organization as well as by the presence within the cyst of sanguineous fluid that contained a parathormone concentration greater than 100 times normal serum levels.

Effects of radiation on parafollicular C cells of the thyroid gland

While radiation has well-recognized effects on follicular cells of the thyroid gland, those on parafollicular C cells are not yet established. Low-dose radiation that has been proved to be nonablative and carcinogenic to follicular cells was administered to 8-week-old Long-Evans rats to study the changes in C cell number and function. Circulating calcitonin levels were significantly reduced in animals that had undergone radiation at age 24 months. Mean calcitonin values were 0.66 (+/- 0.20) ng/ml and 1.64 (+/- 0.59) ng/ml for control males and females compared with 0.14 (+/- 0.06) ng/ml and 0.11 (+/- 0.01) ng/ml for males (P less than 0.05) and females (P less than 0.001) that had undergone radiation, respectively. These levels correlated well with C cell population density in thyroid glands in the control group and in the group that had undergone radiation as evidenced by light microscopy. Routine hematoxylin and eosin staining showed C cell hyperplasia in 77% of control animals of both sexes compared with 4% in animals that had undergone radiation (P less than 0.005). Immunoperoxidase staining with an anticalcitonin antibody showed virtual absence of C cells in most animals that had undergone radiation compared with diffusely scattered cells in animals in the control group. Medullary carcinomas occurred in 14% of animals in the control group compared with 3% of animals that had undergone radiation (P less than 0.05). These data indicate that the radiation dosage that is carcinogenic to the follicular epithelium causes lethal injury to C cells and thus suggest that C cells are more sensitive to radiation than are follicular cells. This increased sensitivity could explain the virtual absence of C cells, decrease in calcitonin levels, and reduced numbers of medullary carcinomas in the animals that had undergone radiation.

Successful autotransplantation of parathyroid adenomas in seven patients

The autotransplantation of normal as well as adenomatous parathyroid tissue is currently being used with increasing frequency. In the present report, we describe our experiences with the successful transplantation of adenomatous or hyperplastic parathyroid tissue in seven patients. Prior to transplant surgery, six of these patients had recurrent or persistent primary hyperparathyroidism. The last patient was on hemodialysis for chronic renal failure and was presumed to have tertiary hyperparathyroidism. A large superior mediastinal parathyroid adenoma was found at a second neck exploration. In all patients, the only remaining parathyroid tissue was either adenomatous or hyperplastic. A total of 30 to 75 mg of this parathyroid tissue was diced and transplanted into single subfascial pockets of the forearm muscles (6) or sternocleidomastoid muscle (1). Following transplantation, all patients required transient calcium and vitamin D supplements for six to 12 weeks. In follow-up studies of ten months to 12 years, all patients have remained eucalcemic with normal parathyroid hormone levels. The use of a single subfascial pocket (versus the popular method of multiple implants) may explain the lack of recurrent hyperparathyroidism in our small population.

Subtotal parathyroidectomy for primary hyperparathyroidism. Long-term results in 292 patients

Subtotal parathyroidectomy was performed in a consecutive series of 292 patients with primary hyperparathyroidism. We evaluated the long-term postoperative results during a period of 16 years. Patients ranged in age from 14 to 83 years and included 176 women and 116 men. Of these, 16% had a history of exposure to radiation in childhood or adolescence, while thyroid disease requiring some form of thyroidectomy coexisted in 91 (31%) of the patients. Histologic information on three or more parathyroid glands was obtained in 73% of the cases. We considered 285 patients (97.6%) cured after their first operation. The remaining seven patients (2.4%) had persistent hyperparathyroidism. However, five were cured after a sternum-splitting mediastinal exploration and one after a second neck exploration. The seventh remains hypercalcemic despite a subsequent mediastinal exploration. Temporary postoperative hypoparathyroidism occurred in 10% of our cases and permanent hypoparathyroidism in 1%. There have been no instances of recurrent hyperparathyroidism.

Castration induces a marked reduction in the incidence of thyroid cancers

Although thyroid disease in humans predominates in females, the prognosis of thyroid cancer in males is much less favorable. To further explore the role of male sex hormones, we utilized the experimental model of radiation-induced follicular cancer in the rat, studying the effects of castration on tumor development. Microscopic evidence of tumor formation was correlated with the biochemical parameters serum thyroxine (T4), thyrotropin (TSH), and thyrocalcitonin (TC) at 24 months. The incidence of follicular carcinomas in intact males ws 58%, compared to 28% in comparable females. Castration of males caused a reduction in the incidence to 22%. Mean circulating levels of TSH were markedly elevated in all three irradiated groups. Mean T4 levels were reduced significantly only in irradiated castrated animals. TC levels were reduced in all irradiated groups. We conclude that although elevated levels of TSH probably play a significant role in the development of radioactive iodine-triggered follicular thyroid neoplasms in the rat, male sex hormone may also play an important role beyond their known effect on basal and thyrotropin-releasing hormone-stimulated TSH.

Immunoperoxidase localization of papillomavirus antigens in cervical dysplasia and vulvar condylomas

Biopsies of 50 cases of cervical dysplasia (46 mild and 4 moderate) and 40 cases of vulvar condyloma acuminata (genital warts) were screened for the presence of papillomavirus antigens by means of a peroxidase-antiperoxidase method having immunospecificity against the genus-specific (common) antigen(s) of the papillomaviruses. With the use of this technique, on formalin-fixed, paraffin-embedded tissue, papillomavirus antigens were detected in cells with cytologic and histologic features of wart virus infection (so-called koilocytotic atypia). Cells showing a positive reaction for papillomavirus antigens were identified in 24 of 50 (48%) cases of cervical dysplasia and in 20 of 40 (50%) cases of vulvar condyloma. The results of this study provide specific confirmation of the presence of papillomavirus antigens in cervical dysplasia and suggest that the papillomavirus may be an important factor in the etiology of this disease.

Epidermoid cysts of the testis: a report of three cases and an analysis of 141 cases from the world literature

Epidermoid cysts of the testis are rare and represent about 1% of all testicular tumors. An analysis of 141 cases reported to date in the world literature, including the cases reported here, indicates that 50% of the lesions occur in the third decade and 86% between the second and fourth decade. The most common presentations are painless enlargement of the testis (41%) for an average period of 2.25 years or incidental detection during routine physical examination (33%). Clinically, a discrete testicular nodule can be palpated in the majority of the cases (76%). Pathologic findings are those of a squamous lined cyst containing keratin with absence of appendages or other elements. It is believed that, despite the benign nature of the lesion, they should be treated by orchiectomy so that a thorough pathologic examination can be done to establish a confident diagnosis. While some controversy exists about their source of origin, all the evidence, including the age, more common occurrence among whites, and the rare reported cases arising in cryptorchid testis points to a germ cell origin for these lesions. The epidermoid cyst should thus be recognized as another subtype in the category of germ cell tumors of the testis and perhaps the ovary.

Langerhans cells in dermoid cysts: transmission electron microscopic, cytochemical and immunofluorescent observations

Langerhans cells were detected in squamous, stratified epithelia lining human dermoid cysts. Their presence was assayed by ATPase staining and reactivity with heteroantisera against "Ia-like" antigens. Transmission electron microscopic studies demonstrated variations in the numbers of cells showing Birbeck granules in epithelia with different degrees of keratinization. Indeterminate cells (i.e. lacking granules), were more frequent in epithelia showing combined mucous and keratinizing differentiation. Membrane-coating-granules and keratohyalin granules were present in epithelia containing Langerhans cells with clearly identifiable Birbeck granules. Interepithelial mast cells were observed in epithelia with mucous differentiation. A relationship between Langerhans cells and keratinization was suggested. Such non-immune functions are compatible with the known macrophage characteristics of the cell.

Morphological findings in duct-ligated pancreas grafts in the rat. An analysis of isografts, allografts, and long-standing allografts in hosts conditioned by previous spleen allograft

The morphological findings of duct-ligated pancreas grafts in streptozotocin-induced diabetic hosts were studied using inbred AGUS and WAG rats with a major histocompatibility complex differences. AGUS to AGUS pancreas isografts survived indefinitely. Morphologically, islet tissue was partly dispersed and showed about 75% granulated beta cells. Fibrosis was minimal and inflammatory cells generally absent. WAG to AGUS allografts were quickly rejected and showed severe pancreatitis with a polymorphonuclear and mononuclear infiltrate. Islet destruction lagged behind that of exocrine tissue and vascular thrombosis was a late event. In the last group, AGUS recipients first received WAG spleen allografts which survived spontaneously. There to 5 months later they were removed and WAG pancreas allografts inserted. Sixty-eight percent of these pancreas allografts survived. Four to 10 months later they were characterized by severe dense fibrosis surrounding islet tissue. Capillaries were always present between islet cells, about 75% of which showed beta granules. A mild to moderate mononuclear cell infiltrate and vascular intimal proliferation were also part of the picture. We conclude that pancreatitis after duct-ligated pancreas allografts is not a sequel of duct ligation but results from rejection and can be prevented with adequate immunosuppression. Fibrosis does not have a detrimental effect on islet cell function as a result of the feasibility of insulin secretion by beta cells into adjacent capillaries and thence to larger vessels traversing through the dense fibrosis.

Renal papillary necrosis following rapidly progressive glomerulonephritis

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Infarction of the lymph nodes: a cause of a palisading macrophage reaction mimicking necrotizing granulomas

A case of multiple cholesterol atheromatous emboli with infarction in various parts of the body is described. The histologic appearance of infarction in the lymph nodes, a rare condition, mimicked that seen in necrotizing granulomas usually secondary to micro-organisms.