Changing concepts in the surgical management of pancreatic pseudocysts

A 27-year experience in the surgical management of 160 patients with pancreatic pseudocysts was reviewed. Sixty-eight patients treated from 1964 to 1981 (Group I) were compared to 92 patients managed from 1982 to 1990 (Group II). During the recent period, computed tomography (CT) scanning, endoscopic retrograde cholangiopancreatography (ERCP), selective visceral angiography, and percutaneous catheter drainage (PCD) techniques were available. The mean age of patients was similar in both groups (45 vs 44 years). Most pseudocysts in both periods represented complications of chronic pancreatitis due to alcohol abuse (82% vs 87%). Pancreatitis-associated complications occurring before management (fistula, obstruction, hemorrhage) were more frequent in Group II (19% vs 40%, P less than .05). There was a significant increase in the number of patients managed with external drainage in Group II (10% vs 52%) attributable to the use of PCD as definitive therapy in 46 per cent of patients in the recent period. Use of internal drainage procedures (cystgastrostomy, cystduodenostomy, cystjejunostomy) decreased in Group II (38% vs 16%, P less than .05). The use of lateral pancreaticojejunostomy (LPJ) combined either with caudal resection or cyst drainage has remained constant in both periods (32% vs 24%, NS). Patient morbidity was similar (26% vs 28%, NS) and mortality improved in Group II (9% vs 1%, P less than .05). Internal or external drainage for pseudocyst is often not definitive because of the underlying ductal disease. The authors' current approach is to manage large symptomatic cysts either with internal drainage or PCD; they employ octreotide acetate in the management of persistent pancreatic fistula following external drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Current views on cervical intraepithelial neoplasia

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The inhibition of monoamine oxidase by brofaromine

The inhibition of rat liver mitochondrial monoamine oxidase-A (MAO-A) by brofaromine was time-dependent at low enzyme and inhibitor concentrations. The apparent sensitivity to inhibition decreased when the concentration of the mitochondrial preparation was increased. After preincubation of the enzyme with brofaromine repeated washing of the preparation, by sedimentation and resuspension, resulted in a gradual recovery of activity. This occurred more slowly than was the case when the reversible inhibitor amphetamine was used. After incubation with radioactively-labeled brofaromine the loss of radioactivity also occurred slowly. After incubation with radioactively-labeled pargyline polyacrylamide-gel electrophoresis in the presence of sodium dodecyl sulphage (SDS-PAGE) showed the radioactivity to be associated with a peptide of approximate Mr 50,000, corresponding to the subunit of MAO. Pretreatment with unlabeled pargyline depressed this labeling by pargyline, indicating the latter compound to bind to the active-site of the enzyme. Labeling experiments with radioactive brofaromine indicated that there was a high degree of non-specific binding but that no significant radioactivity remained associated with the enzyme on SDS-PAGE. Chromatographic techniques and determination of H2O2 liberation indicated that, in liver there was no appreciable metabolism of brofaromine under the conditions used in the inhibition experiments. These data indicate brofaromine to be a tight-binding, but reversible inhibitor of MAO.

Duodenal stricture: a complication of chronic fibrocalcific pancreatitis

Over the past 10 years, one of us (M.C.A.) has treated 92 patients who required operation for symptoms associated with alcohol-induced chronic fibrocalcific pancreatitis. Four of these patients had duodenal obstruction. All four had had lateral pancreaticojejunostomy to relieve pancreatic ductal obstruction and associated chronic abdominal pain; three of the four also required biliary diversion for stenosis of the intrapancreatic portion of the common bile duct. Each duodenal stricture required reoperation and gastrojejunostomy to bypass the site of obstruction. A review of the English language literature revealed that duodenal obstruction in patients with chronic fibrocalcific pancreatitis is uncommon, only 58 previous cases having been reported. All of those patients had pancreatic ductal obstruction, and more than half had concomitant distal biliary stenosis. Two thirds of the duodenal obstructions were treated by gastroenterostomy, and one third were resected. Duodenal obstruction in patients with chronic pancreatitis and biliary stricture appears to reflect an advanced form of the disease. Combined lateral pancreaticojejunostomy and biliary diversion has emerged as the preferred surgical procedure for this problem. Careful preoperative assessment for evidence of duodenal stenosis also is needed in this group of patients, and gastroenterostomy is indicated in appropriate cases.

Pancreatic pseudocysts. When to drain, when to wait

Acute pain in the upper abdomen in a patient recovering from pancreatitis or abdominal trauma may herald a pancreatic pseudocyst. Although small cysts resolve spontaneously, those larger than 6 cm across usually require treatment to prevent such complications as rupture into adjacent structures and infection. The authors describe operative and nonoperative treatment methods and the success reported with each.

Percutaneous catheter drainage of pancreatic pseudocysts

Pancreatic pseudocysts represent a complication of severe pancreatic inflammatory disease. Although operative drainage is the cornerstone of therapy for pseudocysts, we have undertaken percutaneous catheter drainage in a selected group of 28 patients over a six-year period (1982-88). This represents 42 per cent of pseudocyst patients managed by the senior author and 1.7 per cent of admissions for pancreatitis at the Medical University Hospitals during that period of time. There were 26 men and two women with an age range of 26-66 years (mean = 42.1). Twenty-six patients had alcohol abuse as the cause of pancreatitis; two were due to surgical trauma. Nondilated pancreatic ducts were demonstrated in 25 patients. Six had pancreatic ascites associated with pseudocysts. Four had previous operative drainage (2 internal and 2 external drainage procedures). Five patients received octreotide acetate, a synthetic peptide which mimics the action of somatostatin, in an attempt to aid closure of external fistulas. The mean length of catheter drainage was 48 days (range 7-210 days). Eight (29%) patients developed procedure-related complications (1 pneumothorax, 1 sheared guidewire, six drain tract infections). There was no mortality. Successful resolution of pseudocysts was achieved in 26 patients (93%). Two patients subsequently had elective caudal pancreaticojejunostomy (CPJ), and one lateral pancreaticojejunostomy (LPJ) to drain obstructed pancreatic ducts. One patient has required repeat external drainage. Percutaneous external drainage is successful in pseudocyst eradication. When underlying pancreatic pathology remains uncorrected, elective surgical decompression of obstructed, dilated ducts may be necessary.

Percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections

Operative drainage is the cornerstone of therapy for pancreatic abscess. Recently it has been suggested that successful percutaneous catheter drainage of infected pancreatic and peripancreatic fluid collections may serve as definitive therapy. We undertook therapeutic, computed tomography-directed percutaneous drainage in a selected group of 29 patients with infected pancreatic and peripancreatic fluid collections. Twenty-three patients (79%) were successfully treated with percutaneous drainage. Of six patients (21%) representing failures of percutaneous drainage, four died and two recovered after operative drainage. The four patients who died had a mean APACHE (acute physiology and chronic health evaluation) II score of 23 and five of Ranson's prognostic signs. Ranson's signs and APACHE II scores were predictive of success and mortality. We conclude that in selected patients, infected pancreatic and peripancreatic fluid collections can be treated definitively with therapeutic percutaneous catheter drainage. Based on this experience, recommendations regarding patient selection are included.

Oocyte donation: the role of endometrial receptivity

Sixteen patients, 15 with primary ovarian failure and one carrier of chromosomal abnormality, received 21 embryo transfers following in-vitro fertilization of donated oocytes. Hormone replacement therapy was given to mimic a natural menstrual cycle. Five pregnancies were achieved (four infants delivered and one early pregnancy loss). All patients had endometrial biopsies taken in a preceding cycle of hormone replacement therapy. The majority (61%) showed delayed maturation compared with the expected appearances for the day of the cycle as assessed on light microscopy. Patients who conceived had a significantly better endometrial response than those who did not. Five out of seven patients (71%) conceived when the endometrium was 'in phase' (less than 2 days' delay). This suggests that endometrial receptivity is a key factor in conception. The implications for improving outcome from in-vitro fertilization treatment are discussed.

The effects of inferior olive lesion on strychnine seizure

Bilateral inferior olive lesions, produced by systemic administration of the neurotoxin 3-acetylpyridine (3AP) produce a proconvulsant state specific for strychnine-induced seizures and myoclonus. We have proposed that these phenomena are mediated through increased excitation of cerebellar Purkinje cells, through activation of glutamate receptors, in response to climbing fiber deafferentation. An increase in quisqualic acid (QA)-displaceable [3H]AMPA [(RS)-alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid] binding in cerebella from inferior olive-lesioned rats was observed, but no difference in [3H]AMPA binding displaced by glutamate, kainic acid (KA) or glutamate diethylester (GDEE) was seen. The excitatory amino acid antagonists GDEE and MK-801 [(+)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclo-hepten-5,10 imine] were tested as anticonvulsants for strychnine-induced seizures in 3AP inferior olive-lesioned and control rats. Neither drug effected seizures in control rats, however, both GDEE and MK-801 produced a leftward shift in the strychnine-seizure dose-response curve in 3AP inferior olive-lesioned rats. GDEE also inhibited strychnine-induced myoclonus in the lesioned group, while MK-801 had no effect on myoclonus. The decreased threshold for strychnine-induced seizures and myoclonus in the 3AP-inferior olive-lesioned rats may be due to an increase in glutamate receptors as suggested by the [3H]AMPA binding data.

Accuracy of ultrasound measurements of female pelvic organs

Uterine size, endometrial thickness and ovarian volume were measured ultrasonically and the results compared with caliper measurements made shortly afterwards at the time of total hysterectomy and bilateral salpingo-oophorectomy. The results establish the validity of ultrasound measurements. Histological studies also confirmed the diagnosis made with ultrasound of polycystic ovaries in women complaining of pain due to pelvic congestion.

Time course of salamander spinal cord regeneration and recovery of swimming: HRP retrograde pathway tracing and kinematic analysis

The time course of regeneration of supraspinal and descending brachial intraspinal axons was studied using HRP retrograde tracing and kinematic analysis. Five groups of salamanders (10 salamanders/group) received complete thoracic transection 1.0 cm rostral to the hind limbs abolishing swimming. Groups 1-4 recovered for 2, 4, 6, and 8 weeks, respectively, before being filmed to record the animal's ability to swim. After filming, a second transection was made 1.0 cm caudal to the first (at the level of the lumbar enlargement) and HRP was used to label descending axons which had grown past the first lesion. The fifth group was filmed every 2 weeks for 12 weeks before the second transection was made for HRP application. The films were used to perform frame by frame computer analysis of the amplitude and timing of cyclic lateral flexion waves which make up swimming behavior. The earliest return of coordinated swimming behavior was seen 4 weeks after transection (1 of 20 animals). At 6 weeks post-transection, 5 of 10 animals exhibited coordinated swimming. However, the behavior in these animals was subnormal. In the group surviving 8 weeks post-transection, 5 of 10 animals recovered coordinated swimming behavior. In the group that was filmed every 2 weeks, 5 of the 10 salamanders which did recover, exhibited coordinated swimming behavior by the eighth week post-transection. Kinematic analysis of salamanders that exhibited a return of coordinated swimming revealed quantitative differences compared to normal salamanders. While continuous head to tail undulatory waves were present, the propagation time and period were faster than those in normal salamanders. Retransection of the spinal cord abolished coordinated swimming. The numbers and distribution of HRP-labeled supraspinal neurons varied greatly among the animals that displayed recovery of locomotor abilities. In the salamanders examined 6 weeks post-transection the majority of labeled cells were found in medullary nuclei. In recovered salamanders examined 8 and 12 weeks post-transection, HRP-labeled neurons were found in the red nucleus, in the interstitial nucleus of the fasciculus longitudinalis medialis, and in the mesencephalic as well as the medullary reticular neurons. Recovery of coordinated swimming was only observed in salamanders in which descending supraspinal and intraspinal axons were present at the level of the lumbar enlargement (as demonstrated by HRP retrograde labeling). These results indicate that recovery of locomotion is dependent on the reestablishment of descending input and is not a result of changes in spinal reflexes or propagation of electrical activity through the body wall.

Neuroendocrine tumor of the pancreas in a patient with pernicious anemia

A total of 71 patients has been reported in the English literature to have developed carcinoid tumors in the fundus of the stomach in association with chronic atrophic gastritis secondary to pernicious anemia. The tumors appear to develop from argyrophilic cells in response to hypergastrinemia produced by hyperplastic G cells in the antrum of the stomach. We report a similar patient who, in addition, had a neuroendocrine tumor develop in the neck of the pancreas, which obstructed the pancreatic duct and resulted in severe chronic pancreatitis in the body and tail of the gland. There was an associated splenic vein thrombosis with left-sided portal hypertension. The pancreatic neoplasm was treated by excision, including the caudal 85 per cent of the pancreas and spleen. The gastric carcinoids appeared to diminish in size in response to a octreotide acetate (Sandostatin, Sandoz Pharmaceuticals; Hanover, NJ) administered to promote closure of a low-volume postoperative pancreatic fistula. The gastric lesions may require surgical treatment in the future. We were unable to find other examples of pancreatic neuroendocrine tumor occurring in association with pernicious anemia in a search of the English literature.

Treatment of external pancreatic fistulas with somatostatin. Second place winner: Conrad Jobst award

Five patients with external pancreatic fistulas were treated with a synthetic peptide that mimics the action of somatostatin (Sandostatin, Sandoz; East Hanover, NJ). Four of the patients developed fistulas after drainage of pancreatic pseudocysts and one developed a fistula following resection of a pancreatic carcinoid. One day after initiation of therapy, the mean fistula output for the group decreased by 52 per cent. By three days, fistula output decreased by 70 per cent. All fistulas closed in 7 to 44 days. Adverse reactions to the drug included diarrhea in one patient and transient hyperglycemia in another. Sandostatin is effective in decreasing drainage from external pancreatic fistulas and may, therefore, facilitate their closure. No serious adverse reactions to the drug were noted. Further studies will better define the role of Sandostatin in the treatment of pancreatic fistulas.

Laser excision rather than vaporization: the treatment of choice for cervical intraepithelial neoplasia

We are concerned that the use of ablative therapy in the treatment of cervical intraepithelial neoplasia may lead to a failure to diagnose early invasive carcinoma. In view of this, since June 1986, 196 patients considered suitable for laser vaporization were treated by a shallow laser excision cone biopsy instead. The mean age of the women treated was 31 years, and the mean length of the excised specimen, measured after fixation, was 14 mm. All procedures were completed in the colposcopy clinic and took no longer to perform than vaporization. The complication rate was low, and an excellent specimen was available for pathologic examination. In this series, histology on the excised cone revealed that two patients had microinvasive carcinoma and one had adenocarcinoma in situ. In addition, 16 patients had a lesion two or three grades worse on the laser excision biopsy than was predicted by the colposcopically directed biopsy. Because of the inaccuracy of colposcopic biopsy, we now recommend a small laser excision cone biopsy as the treatment of choice for all patients with cervical intraepithelial neoplasia.

Staging of carcinoma of the uterine cervix: MRI-surgical correlation

Forty-six patients with carcinoma of the uterine cervix were examined with spin-echo magnetic resonance imaging (MRI) using a superconducting magnet operating at a field strength of 0.5 T. All subjects later underwent lymphadenectomy and, when appropriate, radical hysterectomy. Surgical-pathologic correlation was carried out in order to assess the accuracy of the imaging modality in the staging of the disease. In the detection of nodal involvement, the accuracy of MR was 76%. The accuracy in determination of tumour size approached 100%. In the assessment of parametrial and vaginal involvement, the accuracy was 85% and 100% respectively.

A comparison of pancreatitis induced by high or low pressure injections of enzymes into the canine pancreatic duct

Purified pancreatic enzymes produced a substantial inflammatory response in the canine pancreas when injected under low pressure (40-60 cm). When high pressures in the range of 140 mm Hg were employed, the severity of the inflammatory response was considerably increased, and systemic hypotension and portal hypertension were common findings. The latter circulatory changes appeared to be related to a large load of enzyme-rich fluid absorbed predominantly by the venous route, and, to a lesser degree, by the lymphatics draining the interstitium of the gland. High pressure infusion appears to introduce variables that increase the intensity of the pathologic changes in the pancreas and the portal and systemic circulations. Infusion pressures within the range of physiologic probability appear to result in a lesion with less injection artifact. Studies involving experimental pancreatitis should take these factors into account, particularly when hemodynamic changes are an important consideration.

Determination of the absolute concentrations of monoamine oxidase A and B in human tissues

The concentrations of monoamine oxidase-A and -B were determined in homogenates of human cerebral cortex, caudatus and placenta and in human platelet-rich plasma and platelet membranes by determining the specific binding of tritium-labelled pargyline. The concentrations of the two enzyme forms were similar in both human brain regions examined. Determinations of the minimum quantities of clorgyline, (-)-deprenyl, J-508 or pargyline necessary to give complete inhibition of enzyme activity was found to give overestimates of the amounts of monoamine oxidase-A and -B present due to nonspecific binding of these inhibitors.

Splanchnic venous obstruction. A complication of chronic pancreatitis

A retrospective review of 20 adult patients with splanchnic venous obstruction secondary to chronic pancreatitis was performed to identify factors important in the preoperative diagnosis and operative management of this disorder. Fifteen patients with isolated splenic vein obstruction, four with portal occlusion and one with isolated inferior mesenteric vein occlusion were studied. Chronic alcoholism was the etiology of the pancreatitis in 18 patients; two patients had a Type IV hyperlipidemia. Four patients with massive hemorrhage from gastric varices were treated with splenectomy. Most patients presented with complaints of chronic pancreatitis, requiring pancreaticojejunostomy to treat the underlying pancreatic disorder. Splenic artery inflow control was obtained preoperatively in six patients and offers a technique that is beneficial in decreasing operative blood loss. The dynamic computerized tomography (CT) scan was a valuable diagnostic tool in identifying splanchnic venous obstruction although selective angiography is required for confirmation of the diagnosis.

Strychnine seizure potentiation by azaspirodecanedione anxiolytics in rats

Buspirone, gepirone and ipsaperone administered intraperitoneally (40 mg/kg) to naive rats were found to be proconvulsive for strychnine-induced seizures. The dose of strychnine required to induce seizures in 50% of test animals (CD50) was 2.18 mg/kg in naive rats, while CD50s for rats treated with the azaspirodecanediones ipsaperone, gepirone and buspirone were 1.65, 0.97 and 0.70 mg/kg respectively. Azaspirodecanediones have high affinity for the 5-HT1A serotonin receptor, however, the specific 5-HT1A agonist, 8-hydroxy-2-(di-n-propyl-amino)-tetralin (8-OH-DPAT) had no effect on strychnine seizure in naive rats (CD50 = 2.0 mg/kg). The strychnine specific proconvulsive effects of inferior olive lesions and buspirone were additive, resulting in a CD50 of 0.1 mg/kg. This observation indicates that the buspirone-induced decrease in strychnine seizure threshold does not require intact inferior olive-climbing fiber pathways. Cerebellar sites for possible azaspirodecanedione action are discussed.

Fine needle aspiration of the prostate gland in the community hospital. A predictive value analysis

Fine needle aspiration cytology of the prostate gland has not been widely accepted into the clinical armamentarium of most urologists, even though its benefits are well recognized. This sluggish acceptance is most likely due to a cautious reluctance on the part of the general pathologist in the community hospital to evaluate these specimens and to uncertainty on the part of the urologist on how to interpret the pathologist's impressions should the pathologist attempt to evaluate the specimens. This article offers a predictive value analysis of the data obtained from four general pathologists after reviewing 50 fine needle aspirations of the prostate.

Nonfunctioning pancreatic neuroendocrine tumors presenting as pancreatitis: report of four cases

The presentation of pancreatic adenocarcinoma as acute or chronic pancreatitis has been well documented; however, there has been only one previous report of either functioning or nonfunctioning pancreatic neuroendocrine tumors associated with pancreatitis. At the Medical University of South Carolina in Charleston, from March 1982 through September 1987, we have managed four patients with nonfunctioning pancreatic islet cell tumors or carcinoids, which presented with attacks of pancreatitis. Three of the patients had recurrent bouts of upper abdominal and lower dorsal back pain with elevation of the serum amylase. One patient presented initially with acute upper abdominal pain and elevation of the serum amylase. Each patient had an endoscopic retrograde cholangeography pancreatography (ERCP) pattern involving the pancreatic duct which was characterized by diffuse dilatation proximal to the site of obstruction. One of the four had a tumor blush on splanchnic angiography. Each patient had CT evidence of a mass in the head of the pancreas; however, one of the four was found to have diffuse involvement of the entire gland at operation. Surgical therapy varied: (a) local excision of the ampullary area with re-anastomosis of the pancreatic duct to the duodenum and choledochoduodenostomy; (b) bypass with cholecystoduodenostomy and caudal pancreaticojejunostomy; (e) total pancreatectomy; or (d) bypass with a Roux-en-Y cholecystojejunostomy and gastrojejunostomy. The choice of the procedure was based on the patient's condition and operative findings.

DNA hybridisation of cervical scrapes: comparison with cytological findings in Papanicolaou smears

One hundred and sixty four cervical scrapes were taken over 26 months from 143 women aged 17 to 53 years, using an Ayre spatula. A smear was prepared from each sample for Papanicolaou staining and for cytological examination for evidence of human papillomavirus (HPV) infection. The cells remaining on the spatula were harvested for DNA analysis. These samples were probed for HPV 6, 16, and 18 and the results of DNA hybridisation and cytology were compared. Cytological changes of HPV (anucleate keratinised and keratinised squamous cells, koilocytic change and dyskeratosis, or multinucleation, or both) were detected in 103 (72%) of the samples where HPV DNA was detected; koilocytic changes were present in only 67 (48%). It is concluded that screening for a range of viral changes is a more sensitive method of detecting HPV infection than screening for koilocytic change alone.

Percutaneous drainage of pancreatic and peripancreatic fluid collections

Radiographically guided therapeutic percutaneous catheter drainage was used to manage 25 patients with 27 pancreatic and peripancreatic fluid collections. Nine of 11 (82%) noninfected and 11 of 16 (69%) infected collections were successfully managed with percutaneous drainage. Overall, eight complications and four deaths occurred in this group of patients. The morbidity and mortality in this series is somewhat higher than that previously reported in the radiologic literature. A discussion of the guidelines for percutaneous drainage is presented.

The role of specific IgE and beta-propiolactone in reactions resulting from booster doses of human diploid cell rabies vaccine

Reactions after booster injections of human diploid cell rabies vaccine (HDCV) were investigated to determine the possibility of IgE-type antibody involvement. Although normal manufacture of HDCV involves the inactivation of the virus with beta-propiolactone (BPL), the effect of BPL on nonviral vaccine components, such as host cell components or stabilizing proteins, may be typical of the haptenic action of small molecular weight chemicals. Specific IgE to commercial HDCV preparations, BPL-treated preparations of noninfected host MRC5 cell sonicate (BPL-MRC5), and a human albumin (HA) (BPL-HA) used as a stabilizing agent were detected in sera from five individuals who reported reactions after booster doses of HDCV. However, these patients had no detectable IgE to normal HA. Sera from nonvaccinated individuals, vaccinated individuals who reported no reaction after HDCV booster, and pollen-allergic individuals had no detectable IgE to HDCV, BPL-MRC5, or BPL-HA. Changes in the ratios of pre- to postbooster serum levels of specific IgE to HDCV and BPL-HA were significantly different in a group of 19 individuals who reported reactions to HDCV boosters; these changes in pre- to postbooster IgE levels in nonreactive vaccinees were not significant. Prebooster serum IgE RAST ratios to HDCV or BPL-HA were not predictive of potential reactions to HDCV. A number of experimental BPL-HA reaction mixtures were assayed to examine the effect of variable concentrations of BPL to HA. Increasing relative molar concentrations of BPL to HA resulted in increased electrophoretic mobility, whereas the highest relative specific IgE binding was detected in BPL-HA molar reaction mixtures of approximately 12.5:1.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of HPV DNA and viral copy numbers in cervical scrapes from women with normal and abnormal cervices

Cervical scrapes were obtained from 215 women with cytologically normal cervices and 74 women with cervical intraepithelial neoplasia (CIN) and probed for HPV 6, 11, 16, and 18 by dot-blot hybridization. Viral copy numbers were determined by densitometric scanning of autoradiographs. The prevalence of HPV DNA in women with normal smears was as follows: 23 per cent of women attending a Family Planning Clinic (FPC), 16 per cent of women attending a Sexually Transmitted Diseases (STD) clinic, and 48 per cent of women attending a laser follow-up clinic after treatment of CIN. Ten per cent of women with normal cervices harboured HPV 16. Viral copy numbers ranged from 1300 to 52,800 genome equivalents per cell. Twenty-seven HPV-positive women with normal smears (including four patients infected with HPV 16) were followed for up to 3 years. None developed CIN irrespective of copy number. Our results show that HPV is present in normal cervices in the absence of CIN. Copy number has no relation to the development of CIN and factors other than the amount of HPV DNA may trigger the neoplastic process.

Effect of inferior olive lesion on seizure threshold in the rat

Cerebellar stimulation has been associated with anticonvulsant activity in several experimental seizure models. We examined the effect of destruction of cerebellar climbing fibers, by systemic administration of 3-acetylpyridine (3AP) or electrothermic lesion of the inferior olive, on seizures produced by various chemical convulsants in rats. We found that inferior olive lesioned rats had lower threshold to seizures induced by strychnine and brucine, both glycine antagonists. The dose response curve for strychnine seizure was shifted 2.5 times to the left in 3AP lesioned rats. No difference in seizure threshold was seen when picrotoxin, bicuculline or pentylenetetrazole PTZ) were used to produce seizures. Abnormal motor behavior (AMB) including myoclonus, backward movement and hyperextension, produced by all of the convulsants tested, was significantly aggravated in 3AP pretreated rats. The inferior olive-climbing fiber projection to the cerebellum appears to modulate seizures induced by inhibition of glycinergic neurotransmission.

A nuclear deoxyribonucleic acid analysis of normal and abnormal vulvar epithelium

Vulvar and groin skin from 21 women with clinical squamous cell carcinoma of the vulva was compared with that from nine patients with vulvar intraepithelial neoplasia. Feulgen-stained nuclear densitometry showed a constancy of Feulgen-deoxyribonucleic acid (DNA) density in normal epithelium and all subepithelial connective tissue nuclei. At three sites--tumor edge, opposite labia, and perineum--there were significant differences in nuclear chromatin content between the two groups and also as compared with normal epithelium.

Determination of monoamine oxidase concentrations in rat liver by inhibitor binding

The concentrations of monoamine oxidase-A and -B have been determined in mitochondria, mitochondrial outer membranes and microsomes from Sprague-Dawley and Wistar rats by determining the binding of tritium-labelled pargyline. Although the amounts of each form present depended on the source and the preparation method, this was paralleled by the specific activity such that the molecular turnover number was found to remain constant. The catalytic constants, kcat/Km, which represents the apparent second-order rate constant for the combination of enzyme and substrate, were about 0.13 and 2.1 sec-1 X microM-1 for 5-hydroxytryptamine and 2-phenethylamine, respectively, regardless of the source. Estimations of the amounts of the two forms by determining the concentrations of the inhibitors clorgyline, (-)-deprenyl, J-508 or pargyline necessary to give complete inhibition were shown to give overestimates of the true values because of the non-specific binding of these inhibitors to sites other than the monoamine oxidase active site.

The effect of interferon on human papillomaviruses associated with cervical intraepithelial neoplasia

A double-blind, placebo-controlled, trial of leucocyte interferon showed that, contrary to previous reports, interferon had no significant effect on cervical intraepithelial neoplasia (CIN) when applied topically in a gel. DNA hybridization of cervical scrapes was used to monitor the effect of interferon on the human papillomaviruses (HPV) associated with CIN. There was, however, no significant difference in the expression of HPV 6 or 16 in the cervical epithelium of patients treated with interferon compared with those given a placebo. By using superficial cells scraped from the surface of the cervical epithelium as a source of DNA for viral studies, we were able to investigate the relation between HPV and CIN without interfering with the natural history of the disease. HPV 16 was detected in lesions which persisted while HPV 6 only was detected in one lesion that regressed. Regression was clearly associated with reduction in the number of copies of viral DNA per cell in this case. Dual infection with HPV types 6 and 16 were recorded in two patients with persistent lesions. In one patient, hybridization studies indicated that infection with HPV 16 could have occurred after infection with type 6 was established, and it is postulated that this may have changed the nature of the cervical lesion.

The preparation and testing of the proposed International Reference (IRP) Bermuda grass (Cynodon dactylon)-pollen extract

A lyophilized candidate extract of Bermuda-grass (Cynodon dactylon) pollen, intended for use as an International Reference Standard, was prepared by pooling four individual candidate extracts. In preliminary investigations, the four candidate extracts encompassed a variety of extraction methods. The collaborative testing program simultaneously analyzed the proposed reference and the individual extracts and included 11 laboratories performing RAST inhibition, histamine release, crossed immunoelectrophoresis, crossed radioimmunoelectrophoresis, isoelectric focusing, sodium dodecyl sulfate gel electrophoresis, and protein determinations with a variety of reagents and methods. The four candidate extracts and the pooled reference were found to be equivalent. The stability of this extract has also been studied. This International Reference Preparation of Bermuda grass-pollen extract should be useful for research and industry.

Use of microcomputer to help teach pathology

A BBC microcomputer was incorporated into a closed circuit television system while it was being used to show microscope slides. The computer generates screens of text that complement the demonstration of the microscopy. An additional feature is the capacity of the system to produce 35 mm transparencies.

Seasonal variation in antigens of the imported fire ant Solenopsis invicta

Eight sequentially collected lots of aqueous extracts of imported fire ant (IFA) front end and abdominal end segments were assayed for phospholipase A (PLA), N-acetyl-beta-glucosaminidase (NAG), and hyaluronidase. Relative potency of each extract lot and pooled venom was measured by RAST inhibition against a venom standard. More than a hundredfold difference in PLA activity was observed. Early summer collections had the highest activity. The May to June collection had more than twice the PLA activity of the next most potent lot. Discordancy in enzyme patterns was noted only in AE extract. NAG levels peaked earlier in the spring and summer and fluctuated less widely. Front end extract had lower activity levels for both enzymes, with no seasonal fluctuation in NAG and a single elevation in PLA activity in the April to May collection. RAST inhibition varied directly with PLA activity (p less than .05) but not with NAG nor hyaluronidase activities. Fifty-one percent of systemic allergic reactions to IFA stings occurred in summer, and 19% occurred in spring. A reported demographic survey demonstrated a higher incidence of IFA stings in the spring (39.9%) with a lower attack rate in the summer (31.9%). These findings suggest that the rate of systemic reactions to stings of the IFA may be related to seasonal variations in allergenic potency, as measured by PLA and RAST inhibition, rather than the sting attack rate.

The relationship between oestradiol metabolism and adrenal steroids in the endometrium of postmenopausal women with and without endometrial cancer

The aim of the present study was to investigate the hypothesis that adrenal androgens are contributory to the development of endometrial cancer either by the oestrogenic action of 5-androstene-3 beta, 17 beta-diol (androstenediol) or through the inhibition of oestradiol metabolism. Concentrations of androstenediol, dehydroepiandrosterone (DHA), DHA sulphate (DHAS), oestrone and oestradiol were measured in plasma and endometrium from postmenopausal women with and without endometrial cancer. There was no difference between normal postmenopausal women and endometrial cancer patients with respect to either tissue or plasma adrenal androgens although there was a tendency for plasma DHAS levels to be increased in cancer patients (normal women: 640 +/- 156 ng/ml; cancer patients: 808 +/- 159 ng/ml). There was a positive correlation between endometrial tissue concentrations of androstenediol and DHA in both normal women (P less than 0.05) and cancer patients (P less than 0.01) but for DHAS the relationship was only significant for non-malignant tissue (androstenediol: DHAS, P less than 0.05; DHA: DHAS, P less than 0.02). A significant positive correlation was found between all three plasma adrenal androgens for both groups. In cancer patients there was a trend towards an inverse correlation between endometrial tissue concentrations of DHAS and the enzyme 17 beta-hydroxysteroid dehydrogenase (17OHSD) although the relationship was not significant (r = 0.49). In endometrium, oestradiol was present in significantly higher concentrations than oestrone whereas in plasma the reverse was the case. There was also a tendency for plasma oestradiol levels to be elevated in the cancer subjects. These data do not support a substantial role for adrenal androgens in endometrial cancer but suggest that a relationship may exist between DHAS and 17OHSD and that an imbalance between sulphatase and sulphotransferase activities may be involved.

Pancreatopleural fistula

The clinical, diagnostic, and therapeutic aspects of 27 patients with pancreatopleural fistula (PPF) reported in the literature, and two additional patients managed by the authors, form the basis of this report. The diagnosis of PPF is based on the triad of massive pleural effusions, elevated pleural fluid amylase, and protein levels. PPF is a complication of chronic fibrocalcific pancreatitis in most cases. It may develop as a consequence of disruption of a dilated obstructed pancreatic duct. Pseudocysts are involved in the process in at least half of reported cases. A substantial number of PPF will close spontaneously utilizing conservative measures including pancreatic rest, total parenteral nutrition, and repeated thoracentesis. Surgical correction of the underlying pancreatic disease, including ductal decompression and drainage or resection of associated pseudocysts, is indicated to prevent recurrence of the fistula and to avoid other complications of advanced chronic pancreatitis. Associated terminal biliary obstruction should be identified and managed with biliary-enteric bypass.

A comparative study of the allergens of cat urine, serum, saliva, and pelt

In direct RAST analyses of sera from 43 individuals with a history of cat allergy, 39.5% were positive to cat pelt, 37.5% to cat saliva, and 12% each to cat urine and serum. The cat pelt and saliva extracts contained allergen 1, but cat serum and cat urine collected by bladder puncture had no detectable levels of this allergen. A crossed immunoelectrophoresis/crossed radioimmunoelectrophoresis analysis failed to reveal any allergen in urine or serum that was not also present in the saliva or pelt preparations, although urine had two allergens not present in serum. When serum from a patient who was direct RAST positive to cat pelt, serum, saliva, and urine was tested by crossed radioimmunoelectrophoresis, it was determined that a total of six allergens were detectable in cat pelt, three in cat urine, and six in cat serum. Since cat serum contains no detectable cat allergen 1, it may be concluded that at least seven allergens derived from the cat are capable of binding to IgE antibody in humans.

The pathology of cervical cancer

The preinvasive phase of squamous cell carcinoma of the cervix is a continuous spectrum of abnormal epithelium, which, for convenience of classification and as a guide to management, is customarily subdivided into three grades. The histological diagnosis of CIN, as well as the distinction between the grades, depends on a combination of features embracing aspects of differentiation, nuclear changes and mitotic activity. Grading of CIN is subjective. Generally, a minor degree of CIN would be expected to progress to a more severe form if not treated, but this progression does not seem to be inevitable; the more severe a CIN is at the time of diagnosis, the more likely it is that it will progress, both to a more severe degree of CIN and, eventually, to invasive carcinoma. Conversely, the more minor the degree of CIN at diagnosis, the more likely it is that it will regress. True figures are not available for the rate of progression from CIN to invasive carcinoma; it is sufficient to accept that the risk of progression probably occurs in a significant proportion of cases, if not the majority. Preclinical invasive carcinoma is divided into microinvasive carcinoma and occult invasive (Stage Ib) carcinoma. The definitions of these lesions have not yet been satisfactorily established; the term microinvasive carcinoma should define the maximum size of tumour which has virtually no metastatic potential and so may be treated in a conservative fashion. Invasive squamous cell carcinoma is classified histologically according to the cell type and the degree of differentiation, although it is debatable whether the cell type has any correlation with prognosis. Adenocarcinomas make up 5-10% of cervical cancers and a variety of histological types have been recognized. Adenocarcinoma in situ is being diagnosed with increasing frequency, often in association with squamous CIN. It seems apparent that AIS is a precursor of adenocarcinoma, but little is known about its natural history.

Hepatic rupture associated with pregnancy: treatment with transcatheter embolotherapy

Spontaneous rupture of the liver associated with pregnancy is a rare and very serious complication, usually occurring in association with eclampsia or preeclampsia. Survival has generally been dependent on early recognition of characteristic signs and symptoms and prompt surgical intervention. Even with surgery, maternal mortality approaches 40% and fetal mortality is even higher. The diagnosis can usually be firmly established based on the clinical and radiographic findings presented in this article. Reported is a patient with hepatic rupture successfully treated by transcatheter embolization of the hepatic artery. It is the authors' belief that if such a patient is clinically stable enough to undergo angiography, then transcatheter embolotherapy is a reasonable alternative to surgery.

Choledochocele and recurrent pancreatitis. Diagnosis and surgical management

A case history has been presented that reports a rare type III choledochal cyst (choledochocele) and describes the association of a choledochocele and recurrent acute pancreatitis. The most reliable diagnostic technique, as used in our patient and supported by our literature review, is endoscopic retrograde cholangiopancreatography. This case further supports surgical correction employing transduodenal sphincteroplasty. This procedure is highly recommended for management of the intramural choledochocele (type IIIc), especially when associated with recurrent pancreatitis. Finally, patients who present with recurrent pancreatitis without the usual historical or diagnostic findings of biliary tract or alcoholic disease should have a choledochocele included in the differential diagnosis.

Giant nodular ovaries with aberrant follicles

Two cases of an unusual variant of the Stein-Leventhal syndrome and ovary are described and two similar reported cases reviewed. Clinically three of the patients had a delayed menarche followed by irregular periods and one had irregular menorrhagia. Pathologically all four had large firm nodular ovaries of 6-9 cm in diameter, showing a gross excess of stroma and distorted or fragmented atretic follicles with unusual granulosal cell persistence. Both grossly and microscopically, ovaries of this type are liable to be mistaken for tumours, but there is no good evidence that they are either neoplastic or pre-neoplastic.

Routine preoperative biliary drainage: effect on management of obstructive jaundice

The routine application of preoperative percutaneous transhepatic biliary drainage (PTBD) to patients who have obstructive jaundice has a significant effect on overall morbidity, mortality, and patient survival by allowing selective application of the most appropriate therapeutic modality. Surgical patients who undergo PTBD were compared with those for whom PTBD was not available. The surgical complication rate was 44% for those who did not undergo PTBD and 15% for those who did. The surgical procedure-related mortality rate was 30% for those who did not undergo PTBD and 12% for those who did. These differentials may have been due either to a beneficial effect of presurgical decompression or to the fact that only more favorable candidates were selected for operative internal bypass. There was an overall increase in length of survival following the application of PTBD, especially in those patients who were surgical candidates.

Monoclonal antibodies for the histopathological diagnosis of cervical neoplasia

Five monoclonal antibodies (Ca1, HMFG 1 and 2, 8.30.3 and 77.1) were used to study the distribution of antibody binding sites in cervical tissue with a view to identifying a marker which would distinguish between benign and malignant cervical epithelium. Both benign tissue (mature and immature metaplastic squamous epithelium, congenital transformation zone and glandular epithelium) and neoplastic tissue (cervical intraepithelial neoplasia, 1, 2 and 3 and invasive squamous cell carcinoma) were stained by these antibodies. Although immature metaplastic epithelium stained strongly with all the antibodies, the intensity and distribution of staining in general did not distinguish between benign and neoplastic conditions. All five antibodies, raised against three different antigens, stained cervical tissue in a similar way and thus were unsuitable for use as specific tumour markers in equivocal cases. Further studies on other tumour markers are indicated in view of the potential value of this approach.

Aromatase activity in uterine leiomyomata

Of the 24 samples of leiomyoma tissues examined 14 were shown to have aromatase activity in vitro. In contrast only 1 of 12 samples of myometrium had any demonstrable activity. Measurements of tissue oestrogen levels showed no correlation with the amount of aromatase activity although oestradiol levels were consistently higher in the tumour tissues compared with the normal myometrium.

Erosion of adjacent organs by pancreatic pseudocysts

Erosion of adjacent organs occurred in 19 of 80 patients with pseudocysts of the pancreas (22%). A total of 26 organs were eroded. Thirteen patients had single organ erosion and six patients had two or more sites of involvement. The gastrointestinal tract was most frequently affected (stomach-seven, duodenum-five, duodenojejunal junction-two, colon-two). It is probable that many of these communications occur without detection and result in spontaneous internal drainage of the cyst. The surgical management of cystenteric fistulas is attended by a low morbidity and mortality. Urinary tract involvement occurred in two patients, both of whom recovered following correction of the communication and retrograde drainage of the pancreatic ducts. Eight patients developed erosion of adjacent major arteries and in six this resulted in major upper gastrointestinal hemorrhage. Two of these patients died as a direct consequence of the vascular erosion. Vascular involvement clearly represents a formidable complication in patients with pancreatic pseudocyst. This study illustrates the diverse complications that may develop when pseudocysts erode into adjacent organs. The risks appear to be greatest in cysts that develop in the course of chronic pancreatitis, in acute cysts associated with severe necrotizing pancreatitis, and when acute cysts are followed for prolonged intervals without surgical decompression.