Follicular cell carcinoma of the thyroid in a child after bone marrow transplantation for acute lymphoblastic leukemia

Follicular cell carcinoma (FCC) of the thyroid is rarely found during childhood. We report a 12 1/2-year-old girl with acute lymphoblastic leukemia, who developed rapidly growing FCC of the thyroid, 3 years after bone marrow transplantation. The role of chemotherapy in the induction of such secondary tumors after transplantation is discussed, and a proposal for the approach to these patients is suggested.

Cholestasis in Crohn's disease: a diagnostic challenge

A 24-year-old male with Crohn's disease who developed three independent episodes of cholestatic liver disease over an eight-year period is described. The first episode was related to an idiosyncratic drug reaction while on sulfasalazine. The second episode, at the time of an exacerbation of his colitis, was characterized by moderate portal inflammation on liver biopsy and resolved quickly while he was on corticosteroid therapy. The most recent episode, occurring when the bowel disease was quiescent, was due to granulomatous hepatitis and resolved clinically with no specific therapy. Because numerous potentially serious hepatobiliary complications have been associated with inflammatory bowel disease, prompt and aggressive investigation in these instances is recommended.

Learning spatial sequences in unilateral neglect

Brain-damaged patients with unilateral spatial neglect ignore aspects of the world located on the side opposite their lesion. In the present study we examined the performance of unilateral neglect patients (UN) on an SRT task in which a hybrid repeating sequence (21313) was used. We analyzed the patients' performance for each location separately as a function of the target's location in the trial preceding the response. The UN patients were severely limited in their learning of the sequence when compared to normal controls. In particular, they appeared to learn unique associations (21 and 13) but not ambiguous ones (31 and 32). We discuss two possible explanations for this phenomenon. The first is that UN patients show a deficit similar to that of normal subjects in dual task situations. The second is that the learning deficit is unique to spatial processing impairments of UN patients and is not directly related to research with normal population. We outline future research that may distinguish between these two explanations.

Evaluation of a new method of administration of the iron chelating agent deferoxamine

We compared the effectiveness of deferoxamine administered by twice-daily subcutaneous injections with conventional administration by prolonged subcutaneous infusion in 20 patients with thalassemia. Urinary iron excretion was comparable with the two methods but decreased significantly when the total daily dose was administered as a single injection. Local reactions were similar with infusion and injection. Subcutaneous injections of deferoxamine may be considered as an alternative to conventional infusions.

Treatment of onychomycosis: a randomized, double-blind comparison study with topical bifonazole-urea ointment alone and in combination with short-duration oral griseofulvin

A parallel-group double-blind study was carried out which compared the efficacy of chemical avulsion of affected nail by urea 40% and bifonazole 1% cream alone with that of the same local therapy combined with short-term oral griseofulvin in onychomycosis. A total of 120 patients were included in the study. Patients' characteristics were comparable in both treatment groups. Of the 98 patients fully evaluated, 91 had toenail involvement and only seven had fingernail involvement. Forty-six of the patients were men and 51 were women. The mean age of the patients was 47.14 +/- 13.84 years (range 17-80 years). The duration of onychomycosis was for more than 1 year in 96 patients and for 3 months duration in only one patient, who was in the placebo group. Forty patients had received different previous therapies. All topical treatments were discontinued for at least 2 weeks and oral therapy for at least 2 months prior to the beginning of the study. The diagnosis was confirmed by positive mycologic cultures. Trychophyton rubrum was identified as the pathogen in 90 patients, 45 in each group, T. tonsurans in four patients, two in each group, and T. mentagrophytes in three patients, two in the griseofulvin treated group, and one in the placebo group. The first phase of treatment given to all patients consisted of occlusive dressing every 24 h with urea 40% and bifonazole 1% ointment until the infected nail became completely detached. Subsequently, in the second phase bifonazole 1% cream was applied to the nail ped every 24 h for 4 weeks. In addition, concomitantly with the bifonazole cream the patients were randomly allocated to a daily oral double-blind treatment with griseofulvin 500 mg or placebo, for 4 weeks. Clinical and mycologic evaluations were carried out at baseline, immediately after removal of the nail, and at 3 days, 4 weeks, and 4 months after the end of treatment with bifonazole cream and griseofulvin/placebo tablets. Mycologic examination included identification of fungi by KOH preparation and culture on potato dextrose agar. Positive cultures were transfered for identification on Sabouraud's. Criteria for evaluation of efficacy comprised: "cure" defined as clinical and mycologic cure (fresh specimen and culture negative) at both investigation times after the end of treatment; "late cure" defined as mycologic cure at both investigation times after the end of treatment, clinical clearing of the nail only 4 months after the end of treatment; "improvement" defined as mycologic cure and only partial clinical improvement at both times after the end of treatment; "failure" indicating no mycologic cure (fresh specimen and/or culture positive); and "relapse" signifying a change from negative findings 1 month after the end of treatment to positive findings 4 months after the end of treatment. Adverse reactions were evaluated on each visit. Only those patients who had completed clinical and mycologic evaluation during the entire study were included in the final statistical analysis. Those patients with partial evaluation were included only in the evaluation of adverse events. Based on the assumptions of a failure rate (failure and relapse) of 30% with bifonazole cream alone and of 10% with bifonazole cream and griseofulvin tables, a = 0.05 and b = 0.2 the required sample size was at least 58 patients for each treatment group (Casagrande formula, one-sided test). The primary efficacy variable "assessment of treatment" (cure and improvement versus failure and relapse) was tested for treatment differences by Fisher's exact test (a = 0.05, one-sided test; Ho, no advantage with additional systemic therapy of griseofulvin). Additionally, the relapse rates of both treatments were tested exploratively in the same way as the primary efficacy variable. All other data were analyzed descriptively.

Safety of dobutamine stress echocardiography. A 24 h Holter monitoring study

BACKGROUND

Dobutamine-atropine stress echocardiography is an efficient method in the evaluation of patients with coronary artery disease. However, because high-dose dobutamine is potentially arrhythmogenic, the safety of this stress modality has been questioned.

METHODS

We performed a 24 h Holter monitoring, before and immediately after this test, in 73 consecutive patients (60 men and 13 women), mean age 60 +/- 12 years. Twenty-eight patients had had a recent myocardial infarction, 25 had stable chronic angina, 10 chronic ischaemic cardiomyopathy and 10 idiopathic dilated cardiomyopathy. Dobutamine was progressively increased (5-40 micrograms.kg-1.min-1) and atropine was injected in 30 patients. Arrhythmias and ST-segment deviation before and after the stress test were evaluated.

RESULTS

The mean peak dobutamine dose was 32 +/- 11 micrograms.kg-1.min-1. The heart rate at rest and at peak dose was, respectively, 69 +/- 16 and 110 +/- 28 beats.min-1. Side effects during the injection of dobutamine were mainly ventricular (n = 14) or atrial (n = 4) premature contractions. Three patients had non-sustained ventricular tachycardia and five had hypotension during the test. No sustained episode of supraventricular or ventricular tachycardia was observed during the study. Non-sustained supraventricular and ventricular tachycardias were detected in 8 and 21 patients before and in 11 and 16 patients after dobutamine stress echocardiography (P = ns). Asymptomatic ST-segment deviation was observed in two patients before and four after dobutamine stress echocardiography. An increase in total ischaemic time (20 vs 102 mn) was observed after the test, but only five patients had ST modifications. A separate analysis of patients with and without beta-blocker did not alter these results. In addition, when the occurrence of significant arrhythmias was stratified according to a left ventricular ejection fraction threshold of 45%, we observed no difference in frequency and severity of cardiac arrhythmias.

CONCLUSION

This study demonstrates that dobutamine stress echocardiography does not significantly increase arrhythmia during the following 24 h. Further studies are required to evaluate the influence of the test on ST-segment modification during the same period.

Association of epidural analgesia with cesarean delivery in nulliparas

OBJECTIVE

To evaluate whether epidural analgesia during the first stage of labor is associated with an increased risk of cesarean delivery.

METHODS

The association of epidural analgesia and cesarean delivery was examined in a retrospective study of 1733 low-risk, term nulliparas with singleton infants in vertex presentations, in which labor began spontaneously. To evaluate the effect of epidural analgesia on cesarean deliveries, independent of other factors influencing the use of epidural analgesia, we used propensity scores to create five subgroups (quintiles) of women who, based on characteristics discernible at admission, appeared equally likely to receive epidural analgesia. Multivariate logistic regression analysis was used to control for confounding.

RESULTS

Overall, the cesarean rate among women receiving epidural analgesia was 17% (168 of 991), compared with 4% (30 of 742) among those who did not receive epidural analgesia. An increased cesarean rate among women receiving epidural analgesia was present in all propensity quintiles. In an adjusted logistic regression analysis, women receiving epidural analgesia were 3.7 times more likely to undergo a cesarean (95% confidence interval 2.4, 5.7). The greatest increase in cesarean risk was noted when epidural analgesia was administered earlier in labor, but there was a more than twofold increase regardless of the dilation and station at administration of epidural analgesia.

CONCLUSIONS

Epidural analgesia may increase substantially the risk of cesarean delivery. Although the causal nature of this association remains open to debate, prenatal care providers should routinely discuss the risks and benefits of epidural analgesia with women during their pregnancies so that they can make informed decisions about the use of pain relief during labor.

Prior exposure to superantigen can inhibit or exacerbate autoimmune encephalomyelitis: T-cell repertoire engaged by the autoantigen determines clinical outcome

Experimental allergic encephalomyelitis (EAE) is inducible in experimental animals immunized with myelin basic protein (MBP), proteolipid protein (PLP) or their peptides. We compared T-cell responses to encephalitogenic epitopes of PLP(43-64) and MBP(Ac1-11) in a single mouse strain, (PL/J x SJL)F1. MBP(1-11)-specific T-cell hybridomas expressed predominantly TCR V beta 8 or V beta 4, while PLP(43-64)-specific hybridomas expressed a diverse TCR repertoire. To analyze the biologic significance of the TCR repertoire (limited vs. diverse) to disease susceptibility, we pretreated mice with a superantigen (SEB), and then induced disease with these autoantigens. Mice injected with SEB and immunized with MBP(Ac1-11) showed significant inhibition of EAE, whereas SEB-pretreated mice immunized with PLP(43-64) had an increased severity of EAE and developed a chronic disease. These data demonstrate that prior exposure to microbial superantigens can significantly alter the autoimmune disease course depending upon the TCR repertoire used by the autoantigen.

NCCN Colorectal Cancer Practice Guidelines. The National Comprehensive Cancer Network

In summary, the committee believes that a multidisciplinary approach is necessary for the management of the patient with colorectal cancer. The committee endorses the concept that treatment of patients on a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for managing resectable colon cancer is an en bloc resection; laparoscopic surgery should be done only in the context of a clinical trial. For patients with stage III disease, 5-FU-based adjuvant chemotherapy is recommended. A patient who has metastatic disease in the liver or lung should be considered for surgical resection if he or she is a candidate for surgery and if surgery can extend survival. The committee advocates a conservative post-treatment surveillance program for colon and rectal cancer patients. A determination of CEA should be done only if CEA was elevated at baseline and decreased following primary resection. Abdominal and pelvic CT scans should be utilized only when there are clinical indications of possible recurrence. Patients whose disease progresses during 5-FU-based therapy should be considered for treatment with irinotecan or encouraged to participate in a phase I or II clinical trial.

Sleep architecture as related to temperature changes in neonates at term

Sleep architecture was assessed under different environmental temperatures in 10 full-term and 10 preterm infants who reached term. Five 30-min periods of baseline, normothermia heating, peak temperature, cooling and normothermia were analysed. A significant decrease in the proportion of active sleep (AS) and an increase in quiet sleep (QS) was noted among the full-term infants during the heating and peak temperature conditions, whereas, among the preterm infants, a similarly significant difference was noted during the heating and cooling stages of the study, but not during the stage of peak temperature. This differential response to environmental hyperthermia is possibly related to maturational factors. This phenomenon may be related to the increased vulnerability of low birth weight infants to apnoea and sudden infant death syndrome.

Identification of a mutation in a GATA binding site of the platelet glycoprotein Ibbeta promoter resulting in the Bernard-Soulier syndrome

Bernard-Soulier Syndrome (BSS) is a rare congenital bleeding disorder due to absent or decreased expression of the glycoprotein Ib-IX-V (GpIb-IX-V) receptor complex on the platelet surface. To date, only mutations in GpIbalpha or GpIX have been reported in patients with BSS. GpIbbeta differs from the other proteins in this receptor in that the gene is more complex, and an alternative form is expressed in cells of non-megakaryocytic lineage, including endothelial cells. It appears that the megakaryocytic and endothelial cell mRNA species are transcribed from different start sites and have different proximal promoter regions. We have identified a patient with BSS who has a deletion on one chromosome 22, resulting in velocardiofacial syndrome. The GpIbbeta gene has been mapped to this deleted (22q11.2) region of chromosome 22. The patient has greatly reduced levels of GpIbbeta mRNA and no detectable platelet GpIbbeta protein, suggesting that his BSS results from a mutation in his remaining GpIbbeta allele. Sequence analysis revealed that the coding region of GpIbbeta is normal, but the 5'-upstream region contains a C to G transversion at base -133 from the transcription start site used in megakaryocytes. The mutation changes a GATA consensus binding site, disrupts GATA-1 binding to the mutated site, and decreases promoter activity by 84%. Thus, in this patient, Bernard-Soulier syndrome results from a deletion of one copy of GpIbbeta and a mutated GATA binding site in the promoter of the remaining allele, resulting in decreased promoter function and GpIbbeta gene transcription.

Dorsal penile nerve block in children undergoing circumcision in a day-care surgery

PURPOSE

Circumcision is performed under general anaesthesia (GA) with dorsal penile nerve block (DPNB) as an analgesic technique for postoperative pain. The purpose of this study was to compare DPNB as the sole anaesthetic procedure vs GA and DPNB for circumcision in children as an outpatient procedure.

METHODS

In a six-month prospective study, 250 boys aged 6 to 17 yr (mean age 11.5 +/- 3.5 yr) were randomized into two groups. Group A (n = 122) received DPNB only prior to circumcision, and Group B (n = 128) received GA + DPNB. The groups were compared for complications of the block, effectiveness of anaesthesia, operating room time, postoperative time and ease of recovery.

RESULTS

There were no major operative complications in the two groups. Minor block complications, including oedema and haematoma, occurred in 16 (13.1%) boys in Group A and 27 (21.10%) boys in Group B (NS). At surgery, 3 (2.6%) from Group A received additional GA and 1 (0.8%) received additional local anaesthesia. They represent a DPNB failure rate of 3.3%. Mean operating room time was 11 +/- 2.5 min in Group A and 19 +/- 3.5 min in Group B, and post-anaesthesia care unit (PACU) time was 51 +/- 10 min in Group A and 101 +/- 14.5 min in Group B (P < 0.001). Nausea and vomiting in the PACU were noted in one patient in Group A and in 15 in Group B (P < 0.05). Only patients in Group B required additional analgesia and tranquilizers in the PACU (0 versus 20; P < 0.05).

CONCLUSIONS

These data confirm that DPNB has advantages over GA + DPNB for paediatric circumcision in day-care surgery.

Determinants of loneliness in Jerusalem's 70-year-old population

This study aims to find the determinants of feelings of loneliness in 70 year olds living in Jerusalem. Results based on home interviews (n = 605) of a 40% systematic sample of 70 year olds in the electoral register showed that around 46.3% of females and 21.3% of males reported being lonely. Persons of European/North American origin felt less lonely than those of Asian or African origin, probably due to the former's wider social support network, perceiving friends, neighbors or other relatives as being available to back up children in an emergency. The major factors associated with loneliness were: being depressed, having a poor self-assessed health status, not attending synagogue, and being widowed but not remarried. Factors that did not reduce loneliness included having paid employment, watching TV or listening to the radio. No association was found between cognitive status and loneliness. Our systems model suggests a strong reciprocal relationship between loneliness and depression.

The nutritional status of 70 year olds in Jerusalem

Inadequate nutrition is a major problem of elderly people today, a rapidly growing segment of western societies. Yet information on the nutritional state of the elderly in the community is much needed. We surveyed the nutritional status of a cohort of 70 year olds living in western Jerusalem. A total of 605 persons were interviewed in their home regarding socioeconomic variables, education, self-assessed global health status, use of medicines, and activities of daily living (ADL). In the second stage, a subsample of 463 of the above attended an outpatient geriatric clinic where a medical history was taken and a physical examination, a cognitive test, a psychological profile, blood and urine tests, electrocardiogram, pulmonary function tests, and grip strength measurement performed. Most of the sample population lived at home. Twelve percent reported having severe financial problems. Approximately 14% exhibited some cognitive problems, 83% were totally independent in ADL, and only 15% were housebound with 2.5% being bedbound. Body mass index (BMI) of < 19 kg/m2 was found in 1.1% of the population, while obesity, defined as a BMI > 30 kg/m2, was found in 13.5% of males and 28.6% of females. Polypharmacy was prevalent. A quarter of the study population were taking three or more prescription drugs. Serum triglycerides were below the normal limit in 7.3% of males and 4.7% of females, while total serum cholesterol concentrations were low in 13.9% and 4.7% of males and females respectively. Serum albumin was found below the lower limit of normal (35 g/l) in 16.9% of females and 11.4% of males. The significance of these results, their relation to other nutritional surveys, and their implications for the future are discussed.

Hypertension in the Jerusalem 70 year olds study population: prevalence, awareness, treatment and control

As part of the Jerusalem 70 year olds study, we evaluated the prevalence, awareness, treatment and control of hypertension (blood pressure > or = 160 mm Hg systolic and/or > or = 95 mm Hg diastolic, or current treatment with prescribed antihypertensive medications). The study cohort consisted of 448 participants, 224 of whom had hypertension. Relative to other populations, awareness was high (87%). Although the treatment rate was also relatively high (86%), the control rate was only 43%. Untreated isolated systolic hypertension was uncommon (5%), as was orthostatic hypotension (6.9%). Thus, despite a remarkable degree of awareness and treatment rate of hypertension, control levels were disappointingly low. This finding, if confirmed, requires further elucidation.

The Jerusalem 70 year olds longitudinal study: gastrointestinal findings

The objective of this part of the first cross-section of the longitudinal study of a cohort of 70 year olds in Jerusalem was to survey the gastrointestinal symptoms and signs of this heterogeneous population and thus contribute to the knowledge of the development of gastrointestinal diseases in this age group. A total of 605 persons replied to a home-visit questionnaire gathering data on socioeconomic and migration variables. Later on, 463 of these attended an examination at the Geriatric Research Institute where an in-depth anamnesis and physical examination were conducted. A battery of biochemical and hematologic blood tests were performed as well as urine analysis, ECG, and pulmonary function tests. At 3 year follow-up, the interviewed subjects, subjects examined in the hospital, and the control group consisting of 70 year olds who were not examined, were compared. By the measures of disease-specific mortality and hospital morbidity, the three groups were found to be similar, demonstrating that the sample population does represent the total Jerusalem 70-year-old population. This paper describes the symptoms, signs and laboratory results of the gastrointestinal part of this study. Up to a third of the subjects complained of upper gastrointestinal symptoms, most prominent of which was heartburn. Almost 10% of subjects complained of abdominal pain occurring at least once a week, but less than 1% noted left lower quadrant pain. There was a direct association between upper abdominal pain and symptoms of ischemic heart disease. The second part of this study, which began in 1996, will provide additional information regarding the natural history of these complaints.

Characteristics of falls in 70 year olds in Jerusalem

Falling is a serious and common problem among the elderly and may result in injury and functional deterioration. The characteristics and risk factors for falling were studied in a cross-sectional study of a cohort of 70-year-old community-dwelling Jewish elderly in Jerusalem. The cohort was found to be representative of the total 70-year-old population of Jerusalem by virtue of having similar hospitalization and mortality rates. Around 28.2% of the cohort reported falling during the past year. Women were more likely than men to have fallen during the past year (39 vs. 19%; P < 0.001). Falls occurred mainly outside of the home, resulting in fractures in 8.4% of persons who fell, all of them women. A female gender, low visual efficiency, poor self-reported general health status, low serum hemoglobin levels, and low lymphocyte counts were associated with a higher incidence of falls. There was no relationship between the pattern of pharmaceutic drug use or utilization of health care services and the risk of falling. We conclude that among the younger elderly, characteristics of falls and risk factors may be different from those in the older elderly.

Poland sequence in two siblings suggesting an autosomal inheritance transmission

We report on Poland sequence observed in two siblings (a girl and a boy) in the same family. This suggests an inheritance pattern consistent with an autosomal recessive or dominant trait transmission with reduced penetrance.

Factors predicting emergency room utilization in a 70-year-old population

Emergency room (ER) utilization in a representative sample (n = 605) of 70-year-old Jerusalem residents was investigated using multiple and logistic regression techniques. Around 23% of the study population visited an ER during the pre-interview year. Problems associated with ER use were heart diseases (mainly ischemic), asthma, renal disorders, psychiatric problems, headaches, and nocturia. Also associated with increased ER use were prior hospital admissions, taking sleeping pills, driving a car, distance from one's general practitioner, and low self-assessed health status. The availability of help from children increased ER use, possibly by sharing in the decision-making process or by helping with post-visit financial bureaucracy. Persons with cognitive problems had decreased ER use, possibly due to their inability to cope with the related complex decision-making process. The inclusion of interaction terms improved the models fit, in keeping with the general philosophy of geriatric care which often deals with cases presenting multiple diagnoses in addition to various social problems. Information on key variables identified as predictors of ER use in order to predict ER use as a basis for budget allocation to specific sick funds, was collected by means of a postal questionnaire or by phone.