Measles antibody seroprevalence rates among immunized Inuit, Innu and Caucasian subjects

Measles antibody seroprevalence was compared in Innu, Inuit, and Caucasian peoples of northern Newfoundland, Canada, who were immunized with a single dose of M-M-R-II (Merck Research Laboratories) vaccine. Healthy, volunteer schoolchildren (n = 606) were enrolled. Measles antibody was measured with a whole virus measles-specific IgG EIA. Native (Innu and Inuit) schoolchildren (n = 253) had a significantly higher seropositive rate (83%) after a single dose of measles vaccine compared to Caucasian (n = 353) children (76%; p = 0.025), and higher mean antibody levels after immunization compared to Caucasian children (1.74 EIA units, vs. 1.63; p = 0.06). Caucasian children were more likely to have been immunized after age 15 months (20.6% vs. 9.6%; p = 0.001). There was no significant difference in the mean time interval between immunization and blood sampling for natives versus Caucasian (8.0 years vs. 7.95 years; p = 0.49). After adjustment for time from immunization and age at immunization, there remained a marginally significant racial difference in seropositivity (OR = 1.65, 95% CI 0.96, 2.83, p = 0.068). The unadjusted odds ratio for seropositivity (comparing natives vs. non-natives, combining negative and equivocal results) was 1.66 (95% CI 1.06-2.59, p = 0.018). The higher measles-seropositive rate found among native compared to non-native Canadian children suggests that genetic and/or environmental factor(s) affect circulating antibody levels following immunization. The determination of these sources of variability may lead to the development of more efficacious vaccines or delivery strategies.

Parental knowledge and attitudes of Minnesota laws concerning adolescent medical care

OBJECTIVE

To determine parents' knowledge and attitudes of medicolegal issues affecting adolescent medical care.

DESIGN

An anonymous, mailed survey with 16 questions concerning Minnesota consent and confidentiality laws that affect adolescents' medical care.

SETTING

A community of >70 000 in rural, southeastern Minnesota.

PARTICIPANTS

Parents of 600 randomly selected 7th- through 12th-grade public school students.

RESULTS

Two hundred eighty-eight (48%) parents returned the surveys. Parents achieved a median score of 18.8% (range, 0%-93.8%) correct on a test of knowledge. Opinion was a median of +0.3 on a scale where -1 signified "a bad law," 0 signified "neither a good nor bad law," and +1 signified "a good law." Four questions, however, generated a more intense response. Seventy-seven percent of parents reported that, as a whole, the laws in the survey had no effect on them and/or their children.

CONCLUSIONS

These results suggest that parents are not knowledgeable of Minnesota laws that affect adolescent medical care. Overall opinion of these laws was mildly positive, with notable exceptions. Parents also lack a sense of impact of laws affecting adolescent medical care. Lack of knowledge and the presence of certain attitudes allow for identification of issues that clinicians should address by incorporating medicolegal education into the care of adolescents and their families. These results are especially timely in light of the Parental Rights and Responsibilities Act under consideration in Congress, which would provide parents greater authority over their children's medical care.

Analysis of surgical referral patterns for endosseous dental implants

Endosseous implants have traditionally been surgically placed by oral and maxillofacial surgeons, periodontists, and general practitioners. The purpose of this study was to examine surgical referral patterns for patients receiving implants in the treatment of partial edentulism. The records of 542 patients who received 1,313 implants between 1993 and 1997 were analyzed. Data relative to anatomic area, patient demographics, type of implant system, and any complication encountered were collected. Surgical cohorts were compared using Wilcoxon's rank-sum or chi-square tests, and complication rates were estimated using survival analysis methods. Results indicate no significant difference (P > .05) between cohorts with regard to placement of implants in the anatomic locations of the anterior mandible, anterior maxilla, posterior mandible, and posterior maxilla. Patient demographic information was not statistically different, with the exception of mean patient age, where oral and maxillofacial surgeons have been younger patients (P < .0001). Relatively few complications were seen, with no significant difference in complications rates between cohorts (P > .05). The type of implant system used showed no significant difference with respect to anatomic location or complication occurrence (P > .05). This study indicates that implant surgical referral patterns were similar in this setting between periodontal and oral and maxillofacial surgeons, with the only difference being a tendency to refer younger patients to the oral surgeons.

Use of alendronate in peri-implant defect regeneration

BACKGROUND

Previous studies have demonstrated an increase in bone mass and density with use of systemic alendronate sodium. This agent acts as an inhibitor of osteoclast activity, and is thought to result in more net osteoblastic activity. The objective of this study was to determine the effects of locally applied alendronate sodium on guided bone regeneration around dental implants.

METHODS

Six adult mongrel dogs were divided into 2 groups: one group received alendronate-coated dental implants, and the other group served as control. Two types of dental implants were used in each dog: hydroxyapatite (HA)-coated and titanium machine-polished (TMP), for a total of 4 groups. Dental implants were placed immediately after extraction of the right and left second, third, and fourth mandibular premolars; a resorbable collagen membrane was secured over the implants and defects; and the flaps were closed primarily. Fluorescent labels were administered intravenously on days 0, 6, 12, and 22 to measure bone formation rate. Dogs were sacrificed on day 28. The specimens were sectioned and mounted, and bone formation rate was recorded with a computerized microscopic digitizer. Specimens were stained with Stevenel's blue and van Gieson's picric fuchsin. Bone-to-implant contact was recorded with a computerized microscopic digitizer.

RESULTS

The results indicated a significant effect of locally applied alendronate (P < 0.0001) with both types of implants (HA and TMP), as well as the HA coating (P< 0.02) on increased bone formation rate. Additionally, alendronate had a significant effect on bone-to-implant contact, with an increase in the TMP model (P < 0.0001) and a decrease in the HA model (P < 0.0001 ). HA coating also had a significant effect on increasing bone-to-implant contact (P < 0.04).

CONCLUSIONS

The results indicate that alendronate increases early bone formation rate around dental implants. Additionally, the local application as described resulted in greater bone-to-implant contact with TMP implants.

Comparison of screening methods in the detection of bladder cancer

PURPOSE

We prospectively evaluate and compare the sensitivity and specificity of urine cytology, BTA stat, NMP22, fibrin/fibrinogen degradation products (FDP), telomerase, chemiluminescent hemoglobin and hemoglobin dipstick to detect bladder cancer.

MATERIALS AND METHODS

Single voided specimens were obtained from 57 patients with bladder cancer, and 139 without evidence of bladder malignancy on cystoscopy or a negative biopsy of indeterminate lesions. A cytology report was available for 125 patients and interpreted independently. BTA stat, NMP22 and FDP were analyzed according to manufacturer specifications. The telomerase assay was performed on cells collected from urine by centrifugation in preparation for polymerase chain reaction based amplification using the telomeric repeat amplification protocol assay. The chemiluminescent screening assay for hemoglobin in urine uses the pseudoperoxidase activity of hemoglobin on hydrogen peroxide and subsequent oxidation of 7-dimethylaminonaphthalene-1,2-dicarbonic acid hydrazide to generate chemiluminescence emission. Hemoglobin dipstick was interpreted as positive if the hemoglobin content in the urine was trace or greater.

RESULTS

Overall sensitivity with urine cytology, BTA stat, NMP22, FDP, telomerase, chemiluminescent hemoglobin and the hemoglobin dipstick was 44, 74, 53, 52, 70, 67 and 47%, respectively. Specificity with cytology, telomerase and FDP was high (95, 99 and 91%, respectively) but BTA stat, NMP22 (optimized), chemiluminescent hemoglobin (optimized) and the hemoglobin dipstick demonstrated lower specificity of 73, 60, 63 and 84%, respectively. Stepwise logistic regression analysis revealed that for all tumors, and within each tumor grade and stage telomerase had the strongest association with bladder cancer among all tests (69% overall concordance). Telomerase was also positive in 91% of the patients (10 of 11) with carcinoma in situ.

CONCLUSIONS

Urinary telomerase had the highest combination of sensitivity and specificity (70 and 99%, respectively) for bladder cancer screening in these patients. It was the strongest predictor with superior accuracy in patients with grade 1 and noninvasive tumors (pTa), and extremely useful in patients with carcinoma in situ. Telomerase appears to be promising and outperformed cytology, BTA stat, NMP22, FDP, chemiluminescent hemoglobin and hemoglobin dipstick in the prediction of bladder cancer.

Cellular proliferation in pilocytic and diffuse astrocytomas

Using quantitative image analysis, we evaluated the MIB-1 labeling index (LI) in a large population of pilocytic (n = 131) and diffuse astrocytomas (n = 140), explored its significance as a prognostic predictor of survival, and compared it to other commonly accepted predictors, including grade and its histologic determinants, atypia, mitoses, endothelial proliferation, and necrosis. Diffuse astrocytomas were graded according to the St Anne-Mayo scheme and included 45 grade 2, 50 grade 3, and 45 grade 4 astrocytomas. In pilocytic astrocytomas, mean, median, and range of MIB-1 LIs were 1.1, 0.9, and 0-3.9%, respectively. In diffuse astrocytomas, these values were 2.3, 2, and 0-7.6% in grade 2; 6, 4.4, and 0.1-25.7% in grade 3; 9.1, 6, and 0.3-36% in grade 4. There was a significant difference in the distribution of MIB-1 LIs between pilocytic and diffuse grade 2 astrocytomas (p < 0.001), between grade 2 and grade 3 (p < 0.001), and between tumors of grade 3 and 4 (p = 0.014). Among pilocytic astrocytomas there was no association between survival and MIB-1 LI or any histologic parameter. In diffuse astrocytomas, MIB-1 LI was significantly correlated with grade as well as with mitotic activity (<0.001) and survival. While in diffuse astrocytomas of all grades, necrosis was the strongest factor associated with survival, in tumors of grades 2 and 3 the MIB-1 LI preceded other histologic parameters and, on multivariate analysis, remained the only feature predictive of survival. Grade 3 astrocytomas with a single "solitary" mitosis had a significantly lower MIB-I LI than did grade 3 tumors with >1 mitosis and, compared to the latter, had a significantly longer survival (p = 0.013), one not significantly different from patients with grade 2 astrocytomas. These findings suggest that the cutoff point between grade 2 and 3 in the St. Anne-Mayo scheme may not be optimal and may need to be revised.

Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on health care charges

BACKGROUND

Asthma is a common and costly condition. Concomitant asthma and allergic rhinitis (AR) have been shown to increase the medication costs for people with asthma. No studies have compared medical care costs of those with and without concomitant AR.

OBJECTIVES

We sought to determine the prevalence and incremental medical care costs of concomitant AR.

METHODS

For each member of a population-based asthma cohort, we used all their medical charts within Olmsted County to record age at first diagnosis of asthma; the presence and age of any diagnosis of AR; and the total, ambulatory, and respiratory care-related costs of medical care. Costs were compared for age- and sex-specific strata of people with asthma who did and did not have AR.

RESULTS

AR was most commonly diagnosed in people whose asthma was diagnosed before age 25 (prevalence of 59%) and uncommonly diagnosed in anyone after age 40 (prevalence <15%). Yearly medical care charges were on average 46% higher for those with asthma and concomitant AR than for persons with asthma alone, controlling for age and sex. We were unable to assess the impact of treatment of AR on medical care charges.

CONCLUSIONS

Physicians should consider the diagnosis of AR (prevalence >50%) in all symptomatic children and young adults with asthma. Further evaluation is necessary to evaluate the ability of treatment to decrease the incremental costs of AR in persons with asthma.

Use of electron-beam computed tomography in the evaluation of chest pain patients in the emergency department

STUDY OBJECTIVE

We sought to determine whether electron-beam computed tomography (EBCT) could be used as a triage tool in the emergency department for patients with angina-like chest pain, no known history of coronary disease, normal or indeterminate ECG findings, and normal initial cardiac enzyme concentrations.

METHODS

We conducted a prospective observational study of 105 patients admitted between December 1995 and October 1997 to the ED of a large tertiary care hospital with 70,000 annual ED visits. The study group was comprised of women aged 40 to 65 years and men aged 30 to 55 years who presented with angina-like chest pain requiring admission to the hospital or chest pain observation unit. All patients underwent EBCT of the coronary arteries, along with other cardiac testing as deemed necessary by staff physicians.

RESULTS

Of the 105 patients, 100 underwent other cardiac testing during hospitalization. Evaluation included treadmill exercise testing in 58, coronary angiography in 25, radionuclide stress testing in 19, and echocardiography in 11. Results of EBCT and cardiac testing were negative for both in 53 patients (53%), positive for both in 14 (14%), positive for tomography and negative for cardiac testing in 32 (32%), and negative for tomography and positive for cardiac testing in only 1 patient. This positive test result, on a treadmill exercise test, was ruled a false positive by an independent staff cardiologist. Two other female patients with normal exercise sestamibi or coronary angiography and EBCT findings also had false-positive treadmill exercise results. The sensitivity of EBCT was 100% (95% confidence interval, 77% to 100%), with a negative predictive value of 100% (95% confidence interval, 94% to 100%). Specificity was 63% (95% confidence interval, 54% to 75%).

CONCLUSION

EBCT is a rapid and efficient screening tool for patients admitted to the ED with angina-like chest pain, normal cardiac enzyme concentrations, indeterminate ECG findings, and no history of coronary artery disease. Our study suggests that patients with normal initial cardiac enzyme concentrations, normal or indeterminate ECG findings, and negative results on EBCT may be safely discharged from the ED without further testing or observation. Larger studies are required to confirm this conclusion.

Prolactinomas in male and female patients: a comparative clinicopathologic study

OBJECTIVE

To explore the basis of the gender-based differences in endocrine and surgical findings in patients with prolactinoma (prolactin cell adenoma) as well as in their clinical outcome.

MATERIAL AND METHODS

In young or reproductive-age female patients, older women (beyond 40 years of age), and male patients, we systematically studied the following factors: operative and endocrine features (tumor size, invasiveness, preoperative serum prolactin level, and biochemical outcome), specific biologic variables (mitotic index, MIB-1 labeling index, and p27 immunoreactivity), and hormone receptor status (estrogen and progesterone receptor proteins as well as dopamine D2 receptor messenger RNA).

RESULTS

Of the various factors assessed, the preoperative prolactin level and MIB-1 labeling index were lower in young female patients in comparison with older female and particularly male patients. Hormone levels were also positively associated with mitotic activity as well as the MIB-1 labeling index. Although invasion was infrequent in microadenomas of young female patients, no statistically significant differences in tumor size or invasiveness were noted among the three patient groups. Absence of differences in invasiveness may, in part, be explained by artifacts of case selection.

CONCLUSION

The basis for the observed differences in proliferative activities in tumors of the three study groups is not readily apparent but may reflect differences in the endocrine milieu or the effect of sex steroid hormone receptors, tumoral vascularity, or specific growth factors.

Prevalence of lymphocytic infiltrate in 1400 pituitary adenomas

To evaluate the prevalence of lymphocytic infiltrate in a large series of pituitary adenomas, we retrospectively studied tumor tissues from 1400 patients. Based on immunocytochemical data, tumors were classified as PRL (n=411), multihormonal (n=310), immunonegative (n=275), ACTH (n=166), GH (n=137), alpha subunit (n=44), FSH and/or LH, (n=42), and TSH (n=15) adenomas. The lymphocytic infiltrate was diagnosed on histological examination and investigated by immunostaining with anti LCA (human leucocyte common antigen), anti CD45RO (human T cell) and anti CD20 (human B cell) antibodies. Lymphocytic infiltrate was present in 40 adenomas (2.9%), 26 females and 14 males, aged 18 to 77 years (mean+/-SD, 37+/-14 years). The tumors were 19 PRL, 8 multihormonal, 4 GH, 4 alpha subunit, 3 ACTH, and 2 immunonegative adenomas. In PRL adenomas, the sex ratio (female/male) and the age were similar in patients with and without lymphocytic infiltrate (2.8 vs. 4.6 and 29+/-6 years vs. 32+/-11 years, respectively). The frequency of lymphocytic infiltrate was similar in PRL, GH, ACTH and multihormonal adenomas, but lymphocytic infiltrate was significantly more frequent in PRL adenoma than in immunonegative adenoma, and in alpha subunit adenoma than in immunonegative, ACTH and multihormonal adenomas. The lymphocytic cells were almost exclusively T cells. We conclude that lymphocytic infiltrates are rare in pituitary adenomas. Their frequency is not statistically different in major categories of secreting adenomas (PRL, GH, ACTH, multihormonal). Their pathophysiological significance remains to be established.

Carcinosarcoma and sarcomatoid carcinoma of the bladder: clinicopathological study of 41 cases

PURPOSE

Carcinosarcoma of the bladder is a rare neoplasm characterized by an intimate admixture of carcinoma and malignant soft tissue neoplasm. The clinical usefulness of separating carcinosarcoma (carcinoma with sarcomatous component) from sarcomatoid carcinoma (carcinoma with spindle cell carcinomatous component) is uncertain, and it comprises the subject of this report.

MATERIALS AND METHODS

We reviewed the clinical and pathological records of 10 men and 5 women a mean of 66 years old with carcinosarcoma, and 21 men and 5 women a mean of 66.5 years old with sarcomatoid carcinoma of the bladder, as documented in the files of the Mayo Clinic between 1936 and 1995.

RESULTS

Of the 15 patients in the carcinosarcoma group 9 had urothelial carcinoma, small cell carcinoma, 3 had squamous cell carcinoma and 2 had more than 1 type. The sarcomatous component included chondrosarcoma in 3 cases, leiomyosarcoma in 3, malignant fibrous histiocytoma in 3, osteosarcoma in 2, fibrosarcoma in 1, rhabdomyosarcoma in 1 and more than 1 type in 2. All disease was high stage at presentation. Treatment included cystectomy in 11 patients with (4) and without (7) radiation therapy, and transurethral resection in 4 with (1) and without (3) radiation therapy. Mean followup available in 14 cases was 34 months (range 1 to 144). A total of 11 patients died of cancer at 1 to 48 months (mean 17.2) and 2 survived for 8 to 131 months. Of the 26 patients in the sarcomatoid carcinoma group 18 had urothelial carcinoma, 1 had squamous carcinoma, 2 had urothelial carcinoma combined with squamous cell carcinoma and 5 had spindle cells only with no recognizable epithelium. All but 1 case was high stage at diagnosis. Treatment included transurethral resection in 17 patients with (7) and without (10) radiation therapy, including 1 who also received chemotherapy, and only cystectomy in 5, including 2 who also underwent radiation therapy and 1 who also received chemotherapy. Mean followup available in 21 cases was 49 months (range 1 to 420). A total of 17 patients died of cancer at 1 to 73 months (mean 9.8), 1 was alive at 140 months and 3 died of unrelated causes.

CONCLUSIONS

Carcinosarcoma and sarcomatoid carcinoma of the bladder are highly aggressive malignancies with a similar outcome regardless of histological findings and treatment. Pathological stage is the best predictor of survival.

Retrospective review of 1170 endosseous implants placed in partially edentulous jaws

STATEMENT OF PROBLEM

Implant-supported restorations in the partially edentulous jaw have been performed at the Mayo Clinic for more than 10 years. Clinical performance of the implants and the prostheses should be reported to ensure effectiveness of this procedure.

PURPOSE

This retrospective study described results for implant survival, implant fracture rate, prosthetic complications, and design changes that may impact these results.

MATERIAL AND METHODS

A retrospective chart review was conducted of all registered implant patients in a large multispecialty medical center. Patients with a partially edentulous jaw who had received endosseous implants to support and retain dental prostheses were included in this review. Implant survival and fracture, prosthetic complications, and demographic data were recorded and analyzed through Kaplan-Meier methods.

RESULTS

A total of 1170 implants were placed in four anatomic locations: anterior maxilla, posterior maxilla, anterior mandible, or posterior mandible. Location of implants was shown to have no effect on implant survival (p = 0.7398), implant fracture rates (p = 0.2385), screw loosening (p = 0.8253), or screw fracture (p = 0.2737). Development of new restorative components has resulted in significantly better rates of implant survival without fracture (p = 0.0054), screw function without loosening (p < 0.0001) and screw function without fracture (p = 0.0013). Implant survival seems to have been improved with the new components (p = 0.0513).

CONCLUSIONS

Implant survival in this study was independent of anatomic location of implants. Virtually all clinical performance factors were improved by design changes in implant restorative components that were brought to market in early 1991.

Effects of the circadian variation in serum cortisol on markers of bone turnover and calcium homeostasis in normal postmenopausal women

Bone turnover has a circadian pattern, with bone resorption and, to a lesser extent, bone formation increasing at night. Serum cortisol also has a circadian pattern and is a potential candidate for mediating the circadian changes in bone turnover. Thus, we measured bone formation and resorption markers before (study A) and after (study B) elimination of the morning peak of cortisol. We also assessed effects of the circadian cortisol pattern on serum calcium, PTH, and urinary calcium excretion. Ten normal postmenopausal women, aged 63-75 yr (mean, 69 yr), were studied. Metyrapone was administered to block endogenous cortisol synthesis and either a variable (study A) or a constant (study B) infusion of cortisol was given to reproduce and then abolish the morning cortisol peak. Blood was sampled every 2 h for serum cortisol, ionized calcium, PTH, and bone formation markers [osteocalcin and carboxyl-terminal propeptide of type I collagen (PICP)], and timed 4-h urine samples were collected for measurement of calcium, phosphorus, sodium, potassium, and bone resorption markers (N-telopeptide of type I collagen and free deoxypyridinoline). During study A, serum osteocalcin had a circadian pattern, with a peak at 0400 h and a nadir at 1400 h. During study B, however, the afternoon nadir of serum osteocalcin was eliminated (P < 0.001 and P < 0.005 for the difference in the patterns of peak and nadir, respectively, on the 2 study days). In contrast, the circadian patterns of serum PICP and urinary N-telopeptide of type I collagen and free deoxypyridinoline were virtually identical during the two studies. Urinary calcium excretion declined after the cortisol peak, without differences between the 2 study days in phosphorus or sodium excretion or in serum PTH. We conclude that the circadian variation in serum cortisol is responsible for the circadian pattern of serum osteocalcin, but not that of PICP or bone resorption markers. The physiological variation in serum cortisol may also reduce urinary calcium excretion.

Patient-physician agreement on reasons for ambulatory general medical examinations

OBJECTIVE

To evaluate the physician's ability to identify patients' reasons for visits (RFVs) for a general medical examination (GME), to assess predictors of agreement between patient and physician on the RFV, and to determine whether agreement about the RFVs was associated with patient satisfaction with the visit.

DESIGN

We conducted a prospective study involving patients scheduled for a GME and internists in a multispecialty group practice.

MATERIAL AND METHODS

Patient-physician agreement on the RFV was independently assessed by two internists. Logistic regression was used to identify predictors of low agreement.

RESULTS

The 458 patients reported a total of 848 RFVs for their GME. Patient-physician agreement on the patient's RFV was low in 20% of the visits. Female gender (odds ratio, 2.02; 95% confidence interval [CI], 1.11 to 3.66), multiple RFVs (odds ratio, 2.03; 95% CI, 1.06 to 3.91), and previous GME (odds ratio, 2.18; 95% CI, 1.07 to 4.44) were independent predictors of low agreement. Patient-physician agreement for RFVs was not associated with patient satisfaction with the medical visit.

CONCLUSION

In this study, physicians correctly identified the patient's main RFV in a majority of the visits. Failures to identify the patient's main RFV occurred more frequently in female patients, in patients with multiple RFVs, and in patients with a previous comprehensive GME. Surprisingly, patient-physician agreement was not associated with patient satisfaction.

Expression of p27kip1 and Ki-67 in benign and malignant thyroid tumors

Thyroid neoplasms represent a broad spectrum of tumors with different biologic behaviors. The majority of these tumors can be readily diagnosed by characteristic histopathologic features, but the distinction between follicular adenomas and follicular carcinomas can be difficult. Recent studies with cell cycle proteins such as p27kip1 (p27), a cell cycle inhibitory protein, and Ki-67, a proliferation marker, suggest that these markers might be useful in predicting the behavior of various neoplasms. We analyzed 95 thyroid lesions (16 follicular adenomas, 23 follicular carcinomas, 22 papillary carcinomas, 27 anaplastic carcinomas, plus 7 non-neoplastic thyroids [NNTs], used as a control group) for expression of p27 and Ki-67 by immunostaining. The distribution of immunoreactivity was analyzed by quantifying nuclear staining in each case without knowledge of the diagnosis or outcome. Clinical history and follow-up information were obtained by chart review. There were significant differences in the expression of p27 between follicular adenomas (labeling index [LI] = 47.9+/-5.6) and follicular carcinomas (LI = 15.7+/-2.0). Papillary carcinomas (LI = 11.6+/-3.0) and anaplastic carcinomas (LI = 9.4+/-1.7) had p27 LIs similar to that of follicular carcinomas; the NNT group had the highest p27 LI (74.1+/-4.9). The Ki-67 LI of anaplastic carcinomas (57.6+/-3.8) was more than threefold greater than that of any other group. Logistic regression showed that p27 was effective in distinguishing follicular adenomas from follicular carcinomas (P = .0056) and that Ki-67 could also distinguish follicular adenomas from follicular carcinomas (P = .0060). Analysis of follicular carcinomas with and without metastases showed significantly higher expression of Ki-67 in patients with metastases (P = .0019). These results indicate that antibodies to p27 and Ki-67 might be useful in distinguishing between thyroid neoplasms that are difficult to diagnose by the usual histopathologic criteria.

Improved retention of the EMS activation component (EMSAC) in adult CPR education

This study was undertaken to determine whether using a model-telephone to simulate the emergency medical services activation component (EMSAC) during adult cardiopulmonary resuscitation (CPR) training practice would lead to better retention of this component during end-of-class assessment. In a prospective randomized manner, 233 medical professionals and lay-persons taking American Heart Association (AHA) CPR classes were evaluated for EMSAC retention during CPR skills performance at the end of class. During the assessment correct versus incorrect activation of EMS was noted. Subject response by age, exposure to previous CPR training, and medical professional or lay-person status was examined. Differences in results among instructors also were examined. Overall, those in the group using the model-telephone remembered to activate EMS correctly more frequently than those in the group not using the phone (69 vs 52%, P = 0.009). The < 30 age group was unaffected by the use of the phone (P = 0.85). The group between 30 and 50 years of age did significantly better with the use of the phone (P = 0.007), as did those 50 years of age and older (P = 0.03). Previous CPR training did not affect the response (P = 0.18). We conclude that use of the model-telephone improved EMSAC retention significantly overall except in the < 30 year-old age group. We recommend using the model-telephone in future adult CPR classes.

Implant reconstruction in the posterior mandible: a long-term retrospective study

STATEMENT OF PROBLEM

Because there is a lack of long-term data, it is unclear whether the determinants of implant and prosthesis survival include the location, angle, design, or number of implants and use of prosthesis cantilevers.

PURPOSE

This retrospective study evaluated the long-term outcome, determinants of outcome, and the type and prevalence of prosthetic complications in a series of patients treated consecutively with Brånemark implants in the partially edentulous posterior mandible.

MATERIAL AND METHODS

A total of 392 consecutively placed Brånemark implants were inserted in 152 partially edentulous patients and restored with 56 single-tooth and 168 fixed partial dentures restorations.

RESULTS

The cumulative success rates of implants and prostheses were 89.0% +/- 0.03% and 81.9% +/- 0.03%, respectively, at 6 years, with no further decrease in success noted during the remainder of the 10-year study. Significantly fewer major complications were found in prostheses supported by one or more implants, located exclusively in premolar sites, versus prostheses supported by either molar implant(s) or both premolar and molar implants. In single-tooth restorations, fewer major complications were seen in the cemented restorations, compared with the screw retained.

CONCLUSION

The results were strongly influenced by the phase of experience.

Organizing pneumonia. Features and prognosis of cryptogenic, secondary, and focal variants

BACKGROUND

Organizing pneumonia (OP) is a non-specific response to many types of lung injury. Clinicians frequently encounter pathology reports of OP in patients with no underlying condition (cryptogenic OP, also known as BOOP or bronchiolitis obliterans OP) or in association with drugs or nonpulmonary disease. The goals of this study are to describe the clinical course and outcomes in patients with 3 clinical variants of OP.

METHODS

A retrospective study of patients with OP seen at the Mayo Clinic, Rochester, Minn, from January 1, 1984, through June 30, 1994, was conducted. Initial features were obtained from medical records. Chest radiographs and pathology specimens were reviewed for this study. Resolution, relapse, and survival were obtained from medical records and a follow-up patient questionnaire.

RESULTS

Seventy-four patients had pathologically confirmed OP. Organizing pneumonia was classified into 3 clinical groups: symptomatic cryptogenic OP; symptomatic OP related to underlying hematologic malignant neoplasm, collagen vascular disease, or drugs (secondary OP); and asymptomatic OP presenting as a focal nodule (focal OP). Thirty-seven patients (50%) had cryptogenic OP and 27 patients (36%) had secondary OP. No difference was found between cryptogenic and secondary OP in type or severity of symptoms, signs, laboratory and pulmonary function tests, or radiologic or pathologic findings. Corticosteroids were given at a similar initial dose (prednisone, about 50 mg/d). Resolution of symptoms was more frequent in patients with cryptogenic OP than those with secondary OP. Relapse was infrequent in both of these groups. Five-year survival was higher in patients with cryptogenic OP (73%) than in secondary OP (44%), and respiratory-related deaths were more frequent in patients with secondary OP. Organizing pneumonia was an asymptomatic focal rounded opacity in 10 patients (14%), most often detected on chest radiograph and diagnosed on lung biopsy done for suspicion of lung cancer. Patients with focal OP required no treatment and had no relapse or respiratory-related deaths.

CONCLUSIONS

Clinical classification of OP is useful to predict clinical course and outcome. Cryptogenic OP most often was a symptomatic bilateral lung process that had an overall favorable prognosis with prolonged corticosteroid therapy. Patients with secondary OP had a high mortality rate when the disease was associated with predisposing conditions or drugs. Patients with asymptomatic focal OP had an excellent prognosis.

Exercise tolerance in patients with Ebstein's anomaly

OBJECTIVES

The purpose of this study was to identify the determinants of exercise tolerance in patients with Ebstein's anomaly.

BACKGROUND

Patients with Ebstein's anomaly of the tricuspid valve may have exercise limitation that improves after surgical repair.

METHODS

One hundred seventeen patients performed cycle ergometry for a total of 124 tests (preoperative test in 76 patients, postoperative test in 23, test but no operation in 18, preoperative and postoperative test in 7). Multiple linear regression analysis was used to identify predictors of maximal oxygen uptake, oxygen saturation and heart rate at peak exercise.

RESULTS

Age at the time of exercise ranged from 6 to 60 years (median 15). An atrial septal defect was present in 67 patients (88%) preoperatively. Compared with the preoperative group, the postoperative group had significantly higher maximal oxygen uptake (mean [+/- SD] 20.5 +/- 7.4 vs. 25.3 +/- 7.0 ml/kg body weight per min, p = 0.006). Postoperative rest and exercise blood oxygen saturation was higher than that measured preoperatively (p = 0.0001). Six of seven patients tested before and after the operation showed improved exercise tolerance. Preoperatively, major predictors of maximal oxygen uptake were oxygen saturation at rest (p = 0.01) and age (p = 0.0001). Preoperatively, the major predictor of oxygen saturation at peak exercise was rest oxygen saturation (p = 0.0001), and major predictors of peak exercise heart rate were rest heart rate (p = 0.01) and rest oxygen saturation (p = 0.01). In the postoperative group, predictors of maximal oxygen uptake included age at exercise testing, male gender and heart size.

CONCLUSIONS

Definitive operation for Ebstein's anomaly results in improved exercise tolerance. Before the operation, rest oxygen saturation is the major predictor of exercise tolerance, oxygen saturation at peak exercise and peak heart rate. Postoperatively, age, gender and heart size influenced maximal oxygen uptake.

Measles reimmunization in children seronegative after initial immunization

OBJECTIVE

To evaluate the success of measles reimmunization in children without measles antibody after the initial dose of measles vaccine.

DESIGN AND SETTING

A prospective clinical trial in Olmsted County, Minnesota, and Northern Newfoundland and Labrador in Canada.

SUBJECTS

A total of 130 healthy white, Innu, and Inuit schoolchildren. All subjects had received the post-1980 Moraten measles vaccine 4 to 11 years earlier.

METHODS

Children previously identified as measles antibody seronegative or equivocal after 1 dose of measles vaccine were entered into the trial and reimmunized. Measles antibody was measured a minimum of 6 weeks later using a whole-virus IgG measles-specific enzyme-linked immunoassay (EIA).

RESULTS

Of the 130 children reimmunized, 106 (81.5%) became measles antibody seropositive, but 24 children (18.5%) remained seronegative. Younger age at initial immunization (<13 months vs > or = 13 months) was significantly associated with lack of seropositive antibody levels following reimmunization (odds ratio, 3.9; 95% confidence interval, 1.5-9.7). In addition, antibody levels after reimmunization were significantly reduced with increasing time since initial immunization (P=.001).

CONCLUSIONS

After 2 doses of measles vaccine, 98.2% of all subjects in this study were seropositive for measles antibody, despite the fact that almost 20% of children did not have measurable antibodies 4 to 11 years following a first dose. These findings suggest that the current public health policy recommending a 2-dose measles immunization strategy, with the second dose given at school entry, will provide high levels of immunity in the community.