Indium-111 leucocyte scintigraphy and ultrasound scanning in the detection of intra-abdominal abscesses in patients without localizing signs

The clinical records of 45 patients with suspected intra-abdominal sepsis but without localizing abdominal signs were retrospectively reviewed. All had undergone both indium-111 leucocyte scintigraphy and real time ultrasound. Twenty-two of the 45 patients were subsequently shown to have intra-abdominal abscesses. Twenty-one patients were identified correctly by indium-111 scintigraphy (sensitivity 95%) and 10 by ultrasound (US: sensitivity 45%). There were two false positive scintiscans (specificity 91%) but no false positive US scans (specificity 100%). There was no correlation between the peripheral white cell count and the presence of absence of an abscess or the likelihood of obtaining a positive scintiscan result. Because of the excellent specificity ultrasound scanning should remain the initial investigations in this group of critically ill patients with indium-111 scintigraphy being used to clarify the US findings or in US negative patients.

Hematopoietic growth factors after HLA-identical allogeneic bone marrow transplantation in patients treated with methotrexate-containing graft-vs.-host disease prophylaxis

The use of hematopoietic growth factors (HGFs) in the allogeneic transplant setting has sometimes been avoided for fear of stimulating leukemic cell growth and intensifying graft-vs.-host disease (GVHD). However, neither an increase in relapse rate nor an aggravation of GVHD has been routinely described when HGFs are used after allogeneic bone marrow transplantation (allo-BMT). Early outcomes after HLA-matched allo-BMT in 26 patients with hematologic malignancies treated with recombinant human granulocyte colony-stimulating factor (rhG-CSF) or recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) from the day of transplantation were analyzed. Results were compared to those from a series of 38 patients treated earlier with an identical approach, but not scheduled to receive HGFs after transplantation. All patients received a preparative regimen consisting of etoposide, cyclophosphamide, and total-body irradiation and GVHD prophylaxis with cyclosporine and a short course of methotrexate (MTX). The analysis has shown that the duration of neutropenia was significantly decreased in the group of patients treated routinely with HGFs (median 17 vs. 20 days; p < 0.001). These patients also required fewer days of intravenous antibiotic therapy (median 20 vs. 34 days; p < 0.001), had fewer positive blood and tissue cultures (median 2 vs. 12 and 13 vs. 28; p = 0.02 and p = 0.05, respectively), needed fewer packed red blood cell transfusions (median 7 vs. 11; p < 0.03), and were discharged earlier from the hospital (median 33.5 vs. 39 days; p < 0.001). The use of HGFs was not associated with an increase in acute GVHD or early leukemic relapse. No side effects were attributable to the simultaneous administration of MTX and HGF during the neutropenic period. A trend toward better 100-day actuarial survival for patients treated with rhG-CSF or rhGM-CSF did not reach statistical significance. A decrease in the number of early deaths from fungal or bacterial infections was found in the cytokine-treated group (p = 0.05). These data suggest that the early use of rhG-CSF or rhGM-CSF after HLA-matched allo-BMT in hematologic malignancies accelerates engraftment, reduces hospitalization time, and improves outcome, without increasing acute GVHD or early relapse. Because MTX-based prophylaxis regimens are associated with prolonged neutropenia, the routine use of HGFs after transplantation may be particularly useful in regimens including MTX.

Genital tract infections in women

The future holds promise of new, more accurate diagnostic tests; more effective therapies; and development of better barriers and eventual vaccines. GTI is, however, and for the foreseeable future will continue to be a major health care problem for women, requiring careful surveillance, management, and ongoing education for both patient and provider.

Symptomatic outcome 1 year after laparoscopic and minilaparotomy cholecystectomy: a randomized trial

In a randomized controlled trial, 299 patients were sent a symptoms questionnaire 1 year after laparoscopic (n = 151) or minilaparotomy (n = 148) cholecystectomy for symptomatic cholelithiasis. The response rate to the questionnaire from contactable patients was 86 per cent. In both groups, at least 90 per cent of patients reported that their symptoms were improved, and at least 93 per cent rated the success of their operation as 'excellent', 'good', or 'fair'. However, over half the patients reported abdominal pain, a quarter reported flatulence, and a quarter dyspepsia. The only difference between treatment groups was that a higher proportion of patients who underwent minilaparotomy reported heartburn (35 per cent versus 19 per cent, P = 0.005). Patients who reported a 'poor' outcome were more likely to have suffered a postoperative complication, had lower quality of life scores, and higher anxiety and depression scores. Both laparoscopic and minilaparotomy cholecystectomy result in symptomatic benefit in at least 90 per cent of patients with symptomatic cholelithiasis.

Principal component analysis and the scaled subprofile model compared to intersubject averaging and statistical parametric mapping: I. "Functional connectivity" of the human motor system studied with [15O]water PET

Using [15O]water PET and a previously well studied motor activation task, repetitive finger-to-thumb opposition, we compared the spatial activation patterns produced by (1) global normalization and intersubject averaging of paired-image subtractions, (2) the mean differences of ANCOVA-adjusted voxels in Statistical Parametric Mapping, (3) ANCOVA-adjusted voxels followed by principal component analysis (PCA), (4) ANCOVA-adjustment of mean image volumes (mean over subjects at each time point) followed by F-masking and PCA, and (5) PCA with Scaled Subprofile Model pre- and postprocessing. All data analysis techniques identified large positive focal activations in the contralateral sensorimotor cortex and ipsilateral cerebellar cortex, with varying levels of activation in other parts of the motor system, e.g., supplementary motor area, thalamus, putamen; techniques 1-4 also produced extensive negative areas. The activation signal of interest constitutes a very small fraction of the total nonrandom signal in the original dataset, and the exact choice of data preprocessing steps together with a particular analysis procedure have a significant impact on the identification and relative levels of activated regions. The challenge for the future is to identify those preprocessing algorithms and data analysis models that reproducibly optimize the identification and quantification of higher-order sensorimotor and cognitive responses.

Generation and characterization of a delta F508 cystic fibrosis mouse model

We have generated mice carrying the most common mutation in cystic fibrosis (CF), delta F508, within the cystic fibrosis (Cftr) gene. Mutant animals show pathological and electrophysiological changes consistent with a CF phenotype. delta F508-/- mice die from peritonitis and show deficiencies in cAMP-activated electrogenic Cl- transport. These mice produce delta F508 transcripts and show the temperature-dependent trafficking defect first described for the human delta F508 CFTR protein. A functional CFTR Cl- channel not demonstrated by null CF mice or present at 37 degrees C was detected following incubation of epithelial cells at 27 degrees C. Thus, these mice are an accurate delta F508 model and will be valuable for testing drugs aimed at overcoming the delta F508 trafficking defect.

Recent advances in muscular dystrophies and myopathies

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Creatine kinase MB isoforms: a potential predictor of acute cardiac allograft rejection

BACKGROUND

Noninvasive studies to detect or predict acute allograft rejection after heart transplantation have failed to be sufficiently reliable to substitute for endomyocardial biopsy. Isoforms of creatine kinase MB isoenzyme (MB2 and MB1) are extremely sensitive markers of ischemic myocardial damage and, in theory, may be elevated in cardiac allograft rejection when myocardial necrosis is visible on microscopy (International Society for Heart and Lung Transplantation grade 2 or greater).

METHODS

We examined, prospectively, the endomyocardial biopsy specimens (n = 256) of 50 consecutive patients undergoing orthotopic heart transplantation. Blood samples for creatine kinase MB isoforms (n = 527) were taken immediately before endomyocardial biopsy and at intervals between biopsies.

RESULTS

The median ratio of MB2/MB1 in plasma samples taken at the time of biopsy for grades 2 and 3 was not significantly different from the ratio from biopsy specimens graded 0 and 1 (1.65 versus 1.33; p = Not significant). The sensitivity for diagnosing a moderately severe rejection was 47% with a specificity of 58%. However, in patients with significant acute rejection (grades 2 and 3) in whom consecutive samples were collected, the MB2/MB1 ratio was significantly increased before histologic changes seen on biopsy in 13 of 16 rejection episodes by a mean of 14 days. The sensitivity for predicting rejection (grade 2 or 3) before endomyocardial biopsy was 60% with a specificity of 71% (positive predictive value 43%, negative predictive value 86%).

CONCLUSIONS

Creatine kinase MB isoforms may predict the occurrence of acute rejection before histologic evidence seen on endomyocardial biopsy.

Causal inferences as perceptual judgements

We analyze how subjects make causal judgements based on contingency information in two paradigms. In the discrete paradigm, subjects are given specific information about the frequency a, with which a purported cause occurs with the effect; the frequency b, with which it occurs without the effect; the frequency c, with which the effect occurs when the cause is absent; and the frequency d, with which both cause and effect are absent. Subjects respond to P1 = a/(a + b) and P2 = c/(c + d). Some subjects' ratings are just a function of P1 while others are a function of delta P = P1-P2. Subjects' post-experiment reports are accurate reflections of which model they use. Combining these two types of subjects results in data well fit by the weighted delta P model (Allan, 1993). In the continuous paradigm, subjects control the purported causes (by clicking a mouse) and observe whether an effect occurs. Because cause and effects occur continuously in time, it is not possible to explicitly pair causes and effects. Rather, subjects report that they are responding to the rate at which the effects occur when they click versus when they do not click. Their ratings are a function of rates and not probabilities. In general, we argue that subjects' causal ratings are judgments of the magnitude of perceptually salient variables in the experiment.

Primary mediastinal large cell lymphoma in children: a report from the Childrens Cancer Group

Malignant lymphomas arising in the mediastinum account for approximately 60% of all mediastinal tumors in children; two-thirds are non-Hodgkin's lymphomas and one-third represent Hodgkin's disease. In contrast to adults, in children mediastinal non-Hodgkin's lymphomas are usually synonymous with lymphoblastic lymphoma, and nonlymphoblastic lymphomas are rare. We describe nine children with primary mediastinal large cell lymphoma who were treated with the Children's Cancer Group protocol CCG-503, a randomized phase III protocol for disseminated nonlymphoblastic lymphoma. Histologic subclassification revealed three immunoblastic lymphomas, three multilobated large cell lymphomas, one with clear cell features, and two large noncleaved cell lymphomas. Sclerosis, of variable degrees, was seen in all tumors. Immunophenotyping revealed all tumors to be of B cell lineage. Thymic epithelial cells could be demonstrated, utilizing antibody to keratin, in two of nine patients, suggesting that some of the tumors are of thymic origin. None of the patients had central nervous system or bone marrow involvement. It appears that primary mediastinal nonlymphoblastic lymphomas in children, although much less common, are similar to those seen in adults. These tumors must be differentiated from lymphoblastic lymphoma and Hodgkin's disease, as the therapeutic approach may depend on histologic subtype. Primary mediastinal large cell lymphoma in children appears curable with aggressive treatment in the majority of patients.

Myocyte nuclear area as a measure of left ventricular hypertrophy in transplant patients

Transplanted hearts have been reported to increase in size/weight in the first few months after transplant and to remain stable thereafter. An indirect way of assessing the changes in heart weight is through the changes in the area of the myocyte nucleus (MNA). We studied 20 patients who had undergone orthotopic heart transplantation more than 12 months previously; 10 had become hypertensive, and the remaining 10 were normotensive. Myocardial biopsies taken the first week after transplant and 6, 12, 24, and 52 weeks after transplant were assessed. Myocyte nuclear area was measured in 200 myocytes/biopsy with an image analyzer. Individual measurements showed a wide variation in MNA, with significant overlaps among the different biopsies. Assessment of MNA at one year showed increased MNA in 4 10 patients in the hypertensive group and 5 10 in the normotensive group. The remaining patients showed either no statistically significant changes in MNA or a significant (p < 0.0001) decrease in MNA. The presence of systemic hypertension was not a predictive factor for significant hypertrophy and, in some cases, not even for hypertrophy itself. We conclude that although there is often an increase in MNA of the transplanted heart at one year posttransplant, this increase is not systematic, and isolated morphometric results should be viewed cautiously.

Ischaemic retinopathy occurring in patients receiving bone marrow allografts and campath-1G: a clinicopathological study

AIMS/BACKGROUND

Ischaemic retinopathy is a well characterised complication of bone marrow transplantation (BMT). Although the aetiology is unclear, it is most probably multifactorial, and may be related to treatment such as radiation and cyclosporin A. The clinical findings are reported of two patients who developed such a retinopathy and the ocular histology from one of these cases is presented.

METHODS

Two patients underwent BMT for acute lymphoblastic leukaemia, receiving campath-1G for prophylaxis against graft versus host disease, and showed fundal changes compatible with BMT retinopathy. The eyes from one patient were retrieved at post mortem and examined by both light and electron microscopy.

RESULTS

The visual symptoms and fundal signs resolved spontaneously with no specific treatment in one patient. Light and electron microscopic examination of the eyes of the other patient was compatible with an ischaemic aetiology and showed evidence of retinal capillary endothelial loss.

CONCLUSIONS

(i) Histopathology in one case of BMT retinopathy demonstrates a retinal endotheliopathy similar to that described in radiation retinopathy. (ii) BMT retinopathy may occur in the absence of cyclosporin A treatment. (iii) The retinopathy can recover spontaneously with no specific treatment.

Free flight of Lambornella clarki-infected, blood-fed, and gravid Aedes sierrensis (Diptera: Culicidae)

Total flight times and flight numbers of Lambornella clarki Corliss & Coats-infected and uninfected nonblood-fed (control), blooded, and gravid Aedes sierrensis (Ludlow) were monitored in laboratory experiments using a free-flight acoustical system. Mean flight time and number of males were not affected by L. clarki infection, but mean flight time of infected females was significantly less than those of control and gravid females. Flight numbers of infected and control females did not differ significantly. Blood feeding initially suppressed flight, but flight dramatically increased with increasing time after the blood meal. There was an increase in flight that corresponded to increased parasite presence inside the ovaries in young, but not older, females.

Effect of memory decay on predictions from changing categories

In contrast to the static categories assumed in most categorization experiments, many real-world categories undergo gradual and systematic change in their definitions over time. Four experiments were carried out to study such category change. In these studies, participants successfully adjusted as category change occurred, but also showed a lingering and cumulative effect of past observations. The participants' performance was closely modeled by incorporating memory decay for past observations into J. R. Anderson's (1990, 1991) rational categorization algorithm and into a version of R. M. Nosofsky's (1986) exemplar categorization model. The resulting models suggest that the decay function is closer to a power law than to an exponential and that decay occurs both by item and by time, with the item decay being stronger than the time decay. The finding of power law decay gives additional support to claims that exemplar memories are used in categorization.

Age-specific reference ranges for serum prostate-specific antigen

OBJECTIVES

To assess the relationship of the distribution of serum prostate-specific antigen (PSA) to age in a population of subjects for whom PSA levels were determined as part of a health fair.

METHODS

Between March 19 and March 28, 1993, 1716 men aged 40 to 79 years from eastern Nebraska who participated in "The Health Fair of the Midlands" provided blood for serum PSA determination.

RESULTS

Serum PSA concentration was correlated with patient age, with the observed 95th percentile increasing from 1.5 ng/mL for subjects 40 to 44 years of age to 7.7 ng/mL for subjects 75 to 79 years of age. Variability in serum PSA concentrations increased with increasing age. Taking this heteroscedasticity into account provided the following upper limits of normal (95th percentiles) for serum PSA: age 40 to 49, 1.5; age 50 to 59, 2.6; age 60 to 69, 4.4; age 70 to 79, 7.5.

CONCLUSIONS

Previously published age-specific reference ranges did not consider the increasing variability of PSA concentration with age and have upper limits of normal that are too high for subjects under age 60 and may be too low for subjects aged 70 to 79. Upper reference ranges of 1.5 ng/mL for subjects aged 40 to 49, 2.5 ng/mL for subjects aged 50 to 59, 4.5 ng/mL for subjects aged 60 to 69, and 7.5 ng/mL for subjects aged 70 to 79 years provide specificity near 95%.

Oral ciprofloxacin as prophylaxis in gastroduodenal surgery

One hundred and fifty patients undergoing gastroduodenal surgery were randomly allocated to receive intravenous (iv) cefuroxime, iv ciprofloxacin or oral ciprofloxacin as prophylaxis. There were no differences in the incidence of postoperative infection complications or duration of stay among the three groups. Oral ciprofloxacin offers obvious advantages in terms of ease of administration and cost.

Effect of memory decay on predictions from changing categories

In contrast to the static categories assumed in most categorization experiments, many real-world categories undergo gradual and systematic change in their definitions over time. Four experiments were carried out to study such category change. In these studies, participants successfully adjusted as category change occurred, but also showed a lingering and cumulative effect of past observations. The participants' performance was closely modeled by incorporating memory decay for past observations into J. R. Anderson's (1990, 1991) rational categorization algorithm and into a version of R. M. Nosofsky's (1986) exemplar categorization model. The resulting models suggest that the decay function is closer to a power law than to an exponential and that decay occurs both by item and by time, with the item decay being stronger than the time decay. The finding of power law decay gives additional support to claims that exemplar memories are used in categorization.

Prognostic value of cellular proliferation and histologic grade in follicular lymphoma

The clinical usefulness of histologic grading in follicular lymphoma (FL) is controversial and is further compromised by the subjective nature and poor reproducibility of most systems in current use. Therefore, we decided to objectively evaluate the importance of cellular proliferation in FL, along with the current grading systems. We studied 106 patients with FL who were uniformly staged and aggressively treated. A proliferative index (PI) was determined quantitatively using an automated image analyzer and a new Ki-67 antibody that stains archival paraffin tissues. The cases were also subclassified according to the Berard, Rappaport, Luke-Collins, and Jaffe methods, and survival analysis was performed. Patients with a low PI (< 40%) had a significantly longer overall survival (OS) than those with a high PI (> or = 40%), but the PI did not predict failure-free survival (FFS). The mean PI correlated well with the subgroups in each of the various classifications. All four of the classification methods were predictive of OS, but only the Berard method appeared to predict FFS and suggest that a proportion of patients with FL may be curable. In multivariate analysis, histologic classification was the only independent predictor of OS (Berard method: relative risk, 3.1) and the International Prognostic Index was the only independent predictor of FFS (relative risk, 2.3). We conclude that the Berard method for grading of FL is clinically useful and, along with the International Prognostic Index, should be included in future clinical studies of FL. The measurement of cellular proliferation does not appear to add additional useful information in FL.

Clinical and prognostic significance of bone marrow involvement in patients with diffuse aggressive B-cell lymphoma

PURPOSE

We studied the effect of morphology and extent of bone marrow (BM) infiltrate on the survival of patients with diffuse aggressive B-cell non-Hodgkin's lymphoma (NHL), along with clinical features.

PATIENTS AND METHODS

Sixty adult patients with diffuse aggressive B-cell NHL and BM involvement at the time of presentation were studied. All patients were uniformly staged and treated with a curative high-dose chemotherapy regimen. BM involvement was assessed according to the cytology, pattern of infiltration, and extent of involvement, and was correlated with overall survival (OS) and failure-free survival (FFS).

RESULTS

Patients with BM involvement that consisted of > or = 50% large cells or BM involvement of > or = 70% had a poorer OS (P = .065 and P = .055, respectively). Those who presented with an infiltrate of less than 50% large cells and an international prognostic index (IPI) of < or = 3 had a significantly longer postrelapse survival time (P = .003). A diffuse or interstitial pattern of BM involvement was predictive of both poor OS and FFS (P = .008 and .009, respectively). Multivariate analysis indicated that only IPI (P = .0005) and pattern of BM infiltration (P = .009) were independent predictors of OS, and only the former was predictive of FFS (P = .03).

CONCLUSION

The IPI is predictive of OS and FFS, while BM involvement with a diffuse or interstitial pattern is associated with significantly poorer OS. Patients with BM infiltration that involved > or = 70% of the marrow or contained > or = 50% large cells had poor OS, but more patients need to be studied to determine the significance. Two parameters, IPI < or = 3 and BM large cells less than 50%, identify a group of patients with long-term survival after relapse.

Radiographic evaluation of the complications of long bone allografts

PURPOSE

To study the long-term results of long bone allografts in patients with benign and malignant bone tumors.

MATERIAL AND METHODS

Forty patients for whom full clinical and radiological information was held were investigated in order to assess the overall incidence of complications including fractures, nonunion, hardware problems, infections, and bone resorption.

RESULTS

There were four deaths; four more patients had distant metastases and one patient had a recurrent chondrosarcoma. Seventeen patients (42%) had either no complications (nine patients) or only minor ones (eight patients). Eleven patients (27%) sustained fractures of either their allograft (eight patients) or of their hardware (three patients). Hardware problems occurred in nine patients (22.5%), six of whom had serious problems requiring revision. The majority of the fractures and hardware problems occurred in younger male patients (82%). Infection occurred in five patients (12.5%), two of whom required revision, while two cases were superficial. Dissolution of the allograft occurred in 12 patients (30%), 7 of whom required removal of the allograft. Ten of these 12 patients were female.

CONCLUSION

The long-term survival of long bone allografts is not as good as generally reported if an adequate follow-up time period is used. Most of the fractures and hardware problems occurred in the younger active male patients, whose activities should probably be curtailed. Resorption of the allograft is another serious complication which appears to occur mainly in female patients and could possibly be controlled by chemotherapy.

Costs of care and outcomes for high-dose therapy and autologous transplantation for lymphoid malignancies: results from the University of Nebraska 1987 through 1991

PURPOSE AND METHODS

High-dose therapy with autologous stem-cell support has become common treatment for relapsed or refractory lymphomas. We conducted a study of 178 patients with Hodgkin's disease and 149 patients with non-Hodgkin's lymphoma who received high-dose therapy with stem-cell support. We evaluated the following: (1) whether improvements in outcomes over time found for surgical procedures were also true for a new nonsurgical procedure, autologous bone marrow and peripheral stem-cell transplantation; and (2) whether such a relationship, if it existed, applied to both clinical and economic outcomes.

RESULTS

Mortality rates for patients with Hodgkin's disease decreased from 20% in 1987 to 0% in 1991. For non-Hodgkin's lymphoma, the mortality rate decreased from 29% in 1987 to 4% in 1991. Multivariate analyses indicated that the number of previous transplants was the most important factor associated with survival and low-cost care. After controlling for differences in clinical factors, a logistic regression model predicted that patients with Hodgkin's disease had a 20% chance of dying after 30 cases and a 5% chance after 178 cases; patients with non-Hodgkin's disease had a 33% chance of dying after 14 cases and a 5% chance after 149 cases. For patients with Hodgkin's disease, the cost decreased at a rate of 10% per year from 1987 to 1991 (P = .001), while for patients with non-Hodgkin's lymphoma, the cost of transplants decreased at a rate of 8% per year.

CONCLUSION

Survival rates improved and costs of care decreased over time for patients who received high-dose therapy with stem-cell support. These changes are most likely related to improvements in supportive care technologies, better patient selection, and experience of the transplant team.

Comparison of subcutaneous and intravenous administration of recombinant human granulocyte-macrophage colony-stimulating factor for peripheral blood stem cell mobilization

In an effort to determine whether subcutaneous or continuous intravenous infusion administration of rhGM-CSF results in better hematopoietic progenitor mobilization, the findings of two sequential clinical trials were reviewed. Patients who had received prior chemotherapy for leukemia, lymphoma, multiple myeloma, breast cancer, or other solid tumors and were candidates for high-dose therapy received rhGM-CSF, 250 micrograms/m2/day, either as a continuous intravenous infusion (trial 1) or subcutaneously (trial 2) for stem cell mobilization. At least five apheresis collection procedures were performed to collect a target number of 6.5 x 10(8) mononuclear cells (MNC)/kg. For the 37 patients in trial 1, the collections contained a median of 7.99 x 10(8) MNC/L (range 6.42-21.36) and a median of 5.27 x 10(4) CFU-GM/kg (range 0.28-19.35). In trial 1, 25 patients were autografted with their cells and recovered 0.5 x 10(9) granulocytes/L at a median of 12 days (range 6-16). For the 33 patients in trial 2, the autograft product contained a median of 7.63 x 10(8) MNC/kg (range 6.51-22.66) and 6.31 x 10(4) CFU-GM/kg (range 0.06-60.4). In trial 2, 25 patients were autografted. The median time to reach 0.5 x 10(9) granulocytes/L was 11 days (range 9-26). All patients received rhGM-CSF after peripheral stem cell transplant. No significant differences in the collected products or the time to hematopoietic recovery was found between the two trials (p > 0.05). The mobilization effects of subcutaneous rhGM-CSF in these pretreated patients were similar to those of intravenous rhGM-CSF.

Steroid hormone receptor content and lymph node status in endometrial cancer

The purpose of this study was to correlate the steroid hormone receptor status in endometrial adenocarcinoma with tumor metastasis to the pelvic and para-aortic lymph nodes, and with other known prognostic variables which influence survival. Tumor samples from 85 patients with endometrioid adenocarcinoma, or adenocarcinoma with squamous differentiation of the endometrium who underwent complete surgical staging, were assayed for cytoplasmic steroid hormone receptors using a dextran-coated charcoal technique. Steroid hormone receptor content was correlated to lymph node status, along with other prognostic variables, such as patient's age, depth of myometrial invasion, tumor grade, and pelvic cytology. By univariate analysis, the likelihood of nodal involvement was associated with younger age and poorly differentiated tumors. Multivariate analysis revealed that age, tumor grade, and myometrial involvement added significant independent prognostic information. Estrogen or progesterone receptor content did not add independent prognostic information concerning lymph node status once other factors were controlled. Knowledge of estrogen and progesterone receptor binding status in adenocarcinoma of the uterus does not replace the prognostic information imparted by careful sampling of lymph nodes.

Tethered flight capabilities and survival of Lambornella clarki-infected, blood-fed, and gravid Aedes sierrensis (Diptera: Culicidae)

Flight capabilities and survival of Lambornella clarki Corliss & Coats-infected, control, blood-fed, and gravid Aedes sierrensis (Ludlow) were monitored using a tethered flight mill system and by recording deaths at various times after initiation of these tests. Flight capabilities of infected and control males as measured by total number of flights, total time spent flying, total distance flown, average flight speed, and percentage time flying were similar. Flight capabilities of females with parasites, with fresh blood meals, and with fully developed eggs did not differ significantly. Flight capabilities of 1- to 2-d-old starved infected and starved control females also did not differ significantly. Although flight capabilities did not differ significantly, infected males died earlier than control males. For females, blooded individuals lived longest, followed by controls, and then gravid and infected individuals. These results and results of glycogen analyses of mosquito thoraces indicate that the parasite primarily affected resources needed by the mosquito for survival and not those for flight.

The role of high-dose therapy and autologous hematopoietic stem cell transplantation for mantle cell lymphoma

BACKGROUND

Although mantle cell lymphoma (MCL) is a distinct disease entity with well described clinical and pathological features, little information exists regarding its therapy. This paper will evaluate patients with MCL receiving either induction therapy with an anthracycline or high-dose chemotherapy and autologous hematopoietic stem cell transplantation for relapsed disease.

PATIENTS AND METHODS

The cases of 14 previously untreated patients with MCL who received an anthracycline-containing combination chemotherapy regimen on Nebraska Lymphoma Study Group protocols from 3/83 to 2/92 were reviewed. During the same time period, a different set of nine patients with recurrent MCL were referred for high-dose chemoradiotherapy and autologous stem cell rescue as salvage therapy.

RESULTS

The five year overall (OS) and failure-free (FFS) survivals from the initiation of chemotherapy for the patients receiving an induction therapy with an anthracycline containing regimen were 23% and 8%, respectively. At the time of this analysis, three of the nine transplant patients remain progression-free 7, 12, and 25 months post-transplant. Two year overall and FFS for all nine patients was 34%.

CONCLUSIONS

Longer follow-up of greater patient numbers is required to determine whether high-dose therapy can overcome the chemoresistance and increase the cure rate of MCL. Since most patients with this disease have minimal chance of cure with standard chemotherapy, the optimal timing for high dose therapy may be as part of front-line treatment. Further clinical trials are required to investigate the potential benefits of high-dose therapy for patients with MCL.

Laparoscopy in the management of patients with cancer of the gastric cardia and oesophagus

The role of laparoscopy in determining suitability for resection was prospectively evaluated in 244 patients with cancer of the gastric cardia and oesophagus. Laparoscopy enabled detection of inoperable disease in 92 patients (38 per cent), several of whom had more than one contraindication to surgery. Hepatic metastases (n = 75, 31 per cent), extensive peritoneal (n = 25, 10 per cent) or lymph node involvement (n = 5, 2 per cent) and direct invasion of the liver or colon (n = 5, 2 per cent) were considered contraindications to surgery. Laparoscopy was poorly tolerated in a further 11 (5 per cent) patients, who were not considered suitable for resection. Extra-abdominal metastatic disease was detected in 17 patients who appeared normal at laparoscopy, and a further six patients refused surgery. The remaining 118 patients underwent laparotomy with a view to resection which was successful in 85 (72 per cent). Laparoscopy thus prevented ill-advised laparotomy in 103 patients (42 per cent), either because of extensive intra-abdominal disease or poor tolerance to anaesthesia. Laparoscopy may be a valuable investigation when used to assess the feasibility of resection.

Laparoscopic subtotal cholecystectomy

Laparoscopic subtotal cholecystectomy has been carried out on 5 patients during a 28-month period. The indications were severe inflammation/fibrosis in 3 patients, cirrhosis with mild portal hypertension in 1 patient and the Mirizzi syndrome in the last patient. There were no deaths and only minor in hospital morbidity. Subtotal cholecystectomy carried out laparoscopically is a safe procedure and can be used in selected patients in order to avoid conversion to an open operation.

Acquisition of procedural skills from examples

Three experiments were run in which Ss first memorized examples of input-output pairs and then generated the outputs for a series of new inputs by analogy to the original examples. Ss first performed these mappings by explicit analogy to an example, but with practice they learned to make these input-output mappings directly without reference to the examples. Ss sped up as a power function of practice over a day (Experiment 1) or days (Experiments 2 and 3). Ss developed a directional asymmetry such that they were slower to calculate the input from the output than the output from the input (whereas initially they had not been). Ss showed similar speed up in their ability to recall the original examples but did not show the same directional asymmetry. Initially, there was some transfer from practicing the procedure to recalling the examples, but this diminished over days.

Apolipoprotein E type epsilon 4 allele frequency is not increased in patients with sporadic inclusion-body myositis

The apolipoprotein E genotype was determined for 11 patients with sporadic inclusion-body myositis. Seven cases had the genotype epsilon 3/epsilon 3, the other four cases, epsilon 3/epsilon 4. The frequency of the epsilon 4 allele in this group of patients (0.182) was not significantly increased compared with elderly controls (0.147; n = 58), in contrast to Alzheimer's disease in which there was a significant increase (0.328; n = 67). The epsilon 2 allele was not found in any of the 11 sporadic inclusion-body myositis patients and its frequency was decreased in Alzheimer's disease. Despite certain pathological similarities that exist between inclusion body myositis and Alzheimer's disease, their association with particular apolipoprotein E genotypes is distinct.

Incidence and characterization of secondary myelodysplastic syndrome and acute myelogenous leukemia following high-dose chemoradiotherapy and autologous stem-cell transplantation for lymphoid malignancies

PURPOSE

To analyze the risk of developing myelodysplastic syndrome (MDS) or acute myelogenous leukemia (AML) following autologous bone marrow transplantation (ABMT) or peripheral stem-cell transplantation (PSCT) and to determine the impact on failure-free survival (FFS).

PATIENTS AND METHODS

Patients underwent ABMT or PSCT for the treatment of Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) at the University of Nebraska Medical Center. For those patients who went on to develop MDS/AML, controls were selected and a case-control-within-a-cohort study undertaken.

RESULTS

Twelve patients developed MDS or AML a median of 44 months following ABMT/PSCT. The cumulative incidence (P = .42) and the conditional probability (P = .32) of MDS/AML were not statistically different between HD and NHL patients. Age greater than 40 years at the time of transplant (P = .05) and receipt of a total-body irradiation (TBI)-containing regimen (P = .06) were predictive for developing MDS/AML in patients with NHL.

CONCLUSION

There is an increased risk of MDS/AML following ABMT/PSCT for lymphoid malignancies. NHL patients age > or = 40 years at the time of transplant and who received TBI are at greatest risk.

Magnesium flux caused by coronary artery bypass operation: three patterns of deficiency

We undertook a study to evaluate the patterns of magnesium deficiency that may develop during and following coronary artery bypass operation without cardioplegia. In 18 patients intraoperative measurements of plasma magnesium and potassium concentrations and measurements of cardiac and skeletal muscle content of these ions were taken. The changes in plasma concentrations and excretion were evaluated postoperatively. Hemodilution at initiation of cardiopulmonary bypass caused a 17.3% decrease in plasma magnesium concentration (p < 0.01), which persisted until the first postoperative day. By the fifth postoperative day the level was 19.5% greater than the preoperative value. Urinary excretion of magnesium reflected changes in plasma magnesium concentration. Cardiac muscle content of magnesium decreased by 13.3%. Plasma potassium concentration was elevated by hemodilution (p < 0.01), and muscle potassium was not depleted. We conclude that three patterns of magnesium depletion occur: hemodilution, intraoperative cellular depletion, and postoperative cellular depletion. The findings support the need for magnesium supplementation during and after cardiac operation.

Left ventricular volume changes during dobutamine stress echocardiography identify patients with more extensive coronary artery disease

OBJECTIVES

We hypothesized that patients with more extensive coronary artery disease could be identified by abnormal left ventricular volume changes during dobutamine stress echocardiography.

BACKGROUND

In patients with more than one significant coronary artery stenosis, the typical hypercontractile function during dobutamine infusion may not occur. This may result in a smaller decrease or even an increase in left ventricular volumes at peak dobutamine infusion.

METHODS

We measured end-diastolic and end-systolic volumes in 61 patients undergoing dobutamine stress echocardiography and quantitative coronary analysis. Stress echocardiographic findings were positive in 39 patients (Group I) and negative in 22 (Group II). The percent change in these volume measurements from baseline to peak infusion were compared with quantitative coronary analysis jeopardy scores and incidence of two- or three-vessel coronary artery disease. An abnormal response was defined as < 15% decrease in end-diastolic or end-systolic volume.

RESULTS

Among the 39 patients with positive findings on dobutamine stress echocardiography (Group I), 11 had an abnormal end-diastolic volume response (< 15% decrease). Nine of these patients had two- or three-vessel coronary artery disease compared with 11 of 28 patients with a normal volume response (p < 0.05). In the 22 patients with negative findings on dobutamine stress echocardiography (Group II), an abnormal end-diastolic volume response was seen in 12 patients, 8 of whom had two- or three-vessel coronary artery disease, whereas none of the 10 patients with a normal volume response had two- or three-vessel coronary disease (p < 0.005; sensitivity 100%, specificity 68%). In the 12 patients with no significant coronary artery disease, end-diastolic and end-systolic volumes decreased by > 15% in all but 1.

CONCLUSIONS

Failure of end-diastolic volume to significantly decrease during dobutamine stress echocardiography identifies a group of patients with more extensive significant coronary artery disease.

Acquisition of procedural skills from examples

Three experiments were run in which Ss first memorized examples of input-output pairs and then generated the outputs for a series of new inputs by analogy to the original examples. Ss first performed these mappings by explicit analogy to an example, but with practice they learned to make these input-output mappings directly without reference to the examples. Ss sped up as a power function of practice over a day (Experiment 1) or days (Experiments 2 and 3). Ss developed a directional asymmetry such that they were slower to calculate the input from the output than the output from the input (whereas initially they had not been). Ss showed similar speed up in their ability to recall the original examples but did not show the same directional asymmetry. Initially, there was some transfer from practicing the procedure to recalling the examples, but this diminished over days.

Quantitative comparisons of image registration techniques based on high-resolution MRI of the brain

OBJECTIVE

A variety of methods for matching intrasubject MRI-MRI, PET-PET, or MRI-PET image pairs have been proposed. Based on the rigid body transformations needed to align pairs of high-resolution MRI scans and/or simulated PET scans (derived from these MRI scans), we obtained general comparisons of four intrasubject image registration techniques: Talairach coordinates, head and hat, equivalent internal points, and ratio image uniformity. In addition, we obtained a comparison of stereotaxic Z frames with a customized head mold for MRI-MRI image pairs.

MATERIALS AND METHODS AND RESULTS

Each technique was quantitatively evaluated using the mean and maximum voxel registration errors for matched voxel pairs within the brain volumes being registered.

CONCLUSION

We conclude that fiducial markers such as stereotaxic Z frames that are not rigidly fixed to a patient's skull are inaccurate compared with other registration techniques, Talairach coordinate transformations provide surprisingly good registration, and minimizing the variance of MRI-MRI, PET-PET, or MRI-PET ratio images provides significantly better registration than all other techniques tested. Registration optimization based on measurement of the similarity of spatial distributions of voxel values is superior to techniques that do not use such information.

Display of merged multimodality brain images using interleaved pixels with independent color scales

This article reviews common methods for two-dimensional display of registered multimodality brain images and describes a software package for presentation of merged MRI and PET images that runs on a workstation with an eight-bit color display. The software package displays merged brain images from multiple modalities in a way that is readily manipulated, visually pleasing and easy to interpret. The display method used, i.e., interleaving of alternate pixels with independent color scales, is effective in producing merged images with high contrast-detail for each volume. Interleaving images from different volumes creates unusual perceptual effects, one of which is the apparent camouflage of low-contrast signals by high values in the paired volume.

METHODS

The camouflage effect was thought to arise from perceptual merging of adjacent pixels. An observer experiment was conducted to investigate this tendency of high-activity PET data to obscure low-contrast detail in interleaved MRI data in spite of the digital independence of neighboring pixels. Four observers were presented with 20 combinations of signal plus background targets with uniform mask images, using a two-alternative forced-choice experimental design with 50 trials per combination.

RESULTS

The psychophysical evaluation of the ability of human observers to detect the simple test objects in an interleaved image presentation indicated a statistically significant camouflage effect of one volume on the other for some combinations of target and mask. The concept of perceptual merging of adjacent pixels was able to predict which combinations caused the greatest degradations in performance.

CONCLUSIONS

The image interleaving approach to the display of two-dimensional slices from registered image volumes makes efficient use of an eight-bit color display. Contrast resolution of both individual volumes is high compared with that in other techniques and the volumes are presented in familiar color scales. However, the method yields an unexpected camouflage effect that tends to obscure low-contrast signals. The practical effect of such camouflage on the interpretation of clinical images remains to be investigated.

Ethmoid bone sandwich grafting for caudal septal defects

OBJECTIVE

To evaluate a new technique for correction of severe caudal septal defects.

DESIGN

For all patients, preoperative photographs were graded with regard to the severity of caudal septal defects. Preoperatively, nasal airway breathing surveys were conducted and nasal tip projection (NTP) measurements were recorded. The caudal septal defects were then repaired with use of the ethmoid bone sandwich grafting technique. Photographs, NTP measurements, and an airway survey were then repeated 6 and 12 months postoperatively. Preoperative and postoperative assessments were compared and analyzed. Lateral nasal roentgenograms were obtained in five of 10 patients to assess resorption of the bone grafts. Complications were noted if present.

SETTING

Urban medical center.

PATIENTS

Ten volunteers with severe caudal septal defects causing both cosmetic and functional problems. All patients had undergone at least one previous submucous resection.

OUTCOME MEASURES

Durability and degree of correction, maintenance of NTP, airway improvement, and morbidity.

RESULTS

After 1 year, all patients maintained satisfactory correction of their caudal septal defect based on postoperative photographic grading and physical examination findings. The NTP was maintained in eight of 10 patients. Two patients experienced loss of NTP after 1 year that was not present 6 months postoperatively. Average airway improvement was 126.7% after 1 year. Postoperative roentgenograms showed only minor (< 10%) bone graft resorption. The only complication was a granuloma.

CONCLUSIONS

The ethmoid bone sandwich grafting technique corrected severe caudal septal deviations while maintaining or strengthening structural support of the caudal septal strut without loss of NTP, airway compromise, or morbidity.

Multifold sonicated dilutions of albumin with fifty percent dextrose improve left ventricular contrast videointensity after intravenous injection in human beings

An intravenous injection of a onefold dilution of sonicated albumin with 50% dextrose improves echocardiographic left ventricular cavitary opacification in dogs compared with sonicated albumin. The objective of this study was to determine whether sonicated dilutions of albumin with dextrose would improve left ventricular videointensity after intravenous injection in humans and to delineate what ratio of albumin with dextrose results in optimal left ventricular cavitary opacification. We gave intravenous injections (randomized) of sonicated albumin and three different dilutions of albumin with 50% dextrose sonicated at different time intervals (onefold, threefold, and sevenfold dilutions sonicated albumin for 40 seconds and threefold and sevenfold dilutions sonicated albumin for 80 to 100 seconds) to 10 healthy human volunteers. End-diastolic and end-systolic videointensity and mean transit time from the mid-left ventricular cavity were compared after an 8.0 ml intravenous injection of all six samples. The threefold and sevenfold dilutions sonicated for 80 to 100 seconds produced microbubble concentrations similar to those of sonicated albumin but with significantly larger (5.6 microns versus 4.7 microns for sonicated albumin) size. These dilutions produced significantly higher end-diastolic and end-systolic videointensity, area under the time-intensity curve, and mean transit time compared with sonicated albumin or any of the dilutions sonicated for 40 seconds (p < or = 0.005). These data suggest that multifold dilutions of albumin with dextrose produce improved ultrasound contrast.

Comparison of two strategies for myocardial management during coronary artery operations

Despite the current trend for using blood cardioplegia, ventricular fibrillation with intermittent ischemia is still used as a strategy to manage the myocardium with impressive results. These two methods of myocardial management were compared in 40 patients undergoing elective coronary artery operations using creatine kinase MB isoforms and troponin T assays. Each patient was randomized to have either cold blood cardioplegia (n = 20) or ventricular fibrillation with intermittent ischemia (n = 20) for myocardial management during the construction of distal anastomoses. Until recently, the comparison of different methods of myocardial management has been hindered by the lack of a specific and sensitive marker of myocardial damage. Analysis of creatine kinase MB isoforms (MB2, cardiac tissue form; MB1, plasma-modified form) and cardiac-specific troponin T (a structural protein) has been shown to improve the sensitivity for the detection of myocardial damage. There were no significant differences between the two groups in age, sex ratio, extent of disease, or left ventricular function. Blood samples for analysis were collected before cross-clamp application and at time intervals up to 48 hours after. Median peak creatine kinase MB2 activity was found to be significantly higher in the blood cardioplegia group compared with ventricular fibrillation (26.5 U/L versus 19.5 U/L, respectively, p = 0.04). Although median peak troponin T concentration was higher in the blood cardioplegia group, the difference failed to reach significance (2.2 ng/mL versus 1.6 ng/mL, p = 0.15).(ABSTRACT TRUNCATED AT 250 WORDS)