Case report: infiltrating syringomatous adenoma of the breast--appearances on mammography and ultrasonography

Infiltrating syringomatous adenoma is a recently-recognized locally-invasive breast neoplasm which clinically may mimic carcinoma. We describe bilateral syringomatous adenomata in a screened patient, indistinguishable from carcinoma on mammography and ultrasound examination. The clinical and pathological features which suggest the diagnosis are discussed.

Nonoperative treatment of superficial femoral artery disease: long-term follow-up

PURPOSE

Between 1977 and 1991, 405 patients with atherosclerotic occlusive disease of the superficial femoral artery underwent clinical as well as noninvasive laboratory evaluation and were recommended for nonoperative treatment.

METHODS

Limbs with uncorrected aortoiliac occlusive disease, aneurysmal degeneration, or previous femoropopliteal bypass were excluded, leaving 568 involved extremities. Complete follow-up, which forms the basis for this report, was available in 377 patients (93%) with 520 limbs (93%). Patients were monitored for a minimum period of 2 years (range, 24 to 164 months; median, 86 months). During the surveillance period 45 limbs (8.6%) in 42 patients (11.1%) required arterial intervention. This entailed operation in 39 cases and endovascular treatment in six cases. With use of life-table analysis, the risk for intervention was found to be 11% at 5 years and 14% at 10 years. A total of 14 limbs (2.7%) in 14 patients (3.7%) ultimately required major limb amputation, either after failed bypass (8 patients) or as a primary procedure (6 patients).

RESULTS

Analysis of risk factors revealed that female sex (p = 0.04), chronic renal failure (p = 0.0001), diabetes mellitus (p = 0.0011), history of contralateral femoropopliteal bypass (p = 0.0005), level of disease (p = 0.003), and entry ankle/brachial index less than 0.50 (p = 0.004) were associated with an increased risk over time for intervention. Other factors, including age, current or prior smoking history, hypertension, and the presence of coronary artery disease or cerebrovascular disease failed to reach statistical significance.

CONCLUSIONS

These data support the continued conservative approach to surgery for patients with superficial femoral artery occlusive disease without limb-threatening symptoms. Patients with multilevel disease, lower ankle/brachial index, a history of contralateral femoropopliteal bypass, chronic kidney failure, or diabetes mellitus are at increased risk and should be monitored more closely.

Draffin and his rods

Draffin's rods or bipods are now a well-known, internationally accepted ENT instrument. Before their invention in 1951, the attendant anaesthetist or nurse was obliged to support the mouthgag during tonsillectomy. Research into the life of their originator, David Alexander Draffin, reveals that in addition to his evident design skills, he was a surgeon of courage, wit and great charm.

Lipid and lipoprotein abnormalities in lower-extremity arteriosclerosis obliterans

The prevalence of abnormal lipid and lipoprotein values was determined in 125 consecutive patients with lower-extremity arteriosclerosis obliterans, and the lipid and lipoprotein abnormalities in these patients were characterized. Only 13% of the patients had normal lipid/lipoprotein profiles. Forty-eight percent of patients had low levels of high-density lipoprotein cholesterol. High-density lipoprotein cholesterol values were lower in patients with concomitant coronary heart disease compared with those without heart disease. High-density lipoprotein cholesterol values were inversely related to weight, to triglyceride values, and to diabetes mellitus. Twenty-eight percent of patients had "desirable" total cholesterol levels (< 200 mg/dL), and 32% had low-density lipoprotein cholesterol values less than 130 mg/dL. Following National Cholesterol Education Program guidelines may be misleading in patients with documented lower-extremity atherosclerosis; therefore, complete lipid/lipoprotein profiles should be performed in these patients.

Restriction mapping of the genome of the protozoan parasite Theileria parva

We have used a modified linking clone strategy and pulsed-field gel electrophoresis to derive a map of the 29 Sfi I and 4 Not I sites in the 10 million base pair genome of the protozoan parasite Theileria parva. This was achieved in the absence of classical genetic information. The map reveals four chromosomes. Several genes, including those for parasite antigens, have been located on the map, as has the single locus carrying the major repetitive sequence in this organism. The map forms the basis for a study of sexual recombination in T. parva, which will be of importance in the application of present methods of immunization. Aspects of the mapping strategy may be useful in the study of other small eukaryotic genomes.

A common ancestor of the mammalian transcription factors TCF-1 and TCF-1 alpha/LEF-1 expressed in chicken T cells

Several mammalian T cell-specific transcription factors have been cloned recently. Two of these, TCF-1 and TCF-1 alpha/LEF-1, display a moderate level of overall sequence similarity, and contain virtually identical versions of a novel type of DNA-binding domain, the HMG box. To study evolutionary aspects of the TCF transcription factors in relation to lymphoid differentiation, we have isolated chicken TCF clones from a spleen cDNA library. Low-stringency screening with human probes as well as a polymerase chain reaction-aided strategy resulted in the cloning of a single chicken TCF (chTCF) gene. Sequence comparison revealed that chTCF contained a TCF-1 alpha-like N terminus, and a TCF-1-like C terminus. Furthermore, TCF-1 and TCF-1 alpha were more homologous to chTCF than to each other. We postulate that chTCF is the direct descendant of a single ancestral gene, which has been duplicated in mammals to yield TCF-1 and TCF-1 alpha.

Agarose entrapment method for the production of SfiI linking library for Theileria parva

We have developed a simple method for isolation of SfiI linking clones from a eukaryotic genomic DNA. The method involves the physical separation of the small proportion of plasmids in a plasmid genomic library that are linearized by SfiI digestion, from the bulk of molecules that remain circular, by ordinary electrophoresis through high-percentage gels of SeaPlaque agarose. Following the isolation of linearized molecules, their recircularization, and introduction into Escherichia coli, 55% of recovered plasmids contained inserts of the expected size, and 73% of these had SfiI sites. This represented a 25-fold enrichment of linking clones expected to be present at a frequency of 1/60 in the original library of 4- 6-kb fragments of genomic DNA of the protozoan parasite Theileria parva. This approach is rapid and obviates the need for introduction of a selectable marker. It is uniquely appropriate for linking clones spanning SfiI sites as this enzyme leaves degenerate 3' overhanging ends that preclude the direct ligation into vector sites required by most alternative strategies, but that favor the recircularization reactions used here.

Mammographically guided ultrasound: a new technique for assessment of impalpable breast lesions

A new technique for the assessment and localization of breast lesions is described. The position of a lesion is identified mammographically using a fenestrated compression plate. This allows access for an ultrasound probe directly over the lesion. This technique has proved valuable in the assessment of breast lesions and a simple inexpensive, reliable method of localization. We give a preliminary report of our results.

The swollen leg. Clinical significance and differential diagnosis

An elderly patient with a swollen leg or legs can present a challenging problem in differential diagnosis. Although most swollen legs are the result of congestive heart failure, thrombophlebitis, cellulitis, or lymphedema, many other conditions should also be considered.

Unusual hyperechoic ultrasound appearance of testicular Leydig cell tumour

Patients with a testicular mass are usually investigated by ultrasound and the ultrasound appearances have been correlated with the histology. The authors describe two patients with Leydig cell tumours. The first had bilateral tumours which although histologically typical of Leydig cell tumours, had differing ultrasound appearances, one with a previously unreported hyperechoic appearance. The second patient had an impalpable tumour with similar ultrasound appearances to those previously described. The paper illustrates the difficulty of giving an accurate diagnosis of solid testicular lesions and also shows that the previously described appearance of Leydig cell tumour is not pathognomonic.

Identification of expressed bovine class I MHC genes at two loci and demonstration of physical linkage

A cDNA library prepared from lymphocytes of a cow (E98), homozygous at major histocompatibility complex (MHC) loci (BoLA phenotype w10, KN104), was screened with a bovine MHC class I probe. Of the cDNA clones isolated, two, (2.1 and 5.1) were selected and showed divergence at both 5' and 3' termini. E98 DNA was digested with rare-cutter enzymes (Sfi I, Mlu I, Not I, and Cla I) and fragments were size-separated by field inversion gel electrophoresis (FIGE). Hybridization with an entire class I cDNA probe revealed multiple fragments generated by each enzyme. When the 3' untranslated regions (UT) of 2.1 and 5.1 were used as probes, only one fragment was revealed in each digested sample, showing locus specificity of these probes in cattle. Further, DNA of transfected mouse fibroblasts L4 (expressing KN104) and L10 (expressing w10) hybridized to the 3'UT regions of clones 2.1 and 5.1, respectively. Northern blot analysis of the mRNA of the L4 and L10 transfected cells provided further evidence that the cDNA clones 2.1 and 5.1 code for the BoLA-KN104 and BoLA-w10 class I molecules respectively, and thus these represent the products of two different genes. A long range physical mapping of the BoLA-w10 and KN104 genes was performed using FIGE analysis of DNA of an homozygous and an heterozygous animal. This analysis revealed that the BoLA-w10 and KN104 genes are separated by not more than 210 kilobases (kb) and that they are components of a multigene family spanning 1550 kb. As the w10 gene is at the BoLA-A locus we assign the KN104 gene to a B locus.

Safety and efficacy of thrombolytic therapy for superior vena cava syndrome

The experience at the Cleveland Clinic from 1982 to 1990 using thrombolytic therapy for superior vena cava (SVC) syndrome was retrospectively reviewed. Sixteen patients, 11 of whom had indwelling central venous catheters, were treated with either urokinase (n = 11) or streptokinase (n = 5). Either urokinase (4,400 U/kg bolus followed by 4,400 U/kg/h) or streptokinase (250,000 U bolus followed by 100,000 U/h) was used, and venograms were performed before and after. Overall, 56 percent of patients had complete clot lysis and relief of symptoms. Thrombolytic therapy was effective in eight (73 percent) of 11 patients receiving urokinase and one (20 percent) of five patients receiving streptokinase. Of those with a central venous catheter, eight (73 percent) of 11 patients were successfully lysed, whereas only one (20 percent) of five patients was successfully lysed if no catheter was present. If thrombolytic therapy was performed less than or equal to five days of symptom onset, seven (88 percent) of eight patients were successful, if thrombolytic therapy was performed greater than five days after symptom onset, two (25 percent) of eight patients were successful. Symptoms were relieved and the catheter was preserved in patients in whom thrombolytic therapy was effective. Factors predicting success were as follows: (1) the use of urokinase compared with streptokinase; (2) the presence of a central venous catheter; and (3) a duration of symptoms less than or equal to five days.

The changing clinical spectrum of thromboangiitis obliterans (Buerger's disease)

Between 1970 and 1987, 112 patients were diagnosed as having thromboangiitis obliterans (TAO). The age was 42 +/- 11 years (mean +/- SD; range, 20-75 years); 23% were women, and 7% were more than 60 years old when they were first diagnosed. Ischemic ulcerations were present in 85 (76%) patients: 24 (28%) patients with upper-extremity, 39 (46%) patients with lower-extremity, and 22 (26%) patients with both upper- and lower-extremity lesions. Ninety-one (81%) patients had rest pain, 49 (44%) patients had Raynaud's phenomenon, and 43 (38%) patients had superficial thrombophlebitis. We were able to follow up 89 of the 112 (79%) patients for 1-460 months (mean follow-up time, 91.6 +/- 84 months). Sixty-five (73%) patients had no amputations, while 24 (27%) had one or more of the following amputations: finger, six (15%) patients; toe, 13 (33%) patients; transmetatarsal, four (10%) patients; below knee, 14 (36%) patients; and above knee, two (5%) patients. Forty-three (48%) patients stopped smoking for a mean of 80 +/- 105 months (median, 46.5 months; range, 1-420 months), and only two (5%) patients had amputations after they stopped smoking, while 22 (42%) patients had amputations while continuing to smoke (p less than 0.0001). The spectrum of patients with TAO is changing in that the male-to-female ratio is decreasing (3:1), more older patients are being diagnosed, and upper-extremity involvement is commonly present. In the 48% of patients who stopped smoking, amputations and continued disease activity were uncommon.

Stasis ulcer treatment with compression dressing

A compression dressing system is an easily learned and effective alternative to the Unna boot for treatment of venous stasis ulcer. The treatment is well accepted by patients and appears to have efficacy comparable to that achieved with the boot, but without the problems associated with the boot, such as maceration, poor fit, and inability to observe and bathe the skin.

Ginger root--a new antiemetic. The effect of ginger root on postoperative nausea and vomiting after major gynaecological surgery

The effectiveness of ginger (Zingiber officinale) as an antiemetic agent was compared with placebo and metoclopramide in 60 women who had major gynaecological surgery in a double-blind, randomised study. There were statistically significantly fewer recorded incidences of nausea in the group that received ginger root compared with placebo (p less than 0.05). The number of incidences of nausea in the groups that received either ginger root or metoclopramide were similar. The administration of antiemetic after operation was significantly greater in the placebo group compared to the other two groups (p less than 0.05).

SfiI and NotI polymorphisms in Theileria stocks detected by pulsed field gel electrophoresis

DNAs of Theileria parva parva, T. p. lawrencei, T. p. bovis and Theileria mutans stocks, from Kenya, Uganda, Zanzibar and Zimbabwe were digested with either SfiI or NotI and analysed using contour-clamped homogeneous electric field (CHEF) and field-inversion gel electrophoresis (FIGE). The SfiI-digested T. parva genomic DNA resolved into approximately 30 fragments while the NotI digestion produced between 4-7 bands. The summation of the sizes of SfiI fragments gave an estimate of 9-10 X 10(6) base pairs for the size of the T. parva genome. Heterogeneity within T. p. parva Muguga, Pemba/Mnarani and Mariakani stocks was detected. All the T. parva stocks analysed showed SfiI and NotI restriction fragment length polymorphisms (RFLP). Hybridisation of 5 SfiI-digested T. parva DNAs with a Plasmodium berghei telomeric repeat probe suggested that most of the polymorphisms and heterogeneity occurred in the telomeric or sub-telomeric regions of the genome. The recognition by the Plasmodium telomeric probe of 7-8 strongly hybridising SfiI bands indicates that the T. parva genome may possess at least 4 chromosomes. The T. mutans genome was cut frequently with the above enzymes resulting in large numbers of fragments predominantly below 50 kb, thus suggesting either a much higher G + C content than T. parva or the presence of highly reiterated G + C-rich regions.

Characterisation of the gene encoding a 104-kilodalton microneme-rhoptry protein of Theileria parva

A neutralizing antiserum, C16, raised against sporozoites of Theileria parva parva was used to screen a lambda gt11 expression library of T. parva parva (Muguga) genomic DNA fragments. Proteins encoded by one phage clone, lambda TpS-17, were reactive with the C16 antiserum. Detailed characterisation of the DNA insert showed it to encode determinants found on four theilerial antigens of approximately 104, 90, 85 and 35 kDa. The sequence encoded by the clone is expressed during sporogony as a single RNA transcript of about 3000 nucleotides. On sequencing a portion of the 5000-bp insert, an open reading frame of 2772 bp was revealed that encoded a 104-kDa protein. Immunoscreening a library of subfragments of the DNA insert with the original antiserum localised sequences encoding the dominant antigenic determinants to an 800-bp stretch of DNA at the 3' end of the open reading frame. Sequence data from three subclones spanning this region show portions of the antigenic domains to be unusually rich in proline residues which are repeated every three amino acids. These repeats often take the form X-S(T)-P or X-K(R)-P. Antibodies directed against each of the three subclones recognize the 104- and 35-kDa antigens and different combinations of the 90- and 85-kDa kDa antigens, suggesting that the smaller proteins are derived from the 104-kDa antigen by limited proteolysis occurring at the carboxyl terminus end of the protein. In immunoelectron micrographs the antigen is associated with the microneme/rhoptry complexes of the sporozoite.

Prevalence of atherosclerotic renal artery stenosis in patients with atherosclerosis elsewhere

PURPOSE

To determine the prevalence of atherosclerotic renal artery stenosis in patients who have atherosclerosis elsewhere but lack the usual clinical clues to suggest renal artery stenosis.

PATIENTS AND METHODS

The arteriograms and charts of 395 consecutive patients were prospectively reviewed by a member of the Vascular Medicine Department and a member of the Radiology Department. These patients underwent arteriography as part of the routine evaluation for abdominal aortic aneurysm (109 patients), aorto-occlusive disease (21 patients), lower-extremity occlusive disease (189 patients), and suspected renal artery stenosis (76 patients). Patients in the first three groups did not have the usual clues that suggest renal artery stenosis.

RESULTS

There was greater than 50% renal artery stenosis in 41 patients (38%) with abdominal aortic aneurysm, seven patients (33%) with aorto-occlusive disease, 74 patients (39%) with lower-extremity occlusive disease, and 53 patients (70%) with suspected renal artery stenosis. The prevalence of renal artery stenosis was similar in diabetic and nondiabetic patients with abdominal aortic aneurysm, aorto-occlusive disease, or suspected renal artery stenosis, but higher in diabetics with lower-extremity occlusive disease (50%) compared to nondiabetics with lower-extremity occlusive disease (33%) (p = 0.022). High-grade bilateral disease was present in approximately 13% of patients with abdominal aortic aneurysm or lower-extremity occlusive disease, and totally occluded renal arteries occurred in 5% of the patients in these groups. There was an association between increasing degree of renal artery stenosis and the presence of hypertension and worsening of renal function.

CONCLUSION

Patients with atherosclerosis elsewhere, especially abdominal aortic aneurysm, aorto-occlusive disease, or lower-extremity occlusive disease, have a high prevalence of significant renal artery stenosis even in the absence of the usual clues to suspect renal artery stenosis. Diabetic patients have a similar prevalence as nondiabetic patients. This information may have important therapeutic implications in patients being considered for vascular surgery.

Thrombolytic therapy for renal artery occlusions: a preliminary report

Percutaneous transluminal angioplasty and renal artery revascularization have been successful in controlling blood pressure and preserving renal function in patients with atherosclerotic renal artery stenosis. In addition, thrombolysis appears promising for treatment of patients with total occlusion of renal artery bypass grafts. More experience will be necessary to define its role in native renal artery occlusions. The authors describe successful thrombolysis in two of three patients given thrombolytic therapy for total occlusion of renal arteries.

Thrombolysis of peripheral arterial bypass grafts: surgical thrombectomy compared with thrombolysis. A preliminary report

Twenty-two patients were selected from a group of 33 patients who underwent recombinant human tissue-type plasminogen activator (rt-PA) thrombolysis for thrombosed infrainguinal bypass grafts of the lower extremity and were compared with 38 matched patients who had undergone surgical thrombectomy during the same period. The proportion of persons with diabetes mellitus, smokers, and types of bypass grafts was similar in both groups. More patients in the rt-PA-treated group had hypertension (p = 0.01). To evaluate the different lengths of follow-up, Kaplan-Meier survival analysis was used with a log-rank test to compare the proportion of persons with patent grafts in the two treatment groups. At 30 days, 86% of the rt-PA-treated grafts were still patent compared with 42% of the surgically treated grafts (p = 0.001). When risk factors on the Kaplan-Meier curves were compared, there was no statistical difference with regard to graft patency among the groups. According to simultaneous Cox regression analysis, no risk factor was significantly associated with graft patency. When amputation was evaluated between treatment groups simultaneously with other risk factors in a logistic regression analysis, smoking and age of the graft were marginally significant (p = 0.07), whereas all other factors were clearly not significant. In 91% of the rt-PA-treated patients, a secondary surgical procedure was required to maintain patency of the graft segment. Eighty-nine percent of the surgically treated patients required similar graft revisions. Two patients in the surgical group and one patient in the rt-PA-treated group had major complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of cost effectiveness of streptokinase and urokinase in the treatment of deep vein thrombosis

This study examines the comparative efficacy, safety, and cost associated with treatment of deep vein thrombosis with streptokinase or urokinase. Sixty patients were analyzed retrospectively, 30 treated with streptokinase and 30 treated with urokinase. Statistically significant greater fibrinogenolysis was noted when streptokinase was used to treat patients with deep venous thrombosis (p = 0.01). The mean decrease in fibrinogen from preinfusion value was 83% in the streptokinase treated group and 61% in the urokinase treated group. Five of 30 (17%) of the streptokinase treated patients experienced major complications. No major complications were seen in the urokinase treated group (p = 0.019). Cost analysis demonstrates that therapy with urokinase was $11.40 per patient more than streptokinase. If complications are not included in the cost analysis, then urokinase becomes only $650 per patient more expensive than streptokinase therapy. These data support that deep vein thrombosis treatment with urokinase is effective, safer and more cost efficient when compared to streptokinase.