Primary malignant melanoma of the esophagus treated by endoscopic ablation and interferon therapy

Primary malignant melanoma of the esophagus is a rare illness accounting for 0.1-0.2% of malignant diseases of the esophagus; however, the incidence of the disease appears to be rising. The average survival time is between 10 and 15 months. The authors describe the 25 month follow up of a patient with primary malignant melanoma of the esophagus which was treated with endoscopic ablation followed by interferon therapy. No other focus was found and the patient is undergoing regular endoscopic check-ups, currently without any problems.

[Manometry in esophageal achalasia]

OBJECTIVE

Manometric findings in achalasia are pathognomic already in early clinical stages of the disease. The authors evaluate the importance of manometry in the diagnosis and therapy, in particular in early stages of the disease.

METHOD

During manometry we obtain data on the function of the lower oesophageal sphincter and the body of the oesophagus. Impaired relaxation of the sphincter is evaluated, as well as increased tonus of the sphincter and tertiary contraction of the body of the oesophagus. In patients with achalasia we implement laparoscopically extramucous myotomy.

RESULTS

In 1997 we started a prospective manometric study of dysphagic complaints. We examined 304 patients on account of different diseases of the oesophagus incl. 16(5.2%) where we proved or confirmed achalasia in stage I, II or III according to the radiological classification. These patients were indicated for laparoscopic myotomy. In one instance we had to convert the operation to an open one. In two instances we added partial fundoplasty according to Thal on account of perforation of the oesophageal mucosa. Four patients were subjected after a 5-12-month interval to remyotomy. Twice because of the development of a fibrous stricture at the site of myotomy and twice for an obviously inadequate original myotomy. The history of dysphagia in patients with primary operations was on average 37.3 months.

CONCLUSIONS

Manometric examination of patients with functional dysphagia makes it possible to detect achalasia in early stages and to indicate in time surgical treatment. In case of a relapse or persistence of complaints manometry makes it possible to express objectively the cause which is most frequently an atonic oesophagus with inadequate evacuating capacity, stricture at the site of myotomy or inadequate myotomy.

The association between funding by commercial interests and study outcome in randomized controlled drug trials

BACKGROUND

Previous studies limited to specific drugs or journal types have shown an association between the source of funding of research and the published results.

OBJECTIVE

The aim of the present study was to determine the association between source of support of research and published outcomes of randomized controlled drug trials in general interest medical journals.

METHODS

Randomized controlled drug trials (n = 314) published in five general interest medical journals over a 2-year period were reviewed. Study outcome was classified as positive or negative. Support was classified as pharmaceutical industry or non-industry. Association between source of support and outcome was tested with the chi-squared statistic.

RESULTS

Positive findings were found in 77% of studies, negative findings in 20% and an uncertain outcome in 3%. Support from commercial sources was found in 68% of trials. Negative findings were found in 13% of industry-supported studies and in 35% of non-industry-supported studies (chi-squared = 18.36, P < 0.0001, odds ratio = 3.54, 95% confidence interval 1.90-6.62).

CONCLUSIONS

An association was found between the source of study support and the published outcome. Though the reason for this association cannot be determined from the data collected, future studies may clarify the importance of this finding for readers concerned with the relationship of funding bodies to the publication of research outcomes.

Recent advances and future prospects in intestinal and multi-visceral transplantation

From an experimental procedure, intestinal transplantation (ITx) has evolved over the last 10 yr into a treatment option for patients suffering from short bowel syndrome and who develop life-threatening complications from total parenteral nutrition (TPN) (e.g. liver dysfunction, line sepsis, shortage of venous access, etc.). One-year survival rates are approximately 70% and thus similar to lung Tx. However, the intestine remains the most challenging abdominal organ to transplant. This is because of the severe immune response (mostly rejection) that is produced, and therefore the need for profound immunosuppression with its attendant complications (sepsis, lymphoma, direct drug toxicity). Unlike other organs, graft loss as a result of acute rejection can occur late after transplantation (more than 1 yr post-transplant). With regard to the actual immunosuppressive regimens, considerable experience in patient management is required to optimize outcome of those complex transplants, which are permanently at risk of rejection and infection. ITx remains an unfinished product, and the application of ITx to patients doing well on TPN warrants further research in the understanding of the rejection process, in the development of less toxic and more efficient immunosuppressive protocols, and in the development of immunomodulatory strategies, to better control rejection and thereby reduce the need for immunosuppression.

Dysplasia of tubular cells in a kidney- transplanted patient treated with recombinant human growth hormone

After renal transplantation (Tx), children with growth retardation can be successfully treated with recombinant human growth hormone (rhGH). However, the impact of this treatment on kidney allograft function remains a source of concern. We report on one boy who received a cadaveric kidney transplant at 12 yr of age, after developing end-stage focal and segmental glomerulosclerosis and hyalinosis. The early post-transplant period was complicated by thrombosis of an arterial branch of the graft and two acute rejection episodes. Because of poor growth, the boy was treated with rhGH starting 22 months after the Tx. The renal function remained relatively stable for 22 months after initiation of rhGH therapy and then progressively deteriorated over a period of 10 months, with the patient ending up on dialysis. Several biopsies, performed for rejection episodes or before the start of rhGH, or to elucidate the deterioration of the renal function, were analyzed. Histologically, a progressive increase in the amount of hypertrophy of the tubules and of the glomeruli was seen after initiation of rhGH. Hyperplasia of the tubular epithelium with crowding of cells of the proximal tubules, hyperchromasia and irregularities in the shape of the nuclei, and abrupt changes of chromatism along the tubuli, were also observed. These lesions of tubular dysplasia are extremely unusual in transplanted kidneys and are unlikely to be caused by compensatory hypertrophy secondary to destruction of renal tissue. They may be an effect of rhGH treatment. The prognostic significance of these lesions is unknown but merits attention.

Pediatric renal transplantation: a single Belgian center experience over 20 years

Between 1980 and 2000, 100 renal transplantations were performed in 91 children at the pediatric unit of the University Hospital Leuven. The proportion of living-related donors (LRD) was 20%. Patient survival rates were 94% at 3 yr, 91% at 5 yr, and 87% at 10 yr. The commonest causes of death were bacterial infections and cardiovascular complications, which underscores the need for aggressive preventative procedures in this area after transplantation. The overall actuarial graft survival was 82% at 3 yr (n = 73), 74% at 5 yr (n = 53), and 56% at 10 yr (n = 29). In the LRD group, the graft survival was 10% better than the overall actuarial graft survival rate. The overall incidence of acute rejection was 55% but has shown a decrease to 34% in more recent years (1993-99). The major causes of graft failure were chronic rejection and recurrence of the initial disease, and these remain a major concern. Improvement of these results could be achieved by tight immunosuppression management, early aggressive treatment of infection and rejection, and careful educational and psychological support.

Comparison of fluorescein break-up time measurement reproducibility using standard fluorescein strips versus the Dry Eye Test (DET) method

PURPOSE

To compare the repeatability of fluorescein break-up time (FBUT) measurements determined with either a standard fluorescein strip or the Dry Eye Test (DET) modified fluorescein strip methods.

METHODS

This was a prospective, randomized contralateral study of 100 patients, in which FBUT measurements were determined with a standard FUL-GLO fluorescein strip (Akorn, Inc., Buffalo Grove, IL, U.S.A.) in one eye and a DET strip (Akorn, Inc., Buffalo Grove, IL, U.S.A.) for the contralateral eye. Three consecutive measurements were made immediately after fluorescein instillation. The second eye was evaluated 1 minute after completion of the first eye. Data from patients with FBUT values less than 20 seconds were included in the data analysis, because measurements greater than 20 seconds are not diagnostically significant.

RESULTS

Seventy-five patients met enrollment and FBUT measurement criteria. For three consecutive FBUT measurements, the DET values were within 3 seconds for 72 of the 75 patients (96%). Eighty percent of patients reported no sensation with the DET strip, 20% reported mild sensation, and no patient reported moderate sensation. With FUL-GLO strips, measurements were within 3 seconds for 53 of the 75 patients (71%) (p <0.005). The standard fluorescein strip method elicited reports of no sensation from 31% of patients, mild sensation from 60%, and moderate sensation from 9% (p <0.001).

CONCLUSIONS

The DET strip provides a significant reduction in sensation upon application, improved single measurement reliability, and enhanced measurement precision, compared with a conventional fluorescein strip.

Cues to participation in prostate cancer screening: a theory for practice

PURPOSE/OBJECTIVES

To develop and test the Cues to Participation in Prostate Cancer Screening Theory, which proposes that exposure to information from certain sources cues or triggers screening.

DESIGN

Descriptive correlational.

SETTING

11 counties of a southeastern state.

SAMPLE

Convenience sample of 1,867 men at risk for prostate cancer (72% African American; 28% Caucasian).

METHODS

Recent exposure to prostate cancer information was measured. Men were offered free screening by prostate specific antigen (PSA) and digital rectal exam (DRE).

MAIN RESEARCH VARIABLES

Demographic variables (race, age, education, income, and marital status), exposure (electronic media, print media, healthcare provider recommendation, and interpersonal interactions), and screening as measured by PSA and DRE.

FINDINGS

Several major propositions of the Cues to Participation Theory were supported. General exposure to prostate cancer information significantly predicted screening participation. Hearing about prostate cancer from a healthcare provider was the best predictor of screening.

CONCLUSIONS

Men's demographic characteristics should be considered when providing information about prostate cancer. Hearing about prostate cancer from family and friends was not significantly related to screening behavior.

IMPLICATIONS FOR NURSING PRACTICE

The importance of recommendations for prostate cancer screening is underscored.

Aberrant methylation of the adenomatous polyposis coli (APC) gene promoter 1A in breast and lung carcinomas

The adenomatous polyposis coli (APC) gene is a tumor suppressor gene associated with both familial and sporadic cancer. Despite high rates of allelic loss in lung and breast cancers, point mutations of the APC gene are infrequent in these cancer types. Aberrant methylation of the APC promoter 1A occurs in some colorectal and gastric malignancies, and we investigated whether the same mechanism occurs in lung and breast cancers. The methylation status of the APC gene promoter 1A was analyzed in 77 breast, 50 small cell (SCLC), and 106 non-small cell (NSCLC) lung cancer tumors and cell lines and in 68 nonmalignant tissues by methylation-specific PCR. Expression of the APC promoter 1A transcript was examined in a subset of cell lines by reverse transcription-PCR, and loss of heterozygosity at the gene locus was analyzed by the use of 12 microsatellite and polymorphic markers. Statistical tests were two-sided. Promoter 1A was methylated in 34 of 77 breast cancer tumors and cell lines (44%), in 56 of 106 NSCLC tumors and cell lines (53%), in 13 of 50 SCLC cell lines (26%), and in 3 of 68 nonmalignant samples (4%). Most cell lines tested contained the unmethylated or methylated form exclusively. In 27 cell lines tested, there was complete concordance between promoter methylation and silencing of its transcript. Demethylation with 5-aza-2'-deoxycytidine treatment restored transcript 1A expression in all eight methylated cell lines tested. Loss of heterozygosity at the APC locus was observed in 85% of SCLCs, 83% of NSCLCs, and 63% of breast cancer cell lines. The frequency of methylation in breast cancers increased with tumor stage and size. In summary, aberrant methylation of the 1A promoter of the APC gene and loss of its specific transcript is frequently present in breast and NSCLC cancers and cell lines and, to a lesser extent, in SCLC cell lines. Our findings may be of biological and clinical importance.

Medicine: the science and the art

Medicine has been said to be both a science and an art. Many practitioners regard this statement as containing an element of "either/or". A brief look at what scientists and artists have written about their work and their world views, however, suggests that the two fields of endeavour form a complementary part of our attempts to understand ourselves and the world about us. Moreover, on occasion, each can perform some of the other's tasks. This paper quotes from the writings of physicians, scientists and people active in the humanities in order to demonstrate how frequently their thoughts converge. It also presents a case report from general practice illustrative of the idea that there is much common ground between the "hard" and the "soft" in medicine. Indeed, the profession's art and science may really be one.

[Contribution of coloured duplex ultrasonography to preoperative examination of patients with chronic venous insufficiency]

In a prospective study the authors examined by coloured duplex sonography 76 patients (93 extremities) with chronic venous insufficiency (CVI), before a planned operation of the veins of the lower extremities. Attention was focused on the site of the reflux ( superficial, deep venous system, perforators) and the importance of perforators and congenital venous anomalies in CVI. In the investigated group of patients with CVI a combined reflux was present in several venous systems concurrently, confirmed in 69 extremities (74.2%). In 25 extremities the authors found insufficiency of the saphenofemoral junction along with femoropopliteal reflux. This high grade of reflux coincidence in these two neighbouring anatomical areas indicates so-called secondary reflux. Dilated perforators were found in 65 extremities (70%). These insufficient perforators were most frequently on the median side of the leg, regardless whether in the proximal or distal half. Obviously there is direct correlation between the grade of CVI according to the international clinical classification and the number of incompetent perforators. The ratio of inborn venous anomalies in the development of CVI in the authors group of patients was not statistically significant.

Death foretold

We briefly trace the history of a belief in the possibility that a person in apparent good health may accurately predict his or her own demise. The phenomenon is referred to as death foretold and we present presumed examples of it from the Bible, world literature, medical writings and newspaper reports without pretending to completeness. In two widely quoted scientific papers, death foretold is subsumed under the wider heading of decease due to psychic stress. We speculate on a possible link between the two, taking into consideration the fact that most people who prophesy their end are of an advanced age.

The role of a surgeon in a palliative treatment of tumours

The aim of the presented study is to determine a surgeon's part in diagnostics, therapy and dispensary treatment of patients suffering from tumour disease. We carried out an analysis of our own clinical experience and stated the surgeon's participation in the individual stages of diagnostics and treatment of oncological patients with the emphasis on the share in the palliative treatment.

Hydrotherapy in labor

Maternal anxiety and pain prolong labor and contribute to fetal distress. Hydrotherapy during labor may promote relaxation and decrease pain without the risks caused by other treatments. In this pilot study the psychophysiological effects of hydrotherapy on maternal anxiety and pain during labor were examined. Using a randomized, pretest-posttest control group design with repeated measures, 18 term parturients were assigned to a control or an experimental group. Experimental subjects were placed in a tub of 37 degrees C water for 1 hr during early labor. The Wilcoxon two-sample test revealed statistically significant effects. At 15 min bathers' anxiety and pain scores were decreased compared to nonbathers. At 60 min bathers' pain scores were decreased compared to nonbathers. After 15 min of immersion, bathers had a significantly greater increase in plasma volume than nonbathers. No significant differences were found in urine catecholamines or maternal-fetal complications. The small sample limits conclusions, but the findings offer preliminary support for the therapeutic effects of bathing in labor for acute, short-term anxiety and pain reduction.

Postcoital pneumoperitoneum after hysterectomy

Usually, pneumoperitoneum is a serious condition suggesting a perforation of the abdominal viscus. Nonsurgical pneumoperitoneum accounts for approximately 10% of all cases. The authors present a case of postcoital pneumoperitoneum after a hysterectomy. A 46-year-old woman presented to the emergency department 4 months after an abdominal hysterectomy with complaints of abdominal discomfort and radiographic evidence of free air under the diaphragm. The clinical finding did not support the radiographic evidence. An unclear peptic ulcer history led us at first to mistakenly diagnose a covered perforation of gastroduodenal ulcer. Diagnostic perplexity forced us to perform a laparoscopy after 30 h. The abdominal cavity was surprisingly normal, and no perforation was found. Nonsurgical postcoital pneumoperitoneum is rare. We solved such a case for the first time. By means of laparoscopy, we could exclude perforation of the viscus and peritonitis, and the operation was carried out in a minimally invasive way.

Severe cutaneous ulceration following treatment with thalidomide for GVHD

We report two cases of severe leg ulcerations in patients being treated with thalidomide for graft-versus-host disease following bone marrow transplantation. Local wound care and debridement were attempted, but one patient required skin grafting to ensure healing. We propose that this complication may be due to the antiangiogenic properties of thalidomide and urge careful attention to skin breakdown in patients being treated with this compound.

Miniinvasive approaches in varicose vein surgery

Authors present their own experience with the treatment of chronic venous insufficiency. Between August 1995 and November 1998 they operated on 318 patients for the disease of venous system. In 28 patients (i.e. 9%) they performed 30 miniinvasive interventions--8x retroperitoneoscopic lumbar sympathectomy and 22x endoscopic subfascial dissection of vein perforators. The rest of patients (91%) were treated by means of classical operations on superficial venous system.

Specifics on the refinement and application of two serological assays for the detection of antibodies to HHV-8

BACKGROUND

Serologic assays for the detection of antibodies to human herpesvirus type 8 (HHV-8) are important for epidemiological studies and to further investigate the proposed pathogenesis of the virus in cancer. Although a variety of assays are available, a lack of optimization and standardization makes their usefulness uncertain, and may be responsible for the controversy concerning the prevalence of infection.

OBJECTIVES

To refine an indirect immunofluorescent assay (IFA) for the detection of latent antibodies and a recombinant ORF 65 ELISA for the detection of lytic antibodies in order to increase their ability to differentiate individuals at higher and lower risk for HHV-8 infection.

STUDY DESIGN

Sera from Kaposi's sarcoma (KS) patients and blood donors (BDs) were used to modify assay parameters in an attempt to better discriminate between the two populations. Modifications included methods of substrate fixation, incubation times, sample dilution, and antigen/conjugate concentrations.

RESULTS

Optimal modifications to the latent IFA included acetone fixation of substrate, and dilution of sera to 1:64 which enhanced detection of HHV-8 antibodies from 68 to 92% in the KS population. Similarly, successful refinement of the ORF 65 ELISA to increase the signal-to-noise ratio included the use of 88 ng of ORF 65 antigen per well and serum dilutions of 1:50. Optical density-to-cut-off ratios directly correlated with titers, thereby introducing a strategy to predict antibody concentrations. The ORF 65 ELISA and the latent IFA were both able to discriminate between the two populations but with different efficiencies.

CONCLUSIONS

Although neither the latent IFA nor the ORF 65 ELISA produced perfect test indices, improvement in their performances was noted following the optimization strategies. The ELISA produced better detection of antibodies to the virus than the IFA and permitted prediction of sample titers, thus improving cost and time effectiveness.

A course for teaching patient-centered medicine to family medicine residents

In 1988 the Department of Family Medicine at Ben Gurion University of the Negev in Israel developed a course that helps residents to acquire the attitudes and skills required for practicing patient-centered medicine. In the patient-centered approach, the physician relates to patients according to their needs rather than the doctor's own agenda, moving from professional control to patient empowerment. Though there are many elements to this method, certain basic orientations and skills are essential and must be taught, modeled, and reinforced in trainees. To accomplish these aims, a three-year course was developed, which is largely based on directed reading, open discussion, case presentations, role-plays, and Balint groups. It is composed of four levels, each of which must be mastered before residents can move to the next. The levels are (1) doctor-patient communication; (2) family-systems theory-concepts; (3) family-systems theory-practical applications; and (4) multidimensional approaches to simulated patients. In this article, the authors describe the course's concepts and content, and some indicators as to its influence on graduates.

A Rare Complication of Varicose Vein Surgery

Design:

Case report.

Setting:

University Hospital in the Czech Republic.

Patients:

Patient undergoing surgery for primary varicose veins.

Interventions:

The patient underwent attempted long saphenous vein stripping by passing a flexible stripper from ankle to groin. The stripper fractured at its upper end and a fragment of stripper became lodged in the internal iliac vein in the pelvis. This was removed at laparotomy. The patient made an uncomplicated recovery.

Conclusion:

Major complications of varicose vein surgery are rare. This unusual problem was probably caused by material fatigue in the stripper, leading to fracture near the upper end of the stripper.