Factors that influence the prevalence of positive catch trials in glaucoma patients

We evaluated factors that influence the catch-trial response in automated perimetry by consecutively examining 408 glaucoma patients (703 eyes) with either the program 30-2 or a 76-point screen with a quantified defect on the Humphrey Field Analyzer. The prevalence of positive catch trials using both programs was: 15.9% fixation losses, 5.5% false-positives, and 17.0% false-negatives. The only significant difference between the two programs was a lower prevalence of false-negatives on the program 30-2 (P less than 0.01). False-positive responses showed a significant positive correlation to fixation losses, and the catch trial response in general was correlated significantly to defect depth, test time, age, and visual acuity (P less than 0.05). This study suggests that the prevalence of positive catch trials is not an independent variable when testing glaucoma patients with automated perimetry and is not reduced by using a screening strategy over a full-threshold exam.

A comparison between regimens containing chemotherapy alone (busulfan and cyclophosphamide) and chemotherapy (V. RAPID) plus total body irradiation on marrow engraftment following allogeneic bone marrow transplantation

The effect of two conditioning regimens given prior to allogeneic bone marrow transplantation (BMT) on the kinetics of engraftment were compared. 5 patients received busulfan and cyclophosphamide: 7 patients received daunorubicin, vincristine, cytosine arabinoside, methylprednisone and VM-26 plus total body irradiation (TBI). Bone marrow progenitors (BFU-E, CFU-E, CFU-GM, CFU-F) were assayed up to 3 months post-BMT. All progenitors were severely depressed in spite of peripheral blood recovery. There was no stromal recovery in any adult patient post-BMT. There was no significant difference in time to engraftment, or colony forming units, or between patients conditioned with chemotherapy alone or chemotherapy plus TBI. We were unable to detect effects of graft-versus-host disease or cytomegalic viral infection on bone marrow progenitors or peripheral blood recovery in this study.

Giant iatrogenic splenic pseudocyst

Partial splenic arterial embolization was used to treat hypersplenism in a 10-year-old boy with portal hypertension secondary to congenital hepatic fibrosis. After embolization the spleen remained enlarged, but the boy's platelet count increased and his variceal bleeding ceased. One month later, he returned with vomiting and an abdominal mass. Computed tomography showed a large cyst of the spleen with a small rim of residual splenic tissue. Percutaneous drainage with ultrasound guidance yielded 2,800 mL of brown fluid. Wedge-shaped infarctions are described early after splenic embolization, and these areas eventually fibrose and contract. In this case, the embolization resulted in splenic necrosis and liquefaction with pseudocyst formation. This unusual complication was effectively treated without surgery.

Ultrasound of the distal pouch in infants with imperforate anus

Optimal surgical management of the newborn with imperforate anus depends on accurate determination of the level of the rectal pouch. Eighteen children with imperforate anus were evaluated with ultrasound. The distance from the end of the pouch to the perineum was measured. Ultrasound correctly predicted the level of the distal pouch in all 12 children who had confirmation of the pouch level by surgery or by distal contrast stomagrams. Six children have not yet had definitive surgery. Five children with a pouch to perineum (P-P) distance of less than or equal to 10 mm and three of six children with a P-P distance of 10 to 15 mm had successful correction by a simple perineal anoplasty. Three of six children with a P-P distance of 10 to 15 mm and all of those (seven) with a P-P distance greater than 15 mm were diverted with colostomies.

Neck and thorax venous aneurysm: association with cystic hygroma

Eight of 15 patients with mediastinal cystic hygroma were found to have abnormal enlargement of neck or thoracic veins. Five of these children had aneurysmal dilatation of the superior vena cava (SVC). Three more had mild enlargement of the SVC, which was revealed only after comparison with 20 children with no evidence of mediastinal disease. Although the association of venous aneurysms and cystic hygromas has not been previously observed, their coexistence does not appear to be coincidental: None of the patients had other causes of dilatation of the SVC. Knowledge of aneurysmal veins may be helpful to the surgeon planning resection of a cystic hygroma.

Vaginal neoplasms in infancy: the combined role of chemotherapy and conservative surgical resection

This retrospective review of nine infants treated for vaginal tumors between 1964 and 1986 identifies the spectrum of lesions and examines the trend toward more conservative surgical therapy. Our patients' ages ranged from 1 to 30 months. Symptoms of vaginal bleeding or protruding tissue prompted examination under general anesthesia in all cases. Two children had benign protruding polypoid masses treated by simple excision. Seven had malignant tumors, two with endodermal sinus lesions and five with embryonal rhabdomyosarcoma. Early in this series, surgical therapy for embryonal rhabdomyosarcoma consisted of either anterior or complete pelvic exenteration, with adjuvant chemotherapy given in two of the three patients. One patient was operated on prior to the development of effective chemotherapy, and died of recurrent tumor 14 months after surgery. A second patient died from cardiac failure secondary to adriamycin toxicity 6 years after initial therapy. A third patient underwent total pelvic exenteration followed by successful reanastomosis of the colon to the anal verge. This patient, a female, is the oldest survivor and is free of disease 14 years after therapy. The most recent therapeutic approach used in two patients with embryonal rhabdomyosarcoma consisted of local tumor excision followed by postoperative chemotherapy. Both patients are alive and disease-free 9 and 11 years after therapy. Two patients with endodermal sinus tumor were treated with chemotherapy after simple excisional biopsy. They were then followed with serial vaginal biopsies at 3-month intervals. One required a partial vaginectomy for local recurrence 21 months after initial presentation. Both patients are alive and disease-free 18 months and 4 years after surgery.

Neurogenic tumors of the thorax

Neurogenic tumors of the thorax are observed in all age groups, although they are rare in the elderly. They are more likely to be malignant in the child than in the adult. Tumors of the autonomic system are common in children, whereas the nerve sheath tumors are more likely to be found in adults. The malignant lesions are almost always symptomatic and the benign lesions asymptomatic, except in the child, in whom a benign lesion may result in symptoms because of its size relative to the volume of the child's thorax. Intraspinal canal extension, although relatively infrequent, should be sought for in all paravertebral tumors, for a significant percentage of these may be initially asymptomatic. Excision of such an hourglass tumor without foreknowledge of such extension may lead to serious spinal cord complications. Surgical excision of most of these tumors is sufficient except for the malignant lesions, especially in infancy and childhood, for which the addition of postoperative irradiation and chemotherapy may be beneficial. The prognosis after the removal of benign neurogenic tumors of the thorax is excellent. In the infant or child with Stage III or IV neuroblastoma, ganglioneuroblastoma, or an Askin tumor, the prognosis is poor. In the adult with a malignant neurogenic sarcoma or a malignant paraganglioma, the prognosis likewise is grave.

Bacillus Calmette-Guérin immunotherapy in ovarian cancer

Forty-six advanced ovarian cancer patients treated with conventional modalities with the addition of bacillus Calmette-Guérin (BCG) immunotherapy showed prolonged survival when compared to controls not given BCG. Although the data suggest enhancement of survival with the addition of BCG to conventional treatment, the fact remains that disease recurrence ultimately claims the lives of most of these patients. Nonetheless, patients are surviving longer in the face of advanced disease.

Rape victims

In Nursing Standard (week ending November 7) Police Chief Medical Officer, David McLay is quoted as saying that hospitals are not the ideal place for the examination of rape victims. I assume therefore that he is advocating examination on police premises.

Functional consequences of embryonic neocortex transplanted to rats with prefrontal cortex lesions

In four experiments we reexamined the recent report by Labbe, Firl, Mufson, and Stein (1983) that fetal cortical tissue transplanted to an aspirative prefrontal cortical cavity in rats can ameliorate the learning impairments induced by the aspirative lesions. Healthy surviving grafts from young (E16) embryonic donors had no immediate effects on the rats' impairments in T-maze alternation, spatial navigation in the Morris swimming pool task, or locomotor activity, and they produced even greater impairments than the lesions alone when all three tests were conducted after longer (3-5 month) survival periods. Grafts taken from older (E21) donors did produce a short-lasting improvement in the T-maze alternation performance, replicating the previous report. However, this effect was not seen in the other two behavioral tests; the grafts survived poorly, and the beneficial effect was no longer apparent in the long-term tests. It is concluded that (a) functional benefits of embryonic cortical grafts are dependent on a precise combination of conditions rather than being a general phenomenon, and (b) the short-lasting recovery in delayed alternation performance is attributable to diffuse influences of the embryonic tissue on the lesioned host brain rather than to a reconnection of damaged circuitries.

Management of recurrent coarctation of the aorta: a new experimental technique

A new technique is described for the management of recurrent coarctation of the aorta. It involves enlarging the narrowed segment by an onlay patch sutured to the adventitia and outer media of the aortic wall. The procedure was used in 6 mongrel dogs with preexisting surgically created coarctation. Aortic cross-clamping time ranged between 7.5 and 11 minutes (mean, 8.8 +/- 1.3 minutes). There were no operative deaths or complications. Gross and microscopic examination of the aorta 6 to 12 months (mean, 9 +/- 2.2 months) postoperatively revealed a 290 to 380% (mean, 350 +/- 30%) increase in the diameter of the repaired area and no evidence of thrombosis or pseudoaneurysm formation. The need for minimal dissection and the brief period of aortic cross-clamping make this approach an attractive alternative in the surgical treatment of patients with difficult cases of recoarctation.

Myocyte cytochrome oxidase activity and neuromuscular conduction associated with metabolic alkalemia

Many studies have shown increased affinity of hemoglobin for oxygen during metabolic alkalemia and dependence of intramitochondrial cytochrome oxidase activity on arterial oxyhemoglobin saturation. The present studies tested the hypothesis that metabolic alkalemia produces tissue hypoxia independent of arterial oxygen desaturation. Neuromuscular conduction latency was used as an indicator of functional impairment, and was measured following electrostimulation of the sciatic nerve and recording of the electromyogram from the gastrocnemius muscle of rats anesthetized with pentobarbital sodium. To increase the affinity of hemoglobin for oxygen, sodium bicarbonate was administered in graded doses every 15 min. Statistical significance of changes was estimated by the paired Student's t test. Arterial bicarbonate ion concentration increased from 25 +/- 1.3 to 39.0 +/- 3.0 mM while arterial pH increased from 7.30 +/- 0.02 to 7.50 +/- 0.03 (P less than 0.01). Neuromuscular conduction latency increased from 1.9 +/- 0.13 to 2.7 +/- 0.18 ms (P less than 0.01). Tissue hypoxia was suggested by a greater decrease in mass spectrometric determinations of gastrocnemius muscle oxygen tension (PO2) in separate groups of control (arterial pH 7.38 +/- 0.04) and experimental (arterial pH 7.48 +/- 0.03) rats. These changes were accompanied by markedly decreased uptake of 3.3'-diaminobenzidine (DAB) by gastrocnemius muscle mitochondria, suggesting decreased intracellular activity of cytochrome oxidase and intracellular oxygen availability to myocytes in the absence of arterial oxygen desaturation.

Partial splenectomy with the CO2 laser: an alternative technique

Because total splenectomy has been shown to affect immunocompetence in children, partial splenectomy is advocated as an alternative to total splenectomy in traumatic injury as well as in treatment of benign cysts. Present techniques include elaborate hemostatic techniques and extensive suture repair which has led to the development of massive abdominal adhesions. We have investigated CO2 laser sealing of splenic wounds to obviate the need for extensive repair and to minimize intraabdominal reaction. Five dogs underwent partial splenectomy with a scalpel. Hemostasis was obtained with CO2 laser coagulation; a defocused laser beam at 8 W (power density 30-50 W/cm2). After 3 weeks, the laser sealed splenic tissue was amputated and, on this occasion, hemostasis was obtained using a standard suture technique of Teflon pledget-bolstered chromic sutures. Three weeks later the dogs were explored and the sutured splenic tissue was removed. Gross findings on the first exploration demonstrated no signs of hemorrhage and minimal adhesions of the laser sealed spleens. In contrast, exploration after suture repair revealed dense adhesions containing the spleen, omentum, mesentery, and small and large bowel. Microscopic examination of the laser sealed spleen showed a zone of injury only 2-3-mm thick. Excellent hemostasis of the cut surface of the spleen can be accomplished using the CO2 laser. In addition, the minimal depth of injury and the absence of foreign material in the peritoneal cavity make this an attractive alternative to conventional methods.

Sequential studies of bone marrow haemopoietic progenitors (CFU-GEM, BFU-E, CFU-E, CFU-GM) following busulfan treatment in Balb/c mice

The effect of multiple sublethal doses of busulfan on the haemopoietic system of the Balb/c mouse was examined. FBC's bone marrow histology and bone marrow progenitor cell assays (CFU-E, BFU-E, CFU-GM and CFU-GEM) were performed. No effect was seen on FBC's or on marrow histology. However there was a significant depletion noted in the number of haemopoietic progenitor cells as measured by in vitro culture.

The valved conduit prevents ascending cholangitis: a follow-up

Reflux of bacteria-laden intestinal contents into the biliary tree can be prevented by an intussuscepted valve in an isolated segment of jejunum interposed between the porta hepatis and the duodenum. This method of bile duct reconstruction was adopted in 1979 and since then has been used in 17 children with biliary atresia and 9 with choledochal duct cysts. Those with choledochal duct cysts are well. Follow-up HIDA scans demonstrate normal bile flow, and ultrasound examinations have not revealed dilated bile ducts. Bile flow was established in 13 infants with biliary atresia and was persistent in 8. Two expired because of unrelated problems between 2 to 6 months postoperatively. One of these children developed cholangitis, but at autopsy the nipple valve was incompetent. Six children currently have normal serum bilirubin levels and are clinically well. The average postoperative stay for these patients was 7.5 days. Three were rehospitalized for brief periods for suspected cholangitis which was not proven. Bile flow was never established in 4 babies and was present only briefly in 5. Five of these children died of progressive liver failure and one from unrelated causes. Two have had liver transplants, and a third is awaiting transplantation.

Histochemical assessment of cytochrome oxidase activity for monitoring ischemic muscle injury

Electromyographic detection of increased neuromuscular conduction latency that follows electrostimulation of spinal nerves has been used widely as a clinical tool for detection of ischemic muscle injury. We hypothesized that a biochemical marker for stagnant hypoxia provides more direct evidence for evaluating severity and monitoring resolution of ischemic muscle injury than the EMG. To detect intracellular changes in oxygen use during experimental ischemia, ultrathin sections of rat gastrocnemius muscle were treated with reducing agent, 3,3'-diaminobenzidine (DAB), a histochemical marker for intramitochondrial cytochrome oxidase activity. The observed decrease in mitochondrial uptake of DAB suggested that a decrease in cytochrome oxidase activity was associated with experimental ischemia. Neuromuscular conduction latency in rat gastrocnemius muscle was also quantitated after electrostimulation of the sciatic nerve. Ligation of the femoral artery produced ischemic tissue injury, during which recordings of the EMG showed that conduction latency increased [from a mean +/- SEM control value of 3.09 +/- 0.13 to 3.92 +/- 0.22 ms (N = 11, P less than 0.001).] The changes in both histochemically detectable cytochrome oxidase activity and neuromuscular conduction latency were reversed by reperfusion. Response of the rat tissue to arterial occlusion was thereby shown to be a physiologic model for skeletal muscle response to ischemia. In addition, histochemical detection of cytochrome oxidase activity was shown to be a sensitive intracellular marker for decreased oxygen use during ischemic muscle injury.

Human marrow stromal cells in short-term semi-solid bone marrow culture in aplastic anaemia

A short-term methylcellulose technique was used to study the proliferation of marrow-derived stromal, erythroid and myeloid colonies from normal controls and from patients with aplastic anaemia. There was a significant reduction in all colony types in patients with aplastic anaemia when compared with normal controls. In 4 patients who achieved remission following treatment with ATG + oxymetholone or with oxymetholone alone there was a return to normal range of stromal colonies and also of CFU-E. There was no change in the numbers of BFU-E's and only a slight increase in the numbers of CFU-C's.