Thin malignant melanomas (less than 1.5 mm) with metastasis: a histological study and survival analysis

It is known that not all thin malignant melanomas have an excellent prognosis and that the specific features identifying the patients at risk of metastasis have not been fully elucidated. We have looked at thin malignant melanomas (less than 1.5 mm) in the East of Scotland that had proven metastasis and death, and compared the clinical and histological features with a similar group (less than 1.5 mm) that have had no further recurrence after a minimum of 6-year follow-up. We identified 26 patients with thin melanomas who had developed histologically proven metastasis and/or died following adequate surgical treatment of their primary lesion. When compared with the control group, factors found to be significantly different between the two groups and present in the group that did badly were (a) histological regression, (b) lesion size, (c) Clark level IV and (d) depth of the uninvolved dermis.

Diaphragmatic (Bochdalek) hernias simulating pulmonary metastases on computed tomography

Three patients with known primary malignancy and a normal chest radiograph are presented. Computed tomographic scans viewed on 'lung' settings showed a solitary mass lesion simulating a neoplastic mass in the posterior costophrenic recess in each patient. These lesions in fact were small herniations of abdominal fat into the chest through diaphragmatic defects.

Neuropsychological recovery in patients with moderate to severe head injury: 2 year follow-up

Neuropsychological outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. Based on the results we conclude: (1) there is marked impairment of a broad spectrum of neuropsychological functions at 1, 12, and 24 months postinjury; (2) coma length is significantly related to neuropsychological status at all three time periods, although the relationship is weaker at 12 and 24 months; (3) marked improvement in all functions occurs in the first year, while recovery in the second year appears more specific and may depend on the severity of the injury and type of function; (4) practice effects and variability over repeated measures cause difficulties in determining recovery and need to be addressed with larger samples.

Contradictions in the social production of clinical knowledge: the case of schizophrenia

This paper is divided into two parts. In Part I, I contend that the current thrust to synthesize clinical and critical medical anthropology is misdirected and may serve to further fragment, rather than unify their concerns. I then suggest that instead of focusing on their differences, either in levels of analysis ('micro-' versus 'macro-') or in objects for analysis, we should emphasize instead the perspective that they share--one drawn from the common task their work assumes as a critical, emancipatory science of mankind. In Part II, keeping in mind this short prolegomenon, I utilize data regarding the National Alliance for the Mentally Ill (NAMI) to illustrate that medical knowledge is reducible to neither natural nor social forces; it is instead produced by living actors who are constrained by their social and historical conditions and the exigencies of the mode of production in which these actors produce. I show how NAMI members have succeeded in changing 'blame-the-family' ideologies about schizophrenia etiology and treatment, but I also explain how the medicalized alternative they produced in redefining schizophrenia as a disease of the brain is itself limited and fraught with contradictions (e.g. reinforcing a depersonalizing mind/body separation that inhibits healing). These contradictions highlight the difficulty of transcending the assumptions implicit in medical categories since they are tied to the dominant epistemology of the mode of production in which they are produced--one that binds our world views and limits the options we can generate. Anthropologists must draw attention to these constraints as an initial step to transcending them.

Comparison of paragraph comprehension test scores with reading versus listening-reading and multiple-choice versus nominal recall administration techniques: justification for the bypass approach

Eight groups of learning disabled children (N = 100), categorized by the clinical Lexical Paradigm as good readers or poor readers, were individually administered the Gilmore Oral Reading Test, Form D, by one of four input/retrieval methods: (1) the standardized method of administration in which the child reads each paragraph aloud and then answers five questions relating to the paragraph [read/recall method]; (2) the child reads each paragraph aloud and then for each question selects the correct answer from among three choices read by the examiner [read/choice method]; (3) the examiner reads each paragraph aloud and reads each of the five questions to the child to answer [listen/recall method]; and (4) the examiner reads each paragraph aloud and then for each question reads three multiple-choice answers from which the child selects the correct answer [listen/choice method]. The major difference in scores was between the groups tested by the recall versus the orally read multiple-choice methods. This study indicated that poor readers who listened to the material and were tested by orally read multiple-choice format could perform as well as good readers. The performance of good readers was not affected by listening or by the method of testing. The multiple-choice testing improved the performance of poor readers independent of the input method. This supports the arguments made previously that a "bypass approach" to education of poor readers in which testing is accomplished using an orally read multiple-choice format can enhance the child's school performance on reading-related tasks. Using a listening while reading input method may further enhance performance.

Comparison of Paragraph Comprehension Test Scores with Reading versus Listening-Reading and Multiple-Choice versus Nominal Recall Administration Techniques: Justification for the Bypass Approach

Eight groups of learning disabled children ( N = 100), categorized by the clinical Lexical Paradigm as good readers or poor readers, were individually administered the Gilmore Oral Reading Test, Form D, by one of four input/retrieval methods: (1) the standardized method of administration in which the child reads each paragraph aloud and then answers five questions relating to the paragraph [read/recall method]; (2) the child reads each paragraph aloud and then for each question selects the correct answer from among three choices read by the examiner [read/choice method]; (3) the examiner reads each paragraph aloud and reads each of the five questions to the child to answer [listen/recall method]; and (4) the examiner reads each paragraph aloud and then for each question reads three multiple-choice answers from which the child selects the correct answer [listen/choice method]. The major difference in scores was between the groups tested by the recall versus the orally read multiple-choice methods. This study indicated that poor readers who listened to the material and were tested by orally read multiple-choice format could perform as well as good readers. The performance of good readers was not affected by listening or by the method of testing. The multiple-choice testing improved the performance of poor readers independent of the input method. This supports the arguments made previously that a “bypass approach” to education of poor readers in which testing is accomplished using an orally read multiple-choice format can enhance the child's school performance on reading-related tasks. Using a listening while reading input method may further enhance performance.

Role of computed tomography in evaluating asbestos related lung disease

To find how computed tomography (CT) may be effectively used in individuals with suspected asbestos related lung disease 30 men with a history of exposure to asbestos were studied. All subjects underwent high kilovoltage posteroanterior and left lateral chest radiographs and chest CT. Eighteen were randomly selected asbestos workers referred for routine surveillance. The remaining 12 were patients who had been referred for investigation of respiratory symptoms or abnormal routine chest radiograph, or both, and found to have chest radiographic changes compatible with asbestos related lung disease. In the group referred for routine surveillance both pleural shadowing and pulmonary shadowing were shown on CT but not chest radiographs in only one case. Five were thought to have pleural shadowing on chest radiographs but this was confirmed on CT in only one case. All 12 patients referred for investigation showed pleural shadowing on chest radiographs; this was confirmed in all cases on CT which also showed unsuspected pulmonary shadowing in five cases. These findings suggest that it is not appropriate to use chest CT routinely in all asbestos workers referred for routine surveillance. When CT is used selectively in those with pleural shadowing on plain chest radiography, however, it is helpful in refuting or confirming the presence of pleural disease and may show unsuspected pulmonary shadowing.

Ultrasonography shows no abnormality of pelvic structures in women with severe idiopathic constipation

Patients with severe idiopathic constipation are almost exclusively women. Common presenting features include lower abdominal pain, irregular and painful menstruation, and a past history of gynaecological surgery. Pelvic ultrasonography was undertaken in 26 patients with severe idiopathic constipation and 21 age matched control women to detect any gynaecological abnormality. No difference was found in ovarian, uterine or pelvic vein morphology or size. The abdominal pain in these patients is related to the bowel disorder, and minor abnormalities of pelvic morphology on ultrasound are probably incidental findings.

Evaluation of a serologic marker, CA19-9, in the diagnosis of pancreatic cancer

STUDY OBJECTIVE

To determine the utility of the serologic marker CA19-9 in the diagnosis of pancreatic cancer in patients suspected of having a pancreatic disorder.

DESIGN

Blinded study of frozen pedigreed serum samples collected at time of diagnostic evaluation with follow-up review at a mean of 8 years.

SETTING

A general university teaching hospital serving both primary and referral patient populations.

MEASUREMENTS AND MAIN RESULTS

Sera collected prospectively from 1978 to 1980 from 261 patients undergoing imaging studies of the pancreas (ultrasound, computed tomography, endoscopic retrograde cholangiopancreatography) for a variety of symptoms were assayed for CA19-9 levels, and the results were compared with earlier determinations of other potential markers for pancreatic cancer. In 54 patients ultimately shown to have pancreatic cancer, the CA19-9 assay showed a sensitivity of 70% with a median value of 349 u/mL (normal less than 70 u/mL) and range, 7.3 to 2,859,964 u/mL, whereas specificity of the marker in this population was 87%. The positive predictive value was 59%, and the negative predictive value was 92%. Results of CA19-9 testing in the small group of patients with definitive staging information showed no difference in sensitivity between patients with local/regional disease (n = 6) and those with distant metastases (n = 14), 50% compared with 71% (P = 0.613).

CONCLUSION

CA19-9 was found to be a more sensitive and specific marker of pancreatic cancer than other serologic markers and should be a useful test in the patient with suspected pancreatic disease.

Comparison of nominal recall (standard) and multiple-choice methods for administration of WISC-R information subtest: a preliminary study indicating a learning effect of multiple-choice testing

The Wechsler Intelligence Scale for Children--Revised (WISC--R) Information subtest was administered to learning disabled children using two methods of administration, the standard (recall) method and a multiple-choice format. Those children who were tested first with the multiple-choice format and subsequently with the standard format did better on the standard format than expected. This preliminary study suggests a learning effect of such multiple-choice testing and the desirability of further research being undertaken.

General versus disease-specific measures. Further work on the Sickness Impact Profile for head injury

Three modifications devised to make the Sickness Impact Profile more sensitive to head injury are evaluated in 202 head-injured and 132 general trauma patients 1 month and 12 months after injury. The modifications consist of adding items, deleting nonapplicable items, and reweighting areas of function. Each of the modifications, and especially all three combined, slightly but significantly improve discrimination of head-injured and comparison subjects and increase correlations with neurologic and neuropsychologic severity indexes. These slight improvements occur more often at 12 months than at 1 month and among those without rather than with pre-existing conditions. No improvements are found in the ability to classify patients into subgroups. The modifications fail to make improvements sufficiently large or consistent to provide a practical advantage over the SIP. The standard SIP provides a reasonable measure of psychosocial functioning following head injury. It relates to head injury and other system injury severity and reflects recovery with time. The SIP score relates to emotional functioning even after injury severity has been taken into account. Until other factors, such as emotional status and responses style, are better controlled, little benefit is likely to be obtained from creating disease-specific psychosocial measures.

Depression, learning disability, and school behavior problems

It is possible that recurrent depression (primary affective illness) is the most significant variable related to school problems of a behavioral nature in children manifesting developmental specific learning disabilities. The association of school problems and depression was investigated at a private school for children with developmental specific learning disabilities. These children were of normal intelligence and were free of primary conduct or thought disturbances. Prior to entering school, 95% of the students fulfilled criteria for developmental specific learning disabilities and 64% for depression with or without hyperactivity. Students manifesting no diagnosable behavioral condition prior to entrance continued to be relatively free of behavioral problems during their stay at school. Students with both depression and hyperactivity showed the most problematic behavior followed by students with depression without hyperactivity.

Significant intimal abnormalities in muscular pulmonary arteries of patients with early obstructive lung disease

Substantial intimal changes, unrelated to aging, were found in resected lobes or lungs of 30 smokers with early obstructive lung disease (22 men, eight women: age range 46-74 years: forced expiratory volume in one second (FEV1)% predicted range 47-119%). Intimal area was measured using a digitiser and expressed as a proportion of the area enclosed by the internal elastic lamina (IEL), correcting for constriction (intima index). Arteries were subdivided into four size (length IEL) groups. For the smallest group (less than or equal to 600 micron length IEL) the mean intima index (II600) ranged from 0.09-0.34; half the values were greater than or equal to 0.20. Intimal abnormality was unrelated to the size or site of tumour or to macroscopic emphysema, and correlated weakly with pack years. II600 values were, however, significantly correlated with factors known to be affected by smoking such as alveolar wall surface area per unit lung volume, FEV1% predicted, and FEV1/FVC (forced vital capacity); these last two factors were also significantly associated with intimal abnormality in arteries measuring 601-1200 micron length IEL.

Comparison of reading and listening-reading techniques for administration of PIAT Reading Comprehension subtest: justification for the bypass approach

The Peabody Individual Achievement Test (PIAT) Reading Comprehension subtest was administered to a group of 23 learning disabled children in Grades 5 through 7 who had been classified by the clinical Lexical Paradigm as good readers or poor readers. Using standardized test administration, 14 poor readers scored substantially below the 9 good readers; however, when the child was allowed to listen and read silently while the test item was read aloud, poor readers showed marked improvement in performance compared to only moderate improvement shown by the good readers. This difference in improvement between the groups was significant and resulted in poor readers achieving performance similar to that of the good readers administered the test in the standard manner.

CT measurements of lung density in life can quantitate distal airspace enlargement--an essential defining feature of human emphysema

We used a computerized microscopic image analysis system to directly measure the surface area of distal air spaces in methacrylate-embedded blocks randomly selected from inflation-fixed lobes that were resected from 45 patients as treatment of their peripheral lung tumors. In 28 of these patients, a preoperative computer tomography (CT) scan, at 6 and 10 cm below the sternal notch, was used to generate frequency histograms of CT numbers (measured as EMI units), a measure of lung density, in pixels from the lung or lobe that was subsequently resected. A similar CT number histogram was also derived from the lateral two fifths of the area of lobe/lung that was to be resected. The EMI unit that defined the lowest fifth percentile of this latter histogram correlated (n = 28, r = -0.77, p less than 0.001) with the mean value of the surface area of the walls of distal airspaces per unit lung volume (AWUV) in the five 1 mm x 1 mm microscopic fields with the lowest AWUV values, out of the 20 to 35 such fields examined in each patient. In the 34 of the 45 patients in whom we also measured volume-corrected diffusing capacity (DLCO/VA), this also correlated (n = 34, r = 0.84, p less than 0.001) with this value of AWUV, which measures the surface area of airspaces distal to the terminal bronchioles--reflecting an increase in airspace size, a defining characteristic of emphysema. However, a low DLCO/VA is nonspecific, whereas an abnormally low regional lung density is more likely to be specific for emphysema. In addition, highlighting those pixels of the CT display with low CT numbers (i.e., EMI units -500 [air] to -450, where zero = water) can locate areas of macroscopic emphysema, as shown by subsequent pathologic examination. Thus the quantitative CT scan can diagnose, quantitate, and locate mild to moderate emphysema, in humans, in life, noninvasively.

Development and evaluation of modifications to the Sickness Impact Profile for head injury

Three modifications were made to the Sickness Impact Profile, a behavior-based measure of health status, to improve its sensitivity to the effects of head injury. (1) Additional items were included to capture head injury sequelae and behaviors typical of young adults, the age group to which head injury most frequently occurs. (2) Subjects individually excluded behaviors irrelevant to them, thus allowing the score to better reflect injury-related changes. (3) The different areas of functioning on the Sickness Impact Profile were reweighted to reflect global judgments of the construct's contribution to overall functioning rather than the sum of the item contributions. Only the first modification is head-injury specific. The others, are relevant to any disease or injury. The performance of the modifications was evaluated in a longitudinal study of 102 head injured and 102 comparison subjects tested at 1 and 12 months after injury. The evaluation of the modifications was based on their ability to distinguish head injury from comparison subjects and on the strength of their relationship with measures of brain dysfunction. Despite a few statistically significant improvements in discrimination, differences of a practical degree were not obtained. The standard Sickness Impact Profile performed well and is recommended for evaluation of day-to-day functioning in head injury studies.

Memory and head injury severity

One hundred and two consecutive head injured patients were studied at 1 and 12 months after injury. Their performances were compared with a group of uninjured friends. The results indicate that impairment in memory depends on the type of task used, time from injury to testing, and on the severity of head injury (that is, degree of impaired consciousness). Head injury severity indices are more closely related to behavioural outcome early as compared with later after injury. At 1 year, only those with deep or prolonged impaired consciousness (as represented by greater than 1 day of coma, Glasgow Coma Scale of 8 or less, and post traumatic amnesia of 2 weeks or greater) are performing significantly worse than comparison subjects.

Memory training combined with the use of oral physostigmine

Impaired memory function is one of the most frequent and disabling symptoms observed after brain injury. A number of studies have examined the efficacy of using cholinergic agonists, such as physostigmine, in treating memory impairment resulting from various neurologic conditions. Few studies, however, have either combined the drug treatment with a memory training programme or monitored serum cholinesterase levels to increase the likelihood of achieving a therapeutic dose of the medication. The current study addresses both of these issues. Two single-case studies are reported in this investigation. In each case, a double-blind, placebo-controlled, single-subject, A-B-A design was used with A representing the base-line phases, B constituting the memory training combined with medication phase and A representing the return to base-line condition. Both patients sustained anoxia as a result of carbon monoxide poisoning. In the first case, a clinically significant improvement was seen in the patient's performance of both standardized and non-standardized measures of memory function as a result of the combined treatment regimen. No significant changes, however, were seen in the patient's performance on measures of attention and concentration, cognitive flexibility or motor speed. These findings were then replicated with the second anoxic patient. The results from this study point out the potential benefit of combining cholinergic agonists with specific memory training strategies in improving memory function after brain injury.

Aluminium-related osteomalacia: response to reverse osmosis water treatment

It is generally accepted that aluminium induces osteomalacia in chronic hemodialysis patients by binding to the calcification front, thereby inhibiting mineralization of osteoid. Because this form of osteomalacia is vitamin D resistant, the condition has often been assumed to be irreversible, although promising results have been achieved recently by using a chelating agent for removal of aluminium from the skeleton. In this paper we present four chronic hemodialysis patients with aluminium toxicity and histologic osteomalacia in whom the mineralization defect greatly regressed after the use of reverse osmosis treated-water for dialysis, but without further treatment. In three other patients, also with aluminium toxicity and histologic osteomalacia, similarly treated, the histological severity of the osteomalacia remained static. Those patients in whom bone mineralization status improved developed hyperparathyroidism after reverse osmosis water-treatment, whereas the static patients remained euparathyroid. The results suggest that resolution of aluminium related osteomalacia may occur with reduction in dialysis fluid aluminium, and that parathyroid hormone plays a role in the healing of aluminium related osteomalacia. The therapeutic implications are twofold: attempts to remove all traces of hyperparathyroidism may be detrimental to the bone mineralization status; and stimulation of the parathyroid glands by means of a mild reduction in dialysis fluid calcium may be of value in the management of those cases with persistent osteomalacia and low bone turnover.