Limitations of the evaluation of adnexal masses by its macroscopic aspects, cytology and biopsy

To investigate the relevance of intraoperative macroscopic evaluation of adnexal masses a prospective study was conducted from June 1st, 1993 to May 31st, 1994, which included 57 premenopausal and 60 postmenopausal women, who underwent laparotomy because of a cystic adnexal mass. The surgeons were asked to classify the tumor intraoperatively as benign or malignant and to assign to histologic groups. In addition cytology of the cyst fluid and a biopsy from the cystic wall were evaluated. Comparison of these items with the results of permanent section diagnosis revealed the tendency of the surgeons to underestimate adnexal masses depending on patients' age and the complexity of the tumor, despite of the knowledge of preoperative ultrasonographic findings. Sufficient cytolologic examination was possible in only one third of aspirates and only 21% of the examined postmenopausal malignant neoplasms have correctly been diagnosed by cytology. Evaluation of the biopsy specimens demonstrates a marked percentage of false negatives with respect to benign tumors (30% of non-functional benign neoplasms in the premenopause were assessed as functional cysts) as well as malignant neoplasms (only 72% were diagnosed correctly in the postmenopause group). In conclusion intraoperative subjective assessment, cytology and representative biopsies do not necessarily concur with the definitive histological diagnosis.

[Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures]

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.

Sonomorphology of endometriotic cysts

OBJECTIVE

The aim of the study was to evaluate prospectively the sonomorphological feature of histologically verified endometriotic cysts.

METHODS

Transvaginal sonography was performed in 122 patients. Age distribution of the patients, and size and sonomorphology of the lesions were analyzed.

RESULTS

Eighty-one percent of the endometriotic cysts occurred in patients between 31 and 50 years old with a peak of 29% between 31 and 35 years. Most of the cysts (81%) ranged between 30 and 59 mm in diameter. Forty-three percent of the endometriotic cysts were observed as monolocular cysts with internal echoes. More than half of the findings were observed to be multilocular, partially without any internal echos, partially even with solid parts or purely solid.

CONCLUSION

The so-called 'typically' monolocular smooth-walled endometriotic cyst with internal echoes was only found in 43% of the cases. However, data from the literature show that one cannot assume even this special entity to represent endometriomas. Regarding all monolocular cysts with homogeneous internal echoes, one has to be aware of a great amount of functional cysts and a non-calculable residual risk of malignancy.

Neuropsychological changes after cardiopulmonary bypass for coronary artery bypass grafting

BACKGROUND

An alarming incidence (1% to 83%) of neuropsychological dysfunction has been reported after operations using cardiopulmonary bypass (CPB). The present clinical study re-evaluates these complications with current CPB technology in a strictly selected low-risk group of coronary artery bypass (CABG) patients.

METHODS

76 CABG patients, without history of stroke or internal carotid artery stenosis, were examined before, 5 days after, and 2 months after surgery. A neuropsychological test battery was employed according to the "Statement of Consensus on Assessment of Neurobehavioral Outcomes after Cardiac Surgery". Tests include the Block Design Test (problem-solving strategies, recognition and analysis of forms), the Trail Making Test (cognitive achievement at speed), and the Digit Span Test (short-term memory and memory of figures).

RESULTS

Both postoperative test scores were not significantly decreased as compared to preoperative values. In contrast, neuron specific enolase (NSE) and S100 b protein, biochemical markers of cerebral injury, increased markedly during and immediately after surgery (NSE preop.: 7.07 +/- 2.40 ng/ml, 1 h postop.: 13.64 +/- 4.50 ng/ml, p < 0.001; S100 b preop.: 0.04 +/- 0.07 ng/ml, after crossclamp: 0.90 +/- 0.69 ng/ml, p < 0.001). One patient displayed postoperative transitional syndrome, another patient suffered from transitory paresis and hypesthesia of the left arm, which disappeared during hospital stay.

CONCLUSIONS

Biochemical markers demonstrate significant postoperative cerebral injury during and immediately after CPB. However, CPB for CABG does not lead to marked impairment of neuropsychological scores, and clinically relevant neurological findings were observed in one patient only.

Patterns of mycobacterium avium culture and PCR positivity in immunodeficient HIV-infected patients: progression from localized to systematic disease, German Aids Study Group (GASG/IDKF)

Our aim was to establish the frequency and the longitudinal pattern of MAC culture positivity in late stage HIV-infected patients. Two other aims were to analyse risk factors for progression from localized to systemic disease and the value of PCR diagnosis using blood specimens. A total of 107 patients were recruited to be followed for 32 weeks. Prior MAC treatment and CD4 > 100/microliters were exclusion criteria. A total of 56 patients showed M. avium in at least 1 culture. 10/37 patients with MAC detected by culture first in 'non-sterile' specimens (stool, sputum) and urine progressed to systemic disease as determined by positive blood culture. Risk factors associated with this progression were a high symptom score at baseline, lymphadenopathy, anaemia, and low platelets. PCR was less sensitive than culture in detection of M. avium in blood specimens: Only 7/29 patients with positive blood cultures had a positive PCR at the same time. We conclude that symptomatic patients with advanced HIV-infection have a high frequency of MAC detection. Progression from localized to systemic culture positivity is associated with risk factors. Early 'pre-emptive' therapy is discussed.

Prognostic value of angiogenesis in mammary tumors

Vessel density counting has been performed in a variety of tumors and used as predictive parameter for the tumor's malignant behavior (metastasis, five year survival). A number of studies have reported conflicting results on the predictive value of vessel density counts. We have quantitated the number of microvessels in routine pathology specimens of paraffin embedded mammary tumors and related these findings to the histopathological diagnosis. Average vessel density counts of vascular hot spots of malignant and benign mammary tumors were similar (34 +/- 15 vs. 31 +/- 10), though significantly higher as in the adjacent normal mammary tissue (12 +/- 5). Analysis of individual tumors, however, showed that significantly more malignant than benign tumors had vessel density counts beyond a defined cut-off value (50 microvessels/HPF). The results suggest that high counts may indeed serve as an independent prognostic parameter. In contrast, low counts may also be observed in malignant tumors and may, thus, not be used as negative prognostic factor.

Fetal plasma levels of circulating endothelial cell adhesion molecules in normal and preeclamptic pregnancies

OBJECTIVE

Circulating levels of endothelial cell adhesion molecules are elevated in women with preeclampsia. The aim of the present study was to determine levels of these molecules in the fetal circulation of normal pregnancies and pregnancies complicated by preeclampsia.

STUDY DESIGN

Fetal plasma samples from the umbilical vein and peripheral maternal plasma and serum sample were collected at delivery from women with preeclampsia and women with normal pregnancy. Women with non-proteinuric pregnancy-induced hypertension (PIH) were excluded from the study. A sandwich ELISA technique was employed to quantitate concentrations of soluble ICAM-1 (CD54), VCAM-1 (CD106), and E-selectin (CD62E).

RESULTS

The normal values of soluble endothelial cell adhesion molecules in the fetal circulation were determined as 162+/-45 ng/ml for ICAM-1, 1612+/-582 ng/ml for VCAM-1, and 154+/-58 ng/ml for E-selectin. They were found to markedly differ from the corresponding normal values in the maternal circulation (sICAM-1: 247+/-65 ng/ml; sVCAM-1: 715+/-170 ng/ml; sE-selectin: 34+/-14 ng/ml). The concentrations of sICAM-1, sVCAM-1, and sE-selectin were significantly elevated in women with preeclampsia compared to healthy control pregnant women. In contrast, there was no difference in the circulating fetal concentrations of these molecules between normal pregnancies and pregnancies complicated by preeclampsia.

CONCLUSIONS

Normal values of sICAM-1, sVCAM-1, and sE-selectin in fetal circulation are markedly different from the values obtained for healthy adults. Plasma concentrations of these molecules are elevated in women with preeclampsia but not in the fetal circulation of preeclamptic pregnancies suggesting that based on the analysis of soluble adhesion molecules the fetal circulation may not be affected by the factor(s) that lead to disturbed endothelial cell function in women with preeclampsia.

Regional differences in use of antiretroviral agents and primary prophylaxis in 3122 European HIV-infected patients. EuroSIDA Study Group

Little is known about how widely HIV-related drugs are used outside controlled clinical trials. We therefore assessed factors associated with use of antiretroviral (ARV) therapy and primary prophylactic regimens to prevent HIV-associated opportunistic infections. Baseline data from a prospective study from May to August 1994, on 3122 consecutive HIV infected patients with a CD4 count <500 cells/microl, followed in 37 centers from 16 European countries, were analyzed. Two thousand and twenty patients (65%) were receiving at least 1 ARV drug at the time of the study. ARV therapy was more frequently used among patients from southern and central Europe as compared with patients from northern Europe, especially among patients with CD4 counts >200 cells/microl (73%, 57%, and 42%, respectively, p < 0.0001). Of patients on ARV therapy, 34% received open-label combination therapy. This proportion was higher in central Europe compared with other regions (27%, 50%, and 31% for southern, central, and northern Europe, respectively, p < 0.0001). Primary prophylaxis against Pneumocystis carinii pneumonia (PCP) was used by 85% of patients with a CD4 count <200 cells/microl, without marked regional differences. In patients without esophageal candidiasis or other invasive fungal infections, antifungal drugs were far less frequently used in patients from southern and central Europe compared with patients from northern Europe (10%, 10%, and 25%, respectively, p < 0.0001). Only 5% of patients with a CD4 count <100 cells/microl received rifabutine as primary prophylaxis against nontuberculous mycobacterioses. ARV and antifungal therapies are used differently in different parts of Europe, whereas primary PCP prophylaxis is uniformly administered to most at-risk patients. U.S. recommendations on the use of antimycobacterial prophylaxis have not been implemented in Europe.

Smoking cessation in military personnel

Tobacco use is the single most important preventable cause of death in military personnel. The purpose of this randomized clinical trial was to evaluate the effectiveness of two behavioral interventions when added to nicotine-replacement therapy on smoking cessation. The sample of 512 included 52% active duty military, 29% family, 11% retirees, and 8% Department of Defense civilians. There was a main effect of compliance at the end of the program (EOP); 69% of those who attended 75% of the classes were abstinent from tobacco; regression analysis found the more intensive program to be twice as effective at EOP and at 3 months, an outcome not continued at 6 months. The longer, more intensive Vanderbilt University Medical Center program was significantly more effective at helping the civilian portion of the population (85% versus 60% in the American Cancer Society program) but not the active duty participants.

Clinical course of human immunodeficiency virus type 1 associated pulmonary tuberculosis during short-course antituberculosis therapy

To describe the clinical response to antituberculosis therapy in HIV-1 disease, 49 HIV-1 positive Ugandan adults (mean age 29.4 years; 68% men) with active pulmonary tuberculosis (PTB) were studied in a trial of rifampicin containing short-course antituberculosisis regimens. At presentation, 18 patients were PPD non-reactors (PPD skin test induration < 2mm), ten patients (20%) had non-cavitary lung disease. The mean CD4 lymphocyte count at presentation was 339/microliters (+/- SD 275). Among patients with abnormal baseline clinical values, the median time to resolution of fever, weight gain of 10%, increase of haemoglobin to 10g/dl and of Karnofsky performance score (KPS) to 80 occurred before sputum smear and culture conversion. Short-term survival was associated with: baseline lymphocytes < 1200/microliters, (Odds ratio (OR) 17.5), CD4+ lymphocytes < 200/microliters (OR 9.8), cavitary lung disease, (OR 0.6), atypical chest radiograph, (OR 6.7), and PPD non-reactivity, (OR 13.5), PPD non-reactivity and non-cavitary disease were associated with significantly lower CD4 lymphocyte counts. Affordable serial measurements parallel the response to therapy and predict survival in HIV-associated PTB.

Evidence for a conserved binding motif of the dinuclear metal site in mammalian and plant purple acid phosphatases: 1H NMR studies of the di-iron derivative of the Fe(III)Zn(II) enzyme from kidney bean

The di-iron core of mammalian purple acid phosphatases has been reproduced in the plant enzyme from kidney bean (Mr 111000) upon insertion of an Fe(II) ion in place of the native zinc(II) in the dinuclear Fe(III)Zn(II) core. The shortening of the electronic relaxation time of the metal centre allows detection of hyperfine-shifted 1H NMR resonances, although severe broadening due to Curie relaxation prevents independent signal assignment. Nevertheless, comparison of the spectral features of the structurally characterized plant enzyme with those of the mammalian species, which were previously extensively assigned, is consistent with a close similarity of the metal-binding sites, also suggested by previous sequence-alignment studies. Some differences appear to be mainly localized at the M(II) site. Spectral comparison was also carried out on the Fe(III)Co(II) derivatives.

Supportive pentoxifylline in falciparum malaria: no effect on tumor necrosis factor alpha levels or clinical outcome: a prospective, randomized, placebo-controlled study

Pentoxifylline (POF) may suppress overproduction of tumor necrosis factor alpha (TNF alpha), which is thought to contribute to complications of human falciparum malaria. However, POF is believed to improve impaired capillary blood flow, which can be impaired in falciparum malaria. To test whether POF affects TNF alpha serum levels or other variables in this disease, we administered POF (20 mg/kg/day intravenously in 150 ml of saline for five days) randomized versus placebo (150 ml of saline without POF) in addition to standard antimalarial therapy. After recruitment of 51 patients with Plasmodium falciparum malaria, those receiving POF had more nausea and abdominal discomfort than the placebo group, as expected. Eleven of 27 patients receiving POF and three of 24 patients receiving placebo requested termination of the study medication (P < 0.05). Pentoxifylline did not change the decrease of TNF alpha levels or affect the clinical course in a significant way. Since POF failed to improve the clinical situation or to impact numerous laboratory parameters (including TNF alpha, thrombin-antithrombin III, thrombomodulin, and human neutrophil elastase), the study was terminated earlier than planned. While this study does not specifically address cerebral complications of malaria, the results suggest that POF is not useful as a routine adjunct to the standard therapy of falciparum malaria.

Blood coagulation and thrombosis in patients with ovarian malignancy

Ovarian cancer cells appear to be capable of both thrombin formation and induction of fibrin degradation which may be essential prerequisites for the development of deep vein thrombosis (DVT) as well as the spread of malignancy. To study further this coagulation-cancer interaction in 60 patients with untreated ovarian cancer of FIGO stage I-IV the incidence of DVT was recorded pre-operatively, post-operatively on day 1, 3, 5, 7, 10, before each of six cycles of Cisplatinum/ Epirubicin/Cyclophosphamide chemotherapy, during follow-up and in the post-operative period of second look surgery. In addition, blood coagulation tests results were determined prospectively. Two patients were excluded from these calculations due to previous DVT 5 to 6 weeks before the diagnosis of ovarian cancer but all patients were eligible for surgery and randomized to receive either daily low molecular weight heparin (LMWH) (n = 28) or unfractionated heparin (UFH) (n = 32) for perioperative thrombosis prophylaxis until the 7th post-operative day. According to the FIGO stage, patients were equally distributed in the 2 heparin treatment groups. The predictive value of pre-operative coagulation test results, clinical parameters, and type of heparin used were tested in univariate and multivariate analysis for development of post-operative DVT and overall patients survival. Impedance plethysmography for DVT screening was used. The presence of DVT was then confirmed by phlebography. Only D-dimer and fibrinogen levels were correlated significantly with the FIGO stage while antithrombin, protein C, and plasminogen activator inhibitor activity were not. The incidence of DVT was 6.7% (4/60) up to the 7th and 8.3% (5/60) between the 8th and 29th post-operative day. DVT occurred in 10.6% (5/47) during chemotherapy. Pre-operative coagulation test results, the type of heparin used, and clinical parameters were not significant risk factors for post-operative DVT development in univariate analysis. The D-dimer and fibrinogen levels were significant risk factors for reduced overall survival in univariate analysis but only the FIGO stage was an independent predictor (in multivariate analysis). After a median follow up of 26.5 months (min. 8 months, max. 41 months), 21.4% of LMWH treated and 37.5% of UFH-treated patients died of cancer (p = 0.26). Pre-operative test results were neither predictive for DVT nor the outcome of cancer but patients showed an improved though not statistically significant overall survival after LMWH treatment.

Reactivity of a population of armadillo lymphocytes with an antibody to human gamma,delta T-cells

Reactivity of lymphocytes from the nine-banded armadillo (Dasypus novemcinctus) was examined by flow cytometry using a panel of 16 commercially available fluorochrome-conjugated monoclonal antibodies raised against human or murine leukocyte antigens. The only reactivity observed was with antibody TCRdelta1, directed against a common determinant on the delta chain of the human gamma,delta T-cell receptor. Using this antibody, a distinct, bright population of lymphocytes was seen in the peripheral blood in all of 47 animals examined, accounting for 2.0-47.1% of lymphocytes (median, 10.6%). The gamma,delta-reactive lymphocyte population comprised a greater percentage of intraepithelial lymphocytes in the small intestine than in the blood; variable percentages of gamma,delta-reactive cells were also observed in the spleen, thymus, lymph nodes, and bone marrow, and in cutaneous lepromas. In armadillos with disseminated Mycobacterium leprae infection, a significantly greater percentage of circulating lymphocytes reacted with the anti-gamma,delta antibody. This is the first described reactivity of armadillo lymphocytes with a monoclonal antibody to a lymphocyte antigen, and it may offer a useful tool in disease models involving the armadillo.

Sera from patients with falciparum malaria induce substance P gene expression in cultured human brain microvascular endothelial cells

Substance P is a pluripotent neuropeptide capable of inducing neurogenic inflammation, immunoregulation, and vasodilatation. In an effort to contribute to the understanding of the pathophysiology of cerebral malaria, we have evaluated the effects of sera obtained from patients suffering from severe or mild malaria and from a healthy donor with no previous history of exposure to malaria on the expression of the substance P gene by cultured human brain microvascular endothelial cells (HBMEC) and human umbilical-vein endothelial cells. PCR, Southern blotting, hybridization with an internal probe, and densitometry demonstrated that treatment of HBMEC with sera from patients with severe malaria caused remarkably increased expression of the substance P gene. In HBMEC, substance P was not significantly influenced by serum from a healthy donor. Substance P was expressed at almost undetectable levels in untreated HBMEC. Treatment of cultured human umbilical-vein endothelial cells with the same sera produced no signal. The influence of different sera on the expression of substance P by HBMEC suggests that substance P expression may be involved in events leading to the development of severe malaria.

Architectural features and perceptions of community residences for people with mental retardation

Architects, group home administrators, people with mental retardation, family members of people with mental retardation, and college undergraduates substantially agreed regarding the rated homelikeness of slides of interiors of 20 community residences for people with mental retardation ranging from institutional to homey, mean r = .87. Clusters of physical features identified using an architectural inventory were found to be associated with homelikeness ratings. Adjectives applied to rooms with these features were determined using a Q-sort method. Two factors were identified from Q-sort correlations: Homelikeness-Institutionality and Spatial Organization as well as a third variable, privacy.

Interdependence of architectural features and program variables in community residences for people with mental retardation

In an earlier study, we found that architects, group home administrators, people with mental retardation, family members of people with mental retardation, and college undergraduates rated the homelikeness of slides of community residences for people with mental retardation similarly. In addition, clusters of physical features were identified that were specifically associated with homelikeness ratings. In the present study, behavior of residents with mental retardation living in those residences was assessed using the Aberrant Behavior Checklist and direct behavioral observations. After statistically controlling for confounding variables, we found that adaptive and maladaptive behavior covaried with homelikeness ratings. In addition, we were able to identify associations between specific architectural features of residential settings and the behavior of residents living in those settings.

Evaluation of tubal patency by hysterocontrast sonography (HyCoSy, Echovist) and its correlation with laparoscopic findings

In 20 patients with suspected infertility, fallopian tube patency was assessed using Doppler-supplemented hysterocontrast sonography (HyCoSy). All patients underwent transvaginal HyCoSy with the contrast agent SHU 454/Echovist prior to laparoscopy with chromopertubation (chromolaparoscopy). Following application of the Echovist contrast medium, the fallopian tubes were visualized with B-mode scanning and tubal flow was evaluated by means of Doppler sonography. None of the patients received anesthesia. We found corresponding results with regard to the tube patency between HyCoSy and conventional chromolaparoscopy in 82.5% of cases. These results make transvaginal HyCoSy a suitable first-line diagnostic procedure in patients with infertility disorders.

Blood coagulation during adjuvant epirubicin/cyclophosphamide chemotherapy in patients with primary operable breast cancer

PURPOSE

Influences of adjuvant epirubicin/cyclophosphamide (EC) chemotherapy on blood coagulation were investigated in patients with operable breast cancer and the incidence of thromboembolic events was recorded.

PATIENTS AND METHODS

In 50 consecutive node-positive breast cancer patients, serial coagulation studies (fibrinogen method of Clauss, antithrombin III, protein C amidolytic methods, D dimer enzyme-linked immunoadsorbent assay [ELISA] techniques, and plasminogen activator inhibitor [PAI] activity u-PA inhibition test) and impedance plethysmography (IPG) for screening of deep vein thrombosis (DVT) were performed preoperatively and postoperatively, before each of six cycles of adjuvant chemotherapy (60 mg/m2 epirubicin and 600 mg/m2 cyclophosphamide) and 3 months thereafter. Seventy-two healthy women served as controls.

RESULTS

During chemotherapy, the phlebographically proven DVT incidence was 10% (n = 2 after second cycle; n = 3 after third cycle). Preoperative levels of D-dimer, fibrinogen, and the PAI activity were significantly higher than in healthy women and only mean levels of the D-dimer were significantly higher in patients with DVT compared with patients without DVT. Postoperatively, only D-dimer and fibrinogen levels significantly increased, while in the course of chemotherapy, these levels were significantly decreased. Mean D-dimer levels and PAI increased steadily in patients with DVT. Preoperatively and during chemotherapy, levels of antithrombin III and protein C were within the normal range. Only one patient with DVT had decreased protein C levels throughout chemotherapy.

CONCLUSION

Monitoring with sophisticated coagulation tests during adjuvant EC chemotherapy for breast cancer does not identify patients at higher risk for DVT development. Preoperatively, in patients with later DVT, an imbalance of hemostasis is already present; thus, thrombosis might predominantly be initiated by malignancy-induced hypercoagulability and secondarily by the influence of EC chemotherapy. Prospective randomized trials must determine whether prophylactic anticoagulation during EC chemotherapy reduces the incidence of DVT.

A human SP-C promoter fragment targets alpha 1-proteinase inhibitor gene expression to lung alveolar type II cells in transgenic mice

A 1.277 kb promoter fragment of the gene encoding one of the lung surfactant proteins, SP-C, was cloned from a human genomic library and characterized using the human alpha 1-proteinase inhibitor (alpha 1PI) gene as reporter. Messenger RNA for human alpha 1PI isolated from a single transgenic mouse line was detected solely in lung tissue. Using immunogold electron microscopy, accumulation of human alpha 1PI was shown unambiguously to occur only in type II pulmonary cells and, in discrete amounts, in the alveolar lining fluid. The protein was secreted and glycosylated showing a molecular weight close to that of plasma-derived human alpha 1PI.