Severe carotid arterial disease: a diagnostic enigma

The development of the duplex scanner has made the diagnosis of carotid arterial disease easy to those trained in its interpretation. The difficulty lies in the ability to define the patient population most likely to benefit from early diagnosis and treatment. All patients referred to the vascular laboratories at two major hospitals for evaluation of neurologic symptoms were entered into the study. The indications for the study, comorbid conditions, and medications were tabulated and compared with the results of the carotid duplex scan. The purpose was to see whether there was a relationship between the severity of carotid arterial disease and symptoms. A total of 5,807 carotid duplex scans were performed on 5,001 patients. There were 525 patients (11%) with an internal carotid artery stenosis of >70 per cent and 252 patients (5%) with an occlusion of the internal carotid artery. In addition, there were a group of 139 patients with severe bilateral carotid disease. Bruit and a history of known carotid disease were the only indications that were statistically related to severe carotid arterial disease. Smoking, diabetes, peripheral vascular disease, cardiac conditions, and hyperlipidemia were also statistically related to patients with significant carotid disease. This study indicates that the classic indications for carotid duplex scans such as transient ischemic attack, amaurosis fugax, and dizziness have no correlation with the severity of the disease.

Use of the local lymph node assay for the estimation of relative contact allergenic potency

The effective toxicological evaluation of skin sensitization demands that potential contact allergens are identified and that the likely risks of sensitization among exposed populations assessed. By definition, chemicals which possess the toxicological property of skin sensitization potentially are capable of causing allergic contact dermatitis (ACD) in humans. However, this hazard is not an all-or-none phenomenon; clear dose-response relationships can be discerned and thresholds identified for both the induction of sensitization and the elicitation of contact dermatitis. Commonly, these parameters are grouped under the heading of potency, determination of which is vital for risk assessment. In the present investigation, the local lymph node assay (LLNA) has been employed to determine the relative potency of a range of 20 chemicals. The parameter used is the estimated concentration required to produce a 3-fold increase in draining lymph-node cell proliferative activity, the EC3 value. These measurements have been compared with an assessment of the human sensitizing potency of the 20 selected chemicals, each being assigned to 1 of 5 classes based on their human sensitizing potency. The EC3 value, derived from LLNA work carried out in acetone/ olive oil vehicle, correlated well with the human classification, with the strongest sensitizers having low EC3 values (<O.1%), weaker sensitizers having EC3 values generally in the 1-10% range, and non-sensitizing chemicals having EC3 values in excess of 100%. In conclusion, the derivation of the EC3 for a chemical provides an objective and quantitative estimate of potency that is of considerable utility for skin sensitization risk assessment.

An unusual cause of Cushing's syndrome: primary pigmented nodular adrenal dysplasia

We report a case of Cushing's syndrome due to primary pigmented nodular adrenal dysplasia (PPNAD) and discuss the diagnostic process and management of this rare case. The diagnosis of PPNAD is discussed in the context of other causes of Cushing's syndrome. Eighty-five per cent of cases of Cushing's syndrome are due to a pituitary corticotrophic tumour (Cushing's disease). Rarer causes include cortisol secreting adrenal adenoma and ectopic ACTH secretion. In the routine investigation of Cushing's disease it is not unusual to find bilateral adrenal nodules on the CT scan. We present a case of Cushing's syndrome in which this radiographic finding was present and yet the biochemical diagnosis was one of ACTH independent disease. Histology revealed PPNAD.

Endogenous monoamine oxidase inhibitory activity and HPA activation in the pig

Previously we have shown that an increase in endogenous monoamine oxidase A inhibitory activity (MAO-AI), measured in human saliva, both precedes and predicts psychological stress-induced activation of the hypothalamic pituitary adrenal (HPA) axis, as determined by the cortisol response. We now report the relationship between endogenous MAO-AI and the cortisol response in the plasma of prepubertal pigs (n=5 or 6) under two experimental paradigms of HPA activation. In the first condition, pigs were physically restrained (snaring) for 15 minutes. Blood samples were taken from indwelling catheters at intervals before and after snaring (a sampling period of about 1 hour), and at the same time intervals on a separate day to provide baseline measures. Both cortisol concentration and percentage MAO-AI were determined in each plasma sample. There was a pronounced cortisol response on the snaring day (cortisol peaked 30 minutes after the start of the snaring). There was also a significant MAO-AI response to snaring which peaked 15 minutes after the start of the stress challenge. In the second experimental paradigm, bacterial endotoxin (LPS: 20microg/pig) was used to induce HPA activation and plasma cortisol and MAO-AI were determined. This time, however, the cortisol response was not preceded by any change in MAO-AI. We conclude that generation of MAO-AI, which is associated with HPA activation induced by psychological stress, is not a component of the pathways involved in immunological stimulation of the HPA axis.

Social class, sex, and age differences in mucosal immunity in a large community sample

There have been very few reports addressing levels and distribution of commonly used PNI measures in large community samples. In this study, we report such data for secretion rates of secretory immunoglobulin A (sIgA), as determined from saliva samples taken from 1971 subjects interviewed as part of the West of Scotland Twenty-07 survey of health in West Central Scotland. Univariate analyses of demographic variables found lower sIgA and salivary flow to be significantly related to poorer social class, increased age, and being female. Smokers also had lower sIgA but not lower salivary flow. Multivariate analysis showed that demographic variables were significant predictors of sIgA independently of each other and assay variation. Adding smoking status to the equation confirmed it as an independent predictor and also indicated that social class differences in sIgA are partly explicable in terms of smoking status. In view of reported associations between sIgA levels and stress, its role as a first line of mucosal defense, and its relevance to health, these first results from a large survey are of interest. Further work is now needed to explore which factors, including psychosocial ones, may be contributing to subgroup differences.

Ectopic pregnancy

Ectopic pregnancy occurs in approximately 2% of all pregnancies in the United States, and is the nation's leading cause of first trimester maternal death. Its incidence has increased sixfold in the past 25 years, despite significant improvements in techniques for early diagnosis and management. This article reviews the epidemiology, risk factors, and common clinical presentations of ectopic pregnancy. Both traditional and newly developed strategies for diagnosis and management are described. The primary care physician is in an excellent position to screen for and diagnose ectopic pregnancy, and to counsel patients regarding treatment options and future risks. With the increasing trend toward outpatient nonsurgical management of ectopics, it is expected that the roll of the primary care physician in managing patients with ectopic pregnancy will continue to increase.

The Cortisol Response to Normal and Nocturnal Awakening

Abstract Free cortisol as measured in saliva increases markedly following awakening. It is not clear, however, whether this is truly a stress-neuroendocrine response to awakening or a manifestation of the hypothalamic-pituitary-adrenal (HPA) circadian cycle. We investigated whether the awakening cortisol response can be generated in the middle of nocturnal sleep, when secretory activity in the HPA axis is low. In a within subject design, salivary cortisol response was measured under three different awakening conditions: (1) awakening at the normal morning awakening time; (2) awakening four hours prior to normal awakening time, and (3) awakening the following morning after interrupted sleep. The overall main effect was a linear increase in free cortisol following awakening with no significant interaction with awakening condition. Cortisol levels, as determined by area under the cortisol curve calculated with reference to zero, did differ by awakening condition. The two morning awakening conditions were comparable but values were lower for night awakening. Area under the curve change (calculated with reference to the first awakening cortisol base value), however, did not distinguish the three awakening conditions. We conclude from these data that there is a clear free cortisol response to awakening for both nocturnal and morning awakening although the absolute levels produced are lower for nocturnal awakening when basal cortisol is low. Nocturnal interruption of sleep did not affect the subsequent morning response.

Manometry based randomised trial of endoscopic sphincterotomy for sphincter of Oddi dysfunction

BACKGROUND

Endoscopic sphincterotomy for biliary-type pain after cholecystectomy remains controversial despite evidence of efficacy in some patients with a high sphincter of Oddi (SO) basal pressure (SO stenosis).

AIM

To evaluate the effects of sphincterotomy in patients randomised on the basis of results from endoscopic biliary manometry.

METHODS

Endoscopic biliary manometry was performed in 81 patients with biliary-type pain after cholecystectomy who had a dilated bile duct on retrograde cholangiography, transient increases in liver enzymes after episodes of pain, or positive responses to challenge with morphine/neostigmine. The manometric record was categorised as SO stenosis, SO dyskinesia, or normal, after which the patient was randomised in each category to sphincterotomy or to a sham procedure in a prospective double blind study. Symptoms were assessed at intervals of three months for 24 months by an independent observer, and the effects of sphincterotomy on sphincter function were monitored by repeat manometry after three and 24 months.

RESULTS

In the SO stenosis group, symptoms improved in 11 of 13 patients treated by sphincterotomy and in five of 13 subjected to a sham procedure (p = 0.041). When manometric records were categorised as dyskinesia or normal, results from sphincterotomy and sham procedures did not differ. Complications were rare, but included mild pancreatitis in seven patients (14 episodes) and a collection in the right upper quadrant, presumably related to a minor perforation. At three months, the endoscopic incision was extended in 19 patients because of manometric evidence of incomplete division of the sphincter.

CONCLUSION

In patients with presumed SO dysfunction, endoscopic sphincterotomy is helpful in those with manometric features of SO stenosis.

Psychological and sex features of delayed gut transit in functional gastrointestinal disorders

BACKGROUND

The relation of demographic and psychological factors to the presence and extent of gut transit impairment in the functional gastrointestinal disorders has received little attention.

AIMS

To compare the psychosocial and demographic features of patients with functional gastrointestinal disorders and delayed transit in one region of the gastrointestinal tract with those displaying more widespread delayed transit (that is, delay in two or three regions), and those with normal transit in all three regions.

PATIENTS

Of 110 outpatient participants who satisfied standardised criteria for functional gastrointestinal disorders, 46 had delayed transit in one region, 32 had delay in two or three regions, and 17 exhibited normal transit in all regions.

METHODS

Transit in the stomach, the small intestine, and the large intestine was assessed concurrently using a wholly scintigraphic technique; psychological status was assessed using established psychometric measures.

RESULTS

Patients with delayed transit displayed demographic and psychological features that contrasted with patients with normal transit in all regions. In particular, widespread delayed transit featured female sex, a highly depressed mood state, increased age, frequent control of anger, and more severe gastric stasis, while the features distinguishing normal transit were male sex and high levels of hypochondriasis.

CONCLUSION

These data suggest the existence of a distinct psychophysiological subgroup, defined by the presence of delayed transit, in patients with functional gastrointestinal disorders.

Free radicals and hearing. Cause, consequence, and criteria

Reactive oxygen and nitrogen species, including free radicals, are produced in the human body in both health and disease. In health, they may arise as regulatory mechanisms, intercellular signaling species, or as bacteriocidal agents. Their production is normally controlled by the antioxidant defense mechanisms that include intracellular enzymes--for example, glutathione peroxidase and superoxide dismutase--and low molecular-mass compounds such as vitamin E or ascorbic acid. Although repair mechanisms exist, some steady-state basal oxidative damage occurs in all individuals. Oxidative stress arises when there is a marked imbalance between the production and removal of reactive oxygen and nitrogen species. This may originate from an overproduction of these substances or from a depletion in the antioxidant defenses. Certain drugs may induce oxidative stress by forming drug-derived radicals that can not only deplete the antioxidant defenses but can also react directly with biomolecules. To be able to assess whether oxidative stress is occurring in a particular tissue, reliable biomarkers of oxidative damage are required. Since oxidative stress can damage all major biomolecules in vitro and probably in vivo, biomarkers for DNA, protein, and lipid damage are being developed which, when taken with an assessment of the antioxidant status of the individual, will allow evaluation of the involvement of oxidative stress in the etiology of disease and in the side effects of drugs. There is some evidence to suggest that free radical-mediated damage may be involved in the ototoxicity of aminoglycosides and cisplatin derivatives. Whether this is a cause or consequence of the toxic insult to the sensory hair cells of the inner ear remains to be determined.

Getting real about virtual commerce

In its first generation, electronic commerce has been a landgrab. Space on the Internet was claimed by whoever got there first with enough resources to create a credible business. It took speed, a willingness to experiment, and a lot of cybersavvy. Companies that had performed brilliantly in traditional settings seemed hopelessly flat-footed on the Web. And despite their astronomical valuations, the new e-commerce stars have appeared to be just as confused. Many have yet to make a profit, and no one has any idea when they will. Now, the authors contend, we are entering the second generation of e-commerce, and it will be shaped more by strategy than by experimentation. The key players--branded-goods suppliers, physical retailers, electronic retailers, and pure navigators--will shift their attention from claiming territory to defending or capturing it. They will be forced to focus on strategies to achieve competitive advantage. Success will go to the businesses that get closest to consumers, the ones that help customers navigate their way through the Web. Indeed, the authors argue, navigation is the battlefield on which competitive advantage will be won or lost. There are three dimensions of navigation: Reach is about access and connection. Affiliation is about whose interests the business represents. And richness is the depth of the information that a business gives to or collects about its customers. Navigators and e-retailers have the natural advantage in reach and affiliation, while traditional product suppliers and retailers have the edge in richness. The authors offer practical advice to each player on competing in the second generation of e-commerce.

Culture of human renal tubular cells: positive selection of kallikrein-containing cells

Human renal tubular cells derived from nephrectomy specimens were maintained in culture and grown to confluence. Immunocytochemistry, using a panel of antibodies selected for their ability to bind to different cell types within the nephron, showed the cells to be predominantly of epithelial origin with no significant contamination by fibroblasts or cells of endothelial origin. Ten to thirty percent of the cells expressed the putative distal marker, epithelial membrane antigen (EMA), a finding confirmed by flow cytometry. Cells expressing EMA were positively selected from mixed cultures by magnetic activated cell sorting (MACS). Kallikrein activity, expressed as mU/10(6) cells, in the EMA +ve cells, was increased fourfold to sixfold when compared with that in the EMA -ve cells. Cultures of characterized human renal tubular cells and sub-populations enriched with distal cells should prove useful in studies of synthesis and release of parameters of the kallikrein kinin system (KKS) to physiological stimuli. Furthermore, a better understanding of the toxic effect on the KKS of clinically useful drugs, particularly those used for immunosuppression, may lead to therapeutic interventions to lessen unwanted effects.

Formation and loss of nitrated proteins in peroxynitrite-treated rat skin in vivo

Peroxynitrite is a reactive cytotoxic species, capable of nitrating tyrosine residues to form 3-nitrotyrosine. Little is known about the formation and loss of nitrated proteins in vivo. We have measured nitrated proteins, by enzyme-linked immunosorbent assay, in rat skin after exposure to peroxynitrite. Peroxynitrite (100-200 nmol site(-1)) was injected into the skin of anesthetized rats. At the highest dose 78.6 +/- 9.5 pmol mg(-1) protein of nitrated BSA equivalents were measured at 4 h and a significant increase was observed for 24 h after administration in skin samples. The loss of nitrated proteins from skin appeared biphasic with an initial (t(1/2) = 2 h) and slower loss (t(1/2) = 22 h). A major nitrated protein was identified as albumin by Western blot analysis. The data demonstrate that a single exposure to peroxynitrite can lead to the presence of nitrated proteins in skin for at least 24 h. The sustained presence of nitrated proteins may influence the inflammatory process in skin disease.

A 5-year residency curriculum in obstetrics, gynecology, and family medicine

OBJECTIVE

To develop a curriculum for residents in obstetrics and gynecology that also provides training in family medicine.

METHODS

We designed a 5-year curriculum with 36 months of obstetrics and gynecology, 12 of which are as chief resident, with a 4-month rotation through family medicine to meet the primary care requirements, and rotations of 1 month each in geriatrics and emergency medicine. The curriculum includes the 30 months of required rotations mandated by family medicine (three of which are in obstetrics and gynecology), with the 6 months' available elective time allocated to obstetrics and gynecology.

RESULTS

The Residency Review Committee for Obstetrics and Gynecology accredited the curriculum, which meets the Accreditation Council for Graduate Medical Education Special Requirements for Family Medicine, in August 1996.

CONCLUSION

This 5-year residency curriculum educates physicians in both obstetrics and gynecology, and family medicine, and graduates are eligible to pursue board certification in both specialties.

The awakening cortisol response and blood glucose levels

The hypothalamic-pituitary-adrenal axis is characterized by a marked circadian cycle with heightened activity in the morning. This is synchronized to awakening such that free cortisol increases two to three fold in the first thirty to forty five minutes following awakening -- the awakening cortisol response. It has been suggested that this activity, by mobilizing energy reserves prepares the body for the metabolic demands of the day. Similar arguments are applied to the cortisol response to psychological challenge. Paradoxically the cortisol response to a psychosocial stressor is abrogated in fasted individuals with low blood glucose. Also cortisol response to a psychosocial stressor is positively correlated to blood glucose levels after glucose load. We examined if the same relationship applies to the awakening cortisol response. There was no correlation between the cortisol response and awakening blood glucose levels. Moreover a group with mean blood glucose at the bottom of the euglycemic range, identified by split at the median for glucose level upon awakening, showed no deficit in cortisol response. Hence the physiology of the awakening response differs to that of a psychological stress response. These data challenge the view that an oxidisable substrate for energy metabolism is permissive for cortisol responses. In addition the present findings do not support a predominantly gluconeogenic role for morning cortisol activation.

A 12-month randomized controlled trial of patient education on radiographic changes and quality of life in early rheumatoid arthritis

OBJECTIVE

In rheumatoid arthritis, education programmes successfully impart knowledge but, notwithstanding issues of empowerment, this knowledge has to be translated into behavioural change to have a chance of improving disease outcome. Arguably, behavioural change must also occur early if outcomes are to be improved. For these reasons, we planned a study of patient education in early disease, with radiological damage and quality of life as the main outcome variables.

METHODS

We performed a randomized controlled trial in people with rheumatoid arthritis of < 5 yr duration. The main intervention was a 4 week education programme, each weekly session lasting 2 h. Assessments were made at entry, at 4 weeks and at 12 months. The main outcome variables were the modified Larsen radiological score for the hands and the SF-36 quality of life questionnaire. Secondary outcome variables were the Health Assessment Questionnaire (HAQ), Ritchie Articular Index (RAI), Patient Knowledge Questionnaire (PKQ), Compliance Questionnaire (CQ), plasma viscosity (PV), pharmaceutical changes and consulting behaviour.

RESULTS

The patient numbers were 34 (10 male, 24 female) for the control group and 43 (16 male, 27 female) for the education group. The groups were matched for age (56.5 yr for control, 55 yr for education), disease duration (3.5 yr vs 3.0 yr) and duration of second-line drug therapy (14 months vs 12 months). We found no significant difference between the groups for Larsen scores at 12 months, although scores for the education group were lower (39.5 vs 43.0, P = 0.13). The 'social functioning' and 'general health perception' subscales of the SF-36 showed a significant improvement in the education group, but no significant differences between groups were seen. No significant differences were found for the HAQ, RAI, PV and CQ, but the education group had more disease-specific knowledge than the control group at 12 months (PKQ scores: 17 vs 21, P = 0.0002). No differences were found for out-patient visits and in-patient admissions, but the education group had slightly more changes in second-line drugs during the study (0.43 changes/person in the control group, 0.51 changes/person in the education group).

CONCLUSIONS

We found no significant difference between the groups in our primary outcome measures, but a trend in favour of the education group was found in radiological progression. Further studies of this kind, using larger patient numbers, are required since the difference may result from improved self-care, better compliance with joint protection strategies and, possibly, improved drug compliance.

Effect of surface chemical modification of bioceramic on phenotype of human bone-derived cells

In the search for methods to improve the biocompatibility of prosthetic materials, attention has recently been directed toward the potential use of surface chemical modification and its influence on cellular behavior. This in vitro study investigates the effect of surface chemistry modification of bioceramics on human bone-derived cells (HBDCs) grown on biomaterial surfaces for 2 weeks. Cells were cultured on either alumina (Al2O3), alumina doped with magnesium ions ([Mg]-Al2O3), or hydroxyapatite (HAP), as well as tissue culture polystyrene (TCPS). Expression of alkaline phosphatase (ALP), thrombospondin (Tsp), osteopontin (OP), osteocalcin (OC), osteonectin (ON/SPARC), type I collagen (Col I), and bone sialoprotein (BSP) were determined in terms of mRNAs and proteins. Protein levels for ALP, OP, OC, and BSP were significantly (p < 0. 05) greater at day 5 in HBDCs cultured on [Mg]-Al2O3 compared to those cells grown on Al2O3. At day 14 the levels of ALP, Tsp, Col I, OP, ON/SPARC, and BSP rose significantly (p < 0.05) above those occurring in HBDCs grown on Al2O3, HAP, and TCPS. This suggests that HBDCs from the same patient respond to differences in the surface chemical groups. This study confirms that the chemistry of a substratum, which facilitates cellular adhesion, will enhance cellular differentiation.

The effect of stress on salivary cortisol in panic disorder patients

BACKGROUND

Various findings suggest the possibility of an abnormal cortisol response to CRH in panic disorder patients, which raises the question of whether such patients might also produce an abnormal cortisol response to stress. The purpose of the present study was to use salivary cortisol measurement in assessing differences in response to novelty/mild stress situations between panic disorder subjects and controls.

METHODS

Subjects were recruited by means of posters and subsequently screened for suitability as controls or panic subjects. Twenty-four panic disorder (PD) sufferers and 15 panic-free control subjects were tested on a range of psychometric and physiological measures, at both the start and the end of the experiment. Subjects were tested at the beginning for state anxiety, salivary cortisol, heart rate, and blood pressure, and these tests were repeated at the end of the session (which had been designed to promote reassurance).

RESULTS

The state anxiety scores (STAI) showed a reduction in anxiety level over the test period, and there was a corresponding fall in both blood pressure and heart rate for both groups. Cortisol levels also fell over the course of the interview in the control group, but in the PD group cortisol levels showed no such reduction. In addition, there was a significant difference in the levels of cortisol at the start of the session between the two groups (PD group lower).

CONCLUSIONS

These data indicate a possible alteration in cortisol responsiveness to stress/novelty situations in PD subjects. This was considered to be consistent with previous suggestions of HPA axis dysregulation in PD patients, although our research indicates unresponsiveness rather than responsiveness to be a factor to be considered for future investigation.

CLINICAL IMPLICATIONS

Our results suggest that not all subjects suffering PD may benefit from stress reduction therapies as a first choice of treatment for their panic attacks. The existence of nocturnal panic attacks (considering sleep as a combination of mental and physical relaxation), in the absence of nightmares, as well as the induction of panic attacks during relaxation support this view.

LIMITATIONS OF THE STUDY

Apart from the difficulty in accessing sufficient symptomatic subjects, the induction of higher levels of stress could be useful for confirmation of these results. However, this requires specialist support in case of subjects developing panic attacks during the experiments, which was not available during the present study.

SUMMARY

Twenty-four panic disorder (PD) sufferers and 15 panic-free control subjects were tested on a range of psychometric and physiological measures, at both the start and the end of an experimental session. Subjects were tested at the beginning for state anxiety, salivary cortisol, heart rate, and blood pressure, and these tests were repeated at the end of the session. The state anxiety scores (STAI) showed a reduction in anxiety level over the test period for both groups, and there was a corresponding fall in both blood pressure and heart rate. Cortisol levels also fell over the course of the session in the control group, but in the PD group cortisol levels showed no such reduction. In addition, there was a significant difference in the levels of cortisol at the start of the session between the two groups (PD group lower). These data indicate a possible alteration in cortisol responsiveness to stress/novelty situations in PD subjects. This was considered to be consistent with previous suggestions of HPA axis dysregulation in PD patients, although our research indicates unresponsiveness rather than responsiveness to be a factor to be considered for future investigation.

Comparison of cytokine secretion profiles provoked in mice by glutaraldehyde and formaldehyde

BACKGROUND

Glutaraldehyde and formaldehyde are commonly used sterilizing agents that are known skin sensitizers. There is some controversy, however, regarding their capacity to cause respiratory allergy. The authors have demonstrated previously that topical exposure of mice to chemical contact allergens such as 2,4-dinitrochlorobenzene (DNCB) or respiratory allergens such as trimellitic anhydride (TMA) induces characteristic cytokine secretion profiles consistent with the selective activation of T helper1 (TH1)- and TH2-type cells, respectively.

OBJECTIVE

To investigate the quality of immune response provoked following topical exposure of mice to these materials.

METHODS

BALB/c strain mice were exposed topically to 50% formaldehyde or to various concentrations of glutaraldehyde in acetone. Control animals were treated concurrently with the reference contact allergen DNCB (1% in acetone:olive oil [AOO]) or with the reference respiratory sensitizer TMA (10% in AOO). Thirteen days after the initiation of exposure, draining lymph node cells (LNCs) were cultured for 12-120h and cytokine content of supernatants analysed by cytokine-specific enzyme-linked immunosorbent assay.

RESULTS

DNCB-alpha and formaldehyde-activated LNCs produced high levels of the TH1-type cytokine interferon gamma, but little of the TH2-type products interleukins 4 and 10. TMA- and glutaraldehyde-stimulated LNCs displayed the converse TH2-type pattern of cytokine expression.

CONCLUSIONS

These data are consistent with glutaraldehyde, but not formaldehyde, having significant potential to cause allergic sensitization of the respiratory tract.

Primary nonampullary/periampullary adenocarcinoma of the duodenum

Primary duodenal adenocarcinoma not involving the ampullary region is rare. Our aim was to review the outcome of these patients and determine the factors that affect survival. We performed a retrospective review of all patients with primary, nonampullary duodenal adenocarcinoma at the Cleveland Clinic Foundation from January 1986 through December 1996. Twenty-six patients with primary, nonampullary duodenal malignancies were identified. There were 16 adenocarcinomas, 3 gastrinomas, 3 stromal tumors, 3 leiomyosarcomas, and 1 carcinoid tumor. Patients with adenocarcinoma had symptoms present an average of 6.1 months. Tumors were identified by upper gastrointestinal contrast study and esophagogastroduodenoscopy in 90 per cent and 87 per cent of patients, respectively. Twelve of 13 (93%) cancers found in the third or fourth portion of the duodenum were adenocarcinomas. Seven of the 16 adenocarcinomas were resectable on exploration. Those that were contained within the serosa have not recurred (mean, 6 years); one of the two patients with locally invasive adenocarcinoma remains disease free. The average survival for patients with unresectable disease was 6.7 months. The 5-year survival rates were: all adenocarcinoma, 38 per cent; resectable, 86 per cent; and unresectable, 0 per cent. All patients presenting with weight loss or obstructive symptoms died of disease; those with melena survived long term. Patients with tumors other than adenocarcinoma had a 90 per cent 5-year survival. We conclude that patients typically present with a long history of symptoms. Distal duodenal malignancies are most frequently adenocarcinomas. Upper gastrointestinal contrast study or endoscopy is often diagnostic. Patients with weight loss and/or obstructive symptoms had invasive disease and a morbid prognosis. Aggressive surgery is warranted, and most with resectable disease (86%) had long-term survival.