Treatment of CMV retinitis in an AIDS patient

We present a case of cytomegalovirus (CMV) retinitis in an AIDS patient who survived for 10 months after the start of his ocular problems. The retinitis responded to dihydroxy propoxy methyl guanine (DHPG) but relapsed four to six weeks after each course of treatment with progressive retinal destruction. One relapse was therefore treated with trisodium phosphoformate hexahydrate (Foscarnet). There are few reports of the use of this drug in the treatment of CMV retinitis with AIDS, but it appeared to be less effective in our patient than DHPG, possibly because of poor penetration of the blood-ocular barrier. A final course of outpatient maintenance therapy with DHPG failed to prevent a preterminal relapse of the retinitis. Fundus photographs demonstrated the resolution and relapse of the retinitis associated with each course of treatment. Maintenance therapy with DHPG would appear to be necessary to prevent relapse, but the logistics of this are difficult, and the effective dosage of DHPG is as yet uncertain.

Origin of Whales in Epicontinental Remnant Seas: New Evidence from the Early Eocene of Pakistan

Pakicetus inachus from the early Eocene of Pakistan is the oldest and most primitive cetacean known. The dentition of Pakicetus resembles that of carnivorous mesonychid land mammals as well as middle Eocene cetaceans. The otic region of the cranium lacks characteristic specializations of whales necessary for efficient directional hearing under water. Pakicetus occurs with a land-mammal fauna in fluvial sediments bordering epicontinental Eocene remnants of the eastern Tethys seaway. Discovery of Pakicetus strengthens earlier inferences that whales originated from terrestrial carnivorous mammals and suggests that whales made a gradual transition from land to sea in the early Eocene, spending progressively more time feeding on planktivorous fishes in shallow, highly productive seas and embayments associated with tectonic closure of eastern Tethys.

Nonsurgical diagnosis of pancreatic mass

Because of recent advances made in various diagnostic procedures, it has become easier to diagnose cancer of the head of the pancreas. Chronic pancreatitis, however, may show morphologic mass findings similar to pancreatic cancer. Twenty-three patients with a pancreatic head "mass," identified through surgical exploration, have been reviewed retrospectively with regard to differential diagnosis by comparing the preoperative findings of duodenoscopy, endoscopic retrograde pancreatography (ERP), endoscopic retrograde cholangiography (ERC), and percutaneous transhepatic cholangiography (PTC). Emphasizing the findings, value, and limitations of each procedure, we used simple morphologic criteria for our differential diagnosis. Duodenoscopic findings gave information for accurate diagnosis in 66%, ERP was correct in 50%, and ERC in 88%. PTC in 88%. PTC was helpful in establishing the correct diagnosis in 90%. This study clarifies some technical and practical aspects of these procedures. We believe duodenoscopy must be used more often for direct histologic study, cytology, and needle biopsy in addition to ductal visualization in a pancreatic head mass. PTC is recommended more strongly for use in establishing the correct diagnosis of a pancreatic head "mass."

Self-care in rural areas of India and Nepal

Self-care during illness and pregnancies by individuals and their families is a ubiquitous and integral part of societies throughout the world. This paper reports findings about self-care practices identified during four studies carried out over a ten-year period involving about 14,000 interviews in 7,400 households comprising over 48,000 people in three Indian states and three districts of Nepal. The proportion of ill individuals using self-care over a two-week period in the different study areas ranged from 19 to 42 percent. This involved 5 to 9 percent of the total population in self-care activities during these two weeks. Much larger differences were found between India and Nepal in the use of self-care during pregnancies. Self-care or care by relatives and friends was the predominant source of maternity care in Nepal, including deliveries, while Indian maternal care was dominated by traditional birth attendants. Comparisons also were made between self-care and the use of professional healers or health care services during the same time period. Differences in the use of self-care by age, sex, caste, access to government or special project services, type of illness, and duration and severity of illness have also been shown. The need for similar, better standardized surveys in combination with intensive studies examining the details and rationale behind self-care practices in different societies has been stressed as an essential step in developing programs to expand or modify self-care practices of individuals and their families.

Metastatic melanoma of the stomach: the endoscopic and roentgenographic findings and review of the literature

A case of metastatic melanoma of the stomach is reported with illustrative endoscopic and radiographic findings. Metastatic melanoma of the stomach may present with vague gastrointestinal symptoms, abdominal pain, or gastrointestinal bleeding. A history of melanoma may not be readily obtainable. When gastrointestinal symptoms occur in a patient with known melanoma, gastric metastases should be considered. Polypoid or target lesions are frequently seen on barium x-ray study. Small bowel roentgenograms should be obtained. Endoscopy, cytologic study, brushing, and biopsy may yield the diagnosis. The prognosis is poor. Surgery should be performed only to relieve significant symptoms.

Cytologic diagnosis of herpetic esophagitis. A case report

A diagnosis of herpetic esophagitis was made in a patient with alcoholic liver disease by means of endoscopy and brush cytology. Herpetic esophagitis is a common cause of esophageal ulceration in severely debilitated or immunosuppressed patients especially when the esophagus is traumatized by nasogastric intubation. Dysphagia or odynophagia may occur in some but not all patients. Radiographic picture may resemble Candida esophagitis. Endoscopy, biopsy, cytology, culture and serological studies will help in making a diagnosis. Specific antiviral agents may be used for treatment but spontaneous resolution without any sequelae was documented in our patient.