In vitro activities of fleroxacin, cefetamet, ciprofloxacin, ceftriaxone, trimethoprim-sulfamethoxazole, and amoxicillin-clavulanic acid against rare members of the family Enterobacteriaceae primarily of human (clinical) origin

Fleroxacin and cefetamet were evaluated in vitro against 38 infrequently encountered species (250 strains) of the family Enterobacteriaceae and compared with four established compounds. For all the strains tested, the fleroxacin MIC was less than or equal to 0.5 mg/liter, and for 98% of strains the cefetamet MIC was less than or equal to 8 mg/liter; even though the two new compounds did not quite reach the activities (on a weight-by-weight basis) of ciprofloxacin and ceftriaxone, respectively, they nonetheless clearly surpassed trimethoprim-sulfamethaxazole and amoxicillin-clavulanic acid. The very potent new oral compounds tested in this study appear to be promising for the treatment of clinically relevant infections due to uncommon species of Enterobacteriaceae.

Nasopharyngeal craniopharyngioma. Case report and literature review

Craniopharyngioma is an intracranial tumor that occurs rarely in the infrasellar region. Eight patients with craniopharyngioma located within the nasopharynx have been reported previously. These cases originated in the nasopharynx and involved the sella turcica (6), the sphenoid sinus (1), and the vomer (1). Craniopharyngioma usually originates intracranially. When there is no evidence of sellar involvement, the tumor most likely arises along the path of the craniopharyngeal duct. According to the neurosurgical literature, the optimal treatment consists of total surgical excision. Incomplete tumor removal is supplemented by adjunctive radiotherapy, which has been shown to significantly increase the survival rate. A patient with craniopharyngioma of the nasopharynx and paranasal sinuses who presented with nasal obstruction is reported. Radiographic studies were employed for tumor evaluation, and biopsy was done to establish the histopathologic diagnosis. Treatment included a combination of surgical excision and irradiation.

Techniques for obtaining the diagnosis of malignant breast lesions

Although fine needle aspiration is an efficacious method for diagnosing the palpable breast cancer, a negative aspirate does not exclude the presence of a malignancy. Open breast biopsy remains the standard of care in diagnosing a malignant breast lesion. All breast biopsies should be planned as if the scar were to be excised by a definitive surgical procedure (either mastectomy or tylectomy). New lesions in the treated breast require immediate biopsy because of the high likelihood of recurrent disease. Preferably, definitive surgery for malignancy should not be delayed more than 2 weeks after biopsy.

Pulmonary coin lesions caused by Dirofilaria immitis

The dog heartworm Dirofilaria immitis has been diagnosed by thoracotomy as the etiology of neoplastic-appearing nodules in two patients in the Peoria, Illinois area. This brings the total number of reported cases of human pulmonary dirofilariasis to approximately 81 in the United States. The major concern of this benign disease is that in making the diagnosis the patients undergo the risk of surgery because of the presumed preoperative diagnosis of cancer. Greater awareness of this disease is needed as the geographic distribution of human pulmonary dirofilariasis expands in this country.

Airway compromise from nasal obstruction in neonates and infants

Nasal obstruction in neonates can cause significant airway compromise and even be life-threatening. In general, otolaryngologists are familiar with management of the neonate born with choanal atresia but there have been few reports and there are no guidelines for management of the neonate or young infant who presents with nasal obstruction and airway compromise but who does not have choanal atresia (NOWCA). This study demonstrates the difficulty in diagnosis, variability in severity of airway compromise, and delineates the problematic aspects of management.

Neurological manifestations of osteoid osteoma

The clinical and radiological features of 38 children with osteoid osteomas were analysed retrospectively. Twenty nine patients had lesions of the femur (n = 17) or tibia (n = 12). The mean duration from the onset of symptoms to diagnosis was 13.8 months. In seven patients the history of pain and abnormalities on examination suggested a possible neurological disorder. Fourteen of 29 patients (48%) with femoral or tibial osteomas had localised muscle atrophy, and 10 patients (34%) had diminished or absent deep tendon reflexes in the affected limb. Two patients had painless lesions. Six patients had normal plain radiographs. Delay in the diagnosis of osteoid osteoma may be prevented by the knowledge that pain may be referred or radicular, that the concomitant occurrence of muscle atrophy and depressed deep tendon reflexes are relatively common findings, and that the characteristic radiological features may only appear late in the course of the disease.

Pulmonary tumor thrombotic microangiopathy with pulmonary hypertension

Pulmonary tumor thrombotic microangiopathy is characterized by fibrocellular intimal proliferation of small pulmonary arteries and arterioles in patients with metastatic carcinoma. Its morphologic features, including precursor lesions, were studied in 21 patients diagnosed in 630 consecutive autopsy cases with carcinoma (3.3%). Nineteen of 21 patients had adenocarcinoma and 11 of these 19 patients had gastric carcinoma. The pathogenetic events start with microscopic tumor cell embolism. Tumor emboli do not occlude affected vessels but induce both local activation of coagulation and fibrocellular intimal proliferation, which lead into stenosis or occlusion. Hemodynamically, an increase in vascular resistance results in pulmonary hypertension. In three patients, metastatic carcinoma was unknown before death, and the condition was diagnosed as pulmonary hypertension of unknown origin. Thus, pulmonary tumor thrombotic microangiopathy should be considered in the differential diagnosis of primary pulmonary hypertension, particularly in patients with well-known carcinoma who develop acute or subacute cor pulmonale.

Massive primary chylopericardium: a case report

A large pericardial effusion was discovered in an asymptomatic 12-year-old boy admitted for an elective orthopedic procedure. On physical examination, heart rate was 96 and blood pressure was 130/70 without paradox. The neck veins were not distended, but heart tones were distant. Chest roentgenogram (CXR) showed an enlarged cardiac silhouette. Echocardiogram showed a massive pericardial effusion compressing the right atrium, with depressed ventricular contractility. Pericardiocentesis yielded 450 mL of chylous fluid. A percutaneous pericardial drain was placed and drained another 400 mL of chyle. Pericardial fluid reaccumulated even though the patient was on a low-fat diet, and 1 week after admission left thoracotomy was performed with partial pericardiectomy and pericardial window. There was 1 L of chyle in the pericardial sac; frozen section of the pericardium showed lymphangiectasia. Chest tube drainage diminished rapidly and the patient was discharged. Follow-up CXR at 1 week showed fluid in both pleural spaces requiring bilateral tube thoracostomies again draining chyle. Even with total parenteral nutrition (TPN), 500 mL/d of chyle drained from the pleural tubes. Right thoracotomy with ligation of the thoracic duct was performed after 1 week of TPN. Pleural drainage abruptly dropped, and there has been no reaccumulation in either the pleural spaces or pericardium at 6-month follow-up. This case dramatically supports early thoracic duct ligation and partial pericardiectomy as the treatment of choice for primary massive chylopericardium.

Tarsal tunnel syndrome: review of the literature

Tarsal tunnel syndrome is defined as entrapment of the posterior tibial nerve at the level of the ankle. The syndrome has been associated with traumatic inflammatory etiologies. The diagnosis is made clinically by the presence of dysesthesia in the distribution of the medial and lateral plantar nerves, a positive Tinel's sign, paresthesias with compression of the nerve at the tarsal tunnel, tenderness of the nerve along its course (Valleix Phenomenon), and sensory or motor changes. Most authors suggest surgical decompression for the treatment of tarsal tunnel syndrome. The purpose of this review is to summarize the etiologies of tarsal tunnel found in the literature, to evaluate the current role of electrodiagnosis in the diagnosis of tarsal tunnel syndrome and to examine the results of treatment modalities presented.

Rehabilitation of burned patients with bilateral above-knee amputations

Bilateral above the knee amputations occur rarely in the seriously burned population. In a 6-month interval, two patients were treated in our Burn Center whose trauma necessitated bilateral above-knee amputations. This led us to review our experience with such cases. A review of 5018 patients treated over a 28-year period identified six patients over a 20-year period who had bilateral above-knee amputations, four of whom survived. These patients were found to have large and deep burns, concomitant injuries and a number of complications. Recovery was time consuming and costly. Physical therapists were challenged to create adaptations of traditional methods to meet the rehabilitation needs of these patients. The patients who survived remain wheelchair bound and unemployed, but are socially active, appear relatively well adjusted and report themselves satisfied with their lives. During a period of time when technological advances in medicine are ensuring survival of victims of massive trauma, questions are raised concerning the advisability of resuscitation. Knowledge gained in the treatment of these patients who are both burned and have had bilateral above-knee amputations can be reassuring to care providers with limited experience with such massive injury.

Streptokinase therapy for extensive venous thromboses in a patient with severe ulcerative colitis

Thromboembolic disease is a known complication of patients with inflammatory bowel disease and often is associated with increased morbidity and mortality. In a patient with severe ulcerative colitis, extensive venous thromboses developed in three extremities. Despite active bleeding in the lower gastrointestinal tract, he was successfully managed preoperatively with infusions of streptokinase followed by full-dose heparinization. During the 48 hours he received streptokinase, his venous thromboses resolved dramatically. Within 2 weeks after admission, he underwent an uneventful proctocolectomy in conjunction with an ileoanal anastomosis.

When a Stingray Strikes

In brief Untoward encounters with hazardous marine animals are in creasing as more people take to the water for recreation, work, or science. This article reviews the most common envenomations and outlines their treatment. These injuries can be mild to severe; some are life threatening. Usually, marine animal stings can be treated effectively with topical agents, while spine-puncture envenomations respond to hot-water immersion (to inactivate venom proteins) followed by analgesics and wound care as needed. In rare instances, life-support measures may be needed. Prevention depends on learning these animals' habits.

Psychiatric distress in systemic lupus erythematosus outpatients

A belief exists that systemic lupus erythematosus (SLE) patients have more psychiatric symptoms than patients with most other medical illnesses and that they often are as psychiatrically disturbed as psychiatric patient groups. These beliefs did not prove to be true for SLE outpatients. Twenty-two outpatients with SLE, 81 general medical outpatients, and 40 psychiatric outpatients were screened with psychometrically validated self-report instruments designed to assess psychiatric symptoms and stress. The SLE outpatients' psychiatric symptoms and stresses were much more similar to those reported by general medical outpatients, rather than by psychiatric outpatients, except in a few areas, and SLE patients were significantly less distressed than psychiatric patients in all areas except those relating directly to their SLE.

Guillain-Barré Syndrome Part 1. Background and Diagnosis

Few articles have been written specifically for therapists treating patients with Guillain-Barré syndrome (GBS). This literature review is intended as a quick reference on the disease. It concentrates on the signs and symptoms of GBS and looks at its aetiology and incidence.

Sexual assault of men: a series

The case records of five male victims of sexual assault presenting to two genito-urinary clinics are presented. The cases were chosen to illustrate the variety of presentations and possible sequelae of sexual assault of adult males.

Radiologic imaging of inflicted injury in the child abuse syndrome

Injuries associated with child abuse may involve any anatomic focus and organ system. Although many if not most of the injuries associated with physical abuse cannot serve as definitive evidence of maltreatment, awareness of patterns of injuries in abused infants and children initially may serve to identify potential victims of abuse and stimulate more thorough clinical and radiologic investigation. It is essential that less familiar intracranial and abdominal injuries be thoroughly evaluated for possible abuse when circumstances suggest maltreatment, or no plausible explanation is given for radiologic findings.

Intrahepatic cholestasis and phospholipidosis associated with the use of trimethoprim-sulfamethoxazole

Although liver injury after administration of the trimethoprim-sulfamethoxazole combination is rare, hepatocellular necrosis and cholestasis have developed in a few cases. We describe a patient who developed a severe, prolonged cholestatic reaction after trimethoprim-sulfamethoxazole administration. The findings from serial liver biopsy samples showed characteristic abnormalities of phospholipidosis that have not been previously described for trimethoprim-sulfamethoxazole-related hepatic injury. The most prominent finding on electron microscopic evaluation of the liver was the presence of prominent hepatocyte lysosomal inclusions characterized by concentric arrangements of membranous and lamellated structures. The patient improved after several courses of exchange plasmapheresis, which may have assisted in the removal of toxic drug-lipid complexes. The pathogenesis of this acquired secondary phospholipidosis is unknown. Possible mechanisms include generation of highly lipid-soluble metabolites and inhibition of the lysosomal enzyme phospholipase A1.

Ultrasound guidance. For interventional and intraoperative techniques in infants and children

Since the advent of improved realtime ultrasound (US) imaging and the availability of the needle biopsy attachment, US-guided percutaneous biopsy and the drainage procedure can be performed safely in the pediatric patient. The authors review their experience over 3 years using US-guided interventional techniques in 96 children aged 5 days to 21 years. A wide variety of procedures were performed and included renal biopsy, nephrostomy tube placement, renal mass biopsy, puncture of bladder sinus tract and pancreatic pseudocyst, ventriculoperitoneal shunt placement and intraoperative localization of brain or renal tumor and renal calculi. No complication occurred. US can be safely and accurately used as guide for interventional procedures in children as long as the area of interest can be clearly demonstrated and the depth and necessary angle of needle insertion can be predetermined as feasible.

Tolerance of intravitreal povidone-iodine in rabbit eyes

Povidone-iodine is frequently instilled on to the conjunctival surface prior to intraocular surgery in order to prevent septic endophthalmitis. A small amount of povidone-iodine is inevitably introduced into the eye when it is used in this manner. The toxicity of intravitreal povidone-iodine was assessed in rabbit eyes by injecting 0.1 ml of povidone-iodine in concentrations of 0.05%, 0.5% and 5% into the vitreous cavity. The injected eyes were evaluated by clinical examination, anterior segment and fundus photography, endothelial cell counts, electroretinography and histopathology. Compared to control eyes, no changes were observed in all 6 eyes injected with 0.1 ml of 0.05% povidone-iodine solution. 9 of 10 eyes tolerated a concentration of 0.5% with no detectable adverse changes. One eye developed a temporary mild iritis and mild suppression of the ERG. Intra-retinal hemorrhages, edema, arteriolar narrowing and retinal edema were seen one week following injection. Mild retinal necrosis of the same area was seen on histology. All 4 eyes injected with 5% povidone-iodine developed temporary hypotony and iridocyclitis. A dense cataract developed in all eyes. Full thickness retinal necrosis and a profound lasting reduction in the ERG was produced in all of these eyes. No corneal epithelial or endothelial changes were observed in any eye in this series. Low concentrations of intravitreal povidone-iodine likely to be produced by instillation prior to surgery are tolerated by rabbit eyes. The concentrations tolerated by the studied eyes are near reported bactericidal levels.

Long-term follow-up of brachial artery ligation in children

Ligation of the brachial artery in the antecubital fossa in children can be performed without limb loss, but the effect on subsequent limb growth is unknown. From 1969 to 1974, brachial artery ligation for insertion of a Scribner shunt was performed in 27 patients with a mean age of 8.4 years (range, 3 to 15 years). We examined 11 patients, all with functional renal transplants, a mean of 15.8 years (range, 13 to 18 years) after ligation. Nine patients had unilateral ligation and two had bilateral ligation. The patients were examined for arm length and circumference, resting blood pressure at the wrist, neurologic function of the arm, and exercise tolerance. A significant difference in resting arterial pressures in the ligated extremity was uniformly noted (mean systolic pressure 106 mmHg versus 123 mmHg in 7 patients, p less than 0.01). Although no patient specifically complained of problems with the ligated side, six of nine patients with unilateral ligation experienced arm discomfort on stress testing. There was no significant difference in limb circumference or length between the ligated and unligated extremity. Ligation of the brachial artery in growing children with renal disease caused diminished resting pressure and mildly decreased exercise tolerance but did not lead to limb loss or subsequent growth abnormalities.

Long-lasting contact urticaria from castor bean

Type I (immediate) and type IV (delayed) allergic reactions to castor bean developed in a stockroom worker in a coffee roasting plant. The exceptionally strong contact urticarial patch rest reaction persisted for more than 48 hours and was therefore called "long-lasting contact urticaria." Light and electron microscopic observations indicated that eosinophils and mast cells were activated and participated in patch test reactions, which include both type I and type IV allergic reactions. Although patch testing is an absolute prerequisite for an accurate diagnosis of delayed allergy, it should be stressed that skin tests should not be performed with castor bean because of its toxicity and potential danger.

Flat condylomata of the penis presenting as patchy balanoposthitis

Fifty patients presenting with either primary or recurrent patchy balanoposthitis which became aceto-white after the application of 5% acetic acid underwent biopsy. Microbiological screening, including Grocott staining of the biopsy material for fungal hyphae was performed. Forty nine biopsies showed marked koilocytosis suggestive of human papilloma virus (HPV) infection, and of these, only three showed fungal hyphae. This study suggests that HPV may be associated with some cases of patchy balanoposthitis.

Efficacy of diltiazem in the treatment of diffuse oesophageal spasm

Calcium antagonist relax smooth muscle, a possible useful concept in treatment of diffuse oesophageal spasm. Therefore the effects of oral diltiazem (60 mg t.d.s.) and placebo were compared in eight patients with diffuse oesophageal spasm in a 10-week double-blind crossover study. The patients recorded the severity of chest pain and/or dysphagia in daily pain diaries using visual analogue scales. Chest pain index and dysphagia index were calculated by multiplying frequency with daily intensity of each individual symptom. When compared to placebo, diltiazem did not significantly change the overall dysphagia index and chest pain index. An individual sizeable reduction of dysphagia was attained on diltiazem in four out of six patients and in six out of eight patients suffering from chestpain. Side effects were not seen during diltiazem therapy. Diltiazem, in our study, did not yield in a significant improvement of symptoms in diffuse oesophageal spasm. Diltiazem, however, can offer relief in selected individual patients suffering from diffuse oesophageal spasm.

Herpes zoster virus infection: a clinicopathologic review and case reports

Herpes zoster virus (HZV) infection, particularly of the trigeminal nerve, can be a disabling and disfiguring condition with variable clinical presentations. Acyclovir is a highly effective treatment modality during the acute clinical phase; however, pain control may be very difficult particularly with protracted and severe post herpetic neuralgia (PHN). The clinicopathologic features are reviewed and two cases in immunosuppressed patients with HZV infection of different divisions of the trigeminal nerve are presented.

Vascular access in patients with arterial insufficiency. Construction of proximal bridge fistulae based on inflow from axillary branch arteries

Patients with renal failure and underlying peripheral vascular disease pose a difficult management problem in establishing long-term angioaccess for chronic hemodialysis. This report summarizes our experience with five debilitated patients who developed acute upper extremity ischemia after forearm fistula construction corrected by fistula ligation. Successful angioaccess was achieved without ischemia recurrence by construction of proximal bridge fistulae with arterial inflow based on branch arteries of the axillary artery. The relatively small size of the branch vessel was the main factor in limiting fistula flow while permitting normal distal axillary artery flow. In four patients direct fistula flow measurements ranged from 200 mL per minute to 620 mL per minute. Axillary arterial flow distal to the fistula ranged from 120 to 200 mL per minute and did not significantly change after fistula construction or during temporary occlusion of the fistula. Four of the five patients continue to dialyze uneventfully from 4 to 8.5 months. One patient died after discontinuation of dialysis 1 month after operation.

Spontaneous intramural rupture of the oesophagus

The clinical, endoscopic, and radiological features of seven patients with an uncommon oesophageal injury characterised by long lacerations of the oesophageal mucosa with haematoma formation but without perforation are reported. The injuries were not related to forceful vomiting or any other definable cause but were similar to those previously described as intramural oesophageal rupture. Upper gastrointestinal endoscopy undertaken to identify the cause of haematemesis in six patients proved safe and useful. When dysphagia and odynophagia occurred early in the clinical course to alert the clinician to possible oesophageal injury, radiological contrast studies were used to exclude perforation. One patient in this study had oesophageal cavernocapillary haemangiomatosis which may have caused intramural oesophageal bleeding and submucosal dissection but in the remainder the aetiology of intramural oesophageal rupture remains uncertain. Conservative management was successful in all patients.

Upper extremity venous thrombosis diagnosed by duplex scanning

The incidence of axillary-subclavian venous thrombosis continues to rise, while reports of noninvasive methods to diagnose this condition have been sparse. A review of the records of 693 consecutive upper extremity duplex scans was performed, and a diagnosis of acute venous thrombosis was made in 123 of these patients. Of these, 85 involved the axillary or subclavian vein. Use of a central venous catheter was the most common risk factor for axillary-subclavian venous thrombosis. Within this group, 8% had a pulmonary embolism, of which 25% were fatal. Follow-up of patients with axillary-subclavian venous thrombosis at a mean of 2 years revealed that 49% of these patients had died. Of the remaining patients, more than one third had evidence of the post-thrombotic syndrome. Duplex scanning of the venous system provides a safe, reliable, and repeatable method of evaluating and following patients with suspected venous thrombosis of the upper extremity.

Incremental diagnostic yield of loop electrocardiographic recorders in unexplained syncope

The Holter monitor, the most frequently used diagnostic test in patients with syncope, is nondiagnostic in over 90% of cases. This study sought to determine the impact of a new noninvasive device, the cardiac loop electrocardiographic (ECG) recorder, after Holter monitoring in 57 patients with unexplained syncope. All patients underwent a standardized evaluation protocol and were the monitor for up to 1 month. In 14 patients, loop recording definitively determined whether an arrhythmia was the cause of symptoms (diagnostic yield 25%; 95% confidence intervals 14 to 38%). Diagnoses included unsuspected ventricular tachycardia (1 patient), high grade atrioventricular block (2 patients), supraventricular tachycardia (1 patient), asystole or junctional bradycardia from neurally mediated syncope (3 patients) and normal cardiac rhythms (the remaining 7 patients). Follow-up of all patients diagnosed as having nonarrhythmic syncope by loop recording showed that none of these patients died suddenly. Cardiac loop ECG recording is an important new diagnostic test in patients with syncope unexplained by Holter monitoring.

Spontaneous paracentesis following rupture of an umbilical hernia

Spontaneous paracentesis following a ruptured umbilical hernia is a rare but dramatic event. Only 58 cases have been recorded in the English language literature. We describe here the management and successful outcome of one such case with documented substantial paracentesis of approximately 11 L.

Drug administration to the pregnant or lactating woman: a reference guide for dermatologists

Dermatologists are occasionally faced with the problem of appropriate systemic drug administration to the lactating or pregnant woman. The physician's responsibility is to be aware of the potential risk of prescribing a specific therapeutic agent, to inform the mother of this risk, and to administer an alternate, less deleterious drug, if available. The purpose of this review is to provide guidelines for dermatologists who must consider the risks to the fetus or neonate of drug administration to the pregnant woman or lactating mother.

Restless legs syndrome and periodic movements of sleep

Two entities of special interest in sleep disorders medicine are restless legs syndrome and periodic movements of sleep. Most patients with restless legs syndrome have periodic movements of sleep, but most patients with the nocturnal disorder do not have restless legs when awake. In both conditions, the underlying cause is obscure, and the frequency of occurrence increases with advancing age. In most patients with restless legs syndrome, the results of complete blood cell counts and iron, ferritin, folate, and vitamin B12 levels are normal. No hematologic or chemical abnormalities have been reported in patients with periodic movements of sleep who do not also have restless legs syndrome. Various pharmacologic agents, including benzodiazepines, opiates, and levodopa, have been proposed for the treatment of both disorders. Although some patients respond to a single drug for long periods, in many patients tolerance develops and the efficacy diminishes. In such circumstances, a reasonable approach is to alternate chemically unrelated agents on a weekly or biweekly schedule. Transcutaneous electric nerve stimulation may be beneficial.

Combining pharmacological antagonists and behavioural psychotherapy in treating addictions. Why it is effective but unpopular

Supervised administration of disulfiram is one of the very few treatments that can significantly reduce alcohol consumption, yet it is rarely used, despite being simple and cheap. Disulfiram is not 'aversion therapy', but a technique for facilitating exposure and response prevention, and it fits comfortably into a behavioural, social-learning model of addiction (or dependence) and its treatment. The availability of other effective antagonists, notably to opiates, suggests that an approach that is demonstrably effective in alcohol dependence may be helpful in treating other addictions. The reasons for the unpopularity of this approach appear to be largely ideological.

Superficial thrombophlebitis. II. Secondary hypercoagulable states

Secondary hypercoagulable states are complex clinical conditions associated with an increased risk of thrombosis in which the exact pathophysiology is poorly understood. Secondary causes of superficial thrombophlebitis include malignancy, pregnancy, use of oral contraceptives, infusion of prothrombin complex concentrates, Behçet's disease, Buerger's disease, Mondor's disease, infectious agents, conditions that promote venous stasis, intravenous catheters and intravenous drug use. Conditions that may stimulate superficial thrombophlebitis include dermatophyte cellulitis at saphenous phlebectomy sites, sarcoidal granulomas, cutaneous polyarteritis nodosa, and hyperalgesic pseudothrombophlebitis in patients who test positive for human immunodeficiency virus. The distinguishing features, clinical evaluation, treatment, and histologic characteristics of the various disorders are reviewed.

Presence of human papillomavirus type-6-related sequences in inverted nasal papillomas

Twenty DNA samples obtained from seven cases of inverted papillomas, eight cases of nasal polyps and five cases of chronic sinusitis were investigated by Southern blot hybridization for the possible presence of sequences homologous to human papillomavirus (HPV) types 6, 11, 16 and 18. HPV type-6-related DNA was identified in one of the seven inverted papillomas. The restriction endonuclease cleavage patterns showed that this latter DNA is a new subtype of HPV type 6 DNA. In the other six papillomas and in all cases of nasal polyps and chronic sinusitis, no HPV sequence could be demonstrated, even under low stringent conditions (Tm-40 degrees C). These results indicate that HPV infection might be one of the possible causative factors in the pathogenesis of inverted papillomas but is not essential for the induction of the tumor.

Delayed pneumothorax after subclavian vein catheterization

One hundred fourteen patients having 121 subclavian venipunctures were studied retrospectively. Eight pneumothoraces occurred (6.6%) and were most frequent after the insertion of large catheters, or when the subclavian area was distorted by previous venipuncture or radiation. Delayed pneumothorax occurred in five patients. This unusual diagnosis was made radiographically 8 to 96 hr postoperatively in response to the appearance of new pulmonary symptoms. Delayed pneumothorax required treatment with tube thoracostomy more frequently than immediate pneumothorax. This study establishes the approximate incidence of delayed pneumothorax for the first time. The relative frequency of this complication may challenge the cost effectiveness of pneumothorax diagnosis by chest films done within 1 or 2 hr of subclavian venipuncture. An alternative diagnostic protocol is considered.

Hepatitis with bridging fibrosis and reversible hepatic insufficiency in a woman with rheumatoid arthritis taking methotrexate

A patient with seropositive rheumatoid arthritis developed ascites while taking weekly doses of methotrexate (MTX). Her serum transaminase and albumin levels were normal. A liver biopsy revealed chronic hepatitis with bridging fibrosis and piecemeal necrosis. Upon discontinuation of MTX, her ascites resolved, and her arthritis became more active. This is the third report of reversible hepatic decompensation associated with prolonged MTX therapy in patients with rheumatoid arthritis.