Understanding healthcare providers' preferred attributes of pediatric pneumococcal conjugate vaccines in the United States

As higher-valent pneumococcal conjugate vaccines (PCVs) become available for pediatric populations in the US, it is important to understand healthcare provider (HCP) preferences for and acceptability of PCVs. US HCPs (pediatricians, family medicine physicians and advanced practitioners) completed an online, cross-sectional survey between March and April 2023. HCPs were eligible if they recommended or prescribed vaccines to children age <24 months, spent ≥25% of their time in direct patient care, and had ≥2 y of experience in their profession. The survey included a discrete choice experiment (DCE) in which HCPs selected preferred options from different hypothetical vaccine profiles with systematic variation in the levels of five attributes. Relative attribute importance was quantified. Among 548 HCP respondents, the median age was 43.2 y, and the majority were male (57.9%) and practiced in urban areas (69.7%). DCE results showed that attributes with the greatest impact on HCP decision-making were 1) immune response for the shared serotypes covered by PCV13 (31.4%), 2) percent of invasive pneumococcal disease (IPD) covered by vaccine serotypes (21.3%), 3) acute otitis media (AOM) label indication (20.3%), 4) effectiveness against serotype 3 (17.6%), and 5) number of serotypes in the vaccine (9.5%). Among US HCPs, the most important attribute of PCVs was comparability of immune response for PCV13 shared serotypes, while the number of serotypes was least important. Findings suggest new PCVs eliciting high immune responses for serotypes that contribute substantially to IPD burden and maintaining immunogenicity against serotypes in existing PCVs are preferred by HCPs.

Expanding access to nurse-managed medication for opioid use disorder

BACKGROUND

Advanced practice registered nurses (APRNs) are increasingly caring for individuals with opioid use disorder. Advances have been made to increase APRN education, outreach, and prescribing privileges, but as demand for medication for opioid use disorder (MOUD) grows, evidence suggests that policy and care barriers inhibit the ability of APRNs to support MOUD.

PURPOSE

This paper highlights the significant challenges of expanding access to buprenorphine prescribing by APRNs.

RESULTS

Barriers and recommendations were derived from the culmination of literature review, expert consensus discussions among a diverse stakeholder panel including patient representatives, and feedback from community webinars with care providers.

DISCUSSION

We provide an overview of existing care barriers, promising practices, and proposed recommendations to enhance the care of individuals and communities with opioid use disorder.

Variable response of cholinesterase activities following human exposure to different types of organophosphates

We investigated the red blood cell (RBC) acetylcholinesterase (AChE) activities and butyrylcholinesterase (BChE) activities at presentation to the emergency department (ED) and at 24 h after presentation following poisoning by dichlorvos, fenitrothion, or ethyl p-nitrophenol thio-benzene phosphonate (EPN). Although the patients from different groups had similar characteristics at presentation such as time interval from ingestion to presentation to the ED and the amount of organophosphate ingested, the dichlorvos group had significantly lower BChE levels than the fenitrothion group and lower RBC cholinesterase activity than the EPN group. Patients poisoned with EPN or dichlorvos had significantly higher inhibition of BChE activities from baseline than RBC AChE activities at presentation. Twenty four hours after administration of pralidoxime, RBC AChE activities had increased in patients in the dichlorvos and EPN groups, while RBC AChE activities had slightly decreased in the fenitrothion group. BChE activities increased significantly in the dichlorvos group but decreased in the EPN group. The recovery patterns of RBC AChE and BChE activities did not match in any particular individual. This study showed that the patterns of inhibition and recovery of the activities of two cholinesterases after treatment are highly variable according to the organophosphate and in different individuals.

Secretory clusterin (sCLU) overexpression is associated with resistance to preoperative neoadjuvant chemotherapy in primary breast cancer

OBJECTIVES

Preoperative chemotherapy is often used in patients with locally advanced breast cancer. However, commonly used clinical and pathological parameters are poor predictors of response to this type of therapy. The secreted form of the CLU protein (sCLU) is a glycosylated protein of 76-80 kDa. It has become increasingly clear that in most cells sCLU is a stress-associated cytoprotective protein that is upregulated by various apoptotic triggers. Furthermore, sCLU confers resistance by some unknown mechanism when overexpressed. The purpose of the present study was to examine the sCLU proteins as predictors of clinical outcome and response to chemotherapy in locally advanced breast cancer.

PATIENTS AND METHODS

The expression levels of sCLU was determined by immunohistochemistry before preoperative chemotherapy in 72 patients with locally advanced breast cancer. All patients were treated with cyclophosphamide/doxorubicin/5-FU(CAF) and some patients received additional treatment with docetaxel. Expression data were compared with patients' clinical and pathological features, clinical outcome, and response to chemotherapy.

RESULTS

The results showed sCLU expression before preoperative chemotherapy was inversely related to the tumor size, expression of estrogen and progesterone receptors. High preoperative expression of sCLU was associated with resistance to CAF therapy, but not with resistance to docetaxel.

CONCLUSIONS

We, therefore, suggested sCLU expression may be a useful marker for predicting response to preoperative chemotherapy and clinical outcome in patients with locally advanced breast cancer.

Interpolated boundary condition for lattice Boltzmann simulations of flows in narrow gaps

Several different interpolation schemes have been proposed for improving the accuracy of lattice Boltzmann simulations in the vicinity of a solid boundary. However, these methods require at least two or three fluid nodes between nearby solid surfaces, a condition that may not be fulfilled in dense suspensions or porous media for example. Here we propose an interpolation of the equilibrium distribution, which leads to a velocity field that is both second-order accurate in space and independent of viscosity. The equilibrium interpolation rule infers population densities on the boundary itself to reduce the span of nodes needed for interpolation; it requires a minimum of one grid spacing between the nodes. By contrast, the linear interpolation rule requires two fluid nodes in the gap and leads to a viscosity-dependent slip velocity, while the multireflection rule is viscosity independent but requires a minimum of three fluid nodes.

The electroviscous force between charged particles: beyond the thin-double-layer approximation

We have investigated the hydrodynamic drag force between charged particles in electrolyte solutions, specifically the electroviscous force that arises from the distortion of the electrical double layers by the flow field. We report an improvement on the thin-double-layer theory (S.G. Bike, D.C. Prieve, J. Colloid Interface Sci. 136 (1990) 95-112), using a more accurate boundary condition for the radial charge current. The differences become important when the double layers start to overlap. We have found that nonlinear hydrodynamic effects are small, whereas nonlinear electric effects can be significant, in some instances leading to qualitatively different behavior. If the ion diffusivities are highly asymmetric, the electroviscous force can be reduced by an order of magnitude when there is an excess of the mobile ions in the double layer. The common supposition that there are substantial differences in the electroviscous force predicted by constant-charge and constant-potential boundary conditions is incorrect; our calculations show that it is an artifact introduced by the Debye-Hückel approximation.

Macrophage migration inhibitory factor is an important mediator in the pathogenesis of gastric inflammation in rats

BACKGROUND & AIMS

Macrophage migration inhibitory factor (MIF) has been shown to play a pivotal role in inflammatory and immune-mediated diseases. This study investigates the role of MIF in gastric inflammation.

METHODS

Expression of MIF was examined in a rat gastric ulcer model induced by acetic acid, and the functional role of MIF in acute gastric ulcer was investigated by administration of a neutralizing anti-MIF antibody.

RESULTS

MIF messenger RNA and protein were markedly up-regulated in acute gastric ulcer, which correlated with the accumulation of macrophages (P < 0.001) and neutrophils (P < 0.05) at the site of inflammation. Macrophages, like neutrophils, were the major inflammatory cells infiltrating the ulcer base and they strongly expressed inducible nitric oxide synthase. However, macrophages, not neutrophils, were a rich source of MIF production in acute gastric ulcer. In vivo and in vitro blockade of MIF with the neutralizing anti-MIF antibody significantly inhibited the marked up-regulation of MIF, tumor necrosis factor alpha, inducible nitric oxide synthase, and intercellular adhesion molecule-1. This was associated with the marked inhibition of macrophage (70% reduced) and neutrophil (60% reduced) accumulation and activation, thus reducing ulcer sizes and attenuating ulceration.

CONCLUSIONS

This study has shown that MIF was markedly up-regulated during acute gastric ulcer. Inhibition of acute gastric ulcer by blockade of MIF indicates that MIF is a key inflammatory mediator and plays a pathogenic role in gastric inflammation.

Mutagenicity of recombinant antihemophilic factor (GC-gamma AHF)

This study was carried out to evaluate the mutagenic potential of recombinant antihemophilic factor VIII (GC-gamma AHF). Salmonella typhimurium (S. typhimurium) reversion assay with/without histidine moiety, chromosomal aberration assay on Chinese hamster lung (CHL) fibroblast cells and in vivo micronucleus assay using mouse bone marrow cells and supravital micronucleus assay using peripheral blood were performed. GC-gamma AHF containing histidine did show inconsistent and irregular mutagenic effects on S. typhimurium TA98, TA100, TA1535 and TA1537 both in the absence and presence of the metabolic activation system, however, GC-gamma AHF without histidine showed no mutagenic effects regardless of the metabolic activation system, thus suggesting that the histidine moiety in GC-gamma AHF might cause inconsistent mutagenic effect. Also GC-gamma AHF did not increase the number of cells having structural or numerical chromosome aberration in the cytogenetic test. In classical and supravital micronucleus assay, no significant increases were observed in the occurrence of micronucleated polychromatic erythrocytes and micronucleated peripheral lymphocytes in male ICR mice. These results strongly indicate that GC-gamma AHF has no genetic toxicity under these experimental conditions.

Insulin-like growth factor II (IGF-II) inhibits insulin-like growth factor binding protein I (IGFBP-1) production in luteinized human granulosa cells with a potency similar to insulin-like growth factor I (IGF-I) and higher than insulin

Insulin-like growth factor binding protein I (IGFBP-I) is produced by human granulosa cells and may be important in follicular development. Production of IGFBP-I in human granulosa cells is under inhibitory control of insulin and insulin-like growth factor-I (IGF-I). It had not been known if IGF-II affected IGFBP-I production in these cells. We examined the effect of IGF-II on IGFBP-I production in human granulosa cells and compared this effect of IGF-II to similar effects of insulin and IGF-I. Human granulosa cells were obtained during in vitro fertilization and plated at a density of 10(5) cells/mL in McCoy 5A tissue culture medium supplemented with 10% fetal calf serum. After 48 h of preincubation at 37 C, 90% humidity, 5% CO2, the medium was removed, and serum-free medium was added. After 24 h of incubation in the serum-free medium, the medium was removed, cells were washed, and new serum-free medium supplemented with various concentrations of insulin, IGF-I, or IGF-II was added. After 24 h of incubation with insulin, IGF-I, or IGF-II, the medium was removed and frozen at-20 C until assayed for IGFBP-I. IGFBP-I was measured using kits from Diagnostic System Laboratories, Webster, Texas. Concentrations of IGFBP-I in the medium were 4.4 +/- 1.7 ng/mL for control cells; 3.0 +/- 0.8, 3.0 +/- 0.7, 3.1 +/- 0.7, 1.8 +/- 0.5, and 1.1 +/- 0.3 ng/mL for 1, 10, 10(2), 10(3), and 10(5) ng/mL insulin respectively; 1.4 +/- 0.6, 2.1 +/- 0.5, 0.3 +/- 0.1, 0.1 +/- 0.02, and 0.01 +/- 0.02 ng/mL for 0.5, 1, 5, 10, and 10(2) ng/mL of IGF-I, respectively; and 2.3 +/- 2.2, 1.2 +/- 0.8, 0.9 +/- 0.3, 0.7 +/- 0.2, and 0.04 +/- 0.02 ng/mL for 0.5, 1, 5, 10, and 10(2) ng/mL of IGF-II, respectively. Concentration of IGFBP-I in the medium collected from cells incubated with hormones was statistically lower than that for control cells starting at 10(3) ng/mL of insulin (P < 0.05), 0.5 ng/mL of IGF-I (P < 0.05) and 1 ng/mL of IGF-II (P < 0.05). Within the range of hormone concentrations tested, the P-values (independent groups t-test) never reached less than 0.01 levels for insulin, but reached this level at 5 ng/mL for both IGF-I and IGF-II. We conclude that IGF-II inhibits IGFBP-I production in luteinized human granulosa cells in a dose-dependent manner and with potency similar to IGF-I and higher than insulin. Further studies are needed to determine the physiological significance of this and other effects of IGF-II in the human ovary in both normal and pathological states.

Ectopic pregnancy: prospective study with improved diagnostic accuracy

STUDY OBJECTIVE

To assess the utility of ultrasonography, quantitative serum beta-human chorionic gonadotropin (beta-hCG) level, history, and physical examination in the diagnosis of ectopic pregnancy (EP) in the emergency department.

METHODS

We prospectively studied 481 consecutive pregnant patients who presented to an urban ED with first-trimester abdominal pain or vaginal bleeding. History, physical examination findings, quantitative beta-hCG values, sonography findings, surgical findings, and final diagnosis were collected after patient enrollment in the study. We assessed the proportions of pregnant patients experiencing pain or bleeding with EPs versus those with abnormal and normal intrauterine pregnancies (IUPs).

RESULTS

Pregnant women with abdominal pain or vaginal bleeding received beta-hCG values; positive radioimmunoassays prompted ultrasonography; indeterminate ultrasonography findings resulted in admission. Thirteen percent of patients had confirmed EPs; 99.5% of patients discharged from the ED had documented IUPs. Transvaginal sonography in the ED established EP or IUP in 75%. For EP detection, sonography is 69% sensitive and 99% specific. Single beta-hCG levels are useful in predicting EP; a beta-hCG value of 1,000 mIU/mL or lower shows a fourfold higher risk of EP. History and physical examination do not reliably diagnose or rule out EP; of EP patients, 9% reported no pain and 36% lacked adnexal tenderness.

CONCLUSION

To prevent delayed diagnosis of EP in urban centers, pregnant women with abdominal pain or vaginal bleeding require evaluation by transvaginal ultrasonography. Indeterminate ultrasonography findings necessitate further evaluation. A beta-hCG level of 1,000 mIU/mL or lower should heighten suspicion of EP.

Treatment of obstetrical hemorrhagic emergencies

The common hemorrhagic complications of pregnancy remain among the leading causes of maternal mortality. We review new methods of diagnosis and offer suggestions for management. Abruptio placenta, disseminated intravascular coagulation, placenta previa, uterine rupture, and postpartum hemorrhage are included in this review.

Heterotopia of gastric mucosa and liver involving the gallbladder. Report of two cases with literature review

Two cases of heterotopic tissue involving the gallbladder are presented (one gastric mucosa, the other liver), and the relevant literature is reviewed highlighting problems in differential diagnosis and complications, particularly with regard to gastric mucosal heterotopia. A firm diagnosis of gastric heterotopia is based on the presence of fundic mucosa replete with parietal and chief cells; a clear distinction from intestinal metaplasia should be made, but at times may be difficult. Potential complications include mucosal ulceration, obstruction, and hemorrhage. Of 39 patients presented, about half were 30 years of age or younger, and only nine have had calculi noted in the cholecystectomy specimen. Heightened awareness of gastric heterotopia with separation of smooth-muscle bundles may help to avoid a malignant diagnosis. Hepatic tissue involving the gallbladder that is completely separate from the main part of the liver is an even rarer form of heterotopia that should be distinguished from an accessory lobe.

Birth of the first 100 babies in Hawaii after conception in-vitro: experience at the Pacific In-Vitro Fertilization Institute

This paper reports on the first 100 infants delivered consecutively the result of 63 pregnancies after conception in-vitro at the Pacific In-Vitro Fertilization (IVF) Institute. These pregnancies were established prior to the introduction of embryo-cryopreservation into the program. Ninety-seven percent (97%) of singleton pregnancies delivered after 36 weeks; only 5/31 (16%) required tocolytic therapy. The overall multiple gestation rate was 51%, higher than in many other IVF centers. Maternal complications and neonatal morbidity were associated primarily with these multiple gestations. Forty-one percent (41%) delivered in less than 36 weeks, and tocolytics were administered in 22/27 (81%) of twin and 5/5 (100%) of triplet gestations. Neonatal morbidity was noted in 39 infants (33 from multiple gestations); 28 neonates were admitted to the intensive care unit (27 from multiple gestations). Nine births had or developed minor abnormalities (hernias, pyloric stenosis). One case of Trisomy 21, and one infant death at 11 months occurred in the group. The caesarean section rate for all IVF deliveries was 65%. It is concluded that IVF is clearly established in Hawaii for infertility refractory to other methods of treatment. The risk associated with IVF stem from the possibility of multiple gestations, not whether the pregnancy was initiated in-vitro. In the future, embryo cryopreservation may help to reduce the risk of multiple pregnancy.

Recurrent abdominal pain due to chronic appendiceal disease

Recurrent appendicitis and chronic appendicitis are the subjects of much controversy, but long-standing inflammation of the appendix and surrounding tissues has been reported in rare instances. We have described two patients, both with recurrent episodes of abdominal pain, who subsequently were shown to have chronic appendiceal disease. Appendiceal disease should be considered in the differential diagnosis in patients with recurrent abdominal pain.

The significance of epithelial differentiation in mixed mesodermal tumors of the uterus. A clinicopathologic and immunohistochemical study

Mixed mesodermal tumors and carcinosarcomas of the uterus are classified as sarcomas. However, in other sites, malignant biphasic tumors may be classified as carcinomas, mesotheliomas, or sarcomas. In order to clarify their behavior and patterns of differentiation, we performed a clinicopathologic and immunohistochemical study of 22 cases aimed at analyzing the pattern of spread and histologic appearance of the metastasis, as well as the distribution of intermediate filaments in the primary tumor and the metastasis. Four monoclonal antibodies (Mabs) were used to detect epithelial lineage, three that recognize keratin (AE1/AE3, CAM5.2, MAK6) and one that recognizes epithelial membrane antigen (EMA). A Mab against vimentin was also used. Metastases involved the omentum, pelvic peritoneum, ovaries, fallopian tubes, pelvic or para-aortic lymph nodes, liver parenchyma, and tonsil. These metastases were composed of carcinoma only. Lymphatic/vascular invasion was identified in 11 cases; it consisted exclusively of carcinoma. In all 12 cases evaluated immunohistochemically, keratin and EMA were identified in the majority of the cells in the epithelial component and in a more focal distribution in the spindle cell component in 11 (92%). Vimentin was detected in the majority of spindle cells in nine cases (75%) and in a more focal distribution in the epithelial component in six cases (50%). In the spindle cell component, keratin and EMA were present in widely scattered individual spindle-shaped and rounded cells, within solid clusters of rounded cells, and in nests of cells with small lumens. The distribution of keratin, EMA, and vimentin in the metastases (carcinoma in all instances) was similar to the epithelial component in the primary tumor. Our findings indicate that the epithelial component of these tumors invades lymphatic/vascular spaces and metastasizes, whereas the spindle cell component has limited metastatic potential, if any. Since the behavior of these neoplasms is dictated by the epithelial element, we believe that mixed mesodermal tumors of the uterus should be classified as carcinomas rather than sarcomas.

Sterile splenic abscesses in systemic Weber-Christian disease. Unique source of abdominal pain

A patient with Weber-Christian disease and relapsing abdominal pain due to sterile splenic abscesses is presented. Histologically, acute and chronic inflammation with focal suppurative infiltrates of phagocytosed fat was detected in the absence of vascular or embolic disease, infection, or other apparent cause. Abdominal discomfort, an uncommon manifestation of Weber-Christian disease, usually is related to mesenteric panniculitis. Sterile splenic abscesses represent a previously undescribed complication of Weber-Christian disease, and another source of abdominal pain in this disorder. Although the precise pathophysiology of sterile splenic abscess formation in Weber-Christian disease is unknown, splenectomy is an effective means of alleviating pain.

Pure small-cell carcinoma of the prostate with fatal liver metastasis

A case of small-cell carcinoma (SCC) of the prostate is described with extensive liver metastases in a 60-year-old man. The case is unique because of the rare histologic pattern coupled with death secondary to hepatic failure. A spectrum of neuroendocrine tumors are found in the prostate similar to those found in the lung. Ten cases of prostatic SCC or carcinoid, identified in the English-language literature over a period of 14 years, are summarized. In the absence of an apparent pulmonary lesion, surgical pathologists should also consider the prostate as a primary site for extrapulmonary SCC when confronted with biopsy material of metastatic SCC.

Phenytoin-induced systemic granulomatous vasculitis

Much has been written about adverse effects accompanying the use of phenytoin. However, the rare occurrence of systemic vasculitis induced by this drug has only been the subject of sporadic case reports and has not truly been characterized as a definitive entity. The high fatality rate of this complication is a proof of its severity. A case of multiorgan necrotizing granulomatous vasculitis related to the use of phenytoin is reported and the clinicopathologic aspects of seven similar cases assembled from the literature are summarized and discussed. The most commonly affected patients are elderly black men who present with skin rash, fever, and, frequently, eosinophilia. Tissue examination discloses systemic vasculitis that is often granulomatous and involves mainly the liver, kidneys, and spleen. Immediate recognition of this diagnosis is stressed, since proper treatment may reverse a fatal clinical course.

Undifferentiated ("embryonal") sarcoma of the liver: ultrastructure of a case presenting as a primary intracardiac tumor

We report the ultrastructure of an undifferentiated ("embryonal") sarcoma of the liver that presented as a right-sided intracardiac tumor in an 8-year-old boy. The patient eventually died because of repeated embolization of tumor to the lungs. At autopsy the hepatic primary was composed of primitive mesenchymal cells with occasional small cysts and ducts lined by benign-appearing epithelium. Electron microscopy of the mesenchymal cells indicated a limited capacity for pluripotential differentiation along fibroblastic, lipoblastic, and even myogenous lines. Epithelial elements closely resembled those lining normal bile ducts but contained increased fibrillar material with haphazard orientation. The histogenesis of this rare hepatic tumor is still unknown, but the occurrence of both epithelial and frankly sarcomatous elements within the primary tumor again raises the possibility of malignant transformation within a pre-existing mesenchymal hamartoma.

Human papillomavirus structural antigens in squamous papillomas of the male urethra

Twenty-five squamous papillomas of the male urethra were examined for the presence of human papillomavirus (HPV) whole (structural) virion antigens by a peroxidase-antiperoxidase technique having immunospecificity against genus-specific (common) antigens of the papillomavirus genus. Eleven of 25 (44 per cent) lesions were positive for HPV. The positive reaction was invariably intranuclear in the superficial epithelium. Evidence suggests that these papillomas arise by HPV infection of metaplastic squamous epithelium and not transitional epithelium. This study shows that at least some squamous papillomas of the male urethra are associated with HPV infections and suggest that this lesion may play an important role in venereally transmitted diseases such as cervical dysplasia and condylomas of the vulva and anus.

Mammographic and pathologic correlation of microcalcification in disease of the breast

Fifty-five patients with isolated microcalcification clusters and no palpable tumor of the breast were studied. All patients underwent appropriate localization biopsies and had roentgenographic, specimen roentgenographic examination of histologic confirmation that the area of microcalcification was removed. Fifteen patients proved to have a malignant lesion at biopsy and in 40 patients, it proved to be benign. Of the proved cancers, ten were noninvasive. Fourteen of the patients with cancer were free of axillary metastases. The results of the follow-up study, with a mean time of four years, revealed a 100 per cent survival rate and no recurrence of disease. Careful study of the microcalcification clusters, at preoperative mammographic examination, did not show significant differences between the malignant and benign group that could be helpful to the clinician, in predicting the nature of the lesion. Due to the reasonably high, 27 per cent, rate of malignant disease, we believe all patients with isolated microcalcification clusters at preoperative mammographic examination should have a localization biopsy.

Epidermoid cysts of the testis: a report of three cases and an analysis of 141 cases from the world literature

Epidermoid cysts of the testis are rare and represent about 1% of all testicular tumors. An analysis of 141 cases reported to date in the world literature, including the cases reported here, indicates that 50% of the lesions occur in the third decade and 86% between the second and fourth decade. The most common presentations are painless enlargement of the testis (41%) for an average period of 2.25 years or incidental detection during routine physical examination (33%). Clinically, a discrete testicular nodule can be palpated in the majority of the cases (76%). Pathologic findings are those of a squamous lined cyst containing keratin with absence of appendages or other elements. It is believed that, despite the benign nature of the lesion, they should be treated by orchiectomy so that a thorough pathologic examination can be done to establish a confident diagnosis. While some controversy exists about their source of origin, all the evidence, including the age, more common occurrence among whites, and the rare reported cases arising in cryptorchid testis points to a germ cell origin for these lesions. The epidermoid cyst should thus be recognized as another subtype in the category of germ cell tumors of the testis and perhaps the ovary.

Granular cell tumor: a clinicopathologic study of 110 patients

The clinicopathologic features of 118 granular cell tumors (GCT) encountered at two affiliated hospitals were reviewed. A total of 110 patients were affected over this 32-year period of study (71 men, 39 women), and in 5% GCT were multiple. Patients ranged in age from 16 to 58 years (average 32 years) and were symptomatic for an average duration of 11 months prior to diagnosis. There was a greater than expected frequency of GCT among black patients (29%). Although tongue was the single most common anatomic site involved, relatively more GCT (44%) occurred in skin or subcutaneous tissue. Less common locations were breast parenchyma (10 cases), rectal mucosa and anus (6), vulva (4), esophagus and larynx (2 cases each). The correct preoperative diagnosis of this protean tumor was made in only three patients. GCT were surgically treated with the average diameter of resected tumor being 1.2 cm (range 0.2--3.5 cm). Pseudoepitheliomatous hyperplasia was noted in 11 tumors and in one vulvar GCT there was overlying in situ squamous cell carcinoma. Tumors were incompletely excised in 24 of 56 patients having adequate followup; only five of these 24 patients experienced a local recurrence of tumor. Malignant behavior was not observed. Results of histochemical and ultrastructural study are briefly discussed. The precise histogenesis of GCT is uncertain but Schwann cell origin is favored in most cases.

Intrathoracic paravertebral malignant paraganglioma

This article reviews the clinical and pathologic features of intrathoracic paravertebral paragangliomas. Including the present case, there have been 31 tumors reported in the English literature; the average age of patients was 29 years, with a sex distribution of 20 men and 11 women. Fifteen patients (48%) had symptoms related to excess secretion of catecholamines; the remaining 16 tumors were clinically nonfunctional. Seven patients (22%) had multiple paragangliomas. Complete surgical resection was attempted in 25 patients, 13 were alive with no evidence of tumor an average of 2.2 years later. Tumor was locally invasive in five patients, with involvement of the vertebral canal and symptoms of spinal cord compression. Malignant behavior with distant metastases was observed in two patients. As shown by the present case, the Grimelius stain is a useful diagnostic technique for demonstrating cytoplasmic argyrophilia of neoplastic chief cells. Electron microscopy demonstrated neurosecretory granules (average core diameter, 100 nm). "Light" and "dark" chief cell types were inconspicuous. Due to important clinical and pathologic differences, paravertebral paragangliomas should be distinguished from similar tumors occurring in the anterosuperior mediastinum (aorticopulmonary paragangliomas).

Laryngeal paraganglioma. Case report with ultrastructural analysis and literature review

Laryngeal paraganglioma is an infrequently reported tumor; only 16 examples have been recorded in the English literature. All but one laryngeal paraganglioma originated superiorly in the larynx; involvement of the ipsilateral aryepiglottic fold is common. Male patients predominate (11:5). The average age of patients at the time of diagnosis was 47 years, and symptoms had been present for an average duration of 5.8 years (range 6 months to 27 years). Attempted biopsy has resulted in significant hemorrhage in three cases. As illustrated by the present case, the Grimelius argyrophil stain is a useful diagnostic procedure. Electron microscopy confirmed the presence of neurosecretory granules with core diameters ranging from 110 to 140 nm. Surgical resection is the preferred treatment and has been possible in 14 cases; nine patients are alive and free of tumor for an average of 3 years. Compared to other head and neck paragangliomas, these have a more malignant course with a 25% mortality; tender subcutaneous metastases are commonly observed in these patients.

Benign glandular inclusions in para-aortic lymph nodes in women undergoing lymphadenectomies

Benign glandular inclusions in para-aortic lymph nodes are a relatively common occurrence. The chance of finding these benign glandular inclusions in the para-aortic lymph nodes is dependent on the intensity with which one searches. In our series of 106 para-aortic lymphadenectomies performed on patients with gynecologic malignancies, there were five patients in whom these benign Müllerian rests were found. Other series report up to a 40.8 per cent incidence of benign inclusions in nodes of patients with cervical cancer. They may have been either congenital or acquired. It is critical that these Müllerian tissues are not confused with metastatic disease. The significance of these benign glandular inclusions is discussed.

Paraaortic lymphadenectomy in gynecologic malignancies confined to the pelvis

Eighty-six patients with pelvic malignancies had paraaortic node dissection; 30% had positive paraaortic lymph nodes. At the time of laparotomy, 77 patients had malignancies apparently confined to the pelvis after extensive work-up and histologic examination of tissue biopsies outside the pelvis; 20 (26%) had metastatic cancer in the paraaortic lymph nodes. Thirteen of 49 patients with cancer of the cervix, 5 of 18 with uterine cancer, and 2 of 10 with ovarian cancer had positive paraaortic lymph nodes. The value of paraaortic dissection in patients with pelvic malignancies apparently confined to the pelvis is discussed.

"B" cell origin of malignant cells in a case of American Burkitt's lymphoma. Characterization of cells from a pleural effusion

Ninety-eight percent of the cells isolated from a malignant pleural effusion in a case of American Burkitt's lymphoma showed membrane fluorescence to antihuman IgM antisera, while only 2% of the cells formed spontaneous rosettes with sheep red blood cells. It is concluded that the Burkitt cells in the malignant effusion are derived from bursal equivalent lymphocytes. Epstein-Barr (E-B) viral titers to both viral capsule antigen and early antigen were not elevated. The significance of these findings is discussed.