Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Orthopaedic diagnoses in patients with Klippel-Trenaunay syndrome

PURPOSE

Klippel-Trenaunay syndrome (KTS) is a rare combined vascular malformation composed of capillary malformation, lymphatic and/or venous malformation and limb overgrowth, which commonly affects the extremities. Due to limb involvement, it is not uncommon for these patients to require referral to an orthopaedic surgeon. Herein we reviewed the prevalence of orthopaedic diagnoses in a large cohort of KTS patients and described the associated surgical interventions.

METHODS

Between 1976 and 2012, 410 patients fulfilling strict criteria for KTS were evaluated at a single institution. Patient charts were reviewed for demographic information, details of the clinical evaluation, orthopaedic consultation and surgical interventions.

RESULTS

A total of 264 of 410 patients (64%) with confirmed KTS required orthopaedic evaluation. Of these 264 patients, 84% had documented limb-length discrepancy. Other common diagnoses included: angular deformities (10%), scoliosis (9%), osteopenia/osteoporosis (7%), pathological fractures (6%), joint contracture (5%), degenerative joint disease (4%) and limb/joint pain (4%). Of the 264 patients evaluated by orthopaedic surgery, 133 patients (50.4%) underwent 169 surgeries. Surgery was most commonly performed for limb-length discrepancy (62%). Multivariable analysis confirmed an orthopaedic condition was more likely in patients with lymphatic malformation (odds ratio (OR) 3.78; p < 0.001), as well as in those with bone and/or soft-tissue hypertrophy of the lower extremity (OR 7.51; p < 0.001) or foot (OR 3.23; p < 0.001).

CONCLUSION

Orthopaedic conditions are common in patients with KTS and approximately 50% require surgical intervention. Those with a lymphatic malformation and/or soft-tissue hypertrophy of the lower extremity are more likely to need surgery.

LEVEL OF EVIDENCE

Level IV, Descriptive Case Series.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort

BACKGROUND

Although preterm birth <37 weeks' gestation is the leading cause of neonatal morbidity and mortality in the United States, the majority of data regarding preterm neonatal outcomes come from older studies, and many reports have been limited to only very preterm neonates. Delineation of neonatal outcomes by delivery gestational age is needed to further clarify the continuum of mortality and morbidity frequencies among preterm neonates.

OBJECTIVE

We sought to describe the contemporary frequencies of neonatal death, neonatal morbidities, and neonatal length of stay across the spectrum of preterm gestational ages.

STUDY DESIGN

This was a secondary analysis of an obstetric cohort of 115,502 women and their neonates who were born in 25 hospitals nationwide, 2008 through 2011. All liveborn nonanomalous singleton preterm (23.0-36.9 weeks of gestation) neonates were included in this analysis. The frequency of neonatal death, major neonatal morbidity (intraventricular hemorrhage grade III/IV, seizures, hypoxic-ischemic encephalopathy, necrotizing enterocolitis stage II/III, bronchopulmonary dysplasia, persistent pulmonary hypertension), and minor neonatal morbidity (hypotension requiring treatment, intraventricular hemorrhage grade I/II, necrotizing enterocolitis stage I, respiratory distress syndrome, hyperbilirubinemia requiring treatment) were calculated by delivery gestational age; each neonate was classified once by the worst outcome for which criteria was met.

RESULTS

In all, 8334 deliveries met inclusion criteria. There were 119 (1.4%) neonatal deaths. In all, 657 (7.9%) neonates had major morbidity, 3136 (37.6%) had minor morbidity, and 4422 (53.1%) survived without any of the studied morbidities. Deaths declined rapidly with each advancing week of gestation. This decline in death was accompanied by an increase in major neonatal morbidity, which peaked at 54.8% at 25 weeks of gestation. As frequencies of death and major neonatal morbidity fell, minor neonatal morbidity increased, peaking at 81.7% at 31 weeks of gestation. The frequency of all morbidities fell >32 weeks. After 25 weeks, neonatal length of hospital stay decreased significantly with each additional completed week of pregnancy; among babies delivered from 26-32 weeks of gestation, each additional week in utero reduced the subsequent length of neonatal hospitalization by a minimum of 8 days. The median postmenstrual age at discharge nadired around 36 weeks' postmenstrual age for babies born at 31-35 weeks of gestation.

CONCLUSION

Our data show that there is a continuum of outcomes, with each additional week of gestation conferring survival benefit while reducing the length of initial hospitalization. These contemporary data can be useful for patient counseling regarding preterm outcomes.

ID: 42: FACTORS ASSOCIATED WITH TREATMENT SEEKING IN VETERANS WITH LATE-ONSET PTSD

Background and Significance

Post-traumatic stress disorder (PTSD) is a chronic anxiety disorder with a lifetime prevalence of 6.8% in the general population and up to 30% among Vietnam War veterans. While presentation of PTSD is typically acute, delayed onset of PTSD (i.e., 6 months post trauma) is considered to be relatively rare. There is anecdotal evidence supporting reactivation of trauma memories and symptoms of PTSD among aging veterans who previously had no symptoms or treatment for PTSD. Clinically this type of presentation appears to be different from those presenting with symptoms earlier in life. It is unclear what might precipitate or reactivate these symptoms many years following trauma exposure. The Veterans Health Administration has a growing population of aging veterans exposed to combat during their military service. Current treatment guidelines provide limited guidance towards the management of late-onset PTSD. The prevalence of PTSD among OEF/OIF veterans is very high and as this cohort ages, we need to be better equipped to manage clinical changes seen across the lifespan. Understanding the clinical phenomenology, risk factors and potential biomarkers of this condition could pave the way for better screening methods and treatment interventions for clinicians.

Objective

To identify the characteristics and risk factors among late-life post-traumatic stress disorder (PTSD) treatment seekers.

Methods

The study is a retrospective chart review of patients diagnosed with PTSD after the age of 55 and a comparison group of veterans diagnosed with PTSD prior to the age of 55 in the VA Nebraska–Western Iowa Health Care System.

Results

Primary variables for analysis included demographic factors, military history, age at treatment seeking, PTSD Checklist (PCL) scores, PTSD treatment, recent stressors/reasons for seeking treatment (e.g., recent life changes, another trauma or reminder), and comorbid medical conditions.

Conclusions

A number of explanations have been proposed for the development of late-onset PTSD, including chronic inflammation and cumulative stress. We are conducting a separate study to determine whether plasma concentration of the inflammatory marker C-reactive protein (CRP) might help in predicting late-onset PTSD. Further studies are needed to evaluate the contributions of other factors (e.g., physical or cognitive decline, sleep disturbances, other traumas) to late-onset PTSD.

Nonmedically indicated induction vs expectant treatment in term nulliparous women

OBJECTIVE

The purpose of this study was to compare maternal and neonatal outcomes in nulliparous women with nonmedically indicated inductions at term vs those expectantly treated.

STUDY DESIGN

Data were obtained from maternal and neonatal charts for all deliveries on randomly selected days across 25 US hospitals over a 3-year period. A low-risk subset of nulliparous women with vertex nonanomalous singleton gestations who delivered 38 0/7 to 41 6/7 weeks were selected. Maternal and neonatal outcomes for nonmedically indicated induction within each week were compared with women who did not undergo nonmedically indicated induction during that week. Multivariable analysis was used to adjust for hospital, maternal age, race/ethnicity, body mass index, cigarette use, and insurance status.

RESULTS

We found 31,169 women who met our criteria. Neonatal complications were either less frequent with nonmedically indicated induction or no different between groups. Nonmedically indicated induction was associated with less frequent peripartum infections (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16-0.98) at 38 weeks of gestation and less frequent third- and fourth-degree lacerations (OR, 0.60; 95% CI, 0.42-0.86) and less frequent peripartum infections (OR, 0.66; 95% CI, 0.49-0.90) at 39 weeks of gestation. Nonmedically indicated induction was associated with a longer admission-to-delivery time by approximately 3-4 hours and increased odds of cesarean delivery at 38 (OR, 1.50; 95% CI, 1.08-2.08) and 40 weeks (OR, 1.30; 95% CI, 1.15-1.46) of gestation.

CONCLUSION

At 39 weeks of gestation, nonmedically indicated induction is associated with lower maternal and neonatal morbidity than women who are expectantly treated.

A community prevention model to prevent children from inhaling and ingesting harmful legal products

Children's misuse of harmful legal products (HLPs), including inhaling or ingesting everyday household products, prescription drugs, and over-the-counter drugs, constitutes a serious health problem for American society. This article presents a community prevention model (CPM) focusing on this problem among pre and early adolescents. The model, consisting of a community mobilization strategy and environmental strategies targeting homes, schools, and retail outlets, is designed to increase community readiness and reduce the availability of HLPs, which is hypothesized to reduce HLPs use among children. The CPM is being tested in Alaskan rural communities as part of an inprogress eight-year National Institute on Drug Abuse randomized-controlled trial. This paper presents the CPM conceptual framework, describes the model, and highlights community participation, challenges, and lessons learned from implementation of the model over a 21-month period.

Information needs of hematologic cancer survivors

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Background: Little is known about how information needs of cancer survivors/patients (S/P), caregivers (CG), and non-caregiver relatives (NCG) evolve during the cancer experience. Methods: We conducted structured interviews of 21 leukemia, lymphoma, and multiple myeloma S/P, 13 CG, and 19 NCG, and asked them to prioritize information needs during the 4 cancer experience phases from a list of 13 topics. This research was supported by the Division of Cancer Prevention and Control of the Centers for Disease Control and Prevention. Results: Information preferences varied (Friedman’s test, P < 0.0001) by phase of the cancer experience. Topics ranked highest (median rank in parentheses) before treatment, during treatment, after treatment, and at relapse, respectively, were diagnostic tests (2), cancer/ cancer types (2.5), treatment options (3.4), hospitals/cancer centers (3.5), and insurance/financial issues (4); coping with treatment side effects (3), insurance/financial issues (4.5), treatment options (5), hospitals/cancer centers (5), and long term side effects (5); long term side effects (2), tests to detect recurrence (2), risk factors (3), diagnostic tests (4), and support groups (5); and tests to detect recurrence (3), insurance/financial issues (3), cancer/cancer types (4), diagnostic tests (5), and treatment options (5). Across the cancer experience, the highest priority topics for S/P, CG, and NCG, were cancer/ cancer types (4), treatment options (4), long term side effects (5), and risk factors (5); diagnostic tests (4.5), coping with side effects of treatment (5), and treatment options (5); and treatment options (3), diagnostic tests (4), and 5 other topics tied for 3rd place (6). In-depth, semi-structured interviews conducted with the surveys provided additional detail regarding responses collected in the prioritization exercise. Conclusions: Clinicians can help S/P, CG, and NCG by offering role- and cancer continuum-targeted information.

No significant financial relationships to disclose.

Excitation spectrum of two correlated electrons in a lateral quantum dot with negligible Zeeman splitting

The excitation spectrum of a two-electron quantum dot is investigated by tunneling spectroscopy in conjunction with theoretical calculations. The dot made from a material with negligible Zeeman splitting has a moderate spatial anisotropy leading to a splitting of the two lowest triplet states at zero magnetic field. In addition to the well-known triplet excitation at zero magnetic field, two additional excited states are found at finite magnetic field. The lower one is identified as the second excited singlet state on the basis of an avoided crossing with the first excited singlet state at finite fields. The measured spectra are in remarkable agreement with exact-diagonalization calculations. The results prove the significance of electron correlations and suggest the formation of a state with Wigner-molecular properties at low magnetic fields.

Primary fallopian tube carcinoma: a retrospective clinicopathologic study

INTRODUCTION

Primary fallopian tube carcinoma is a rare tumor. The aim of this study was to evaluate clinical characteristics and management of fallopian tube malignancies at a large tertiary care cancer institute.

METHODS

A retrospective review of the Tumor Registry was conducted to identify all primary fallopian tube carcinomas between 1980 and 2001. Medical charts were retrospectively reviewed. Primary endpoints were overall survival and disease recurrence.

RESULTS

Thirty-five patients had histology consistent with fallopian tube carcinoma. The median age at diagnosis was 56 years. The most common signs or symptoms were abnormal vaginal bleeding (29%) and abdominal/pelvic mass (26%). The most common histology was adenocarcinoma in 16 (46%) patients. Five patients (14%) were Stage I, seven patients (20%) Stage II, 17 patients (49%) Stage III and six patients (17%) Stage IV. Thirty-two (91%) patients received adjuvant chemotherapy and 77% received platinum-based chemotherapy. Twenty-seven (77%) patients underwent second-look surgery, of which 17 patients (63%) were positive for disease. The 5-year survival rate was 64% for Stage I, 42% for Stage II, 32% for Stage III, and 17% for Stage IV.

CONCLUSIONS

Fallopian tube malignancies are rare and carry a poor prognosis. More extensive research needs to be performed to have definitive etiologic, diagnostic and treatment guidelines.

Pelvic exenterations for gynecological malignancies: twenty-year experience at Roswell Park Cancer Institute

The objective of this study is to review the experience with pelvic exenterations for gynecological malignancies at our cancer institute. Charts of 48 women who underwent a pelvic exenteration between January 1980 and December 1999 were reviewed, and several outcomes were analyzed. Majority of patients had received prior radiation therapy. The median survival was 35 months, and the disease-free survival was 32 months. Mortality from the procedure was 4.2%. Early and late postoperative complication rates were 27% and 75%, respectively. Recurrence rate was 60%. Eight patients received intraoperative radiation. Median survival in this group was 11.3 vs 35 months (P = 0.003). Univariate analysis failed to show an association between type of pelvic exenteration, type of fecal and urinary diversion, outcome, need for reoperation, and recurrence. Contemporary pelvic exenterations are associated with a low mortality and a potential for long-term survival in a subset of patients who historically have been given a poor prognosis. In patients with recurrent gynecological cancer confined centrally to the pelvis, pelvic exenteration still remains the choice of therapy as response to chemotherapy to a centrally recurrent tumor in radiated area continues to be poor. Intraoperative radiation in select few patients needs to be further studied.

Pelvic exenterations for gynecological malignancies: twenty-year experience at Roswell Park Cancer Institute

The objective of this study is to review the experience with pelvic exenterations for gynecological malignancies at our cancer institute. Charts of 48 women who underwent a pelvic exenteration between January 1980 and December 1999 were reviewed, and several outcomes were analyzed. Majority of patients had received prior radiation therapy. The median survival was 35 months, and the disease-free survival was 32 months. Mortality from the procedure was 4.2%. Early and late postoperative complication rates were 27% and 75%, respectively. Recurrence rate was 60%. Eight patients received intraoperative radiation. Median survival in this group was 11.3 vs 35 months (P = 0.003). Univariate analysis failed to show an association between type of pelvic exenteration, type of fecal and urinary diversion, outcome, need for reoperation, and recurrence.

Contemporary pelvic exenterations are associated with a low mortality and a potential for long-term survival in a subset of patients who historically have been given a poor prognosis. In patients with recurrent gynecological cancer confined centrally to the pelvis, pelvic exenteration still remains the choice of therapy as response to chemotherapy to a centrally recurrent tumor in radiated area continues to be poor. Intraoperative radiation in select few patients needs to be further studied.

Efficacy of adjuvant CYVADIC chemotherapy in early-stage uterine sarcomas: results of long-term follow-up

Data on adjuvant chemotherapy in early-stage uterine sarcomas are conflicting and most often based on small patient groups with relatively short duration of follow-up. Approximately 60% of patients present with stage I disease with an overall 5-year survival of 30-50% when treated with surgery alone. This study examines the efficacy and results of long-term follow-up of a multiagent chemotherapy regimen of cyclophosphamide, vincristine, doxorubicin, and dacarbazine (CYVADIC) as adjuvant treatment for patients with stage I uterine sarcoma. Between 1982 and 1999, 24 evaluable patients with completely staged uterine sarcomas received adjuvant multiagent chemotherapy with vincristine sulfate (1mg /m(2)) on days 1 and 4, doxorubicin (40 mg /m(2)) and cyclophosphamide (400 mg /m(2)) on day 2, and dacarbazine (200 mg /m(2)) on days 1 through 4 for a total of nine monthly cycles or until recurrence of disease was documented. Survival distributions were calculated by the Kaplan-Meier method, and statistical significance was determined with the log-rank test. Factors significant on univariate analysis were analyzed in a multivariate fashion using Cox proportional hazards model. The histologic distribution of patients was 46% leiomyosarcoma, 33% mixed mullerian tumors, 13% stromal sarcomas, 4% adenosarcomas, and 4% hemangiosarcoma. The patients received 206 of a planned 216 cycles of chemotherapy. The median follow-up of the patient population was 93 months (range 11-213 months). Eight patients (33%) developed recurrent disease. The median time to recurrence was 19 months (range 7-184 months). The estimated survival for the entire group was 88, 75, and 69% at 2, 5, and 15 years, respectively. Factors that did not affect survival included age, histology, and tumor grade. Four patients required dose reductions secondary to grade 2-3 toxicities (hematologic). Grade 1 neurotoxicity was observed in six patients (25%) and grade 2 neurotoxicity in one patient (4%). Adjuvant CYVADIC chemotherapy appears to be safe and well tolerated in patients with stage I uterine sarcomas. Our data provide information on the longest duration of follow-up ever reported and suggests that CYVADIC may have a potential role in the adjuvant treatment of early-stage uterine sarcoma.

Efficacy of adjuvant CYVADIC chemotherapy in early-stage uterine sarcomas: results of long-term follow-up

Data on adjuvant chemotherapy in early-stage uterine sarcomas are conflicting and most often based on small patient groups with relatively short duration of follow-up. Approximately 60% of patients present with stage I disease with an overall 5-year survival of 30–50% when treated with surgery alone. This study examines the efficacy and results of long-term follow-up of a multiagent chemotherapy regimen of cyclophosphamide, vincristine, doxorubicin, and dacarbazine (CYVADIC) as adjuvant treatment for patients with stage I uterine sarcoma. Between 1982 and 1999, 24 evaluable patients with completely staged uterine sarcomas received adjuvant multiagent chemotherapy with vincristine sulfate (1mg/m2) on days 1 and 4, doxorubicin (40 mg/m2) and cyclophosphamide (400 mg/m2) on day 2, and dacarbazine (200 mg/m2) on days 1 through 4 for a total of nine monthly cycles or until recurrence of disease was documented. Survival distributions were calculated by the Kaplan–Meier method, and statistical significance was determined with the log-rank test. Factors significant on univariate analysis were analyzed in a multivariate fashion using Cox proportional hazards model. The histologic distribution of patients was 46% leiomyosarcoma, 33% mixed mullerian tumors, 13% stromal sarcomas, 4% adenosarcomas, and 4% hemangiosarcoma. The patients received 206 of a planned 216 cycles of chemotherapy. The median follow-up of the patient population was 93 months (range 11–213 months). Eight patients (33%) developed recurrent disease. The median time to recurrence was 19 months (range 7–184 months). The estimated survival for the entire group was 88, 75, and 69% at 2, 5, and 15 years, respectively. Factors that did not affect survival included age, histology, and tumor grade. Four patients required dose reductions secondary to grade 2–3 toxicities (hematologic). Grade 1 neurotoxicity was observed in six patients (25%) and grade 2 neurotoxicity in one patient (4%). Adjuvant CYVADIC chemotherapy appears to be safe and well tolerated in patients with stage I uterine sarcomas. Our data provide information on the longest duration of follow-up ever reported and suggests that CYVADIC may have a potential role in the adjuvant treatment of early-stage uterine sarcoma.

Evidence for a strong surface-plasmon resonance on ErAs nanoparticles in GaAs

Room-temperature attenuation measurements are made between lambda=0.8 and 10.0 microm on three GaAs epitaxial samples containing layers of ErAs nanoparticles. An asymmetric attenuation peak is observed around 2.5 microm that increases in strength with ErAs density, and is modeled well by a Maxwell-Garnett formulation and semiclassical transport theory. The nanoparticles are assigned a distribution function of oblate spheroids having a minimum volume corresponding to a 1.0-nm sphere. This is consistent with the self-organizing tendency of ErAs in GaAs, and explains the sharp attenuation peak as a spherical-particle surface-plasmon (i.e., Fröhlich) resonance.

Dynamics of inter-landau-level excitations of a two-dimensional electron gas in the quantum Hall regime

The femtosecond inter-Landau-level dynamics of a two-dimensional electron gas in a large magnetic field is investigated by degenerate four-wave mixing on modulation doped quantum wells. We observe a large transfer of oscillator strength to the lowest Landau level, and unusual dynamics due to Coulomb correlation. We interpret the effects using a model based on shakeup of the electron gas.

Is glucagonoma of the pancreas a curable disease?

BACKGROUND

Glucagonomas are rare neuroendocrine tumors of the pancreas. Because of its rarity, its natural history is not well understood.

AIM

We evaluated the natural history of glucagonomas treated at a tertiary care cancer center.

METHODS

A retrospective analysis of 12 patients during 1970 to 2000 was performed. Six patients (50%) had a tumor located in the head of the pancreas.

RESULTS

Abdominal pain (83%) and weight loss (75%) were the most common symptoms. Median tumor size was 6 cm (range 0.04-10). Seven patients (58%) had liver metastases. Five patients (42%) underwent curative resection. Overall median survival was 66 mo, and 5-yr overall survival was 66%. Five-yr overall survival was 83% for patients who had resection versus 50% for the non-resected patients (p = 0.04). Patients who were disease-free had a complete resection of the primary tumor and no liver involvement.

CONCLUSIONS

Glucagonomas generally present with liver metastases at the time of diagnosis. Cure is only possible if the disease is localized and completely resected.

Early postoperative oral feeding after colectomy: an analysis of factors that may predict failure

BACKGROUND

Previous studies have shown that early postoperative oral feeding is feasible. Traditionally patients were fed when flatus or defecation documented the return of bowel function. This study was undertaken to determine factors that may preclude early feeding.

METHODS

One hundred four successive patients underwent colorectal surgery from October 1999 to January 2001. Eighty-nine patients started an oral diet either on postoperative day 1 or 2. Their clinical outcomes were recorded prospectively. Fifteen of the 104 patients were excluded for small-bowel resection (5 patients), perioperative complications (5 patients), prior radiation (3 patients), and small-bowel obstruction (2 patients). A failure in postoperative feeding consisted of nausea, vomiting, or readmission.

RESULTS

The mean age of our cohort was 65 years (range, 28-87 years). There were 45 male and 44 female patients. The mean postoperative hospital stay was 6 days (range, 3-13 days). The median American Society of Anesthesiology score was II (range, I-IV). The types of resection performed were right colectomy (27 patients), low anterior resection (26 patients), sigmoid resection (11 patients), abdominoperineal resection (8 patients), formation or closure of colostomy (7 patients), posterior pelvic exenteration (4 patients), total colectomy (3 patients), left colectomy (2 patients), and transverse colectomy (1 patient). Sixty-five patients (73%) tolerated early oral feeding. Of the 24 patients that did not, 16 had nausea or emesis, and 8 required readmission for postoperative complications (small-bowel obstruction [4 patients], wound dehiscence [1 patient], abdominal pain [1 patient], and anastomotic leak [2 patients]). Univariate analysis revealed that the use of volume expanders contributed to intolerance of early feeding. On multivariate analysis, blood loss during the operation was the only factor contributing to failure of early postoperative oral feeding.

CONCLUSIONS

Early oral feeding is safe and feasible for postcolectomy patients with a history of colorectal neoplasms.

Angelman syndrome: mimicking conditions and phenotypes

The diagnosis of Angelman syndrome (AS) can be confirmed by genetic laboratory in about 80% of cases. In 20%, the diagnosis remains clinical, but often there is uncertainty about the correctness of the clinical diagnosis and alternative diagnoses may be investigated. In evaluating individuals for AS in our center since 1989, we have encountered several mimicking conditions, and additional ones have been reported in the literature. Mimicking conditions can be grouped into the areas of chromosome, single gene, and symptom complex anomalies. Microdeletions or microduplications include chromosome regions 2,4,17, 22, and 15. Single gene conditions include methylene tetrahydrofolate reductase deficiency (MTHFR), Rett syndrome, alpha-thalassemia retardation syndrome (ATR-X), and Gurrieri syndrome. Symptom complexes include cerebral palsy, static encephalopathy, Lennox-Gastaut syndrome, autism spectrum disorder, pervasive developmental delay (PDD), and mitochondrial disorders. We present a review of these mimicking disorders to increase the awareness about conditions that can lead to an incorrect clinical diagnosis of AS.

Malignant fibrous histiocytoma: an institutional review

BACKGROUND

A thorough understanding of malignant fibrous histiocytoma (MFH), the most common subtype of soft tissue sarcoma, will lead to improved histologic-specific protocols.

METHODS

126 patients with histologically confirmed MFH were analyzed. The median follow-up was 42 months (range 1-233 months).

RESULTS

Overall survival was 58% at 5 years and 38% at 10 years. Grade significantly influenced prognosis, with 10-year survival of 90%, 60%, and 20% for low, intermediate, and high grade tumors, respectively (p = 0.0007). Distant metastases at initial presentation (p = 0.0002) and size of the primary tumor (p = 0.0007) influenced outcome. Neither anatomic site nor depth of the primary tumor were significant prognostic factors. Positive microscopic margins were associated with a decreased disease-free survival (p = 0.006).

CONCLUSIONS

Tumor grade, size, and distant metastases at initial presentation remain the most important prognostic factors for MFH. Resection with negative microscopic margins decreased the incidence of local recurrence.

The 22q11.2 deletion: screening, diagnostic workup, and outcome of results; report on 181 patients

A submicroscopic deletion of chromosome 22q11.2 has been identified in the majority of patients with the DiGeorge syndrome, velocardiofacial syndrome, conotruncal anomaly face syndrome, and in some patients with isolated conotruncal cardiac anomalies, Opitz G/BBB syndrome, and Cayler cardiofacial syndrome. We have evaluated 181 patients with this deletion. We describe our cohort of patients, how they presented, and what has been learned by having the same subspecialists evaluate all of the children. The results help define the extremely variable phenotype associated with this submicroscopic deletion and will assist clinicians in formulating a management plan based on these findings.

Phenotype and genotype in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common disorder in premenopausal women and is characterized by hyperandrogenic chronic anovulation. The cause is unknown. PCOS is associated with significant insulin resistance as well as with defects in insulin secretion. These abnormalities place these women at substantial risk for developing type 2 diabetes mellitus. A defect in insulin-mediated receptor autophosphorylation has been found in a substantial proportion of PCOS women. Both PCOS and the insulin resistance that accompanies it appear to have major genetic components. Family studies of PCOS have supported this, although they suffer from incomplete phenotyping of probands and first-degree relatives. The phenotype in males and nonreproductive age females is uncertain. Despite the shortcomings of the family studies of PCOS, they have consistently indicated familial clustering and suggested that the mode of inheritance is dominant. Our initial studies of 50 families of PCOS probands indicate that 24% of sisters are affected with PCOS. There also appears to be an intermediate phenotype of sisters with regular menstrual cycles who are hyperandrogenic per se (22% of sisters). Additionally, there appears to be a major familial defect, with 50% of first-degree relatives having glucose intolerance (impaired glucose tolerance by oral glucose tolerance test or type 2 diabetes mellitus). These findings suggest that hyperandrogenism in females and glucose intolerance may be genetic traits in PCOS kindreds. Systematic phenotyping will allow assignment of affected status for eventual linkage analysis.

The effects of metronome breathing on the variability of autonomic activity measurements

BACKGROUND

Many chiropractors hypothesize that spinal manipulation affects the autonomic nervous system (ANS). However, the ANS responses to chiropractic manipulative therapy are not well documented, and more research is needed to support this hypothesis. This study represents a step toward the development of a reliable method by which to document that chiropractic manipulative therapy does affect the ANS by exploring the use of paced breathing as a way to reduce the inherent variability in ANS measurements.

OBJECTIVE

To examine the hypothesis that the variability of ANS measurements would be reduced if breathing were paced to a metronome at 12 breaths/min.

SETTING

The study was performed at Parker College Research Institute. Eight normotensive subjects were recruited from the student body and staff.

METHODS

Respiration frequency was measured through a strain gauge. A 3-lead electrocardiogram (ECG) was used to register the electric activity of the heart, and arterial tonometry monitors were used to record the left and right radial artery blood pressures. Signals were recorded on an IBM-compatible computer with a sampling frequency of 100 Hz. Normal breathing was used for the first 3 recordings, and breathing was paced to a metronome for the final 3 recordings at 12 breaths/min. Fourier analysis was performed on the beat-by-beat fluctuations of the ECG-determined R-R interval and systolic arterial pressure (SBP). Low-frequency fluctuations (LF; 0.04-0.15 Hz) reflected sympathetic activity, whereas high-frequency fluctuations (HF; 0.15-0.4 Hz) represented parasympathetic activity. Sympathovagal indices were determined from the ratio of the two bandwidths (LF/HF). The coefficient of variation (CV%) for autonomic parameters was calculated ([average/SD] x 100%) to compare breathing normally and breathing to a metronome with respect to variability. One-way analysis of variance was used to detect differences. A value of P < 0.05 was considered statistically significant; all results are presented as average +/- SD.

RESULTS

Three male and 5 female normotensive subjects were studied. Metronome breathing did not produce any significant changes in blood pressure for the left and right radial arteries, heart rate, or pressure pulse transmission time. Breathing to a metronome increased ECG-HF power (0.25 +/- 0.07 vs 0.35 +/- 0.09, P < 0.04), decreased ECG-LF/HF (1.08 +/- 0.55 vs 0.57 +/- 0.35, P < 0.05), and reduced the CV% for ECG-LF (47.6% +/- 23.4% vs 23.8% +/- 14.6%, P < 0.03), ECG-HF (46.2% +/- 14.2% vs 25.8% +/- 17.0%, P < 0.03) and ECG-LF/HF (50.1% +/- 27.6% vs 23.4% +/- 12.3%, P < 0.03) in comparison with normal breathing. Metronome breathing increased the left and right radial artery SBP-HF fluctuations (left, 0.11 +/- 0.05 vs 0.30 +/- 0.16, P < 0.007; right, 0.09 +/- 0.05 vs 0.27 +/- 0.15, P < 0.008) and decreased the SBP-LF/HF components (left, 3.42 +/- 2.36 vs 1.14 +/- 0.88, P > 0.03; right, 3.08 +/- 1.77 vs 1.20 +/- 0.93, P < 0.02). Metronome breathing did not significantly alter the CV% for SBP-HF, SBP-LF, and SBP-LF/HF.

CONCLUSIONS

Metronome breathing increased parasympathetic activity, as evidenced by augmented HF power in the ECG and SBP data. The variability (CV%) of ECG-determined ANS measurements was significantly reduced with paced breathing at 12 breaths/min, but no significant reductions were observed for the SBP-determined ANS measurements. These findings indicate that ECG data are more sensitive than SBP data for future clinical trials.

Exclusion limits on the WIMP-nucleon cross section from the cryogenic dark matter search

The Cryogenic Dark Matter Search (CDMS) employs Ge and Si detectors to search for weakly interacting massive particles (WIMPs) via their elastic-scattering interactions with nuclei while discriminating against interactions of background particles. CDMS data, accounting for the neutron background, give limits on the spin-independent WIMP-nucleon elastic-scattering cross section that exclude unexplored parameter space above 10 GeV/c2 WIMP mass and, at >75% C.L., the entire 3sigma allowed region for the WIMP signal reported by the DAMA experiment.

Pathologic and clinical features influencing outcome of thin cutaneous melanoma: correlation with newly proposed staging system

The incidence of malignant melanoma is increasing. Because of increased awareness, early recognition of malignant melanoma has become more common. In 1997, a new staging system for cutaneous melanoma was proposed, with reclassification of thin melanoma < 1 mm, with and without ulceration. This report evaluates the pathologic and clinical features of thin melanomas influencing recurrence and survival from a tertiary cancer center in an attempt to correlate findings with the proposed staging system. A review of the Roswell Park Cancer Institute tumor registry identified 352 patients with thin cutaneous melanomas (< 1.0 mm) seen during an 18-year period ending August 30, 1998. Overall survival was 93 and 87 per cent at 5 and 10 years, respectively. Disease-free survival was 94 and 93 per cent at 5 and 10 years, respectively. Local recurrence occurred in 3 per cent of patients, regional recurrence in 3 per cent, and metastatic disease in 3 per cent, for an overall recurrence of 7 per cent, with a median follow-up of 118 months. Only the presence of ulceration was a significant prognostic factor for recurrence by both univariate and multivariate analysis. Failure rates (any recurrence) by Clark levels I, II, and III/IV were 3, 5, and 10 per cent, respectively (P = 0.14). Failure rates by tumor thickness (mm), for 0.0-0.24, 0.25-0.49, 0.50-0.74, and 0.75-0.99 were 3, 4, 7, and 10 per cent, respectively (P = 0.49). Ten-year disease-free survival for ulceration versus no ulceration was 40 and 94 per cent, respectively (P < 0.0001). We conclude that thin cutaneous melanoma carries an excellent prognosis with appropriate treatment. Our findings support inclusion of ulceration in a new staging system. Lesions 0.76 to 0.99 mm and Clark level III and IV may warrant close observation as a separate subgroup.

Anti-angiogenic activity of selected receptor tyrosine kinase inhibitors, PD166285 and PD173074: implications for combination treatment with photodynamic therapy

Angiogenesis, the formation of new blood vessels from an existing vasculature, is requisite for tumor growth. It entails intercellular coordination of endothelial and tumor cells through angiogenic growth factor signaling. Interruption of these events has implications in the suppression of tumor growth. PD166285, a broad-spectrum receptor tyrosine kinase (RTK) inhibitor, and PD173074, a selective FGFR1TK inhibitor, were evaluated for their anti-angiogenic activity and anti-tumor efficacy in combination with photodynamic therapy (PDT). To evaluate the anti-angiogenic and anti-tumor activities of these compounds, RTK assays, in vitro tumor cell growth and microcapillary formation assays, in vivo murine angiogenesis and anti-tumor efficacy studies utilizing RTK inhibitors in combination with photodynamic therapy were performed. PD166285 inhibited PDGFR-beta-, EGFR-, and FGFR1TKs and c-src TK by 50% (IC50) at concentrations between 7-85 nM. PD173074 displayed selective inhibitory activity towards FGFR1TK at 26 nM. PD173074 demonstrated (>100 fold) selective growth inhibitory action towards human umbilical vein endothelial cells compared with a panel of tumor cell lines. Both PD166285 and PD173074 (at 10 nM) inhibited the formation of microcapillaries on Matrigel-coated plastic. In vivo anti-angiogenesis studies in mice revealed that oral administration (p.o.) of either PD166285 (1-25 mg/kg) or PD173074 (25-100 mg/kg) generated dose dependent inhibition of angiogenesis. Against a murine mammary 16c tumor, significantly prolonged tumor regressions were achieved with daily p.o. doses of PD166285 (5-10 mg/kg) or PD173074 (30-60 mg/kg) following PDT compared with PDT alone (p<0.001). Many long-term survivors were also noted in combination treatment groups. PD166285 and PD173074 displayed potent anti-angiogenic and anti-tumor activity and prolonged the duration of anti-tumor response to PDT. Interference in membrane signal transduction by inhibitors of specific RTKs (e.g. FGFR1TK) should result in new chemotherapeutic agents having the ability to limit tumor angiogenesis and regrowth following cytoreductive treatments such as PDT.

Searching for the polycystic ovary syndrome genes

PCOS is a common disorder of unknown etiology. Studies of first-degree relatives of women diagnosed with PCOS suggest familial clustering of the disease. A prospective study of first-degree female relatives of women with PCOS conducted by NCPIR found that 46% of ascertainable sisters of women with PCOS were hyperandrogenemic. NCPIR has conducted linkage and association studies using affected sibling-pair analysis and the transmission/disequilibrium test to explore candidate PCOS genes. These studies point a finger at a region 1 MB centromeric to the insulin receptor gene on chromosome 19.

Soft tissue sarcoma of the hand

A retrospective review of our institute's tumor registry from January 1972 to January 1996 revealed 24 patients with a diagnosis of primary soft tissue sarcoma of the hand, from a total of 570 extremity soft tissue sarcomas (4%). The most frequent histologic type was malignant fibrous histiocytoma, which occurred in 9 (38%) of the 24 patients. The second most common histologic type was epithelioid sarcoma, which occurred in 6 (25%) patients. There was a statistically significant difference in the rate of local recurrence based on the type of treatment in which amputation was superior to the other forms of treatment. There was no statistically significant difference in the rate of distant failures between treatment groups. The estimated cumulative 5- and 10-year overall survival rates for all patients were 59% and 53%, respectively. Stage II patients had estimated cumulative 5- and 10-year survival rates of 68% and 59%, respectively. Stage III patients had a cumulative 5-year survival rate of 20%. Factors that were statistically significant in predicting survival were the size of the primary tumor, with tumors smaller than 5 cm having a better prognosis, and stage of the tumor at presentation, with stage I and II tumors having the highest survival rate. In selected patients with a primary hand sarcoma, aggressive limb-sparing surgery with adjuvant therapy offered equivalent survival compared with amputation.

Downregulated gelsolin expression in hyperplastic and neoplastic lesions of the prostate

BACKGROUND

Because of its role in cell motility and growth regulation, gelsolin, an actin-binding protein, has been considered a tumor suppressor and a potential prognostic marker in some neoplasias, such as breast and bladder cancer. Little is known about its immunoexpression in prostatic adenocarcinoma (PCA).

METHODS

Formalin-fixed, paraffin-embedded tissues of 72 prostatectomy specimens with adenocarcinoma and 8 nonneoplastic prostates from autopsies were stained with a gelsolin monoclonal antibody using the Avidin-biotin-peroxidase complex (ABC) method after microwave antigen retrieval. Immunoreactivity was evaluated in PCA, prostatic intraepithelial neoplasia (PIN), benign prostatic hyperplasia (BPH), and nonproliferative glandular tissue and stroma. The results were statistically analyzed.

RESULTS

Consistent gelsolin immunoreactivity was seen in prostatic stromal cells, smooth muscle, endothelia, and nerves. Variable gelsolin expression was seen in 20-100% (average (A) = 65.5%) of glandular cells in nonproliferative tissue (N = 75); 0-50% (A = 9.7%) in BPH (N = 59); 0-80% (A = 8.9%) in PIN (N = 61); and 0-90% (A = 9.3%) in PCA (N = 71). The level of gelsolin expression in nonproliferative prostatic tissue was similar between prostates with PCA (A = 63.4%) and nonneoplastic prostates (A = 67.5%). The level of gelsolin expression did not correlate with age, tumor size, Gleason score, or stage.

CONCLUSIONS

Gelsolin is decreased in PCA, PIN, and BPH in comparison to nonproliferative tissue. The role of this downregulation in the development of PCA is not clear. The similar reduction seen in PIN and BPH suggests that this event takes place indiscriminately in hyperplasia and early tumorigenesis in the prostate, which might limit its prognostic significance in PCA.

Prognostic factors affecting survival in patients with colorectal carcinomatosis

This study evaluates prognostic factors that may influence survival in patients who present with carcinomatosis from colorectal cancer. Patients may present with carcinomatosis as the pattern of metastases at the initial diagnosis of colorectal cancer. Little is known about the natural history of carcinomatosis and the prognostic factors affecting outcome. All patients treated at Roswell Park Cancer Institute from 1988 to 1994 who presented with carcinomatosis at the initial diagnosis of colorectal cancer were identified. A retrospective review of the medical records for patient and tumor demographics was performed. Estimated survival distributions were calculated by the method of Kaplan and Meier. Tests of significance with respect to survival distribution were based on the log-rank test. Cox proportional hazards model was used for the multivariate analysis. There were 31 males and 38 females. The median age was 61 years (range, 26-80). The primary cancers were in the sigmoid with 24 patients (35%), cecum with 14 patients (20%), and transverse colon with 11 patients (16%). The remainder were distributed throughout the colon and rectum. The most common presentation was large bowel obstruction in 29 patients (42%). T3 and T4 cancers were present in 39 (57%) and 13 patients (19%), respectively. Lymph nodes were positive in 39 patients (57%), and mucin-producing tumors were also present in 39 patients (57%). Twelve patients (17%) had one site of disease, 17 patients (25%) had two sites of disease, and 37 (54%) patients had three or more sites of disease. Ascites was present in 29 patients (42%). Residual disease was present at the completion of surgery in 45 patients, absent in 13 patients, and status unknown in 11. The presence of residual disease (p = 0.0001), presence of ascites (p = 0.02), stage greater than T3 (p = 0.02), and increasing number of carcinomatosis sites (p = 0.006) were found to have a negative impact on survival on univariate analysis. On multivariate analysis, only the presence of residual disease at the completion of surgery was found to be an independent predictor of survival (p = 0.04). Overall median survival was 14 months with a 26% estimated 2-year survival. The presence of gross residual disease at the completion of surgery was shown to be the only independent factor negatively affecting survival. This has potential implications for the operative management of patients presenting with colorectal carcinomatosis.

The Philadelphia story: the 22q11.2 deletion: report on 250 patients

A submicroscopic deletion of chromosome 22q11.2 has been identified in the majority of patients with the DiGeorge, velocardiofacial, and conotruncal anomaly face syndromes, and in some patients with the Opitz G/BBB and Cayler cardiofacial syndromes. We have been involved in the analysis of DiGeorge syndrome and related diagnoses since 1982 and have evaluated a large number of patients with the deletion. We describe our cohort of 250 patients whose clinical findings help to define the extremely variable phenotype associated with the 22q11.2 deletion and may assist clinicians in providing genetic counseling and guidelines for clinical management based on these findings.

Evidence for a genetic basis for hyperandrogenemia in polycystic ovary syndrome

Our preliminary family studies have suggested that some female first-degree relatives of women with polycystic ovary syndrome (PCOS) have hyperandrogenemia per se. It was our hypothesis that this may be a genetic trait and thus could represent a phenotype suitable for linkage analysis. To investigate this hypothesis, we examined 115 sisters of 80 probands with PCOS from unrelated families. PCOS was diagnosed by the combination of elevated serum androgen levels and Collapse

Key Words Collapse

MESH Headings

• Adolescent
• Adult
• Child
• Female
• Genetic Linkage
• Genetic Predisposition to Disease
• Humans
• Hyperandrogenism/genetics
• Middle Aged
• Polycystic Ovary Syndrome/genetics

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Grants

• M01 RR010732 NCRR NIH HHS
• MO1 RR10732 NCRR NIH HHS
• R01 DK40605 NIDDK NIH HHS
• R01 DK040605 NIDDK NIH HHS
• U54 HD034449 NICHD NIH HHS
• KO8 HD0118 NICHD NIH HHS

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Sarcomas near extremity joints in adults

BACKGROUND AND OBJECTIVES

There are technical difficulties in resecting soft tissue sarcomas extending to or crossing a joint. The objective of this study was to determine the rate of amputation and local recurrence rate for these sarcomas and compare them with the respective rates for overall extremity sarcomas.

METHODS

Retrospective review of 78 patients with sarcoma near a joint compared with 215 patients with extremity sarcomas accrued during the same period, 1977-1994. Of these 78 patients, 64 were in the lower and 14 in the upper extremity. Most common histologic subtypes were malignant fibrous histiocytoma (15/78, 19%), synovial sarcoma (11/78, 14%), liposarcoma (11/78, 14%), and leiomyosarcoma (10/78, 13%). The surgical treatment consisted of local excision in 10 (13%), wide excision in 56 (72%), and amputation in 12 (15%). Adjuvant radiation was given to 26 patients.

RESULTS

Local recurrence was noted in 20% (16/78) patients. The incidence of local recurrence in the surgery alone group (n = 52) was 15% (8/52) and in the surgery plus adjuvant radiation group (n = 26) it was 31% (8/26); P = 0.11. Of the 16 patients with local recurrence, 9 (56%) required amputation. The 5-year and 10-year survival rates for the entire group of patients were 68% and 60% respectively. On multivariate analysis survival varied according to grade (P = 0.05) and tumor size (P = 0.02).

CONCLUSIONS

Amputation was finally required in 27% (21/78) for local control of the disease. The local recurrence rate was 20%. These rates appear to be somewhat higher than those reported in our overall extremity sarcoma series and those in most modern series of overall extremity sarcomas, but the 5- and 10-year survival rates are similar to those of the latter.

Packing and temporary closure in a liver injury

As a component of a staged laparotomy for trauma, perihepatic packing can be lifesaving in the patient with exsanguinating liver injury who, due to hypothermia and coagulopathy, is unable to tolerate a more extensive procedure. However, if intra-abdominal pressure increases, the manoeuvre has been reported to compromise cardiopulmonary stability. Patients who suffer the adverse consequences of intra-abdominal hypertension are commonly managed with a loose temporary closure, frequently using an artificial material to bridge the skin defect across the incision. A case is reported where these two seemingly contradictory options were combined to achieve a successful outcome.

Enlarged Sylvian fissures in infants with interstitial deletion of chromosome 22q11

Two infants with chromosome 22q11 deletion syndrome were noted to have symmetrically enlarged Sylvian fissures on cranial MRI. We compared the size of the Sylvian fissures in neuroimaging studies from 17 other subjects with del 22q11 to age-matched disease controls. The mean anterior interopercular distance was used as an index of Sylvian fissure enlargement. Symmetric enlargement of the Sylvian fissures was present in 10 of 17 subjects with del 22q11. The age-incidence pattern, as well as follow-up scans in 2 patients, suggests delayed growth of the opercular region in these patients. Subjects with del 22q11 consistently had disproportionate enlargement of the left Sylvian fissure compared to the right. This observation suggests that a gene (or genes) in the deleted region affects the development of the left and right perisylvian cortex in different ways. Abnormal development of the operculum may explain some of the neurodevelopmental features that are common among individuals with 22q11 deletion syndrome.

Advanced cutaneous squamous cell carcinoma of the trunk and extremity: analysis of prognostic factors

BACKGROUND

Patients with squamous cell carcinoma (SCC) of the skin may exhibit locally advanced or metastatic disease and present a challenging management problem.

METHODS

A retrospective review of 40 patients with advanced SCC of the trunk or extremity managed at Roswell Park Cancer Institute from 1982 through 1992 was performed to identify clinical and pathologic factors that influenced outcome.

RESULTS

There were 27 males and 13 females with a median age of 61 years. Median follow-up was 24 months. Surgical resection to control the primary tumor was often extensive. Amputation was required in nine patients, hemipelvectomy in three patients, and hemicorporectomy in one patient. Median survival was 28 months, and 5-year survival was 43%. Univariate analysis identified stage (P = 0.04), size (P = 0.0001), type of surgical procedure (P = 0.009), and margins of resection (P = 0.005) as having prognostic significance. On multivariate analysis, stage (P = 0.04) and size (P = 0.02) were found to be significant.

CONCLUSIONS

Optimum treatment for advanced SCC of the trunk and extremity involves surgical resection with uninvolved margins. The role of elective node dissection remains undefined. Investigation is needed to define the role of neoadjuvant therapy that may improve functional and cosmetic results.