Multiple hyperbaric oxygenation (HBO) expands the therapeutic window in acute spinal cord injury in rats

Hyperbaric oxygenation (HBO) therapy has been reported to improve neurological recovery following spinal cord injury (SCI). In the present study, we examined whether multiple HBO expands the therapeutic window for acute SCI. Single HBO (2.8 ATA, 1 hour) treatment was used at 30 minutes, 3 hours, and 6 hours following SCI, and serial HBO treatment (once daily for 1 week) at 6 hours and 24 hours post-injury. Mild SCI was induced by adjusting the height for a weight drop insult (10 g) to 6.25 mm above the exposed spinal cord. The group of animals receiving a single HBO intervention beginning at 30 minutes and 3 hours, or serial HBO treatment starting at 6 hours following the injury had a significantly better neurological recovery than animals with SCI only. The results of this study demonstrate that multiple HBO expands the therapeutic window for acute SCI to 6 hours after injury, further that serial HBO administration is superior to single HBO therapy.

In vitro effects of hyperbaric oxygen on sickle cell morphology

STUDY OBJECTIVE

To determine in vitro whether hyperbaric oxygen has any effect on the morphology of sickle cells.

DESIGN

Prospective, in vitro, study, with each patient sample serving as its own control.

SETTING

University medical center.

PATIENTS

10 children known to be homozygous for hemoglobin S.

INTERVENTIONS

Blood samples were obtained from 10 children during routine visits to the University sickle cell clinic. Blood samples were exposed to room air to achieve maximal sickling. Each sample was divided into control and study aliquots, and the study portions placed in a research hyperbaric chamber with 100% oxygen at 3 atmospheres absolute pressure for 15 min. Then smears were prepared from all samples at regular intervals and examined by technicians in the sickle cell clinic who were blinded as to the details of this study.

MEASUREMENTS

Percentages of normal cells, sickle cells and sickle forms were reported. Data were interpreted using t-tests.

MAIN RESULTS

Hyperbaric oxygen appeared to have no effect on sickle cell morphology. Percentages of each cell type were unaffected by hyperbaric oxygen exposure.

CONCLUSIONS

Hyperbaric oxygen appears to have no effect on the morphology of sickle cells in vitro. Other mechanisms may account for the beneficial clinical effects of hyperbaric oxygen in sickle cell crisis, although in vivo studies are warranted.

Neuroendocrine tumors of the genital tract

Neuroendocrine tumors are more common in the female than male genital tract; most are uterine small cell carcinomas or ovarian carcinoids. Primary ovarian carcinoids are divided into insular, trabecular, strumal, and mucinous types; most are benign. Carcinoids metastatic to the ovary are more aggressive; most arise in the gastrointestinal tract. Scattered neuroendocrine cells are seen in a variety of ovarian surface epithelial tumors; sporadic mucinous cystic tumors with neuroendocrine cells have been associated with Zollinger-Ellison syndrome. Frank neuroendocrine carcinomas in the ovary include small cell carcinoma and large cell neuroendocrine carcinoma, each with a poor prognosis and often associated with a conventional surface epithelial tumor Such carcinomas also occur in the endometrium and cervix. Uterine carcinoids are rare if strict criteria are applied. Small cell neuroendocrine carcinomas also occur rarely in the vagina and vulva. Most male genital tract neuroendocrine tumors are prostatic small cell carcinomas or testicular carcinoids. Extragonadal carcinoids of the male genital tract are rare. Testicular carcinoids should be distinguishedfrom metastatic tumors. It is important to distinguish prostatic small cell carcinoma from poorly differentiated adenocarcinoma with small cells. Small cell neuroendocrine carcinomas also occur rarely in the scrotum, penis, and penile urethra.

Falsely elevated bispectral index during deep hypothermic circulatory arrest

A 2-month-old infant underwent repair of a ventricular septal defect under deep hypothermic circulatory arrest. Bispectral index and EEG suppression ratio were evaluated using an Aspect BIS monitor. Erroneous readings from the monitor could have led to a potentially dangerous alteration in surgical and anaesthetic management.

Preoperative exposure to calcium channel blockers suggests increased blood product use following cardiac surgery

PURPOSE

In this study the authors reviewed the medical records of a random sample of patients undergoing coronary artery bypass grafting (CABG) during the preceding ten years at University Medical Center. The purpose of this study was to evaluate the impact of exposure to calcium channel blockers (CCB's) on blood product use following cardiopulmonary bypass (CPB).

METHODS

DESIGN

Retrospective medical record review.

SETTING

University hospital.

PARTICIPANTS

527 patients undergoing CABG or re-do CABG.

INTERVENTIONS

The medical records of approximately 50% of patients undergoing CABG or re-do CABG at University Medical Center between 1988 and 1998 were randomly selected by the medical records librarian for review. Preoperative medications, bypass time and temperature, and blood product use were recorded.

RESULTS

Of the 527 patients studied, 309 (59%) had no exposure to CCB's. 218 (41%) were on CCB's at the time of admission. Patients who were on CCB's had an average 12.5 (+/- 1.0) blood product units transfused following bypass whereas those not on CCB's had an average 8.7 (+/- 0.6) units transfused (p < 0.001). Use of packed red blood cells (p < 0.001), fresh frozen plasma (p = 0.018) and platelets (p = 0.023) were each individually significantly increased.

CONCLUSIONS

In this study, it appeared that patients exposed to CCB's before cardiac revascularization received significantly more blood products than those who were not exposed to CCB's. Because of the limitations imposed by retrospective studies, further prospective studies are warranted to define the clinical significance of CCB use in the perioperative period.

Interaction of an implanted pacemaker with a transesophageal atrial pacemaker: report of a case

We report an interaction of a transesophageal atrial pacemaker (TAP) with a permanently implanted pacemaker in a cardiac patient who had undergone ablative therapy for atrial tachyarrhythmia 5 years earlier. The patient's permanent A-V pacemaker was completely inhibited by the TAP, and there was loss of ventricular contractions and blood pressure. The patient required epicardial A-V pacing to overcome the programmed heart rate of 76 bpm. We describe alternative methods to epicardial pacing. We also recommend close inspection of the chest radiograph, which often can reveal the serial numbers of the implanted pacemaker, as a means of identifying the device's functions and programming.

Mucinous adenocarcinoma of the parotid gland. Report of a case with fine needle aspiration findings and histologic correlation

BACKGROUND

Mucinous adenocarcinoma rarely arises as a primary tumor within the parotid gland, and only the histologic features of this tumor have been described.

CASE

A 4-cm, firm mass arose in the right parotid gland of a 72-year-old male over a six-week period. Cystic on computed tomography, the mass, on fine needle aspiration biopsy, yielded monomorphic, moderately atypical cells, both single and clustered, associated with abundant mucoid material and focal necrosis. Tumor cells had eccentric nuclei, prominent nucleoli and occasional cytoplasmic vacuolization. A few binucleated and multinucleated tumor cells were present. Histologic sections of the resected gland showed mucinous adenocarcinoma. A metastatic workup was negative. The differential diagnoses on cytology included other primary tumors of the parotid gland producing mucin or a mucoid matrix and metastatic mucinous adenocarcinomas.

CONCLUSION

To our knowledge, this is the first cytologic description of mucinous adenocarcinoma, primary in the parotid gland.

Ovarian serous borderline tumors with micropapillary and cribriform patterns: a study of 40 cases and comparison with 44 cases without these patterns

A group of investigators have proposed that the presence of micropapillary or cribriform patterns within ovarian serous tumors diagnosed as borderline according to World Health Organization (WHO) criteria identifies a subset of these neoplasms that are apt to be associated with invasive peritoneal implants and therefore should be designated as "micropapillary carcinoma." The authors of the current article identified 40 serous borderline tumors that showed one or both of these patterns, using the earlier investigators' published criteria for so-called micropapillary carcinoma, and compared them with 44 tumors that lacked these patterns (controls). Twenty-six patients with micropapillary tumors were aged 21 to 76 years (mean 38); 11 with cribriform tumors were aged 34 to 79 years (mean 60); and 3 with tumors having both patterns were aged 21 to 58 years (mean 38); the control patients were aged 22 to 83 years (mean 54). An advanced stage, bilaterality, and ovarian surface growth were features of the "micropapillary" tumors more often than of the control tumors. Except for a postoperative death related to sepsis, all 11 patients with Stage I tumors with either or both patterns who were followed until their death, or for at least 5 years (mean 7.9 years), survived without evidence of disease; a twelfth patient had a recent removal of recurrent pelvic tumor at 2.8 years and was alive at 3.3 years. Six of the eight patients with Stage II or III tumors with either or both patterns who were followed for at least 5 years (mean 7.5 years) survived disease-free. No deaths from tumor or progressive recurrences occurred in 27 control cases with 5-14 (mean 7.9) years of follow-up data. The two tumor-related deaths in the entire series, one from a micropapillary tumor and one from a cribriform tumor, occurred in patients who had Stage III tumors with invasive peritoneal implants. No patient with "micropapillary" tumors and noninvasive implants had progressive disease. Two women with "micropapillary" tumors and two control subjects had stable recurrent tumor or a newly developed tumor in a contralateral ovary that had been spared during the initial operation. Our findings confirm those of previous investigators that noninvasive serous tumors with a micropapillary or cribriform pattern or both patterns may be accompanied by invasive peritoneal implants more often than tumors without such patterns and that in such cases the disease is likely to be progressive and fatal. Since so-called micropapillary carcinomas lack obvious stromal invasion within the ovary, and their prognosis when they spread to the peritoneum is much closer to that associated with typical Stage II and III serous borderline tumors than to that associated with similarly staged serous carcinomas, the authors believe that this newly described category of tumors should remain as a subset within the borderline category, with a notation that their prognosis is poor if they are associated with invasive peritoneal implants.

Visceral analgesic tolerance to intrathecal butorphanol in rats

PURPOSE

Recent experimental data suggest that intrathecal (it) kappa-opioid agonists produce profound visceral analgesia. This study investigated the development of visceral analgesic tolerance to it butorphanol, a potent kappa-agonist that has fewer side effects than commonly used it opioids. Understanding of this tolerance could make it butorphanol more effective in treating chronic visceral pain.

METHODS

This was a randomized, controlled animal study involving 80 Sprague-Dawley rats. Rats implanted with lumbar it catheters were infused either with it saline or butorphanol (52 nmol.hr-1) for 96 hr. Six hours afterwards, each rat was challenged once with one of the differing it butorphanol doses to construct dose-response curves. Visceral analgesia was evaluated by the abdominal writhing responses to the acetic acid injected intraperitoneally. The time of the first writhe and the total number of writhes were recorded.

RESULTS

For both the saline- and butorphanol-infused groups, a higher challenge dose of it butorphanol produced longer time for the first writhe to occur (P < 0.01, one-way ANOVA), and fewer writhes occurring within 30 min (P < 0.01, one-way ANOVA). However, the dose response curves of the butorphanol-infused groups were shifted rightward (P < 0.001, partial F test).

CONCLUSION

The challenge doses of it butorphanol produced dose-dependent visceral analgesia in both the saline- and butorphanol-infused groups, confirming its efficacy. The butorphanol-infused groups showed dose-response shifts, demonstrating the development of tolerance to this visceral analgesia.

Pulse oximetry monitoring and late postoperative hypoxemia on the general care floor

Hypoxemia has long been recognized as a risk to patients in the operating room and postanesthesia care unit, and hemoglobin oxygen saturation (HbO2) monitoring with pulse oximetry has become a standard of care in these areas. There is growing evidence, however, suggesting that later postoperative hypoxemia also may play a role in organ dysfunction leading to morbidity and mortality. Economic pressures to move patients earlier from expensive postanesthesia recovery and intensive care areas to the general care floor -- where nurse-to-patient ratios are lower and lines of sight and sound may be impaired by walls and curtains -- may lead to inadequate surveillance of at-risk patients. These patient-management trends underscore the importance of improved monitoring of respiratory status on the general care floor. In this environment, telemetric pulse oximetry monitoring may represent a cost-effective approach to maximizing quality of care while enhancing risk management. This review discusses late postoperative hypoxemia and identifies areas for further investigation.

A comparison of two different bronchial cuff designs and four different bronchial cuff inflation methods

OBJECTIVE

To compare directly measured pressures at the cuff/trachea interface that are associated with two different bronchial cuff designs and four different methods of bronchial cuff inflation suggested for use with one-lung ventilation.

DESIGN

In vitro study.

SETTING

Experimental laboratory in a university-affiliated hospital.

INTERVENTIONS

The bronchial cuffs of two different endotracheal tubes were inflated using one of four different methods of determining the cuff volume and pressure necessary to "just seal" the bronchus and obtain lung separation; positive-pressure test, negative-pressure test, CO2 analysis, and a new test using an anesthesia ventilator. When each method predicted the "just-seal" state, the pressure at the cuff/bronchus interface as well as cuff inflation pressure and volume were recorded.

MEASUREMENTS AND MAIN RESULTS

Although the new test was incompatible with the bronchial blocker, the other three tests all accurately predicted lung separation with the Univent, with no significant differences in pressures exerted on the trachea. However, when used with the double-lumen tube, the new test produced significantly lower measured parameters than the other inflation methods. CO2 analysis did not reliably predict bronchial seal with the double-lumen tube.

CONCLUSIONS

To achieve lung separation with the lowest pressure on the trachea, the new test is the most appropriate method for use with the double-lumen tube; however, the negative-pressure test appeared to be the easiest and fastest method for use with the bronchial blocker. Although the bronchial blocker was associated with lower pressures transmitted from the cuff to the trachea, the in vitro model cannot predict which bronchial cuff design would be superior in vivo.

Decreased paralysis and better motor coordination with microspinal versus PE10 intrathecal catheters in pain study rats

We compared the standard PE10 catheter to a smaller microspinal catheter for intrathecal (IT) catheterization in rats. The PE10 or microspinal catheter was implanted in the lumbar subarachnoid space through the atlantooccipital membrane in rats (21 each group). Surviving rats without paralysis were tested on a rota-rod treadmill for motor function on Postoperative Days (POD) 3-6. Different doses of IT butorphanol were injected to demonstrate the functionality of the catheters by measuring tail-flick antinociception. Methylene blue was injected IT immediately before the spinal necropsy in each rat to identify the catheter tip location. For PE10 and microspinal catheters, the immediate death rate after the catheter implantation was 4 of 21 and 3 of 21 (no significant difference); paralysis rate was 8 of 21 and 2 of 21 (P < 0.05), and motor coordination recovery on POD6 was 67% and 91% (P < 0.01), respectively. Rats in both groups showed a dose-dependent response to IT butorphanol. Intrathecal methylene blue stained the lumbar spinal cord but not the surrounding tissue in both groups. Therefore, the microspinal catheter is better than the PE10 for IT catheterization in rats because it causes less paralysis and provides faster recovery of motor function.

Ovarian neuroendocrine carcinomas of non-small-cell type associated with surface epithelial adenocarcinomas. A study of five cases and review of the literature

Five primary ovarian carcinomas composed of a high-grade neuroendocrine tumor of non-small-cell type and a surface-epithelial-stromal tumor are reported. The five tumors presented in women aged 36 to 77 (mean, 57) years with abdominal distension or a palpable mass in three cases, right lower quadrant pain with tenderness and fever in one case, and a cervicovaginal smear showing a high estrogen effect in one postmenopausal patient. The tumors were unilateral, 9 to 30 (mean, 16) cm in greatest dimension, and had solid and cystic components. Three tumors were stage I; one, stage II; and one, stage III. Two patients who received chemotherapy died of tumor 8 and 36 months postoperatively, another who refused chemotherapy but later received radiation died of tumor after 19 months, a fourth was lost to follow-up, and a fifth was treated recently. Microscopically, the neuroendocrine components of all the tumors were composed predominantly of sheets, closely packed islands, cords, and trabeculae of epithelial cells with little intervening stroma. The tumor cells in the neuroendocrine areas were medium-sized to large compared with the cells of small cell carcinoma, and they contained scanty to moderate amounts of cytoplasm and hyperchromatic nuclei with coarse chromatin clumping in three cases and abundant cytoplasm and vesicular nuclei with single, large eosinophilic nucleoli in the other two. In all the cases, areas of necrosis and single-cell necrosis were extensive, and mitotic figures were abundant. Positive argyrophil and argentaffin reactions were observed in occasional to many cells in all cases. The glandular components of the tumors were grade 1/3 endometrioid adenocarcinoma (one case), grade 2/3 mucinous adenocarcinoma (2 cases), and mucinous borderline tumor with small foci of mucinous adenocarcinoma (two cases). Numerous enterochromaffin cells were identified in hematoxylin and eosin sections of the borderline mucinous components of two tumors; occasional nonargentaffin argyrophilic cells were present in the endometrioid and mucinous carcinoma components. Luteinized stromal cells were present focally in two cases, including the case in which there was evidence of a high estrogen level. Immunohistochemical studies in five cases showed staining of most cells in the solid components for cytokeratin and chromogranin A and some to most cells for serotonin and neuron-specific enolase. Neuropeptides that were detected in the solid component of one or more of the cases included vasoactive intestinal peptide, somatostatin, gastrin, and glucagon; negative results were obtained for pancreatic polypeptide and insulin. Flow cytometry in four tumors revealed that the neuroendocrine component was aneuploid in two, suspicious for aneuploidy in one, and diploid in one. Tumors of the type described are distinct pathologically from primary ovarian carcinoid tumors and small cell carcinoma of pulmonary type. Although experience with this type of tumor is limited, the prognosis appears to be poor.

Endometrioid ciliated-cell tumors of the ovary: a report of five cases

Five patients with ovarian endometrioid tumors composed predominantly of ciliated cells are reported; two patients had bilateral neoplasms. Two unilateral, predominantly cystic ciliated-cell tumors from women in their 40s were associated with endometriosis: one was borderline and arose in an endometriotic cyst; the other was borderline with foci of carcinoma and was associated with ipsilateral ovarian and peritoneal endometriosis. Five predominantly adenofibromatous tumors in the three other women, all postmenopausal, were not associated with endometriosis. One woman with a borderline ciliated-cell adenofibroma had had a prior contralateral adnexectomy, another with a borderline ciliated-cell adenofibroma had a contralateral ciliated-cell adenofibroma, and the third woman had a ciliated-cell adenocarcinoma and a contralateral borderline ciliated-cell adenofibroma. In two of the latter three patients the fallopian tubes contained foci of ciliated-cell hyperplasia. All five ciliated-cell malignant tumors were stage I, were treated by operation alone, and had not recurred 21 to 64 (mean 39) months postoperatively. Ciliated-cell tumors of the ovary should be distinguished from serous and mixed serous and endometrioid cancers because of different pathological and possibly different clinical features. Criteria for separating endometrioid ciliated-cell tumors into benign, borderline, and malignant categories are presented; whether any of these neoplasms behaves in a clinically aggressive fashion has yet to be determined.

Sertoliform endometrial adenocarcinoma: a study of four cases

We studied four endometrial carcinomas with a conspicuous component that resembled patterns in Sertoli cell tumors. The patients presented at age 44-83 years (mean 65 years), with abnormal or postmenopausal vaginal bleeding in three and abnormal cervical cytology in one. All were multiparous, moderately to markedly obese, and hypertensive, and three patients had non-insulin-dependent diabetes mellitus. One tumor was suspected to be an endometrial stromal sarcoma with sex-cord-like differentiation on biopsy. Gross examination of the hysterectomy and bilateral salpingo-oophorectomy specimens showed solid polypoid endometrial tumors in each case. Light microscopic examination showed three to be superficially invasive of the myometrium and one to be confined to the endometrium; none of the tumors showed the tongue-like pattern of myoinvasion or the angiolymphatic invasion characteristic of low-grade endometrial stromal sarcomas. The sertoliform component, which predominated in one case and was only focal in the three others, was composed of uniform small hollow tubules lined by columnar cells with apical cytoplasm and of compact slender cords. The tubules and cords were often present between benign-appearing or carcinomatous glands. In the case with predominate sertoliform areas, the lesional cells had clear cytoplasm suggesting a lipid-rich variant; special stains of this case demonstrated cytoplasmic glycogen but no fat. In none of the cases was cytoplasmic mucin, argyrophil granules, or argentaffinity demonstrated. The nonsertoliform areas of the tumors consisted of typical endometrioid adenocarcinoma; concurrent endometrial hyperplasia was also present in each case. Squamous differentiation and minor foci of anaplastic carcinoma with bizarre tumor giant cells were present in three tumors. Immunoperoxidase stains showed staining for two or more markers of epithelial or glandular differentiation in the sertoliform areas in all cases (keratin, epithelial membrane antigen, carcinoembryonic antigen, CA125, Tag72), with focal expression of vimentin in all cases. In none of the cases was desmin or actin staining observed. The evidence indicates that tumors in this series are variants of endometrioid adenocarcinoma and are distinct from uterine tumors resembling ovarian sex-cord tumors and stromal sarcomas with sex-cord-like differentiation.

Histologic transformation of benign endometriosis to early epithelial ovarian cancer

Between 1975 and 1990, 79 patients with Stage I epithelial ovarian cancer were treated at Massachusetts General Hospital. Patients were identified from the tumor registry and medical records were retrospectively reviewed. Pathological slides were evaluated for the presence of endometriosis, specifically looking for malignancy arising in endometriosis. Evidence of endometriosis was found in 22 of the 79 cases (28%). In the 23 cases of endometrioid histology, 9 cases (39%) were associated with endometriosis and, in the 17 cases of clear cell tumors, 7 (41%) were associated with endometriosis. All 8 cases of mixed histology had clear cell and/or endometrioid components and 4 cases (50%) were associated with endometriosis. Endometrioid adenocarcinoma accounted for 41% of the tumors associated with endometriosis, clear cell carcinoma 31%, mixed (endometrioid and/or clear cell types) 18%, and other types 9%. Among the 22 patients with associated endometriosis, we found 7 carcinomas (32%) arising in endometriosis. In these 7 cases a spectrum of benign and atypical endometriosis with a transition to clear cell or endometrioid adenocarcinoma were identified. These premalignant changes were characterized by cytologic atypia and architectural proliferation. Endometriosis was frequently encountered among patients with Stage I epithelial ovarian cancer of endometrioid and clear cell histologies. Endometriosis may play a role in the pathogenesis of some early stage malignant ovarian epithelial neoplasms.

"Adenoid cystic" and basaloid carcinomas of the ovary: evidence for a surface epithelial lineage. A report of 12 cases

Twelve ovarian neoplasms resembling salivary gland carcinomas and cutaneous basal cell carcinomas were studied and assigned to two groups: six with an exclusive or conspicuous component resembling adenoid cystic carcinoma and six with an exclusive or predominant component resembling basal cell carcinoma. The patients whose tumors simulated an adenoid cystic carcinoma presented at 60 to 78 (mean, 67) years of age. The adenoid cystic-like pattern was present in the primary ovarian tumor in five cases and four of these tumors had an additional surface epithelial-stromal component (serous adenocarcinoma in two, endometrioid adenocarcinoma in one, and mixed clear cell/endometrioid adenocarcinoma in one). The one patient with a Stage Ia tumor was free of disease at 37 months. Of the four patients whose tumors were Stage IIIc, two died of tumor at 13 and 123 months, respectively; another was alive with tumor at 27 months; and one was lost to follow-up. In the sixth case, an adenoid cystic-like pattern was present in a recurrent tumor in a patient from whom an ovarian endometrioid adenocarcinoma had been excised 11 years earlier. The patients whose carcinomas were predominantly or entirely basaloid presented at 19 to 65 (mean, 49) years of age. Three of these tumors had prominent squamous differentiation and gland formation, suggesting a relation to endometrioid carcinoma; three other tumors had an ameloblastoma-like pattern, with focal squamous differentiation in one, and a minor component of endometrioid adenocarcinoma adjacent to another. The four patients in the basaloid carcinoma group with Stage Ia tumors were alive without tumor at 16 to 71 (mean, 35) months.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of anesthetic complications and emergencies in the obstetric patient

The importance of cooperation and understanding between the obstetrician and anesthesiologist in the management of obstetric emergencies cannot be overemphasized. Indications for cesarean section and choice of anesthetic are significant considerations. Algorithms for the management of special treatment problems such as malignant hyperthermia, postdural headache, and epidural abscess and hematoma are presented. Posting of protocols for the management of particular crises in both delivery and postanesthesia care units is strongly recommended.

Prognostic importance of intraoperative rupture of malignant ovarian epithelial neoplasms

OBJECTIVE

To determine whether rupture of malignant ovarian epithelial tumors at the time of operation influences the patient's overall prognosis.

METHODS

Between 1975 and 1990, 79 patients with stage I invasive epithelial ovarian cancer were treated at Massachusetts General Hospital. Patients were identified from the tumor registry, and charts were reviewed retrospectively. In 71 of the 79 cases, pathologic slides were evaluated. Of the 79 patients, 36 had stage Ia tumors, 20 stage Ic secondary to intraoperative rupture (Ic-rupture), and 17 stage Ic secondary to capsular invasion-serosal disease or positive ascites or washings (stage Ic-other). Survival analysis was performed to compare the three groups of patients.

RESULTS

There were four recurrences and deaths among the 20 women with stage Ic-rupture tumors (20%), compared to one (3%) among the 36 women with stage Ia. The recurrence-free survival at the median follow-up time for the two groups was 97 +/- 3 and 78 +/- 10 months, respectively (P = .03); overall survival was 97 +/- 3 and 73 +/- 12 months (P = .04). There were two recurrences (12%) and one death (6%) among the 17 women with stage Ic-other, giving recurrence-free and overall survivals of 88 +/- 8 and 94 +/- 6 months, respectively. The survival experience of this last group was not significantly different from that in the Ic-rupture group (P = .2). The hazard ratios for overall survival associated with stage Ic-rupture and each potential confounder, except for bloating, exceeded 6.5, with P < or = .10. All deaths occurred in the 28 patients with grade 2 or 3 tumors. Even in this smaller group, the hazard ratio for stage Ic-rupture was 6.8 (P = .09).

CONCLUSION

Intraoperative rupture of malignant epithelial ovarian neoplasms may worsen the prognosis of patients with stage I ovarian cancer.

Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School

The increasing use of sedation to enhance patient comfort during diagnostic and therapeutic procedures has been noted by the Joint Commission of Accredited Healthcare Organizations, specialty societies, and the public. Although anesthesiologists, by virtue of training and experience, possess unique qualifications to provide such sedation services, their availability remains somewhat limited by primary commitments to the operating room, intensive care unit, or pain service. The Risk Management Committee of the Department of Anaesthesia of Harvard Medical School has made specific recommendations to the Harvard-affiliated hospitals for anesthesiologists who participate in institutional-level committees in setting guidelines for such services when they are provided by nonanesthesiologists. Specific consideration is given to facilities, backup emergency services, equipment, education and training, issues of informed consent, documentation, and release of patients from medical care. These recommendations emphasize the collaboration of the department of anesthesia and other departments that provide sedation services in formulating policies and procedures that reflect values intrinsic to the practice of anesthesiology.

Nonpulmonary small cell carcinomas of extragenital origin metastatic to the ovary

Seven small cell carcinomas of extragenital and extrapulmonary origin that metastasized to the ovary are described. The tumors occurred in women who were 21-77 years of age (mean, 49 years) and were discovered at, or close to, the time of presentation. The primary sites were the intestine (three cases), thymus (two cases), and inguinal skin (one case), and in one case it was undetermined. The ovarian tumors, four of which were bilateral, ranged from 1.2 to 25 cm in diameter (mean, 11 cm). Microscopic examination showed typical features of small (oat) cell carcinoma in six cases; one neoplasm resembled a small cell carcinoma of intermediate cell type and contained rare glands. On immunohistochemical examination, six of six tumors stained for cytokeratin, five of five for neuron-specific enolase, two of six for chromogranin, and none of four for vimentin. The primary cutaneous tumor was a Merkel cell carcinoma. The patient with that case died at 8 months. Two patients with intestinal tumors died at 1 and 2 months, and one is free of disease at 4 years after receiving chemotherapy. Both patients with mediastinal tumors received chemotherapy; one died at 11 months and one had brain metastases at 5 months and was lost to follow-up. The final case is recent. The differential diagnoses in these cases include primary ovarian small cell carcinomas of hypercalcemic and pulmonary types and various other small cell malignant tumors metastatic to the ovary. Consideration of a variety of clinical and pathologic features should enable these important distinctions to be made.

The standards formulation process

The International Task Force on Anaesthesia Safety was formed in 1989 to institute a new international effort to improve anaesthesia safety worldwide. Membership was by invitation to individuals with strong credentials in the anaesthesia safety movement in their own countries. Two and a half years of debate yielded a comprehensive standards document that covered not only monitoring and equipment issues, but also key issues relating to the professional standing of anaesthetists. A keen awareness of the limited nature of anaesthesia resources in many parts of the world, and a desire to make these international standards useful to all, led to the international standards document incorporating several levels of desirability; an appendix covering several levels of equipment acquisition was also included. Consultation from a variety of individuals and groups not represented on the Task Force was actively sought. In June 1992, the World Federation of Societies of Anaesthesiologists adopted the Task Force's international standards document and commended it to its 98 member societies worldwide.

Administrative guidelines for response to an adverse anesthesia event. The Risk Management Committee of the Harvard Medical School's Department of Anaesthesia

The Risk Management Committee of the Harvard Medical School's Department of Anaesthesia developed a set of guidelines recommending administrative actions that should be taken immediately following an adverse anesthesia event. The guidelines are intended to limit patient injury from a specific event associated with anesthesia and to ensure that the causes of the event are identified to prevent recurrence. The guidelines direct the primary anesthetist to concentrate on continuing care but quickly notify someone in a leadership position, who would become the "incident supervisor." The incident supervisor would be knowledgeable of the details of the protocol and direct activities for ensuring appropriate medical care, sequestration of equipment, documentation of information, and contact of other appropriate administrative personnel. Experience with the guidelines has shown that they can be effective if applied but that it is difficult to do that consistently in our large medical centers.

DNA content and proliferative activity in ovarian small cell carcinomas of the hypercalcemic type. Implications for diagnosis, prognosis, and histogenesis

Ovarian small cell carcinoma of the hypercalcemic type is a rare cancer of young women of nuclear histogenesis. Although usually lethal, a subset of patients with stage I tumors have survived. Twenty-five cases of small cell carcinoma (17 stage I, 1 stage II, and 7 stage III) were evaluated by flow cytometric analysis performed on paraffin-embedded tissue. Forty classifiable histograms from 23 cases were DNA diploid; histograms from two cases could not be interpreted. The mean S-phase fraction was 10.5% (4.7% to 18.4%), and the mean G2/M fraction was 5% (1.5% to 19.5%) in 22 cases. Mean values of mitotic rate, S-phase fraction, G2/M fraction, and proliferation index (%S + %G2/M) were not associated with stage or outcome, nor did any proliferation variable correlate with interval to death. A comparative review of flow cytometric findings in other types of ovarian cancer that may be confused with small cell carcinoma indicates that flow cytometry is an objective diagnostic aid to distinguish small cell carcinoma of the hypercalcemic type from other forms of small cell carcinoma, malignant germ cell tumors, and sex-cord tumors, and that small cell carcinoma probably does not belong in either the surface epithelial or germ cell categories of ovarian cancer. Finally, the flow cytometric findings in this report exemplify the rare phenomenon of a diploid DNA content in a very lethal tumor and indicate that an accurate diagnosis of tumor type is essential before a prognosis on the basis of flow cytometric data can be made.

Primary ovarian small cell carcinoma of pulmonary type. A clinicopathologic, immunohistologic, and flow cytometric analysis of 11 cases

Eleven primary ovarian tumors that resembled small cell carcinoma of the lung are reported. They occurred in women 28-85 (mean 59) years of age, most of whom presented with abdominal swelling. Six of the tumors were unilateral and five bilateral; seven had spread beyond the ovary. The tumors ranged from 4.5 to 26 (mean 13.5) cm in greatest dimension and were mostly solid, with a variable minor cystic component. Microscopic examination showed small to medium-sized round to spindle-shaped cells with scanty cytoplasm, hyperchromatic nuclei, and inconspicuous nucleoli growing in sheets, closely packed nests, and occasionally islands and trabeculae. A component of endometrioid carcinoma was present in four tumors, another tumor showed squamous differentiation, another contained a cyst lined by atypical mucinous cells, and two others were associated with a Brenner tumor. Argyrophil granules were present focally in two of six tumors appropriately stained. Immunohistochemical staining was performed in nine cases: in six there was staining of the small cell component for keratin, in five for epithelial membrane antigen, in seven for neuron-specific enolase, in two for chromogranin, and in one for Leu-7. Vimentin staining was not observed. Flow cytometry was performed on eight tumors: five were aneuploid and three diploid. Five of seven patients with long-term follow-up died of, or with, disease at 1-13 (mean 8) months, one died after an unknown interval, and one was alive at 7.5 years. Two other patients had recurrent or residual disease at 6 and 8 months.

Ovarian involvement by the intra-abdominal desmoplastic small round cell tumor with divergent differentiation: a report of three cases

Three girls, one 14 and two 15 years of age, with the recently described neoplasm that has been designated "intra-abdominal desmoplastic small round cell tumor with divergent differentiation," and ovarian involvement at presentation are described. In two cases the ovarian tumor was initially thought to be the primary neoplasm. In all cases there was extensive extraovarian tumor at the time of presentation. The ovarian involvement was bilateral in two cases and unilateral in the third. Microscopic examination showed prominent nodular growth within the ovaries. The tumors were characterized predominantly by nests of small cells with hyperchromatic nuclei and scant cytoplasm separated by a prominent desmoplastic stroma. A few tubules containing mucinous secretion were present in one case. On immunohistochemical staining many of the tumor cells stained positively for cytokeratin, epithelial membrane antigen, desmin, and vimentin. Staining for neuron-specific enolase was present in two cases but was conspicuous in only one of them. Leu-7 was expressed by the tumor cells in two cases, and S-100 protein by one, giving further support to the possibility of neuroectodermal differentiation within some of these neoplasms. The two cases studied by electron microscopy both showed frequent intercellular junctions, basal lamina, cytoplasmic filaments, and sparse, small dense granules of either neuroendocrine or lysosomal type. Paranuclear aggregates of filaments were found in one case and cellular processes were prominent in the other case. The differential diagnosis in these cases was extensive and included a number of small cell tumors that may involve the ovary, either primarily or secondarily, in young females. The desmoplastic small round cell tumor should be considered in such cases when the appearances on routine examination are consistent with the diagnosis, and appropriate immunohistochemical stains should be performed to confirm the diagnosis.

Sinonasal hemangiopericytoma. A reassessment with electron microscopy, immunohistochemistry, and long-term follow-up

Sinonasal hemangiopericytomas are rare, occasionally misdiagnosed neoplasms that have often been considered distinct from hemangiopericytomas of other sites. Eleven cases were studied. Nine arose from the nasal cavity and two from the paranasal sinuses. The patients' mean age was 58 years. In nine cases there were no appreciable mitoses; in two, mitoses were frequent. Of 10 cases studied by immunostaining, all were positive for vimentin; two had faint focal staining for actin; one focally expressed S-100 protein; all were negative for cytokeratins, desmin, and Factor VIII-related antigen; and none bound Ulex europaeus agglutinin 1. Five cases were studied by electron microscopy. The most consistent features were basal lamina-like material partly surrounding tumor cells and completely separating them from endothelium, tapered cytoplasmic extensions, and orderly bundles of filaments. Intercellular junctions and pinocytotic vesicles were present in some tumors. Of nine cases with adequate follow-up, tumors recurred in four cases (44%) after a mean of 6.5 years, and none metastasized. A review of the literature showed that high local recurrence rates, late recurrences, and low rates of metastasis were features of tumors in this location. This might be a reflection of early presentation, small tumor bulk, and difficulty of complete resection, rather than evidence for a biologically distinct neoplasm.

Postanesthesia care unit standards for anesthesiologists. Board of Directors of the American Society of Post Anesthesia Nurses

The following article describes postanesthesia care unit standards for anesthesiologists as developed by the Harvard Anesthesia Department's Risk Management Committee, Harvard Medical School. The standards were endorsed by the ASPAN Board of Directors, April 10, 1988. It is hoped that publication of these standards will assist PACU nurses in evaluating the anesthesia support they receive in their respective settings.

Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring

Among 1,001,000 ASA Physical Status I and II patients (a subset of the 1,329,000 anesthetics administered from 1976 through mid-1988 in the nine component hospitals of the Harvard Department of Anaesthesia), there were 11 major intraoperative accidents solely attributable to anesthesia (five deaths, four cases of permanent CNS damage, and two cardiac arrests with eventual recovery) among the 70 cases reported to the insurance carrier. Review of these accidents revealed that unrecognized hypoventilation was the most common cause (seven cases). These seven accidents and one other due to discontinuation of inspired oxygen in all likelihood would have been prevented by appropriate response to earlier warnings generated by the "safety monitoring" principles mandated by the Harvard minimal monitoring standards. Analysis suggests capnography (although not mandated) would be the best monitor of ventilation. An important associated issue was the apparent inadequacy of supervision of residents and C.R.N.A.s. The eight preventable accidents represent 88% of the projected insurance payout. Only one accident occurred after the 1985 adoption of the standards (in the month following their implementation). From that time through mid-1988, there have been 319,000 anesthetics without a major preventable intraoperative injury. Although not statistically significant, the accident rate in the target population of healthy people is reduced more than threefold. This and the case analyses support the contention that nearly all the inevitable mishaps (technical or from errors in judgement) that occur during anesthesia can be identified through safety monitoring early enough to prevent most major patient injuries. This improved clinical outcome should lessen the medical-legal and malpractice insurance burdens of anesthesiologists.

Intravascular papillary endothelial hyperplasia involving the synovium

To our knowledge, this is the first reported case of intravascular papillary endothelial hyperplasia occurring in the synovium. The patient, a 16-year-old boy, presented with pain and hemarthrosis of the knee in the absence of known trauma. The lesion arose within a subsynovial varix and episodically bled with the intra-articular hemorrhage and reactive synovial changes producing the patient's symptomatology. The clinical, pathologic, and ultrastructural features of the lesion are summarized from a review of the literature, and the differential diagnosis of hemarthrosis with a hemosiderotic synovitis is discussed.

Inter-instrument comparison of blood gas analyzers and assessment of tonometry using fresh heparinized whole human blood

Because of limitations associated with commercial blood gas quality controls and tonometry of stored blood, fresh heparinized blood was used to compare PO2 and PCO2 performance of ten blood gas analyzers. Function of nine gas mixer/tonometer systems was evaluated. These were used to create blood samples with target values for PO2 and PCO2. All ten analyzers had high precision; this magnified small differences between observed results and target values. Grand mean results from all ten analyzers were within 0.8 mm Hg of the target for PO2 of 40.0 and 100.0 and for PCO2 of 20.0 and 70.0 mm Hg. Eight automated blood gas analyzers gave clinically indistinguishable results for PO2 and PCO2 that were sufficiently accurate for clinical purposes. Also reported is the practicality of using tonometry of fresh heparinized blood in a per shift quality control program for PO2 and PCO2.

Standards for patient monitoring during anesthesia at Harvard Medical School

As part of a major patient safety/risk management effort, the Department of Anaesthesia of Harvard Medical School, Boston, has devised specific, detailed, mandatory standards for minimal patient monitoring during anesthesia at its nine component teaching hospitals. Such standards have not previously existed, and resistance to the concept was anticipated but not seen. The standards are technically achievable in all settings and affordable in terms of effort and cost. Early detection of untoward trends or events during anesthesia will result in prevention or mitigation of patient injury; this, in turn, may also help counter the explosive increases in anesthesia-related malpractice actions, settlements, judgments, and insurance premiums. The committee process used is applicable to the promulgation of standards of practice for all medical specialties and any organized group of medical practitioners.

Quantitative biochemical analysis of microtubule content in normal and transformed 3T3 cells

Microtubules in normal and transformed BALB 3T3 cells were preserved in a stabilizing medium and measured by a [3H]colchicine-binding tubulin assay, and compared to total cellular tubulin measured under nonstabilizing conditions. Essentially no change in tubulin or microtubule content was seen with changes in cell density or with changes in cellular morphology at various stages of growth of normal or transformed cells or induced by dibutyryl cAMP treatment of transformed cells. Of five cell lines transformed by a variety of agents, four had a significantly higher total tubulin content than untransformed 3T3 cells and all of them had an increased microtubule content. None of the transformed lines had a lower fraction of tubulin recoverable as sedimentable microtubules compared to untransformed cells, and in three of them this fraction was significantly higher. These results establish that microtubules are present in transformed cells to at least the extent (if not greater) than in normal cells but that there are variations in the total amount of tubulin and microtubules as well as the fraction of the total tubulin present as microtubules which are not strictly correlated with transformation or cell morphology.

Local anesthetic-induced inhibition of collagen secretion in cultured cells under conditions where microtubules are not depolymerized by these agents

Tertiary amine local anesthetics previously have been shown to influence some microtubule-dependent cellular functions. Since several cell secretion processes, including secretion of collagen, have been shown to be inhibited by microtubule-disrupting drugs such as colchicine, we determined whether local anesthetics affect collagen secretion. Six local anesthetics inhibited collagen and non-collagen protein secretion (up to 98%) into the extracellular medium of 3T3 cells and human fibroblasts, an effect apparently independent of influences on proline transport and total protein synthesis. A combination of colchicine and cytochalasin B did not duplicate the effects of local anesthetics. The effects of subsaturating concentrations of colchicine and procaine on secretion were additive, suggesting that both drugs act on the secretory pathway at the level of microtubules, but other effects of the two types of drugs were strikingly different. In comparing the mechanisms of action of colchicine and local anesthetics, it was seen that, in contrast to colchicine, radioactive procaine and lidocaine were slowly transported into 3T3 cells, did not bind to the tubulin-containing TCA-insoluble fraction, and did not bind to purified tubulin in vitro. The fraction of cellular tubulin present as microtubules (47% in normal cells) was determined by measuring tubulin in stabilized, sedimentable microtubules compared to total tubulin, using a [3H]colchicine binding assay. Pretreatment of cells in the cold or with colchicine led to depolymerization of microtubules, but pretreatment with five local anesthetics tested did not. Therefore, in contrast to colchicine, local anesthetics in concentrations that inhibit secretion do not directly interact with or depolymerize microtubules. These drugs, however, do affect a microtubule-dependent process and may do so by detaching the microtubular system from the cell membrane.

Contamination of medical gas and water pipelines in a new hospital building

Medical gases and water were sampled and tested for purity prior to the opening of a 176-bed addition to a 450-bed general hospital. Contamination was found. In delivered oxygen, compressed air, and nitrous oxide, this consisted of a volatile hydrocarbon at an initial concentration of 10 parts per million and a dust of fine gray particulate matter. In water from new taps bacterial contamination with as many 400,000 organisms per 100 ml was present. All these contaminants were considered potential hazards to patient safety. Studies were done to help delineate the nature and origin of these contaminants. Each contaminant was eventually largely eliminated by purging the respective pipeline systems with continuous flows. Planners, builders, and responsible medical personnel must be aware of the potential for such hazards in a new hospital building.