Survey of respiratory sounds in infants

BACKGROUND

Over the last decade there has been an apparent increase in childhood wheeze. We speculated that much of the reported increase may be attributed to the term wheeze being adopted by parents to describe a variety of other forms of noisy breathing.

AIMS

To investigate terminology used by parents to describe their children's breath sounds.

METHODS

An interview was carried out with the parents of 92 infants with noisy breathing, beginning with an open question and then directed towards a more detailed description. Finally, the parents were asked to choose from a wheeze, ruttle, and stridor on imitation by the investigator and video clips of children.

RESULTS

Wheeze was the most commonly chosen word on initial questioning (59%). Only 36% were still using this term at the end of the interview, representing a decrease of one third, whereas the use of the word ruttles doubled.

CONCLUSIONS

Our results reflect the degree of inaccuracy involved in the use of the term wheeze in clinical practice, which may be leading to over diagnosis. Imprecise use of this term has potentially important implications for therapy and clinical trials.

Screening for colorectal cancer in a high-risk population. Results of a mathematical model

A mathematical model was used to estimate the cost-effectiveness of colorectal cancer screening strategies for people who are at high risk because of a first-degree relative with colorectal cancer. The model uses indirect evidence about such factors as cancer incidence, sensitivity and specificity of different tests, and treatment effectiveness. The analysis indicates that for screening people over 40 yr old an annual fecal occult blood test may reduce colorectal cancer mortality by about one-third, either colonoscopy or barium enema may reduce mortality by approximately 85%, a 3-5-yr frequency for endoscopies or barium enemas preserves 70%-90% of the effectiveness of an annual frequency, and beginning screening at age 50 reduces effectiveness by 5%-10%. Although both barium enemas and colonoscopies appear to be effective in reducing mortality, the lower cost of the barium enema makes it a more cost-effective strategy. All of these estimates depend on the baseline estimates of each of the factors incorporated in the model; the conclusions are most sensitive to assumptions about the natural history of adenomatous polyps, the bleeding of adenomas and presymptomatic cancers, and the sensitivity of the fecal occult blood test. Recommendations about colorectal cancer screening must also consider factors such as discomfort, inconvenience, and the availability of various technologies.

Gastric carcinogenesis induced by N-methyl-N'-nitro-N-nitrosoguanidine: role of gastrectomy and duodenal reflux

The effect of gastrectomy and duodenal reflux on gastric carcinogenesis was studied because gastrectomized patients may be considered at "high risk" for the development of gastric stump cancer. Wistar rats received N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) (83 mg/liter) ad libitum in the drinking water for either four, eight, or twelve weeks. A control group received tap water. After MNNG administration animals were antrectomized. Antrectomy was not performed in a control group. Bowel continuity was restored either with a Billroth II (BIL) or with a ROUX en Y (ROUX) procedure. Duodenogastric reflux is possible after the BIL but not after the ROUX procedure. Eight months after the beginning of the experiment the stomachs of the animals were studied. In both operated and unoperated animals, the number of cancers observed was significantly related to the duration of MNNG administration. Animals receiving MNNG plus the BIL procedure had a significantly higher number of anastomotic cancers than the ROUX animals, indicating that duodenogastric reflux played a promotional role in gastric carcinogenesis. Three BIL gastrectomized rats not receiving the carcinogen had an adenocarcinoma on the anastomotic line further emphasizing the risk attached to the duodeno-gastric reflux.

Barrett's esophagus with adenocarcinoma in scleroderma

The gastrointestinal manifestations of scleroderma are varied. Esophageal problems are common especially in patients with Raynaud's phenomenon. An adenocarcinoma complicating a Barrett's esophagus was identified in a patient with the CREST variant of scleroderma. The significance of this association and its relationship to chronic reflux esophagitis is discussed. Patients with scleroderma should be considered to be at an increased risk of developing this premalignant condition of the esophagus.

Nutrition and cancer

Nutrition and cancer interact at several levels. Both dietary deficiencies and dietary excesses have been linked with changes in prevalence of certain human cancers. With respect to one particular nutrient, riboflavin, a dietary deficiency may decrease the development of spontaneous tumors in experimental animals but increase carcinogenesis due to certain agents. Cancer itself has profound effects upon nutritional status, and neoplastic tissue appears in general to resist dietary deficiency more effectively than normal tissues. Nutrition has a major role in therapy of cancer, but as an adjunct to the treatment plan rather than as an alternative. Parenteral nutrition, either peripheral or total, can provide support that is critically needed when patients cannot eat or swallow, have obstruction or malabsorption, or are otherwise unable to utilize dietary nutrients in adequate amounts. The advent of home parenteral nutrition now provides a means for long-term rehabilitation of cancer patients.

A morphologic and kinetic basis for the more invasive character of N-methyl-N'-nitro-N-nitrosoguanidine induced duodenal tumors following pyloroplasty

Pyloroplasty increased the invasiveness of duodenal tumors in Wistar rats receiving N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) for 12 weeks (83 mg/l in drinking water) (Arch. Surg., 117, 768-771). To assess morphologic and kinetic alterations, analyses of tritiated thymidine (3HTdR) pulse-labeled fundic, antral and duodenal mucosa were carried out. The normal appearance of MNNG-treated antral and duodenal mucosa was characterized by the appearance of elongated hyperactive columns exhibiting elevated levels of DNA synthesis. Pyloroplasty in carcinogen-treated rats induced both a 3-fold enhancement in the number of these elongated columns and an elevation in the number of proliferating cells within them (P less than 0.001). In the MNNG and pyloroplasty treated duodenal mucosa 26% of columns contained over 130 cells/column rather than an average of 100 cells in normal appearing MNNG-treated mucosa. DNA synthesis was increased by 23% within these hyperactive glands (11.3 proliferative cells/column vs. 9.4/column in normal appearing mucosa). Pyloroplasty creates both an increase of gastric bile reflux and an increase of the gastric evacuation rate, conditions which influence cell proliferation. Such alterations in antro-pyloro-duodenal physiology contribute to the increased cellular activity observed, promote malignant transformation and foster the expression of invasiveness.

Surveillance for colorectal cancer in average-risk patients, familial high-risk groups, and patients with adenomas

New concepts and technological advances have stimulated a heightened interest in the secondary prevention of colorectal cancer; the identification and eradication of premalignant lesions, and the detection of early cancer before the development of life-threatening consequences. This approach must be selective based on risk factors. Fecal occult blood testing and sigmoidoscopy have been applied to the average-risk patients, whereas x-rays, endoscopy, biopsy, and cytology have been applied to the high-risk groups for case findings and screening. Program results to date are encouraging for average-risk patients. Compliance with fecal occult blood testing and sigmoidoscopy has been high in motivated groups self-selected for entry into screening programs. The rate of positive slides, false-positivity, and predictive value for neoplasia has been acceptable. Dukes' staging of cancers has been favorable. False-negativity and mortality data are not yet available. Flexible sigmoidoscopy has been shown to be an effective substitute for rigid sigmoidoscopy in trained hands. Familial polyposis and Gardner's syndrome families have been well studied, but interest in the nonpolyposis inherited colon cancer families is relatively new. Followup procedures after polypectomy have been variable and only recently has there been an organized attempt to prospectively study the effectiveness of different followup plans. The National Polyp Study has been developed to address this issue.

Primary gastric lymphoma. A review of 50 cases

The records of 50 patients with localized primary gastric lymphoma were reviewed and clinical and prognostic factors characterized. Pathologic material was reclassified according to Rappaport's, Lukes-Collins, and Lennert's Kiel classifications. Factors with the greatest prognostic significance included initial stage as determined by surgery and pathology, absolute tumor size, degree of penetration through the stomach wall, and histologic grade of the lymphoma. After surgical resection for cure, the overall 5-year disease-free survival was 47%. For stage I disease, this was 78% vs 29% for stage II (P = 0.006). Patients with lymphomas less than 5 cm in diameter had 58% 5-year disease-free survival vs 32% for those with tumors greater than 10 cm (P = 0.06). Full-thickness penetration decreased 5-year survival from 75% to 38% (P = 0.06). Patients with histologically low-grade lymphomas had a better prognosis than those with high-grade lymphomas. The most significant correlation of histology to survival was seen with the Kiel classification with a 5-year survival of 39% for centroblastic polymorphous lymphoma vs 66% for LP immunocytoma. When lymphoma recurred it developed outside the abdomen in a majority of patients. The addition of abdominal radiation therapy to surgical resection made no significant impact on survival for either stage I or II disease.

Cancer induction after pyloroplasty in rats: treatment with N-methyl-N'-nitro-N-nitrosoguanidine

Nineteen male Wistar rats received N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) in drinking water (83 mg/L) to initiate glandular adenocarcinoma of the stomach; eight control rats received tap water. After 12 weeks a pyloroplasty was performed on nine rats receiving MNNG and three control rats. Ten MNNG-treated rats and five control rats had no operation. All were observed for 38 weeks before being killed. No difference in the incidence of antral adenocarcinomas was found between the MNNG-treated groups; however, those without operation showed in situ changes in the duodenum and those treated with pyloroplasty showed five invasive adenocarcinomas. In this model pyloroplasty alone did not increase the risk of gastric cancer but increased the risk of duodenal tumors. Pyloroplasty apparently accelerated the gastric evacuation rate, resulting in greater insult to the duodenal mucosa. Such a condition may require a higher proliferative rate in the duodenum and may increase subsequent formation of malignant tumors.

Primary gastrointestinal lymphoma: a 30-year review

The authors reviewed all cases of non-Hodgkin's lymphoma primarily involving the gastrointestinal tract treated at Memorial Hospital during the period from 1949-1978. Complete clinical records were available in 104 cases. Slides of original pathology specimens were available in 81 cases. Tumors were classified by Rappaport, Lukes-Collins and modified Kiel classifications. All patients were staged retrospectively, using modified Ann Arbor staging. The primary tumor was in the stomach in 76 patients, in the small bowel in 15 and in the large bowel in 13. The life-table survival for all patients at five years was 44% and for the 81 Stage I and II patients it was 53%. We found a trend toward improved survival for patients treated in the last decade (P = 0.05). Using Cox regression analysis, survival was found to be correlated with stage (P less than 0.0001) and involvement of adjacent structures (P = 0.007). For Stage I patients, resection and radiation therapy were equally effective alone in controlling local tumor even though factors responsible for the selection of either treatment could not be identified. For Stage II patients, resection combined with radiation therapy controlled local disease better than either treatment alone. For Stage II, patient survival was correlated with the pattern of nodal involvement (P less than 0.0001). Neither the choice of treatment (resection, radiation therapy, or resection with radiation therapy; P = 0.17) nor the involvement of resected margins (P = 0.22) affects survival. Among 81 Stage I and II patients, 68% had recurrences outside the primary field of treatment and 60% outside the abdomen. Systemic multiple modality therapy should be considered for patients at high risk for recurrence.

Primary gastrointestinal lymphoma: a 30-year review

The authors reviewed all cases of non-Hodgkin's lymphoma primarily involving the gastrointestinal tract treated at Memorial Hospital during the period from 1949-1978. Complete clinical records were available in 104 cases. Slides of original pathology specimens were available in 81 cases. Tumors were classified by Rappaport, Lukes-Collins and modified Kiel classifications. All patients were staged retrospectively, using modified Ann Arbor staging. The primary tumor was in the stomach in 76 patients, in the small bowel in 15 and in the large bowel in 13. The life-table survival for all patients at five years was 44% and for the 81 Stage I and II patients it was 53%. We found a trend toward improved survival for patients treated in the last decade (P = 0.05). Using Cox regression analysis, survival was found to be correlated with stage (P less than 0.0001) and involvement of adjacent structures (P = 0.007). For Stage I patients, resection and radiation therapy were equally effective alone in controlling local tumor even though factors responsible for the selection of either treatment could not be identified. For Stage II patients, resection combined with radiation therapy controlled local disease better than either treatment alone. For Stage II, patient survival was correlated with the pattern of nodal involvement (P less than 0.0001). Neither the choice of treatment (resection, radiation therapy, or resection with radiation therapy; P = 0.17) nor the involvement of resected margins (P = 0.22) affects survival. Among 81 Stage I and II patients, 68% had recurrences outside the primary field of treatment and 60% outside the abdomen. Systemic multiple modality therapy should be considered for patients at high risk for recurrence.

Tissue concentrations and proliferative effects of massive doses of ascorbic acid in the mouse

The effect of ascorbic acid supplementation on CF1 mice fed ascorbic acid for approximately six months at dose levels of 1%, 5%, and 10% of diet was investigated by analysis of tissue ascorbic acid concentration in the liver, kidney, stomach, small intestine, and large bowel. The effect on epithelial cell proliferation was also examined in the small and large bowel but only at the 5% level. In the control animals, ascorbic acid concentration was lowest in the liver (0.406 +/- 0.07 mg/g) and highest in the small bowel (0.754 +/- 0.16 mg/g). Dietary intake of 5% and 10% ascorbic acid significantly elevated levels in the liver (0.741 +/- 0.13; p less than 0.05), and all doses of ascorbic acid significantly raised tissue concentrations in the kidney and colon. No difference was observed in the percentage of DNA-synthesizing cells in the jejunum of controls or animals fed 5% ascorbic acid at 1 or 24 hours after 3HTdR injection. However, at 1 hour a significantly decreased level of proliferation was observed in the distal colon of ascorbic-acid-treated mice compared with controls (labeling index [L.I.] = 7.3 +/- 0.28 vs. 10.1 +/- 1.15; p less than 0.05), and an even greater suppression of DNA synthesis was achieved by 24 hours (L.I. = 11.4 +/- 1.06 vs. 18.6 +/- 1.61; p less than 0.01). None of the doses of ascorbic acid employed was toxic to the experimental mice.

Colon and rectal cancer: etiology and screening

Our ultimate goal is primary prevention of colorectal cancer by delineating the etiologic factors in the pathogenesis of the disease and eliminating or modifying these factors. Further research is needed to accomplish this goal. In the meantime, early detection of colorectal cancer and its precursor lesions can be accomplished by methods currently available. Ultimately, a simple biochemical or immunologic test may become available which will identify individuals at high risk for colon cancer and may indicate that a very early lesion is present. This is the ultimate goal for secondary cancer prevention since the disease would then be discovered at a curable stage in almost all patients.

The gastrointestinal manifestations and complications of malignant lymphoma

Malignant lymphoma involves the gastrointestinal tract as a primary or secondary in the course of disseminated lymphoma. Although primary lymphoma has received the most attention in the literature, secondary lymphoma of the gastrointestinal tract is much more common. The gastrointestinal manifestations and complications are a common problem and there is a lack of information as to diagnosis, management and prognosis. Intensive application of currently-available diagnostic techniques including radiology, cytology, endoscopy, biopsy and gastric secretory studies should be pursued for the evaluation of patients with lymphoma. The management of the multiple gastrointestinal complications such as monilial esophagitis, hemorrhagic gastritis, stress erosions, intestinal perforation, diarrhea, malabsorption and radiation damage that may then affect the gastrointestinal tract in the course of malignant lymphoma or its treatment requires very careful supportive management. Each modality of tretment for lymphoma may be associated with a variety of complications which compromise the structure and function of the gastrointestinal tract and which may be at times more devastating than the underlying neoplasm. Early recognition and active treatment of these complications is vital.

Progress report on controlled trial of fecal occult blood testing for the detection of colorectal neoplasia

Our controlled trial of screening for colorectal cancer has now been in progress for almost five years. Screening is accomplished by rigid sigmoidoscopy in control and study groups and, in addition, by fecal occult blood testing in the study group. Patients screened are men and women age 40 and older, mostly at average risk. Fecal occult blood testing is with Hemoccult slides with patients on a meat-free, high-bulk diet without hydration, and with a four-day storage interval between slide preparation and testing. Patients with positive slides undergo diagnostic investigation that includes both colonoscopy and double-contrast barium enema and, in some, an upper gastrointestinal series. Preliminary results to date include: patient baseline statistics and subgroup comparability, rate of positive slides of 1-4%, predictive value for neoplasia of 44-50%, false-positives of 0.5-2.1%, favorable Dukes' staging of cancers in the study group, and high patient compliance. Considerably more follow-up is need in our study and control population, and issues such as mortality and cost need to be addressed. Additional time will be necessary to provide firm conclusions.

The two stage provocative test for pancreatic disease by serum enzyme measurements

The pancreas can be studied for obstructive disease by measuring serum lipase levels in the two stage provocative test. The test is nonspecific but noninvasive and applicable to all stages of pancreatic diseases. In this test, the pancreas is stimulated twice in two hour intervals before measuring the serum enzyme levels: first, with pancreozyin and secretin--the stage 1 test and, second, with pancreozymin, secretin, betazole hydrochloride and morphine sulfate--the stage 2 test. Among the pancreatic enzymes measured, lipase was most reliable. Serum lipase level elevation in the stage 1 test indicates a pancreatic abnormality and it completes the test. Patients who fail to respond to the stage 1 test have either a normal pancreas or pancreatic insufficiency and need the stage 2 test for differential diagnosis. In the stage 2 test, the serum lipase level is elevated in patients with a normal pancreas but not in those with pancreatic insufficiency. As a preliminary study, ten patients with carcinoma of the pancreas, two with pancreatitis and ten in the control group were studied. All patients with a known pancreatic disease demonstrated an abnormality in the test. Two of ten in the control group also had abnormal results. The two stage provocative test may be used prior to undertaking more invasive examinations, such as an arteriogram, in patients who are suspected of having pancreatic disease, yet other tests have failed to indicate it.

Colonoscopic biopsy and cytology in the diagnosis of colon cancer

Colonoscopy has revolutionalized the approach to the diagnosis and management of patients with colorectal neoplasia. When malignant-appearing lesions are visualized by colonoscopy, a variety of diagnostic techniques are currently available for the assessment of the nature of the lesion including biopsy, brush cytology, and lavage cytology. Comparison of results for biopsy alone with biopsy plus either or both cytologic techniques showed a positive yield of 60% for biopsy alone; 76% for biopsy and lavage; 89% for biopsy, brush, and lavage. When the cancers were divided into infiltrative and exophytic lesions the positive yield for biopsy alone was 33% for infiltrative, cancer, and 71% for exophytic cancer; for biopsy and lavage cytology, 44% for infiltrative cancer, and 94% for exophytic cancer; for biopsy and brush cytology, 78% for infiltrative, and 94% for exophytic cancer; and for biopsy, brush, and lavage cytology, 83% for infiltrative cancer, and 92% for exophytic cancer. The use of brush cytology improved the yield of tissue diagnosis considerably when added to the biopsy technique. Lavage cytology did not seem to increase significantly the diagnostic yield. The diagnostic yield of the various techniques was related not only to the specific combination of techniques used, but also to the gross tumor pattern.

The value of diagnostic aids in detecting pancreas cancer

By contract with the National Cancer Institute, the accuracy of diagnostic techniques was assessed in 184 patients suspected of having pancreas cancer. Of 138 patients who were operated upon, 89 were found to have pancreas duct cancer, 30 had cancer of a different site of origin in the head of the pancreas region and in 19 there was no evidence of cancer at operation. All of the 46 patients who were not operated upon, 13 proven to have cancer and 33 patients discharged as free of cancer, were followed in our clinic. The majority of our patients presented with signs and symptoms of biliary obstruction. Computerized transaxial tomography (CTT) gave a "correct" diagnosis in 31 of 33 patients (94%) with proven cancer, there were 2 patients with a false negative report and a false positive diagnosis occurred in 8 of 20 patients (40%) without cancer. Celiac angiography (CA) gave a correct diagnosis in 78 of 94 patients (83%) with cancer, a false negative in 17%, and a false positive in 32%. 76Selenomethionine pancreas scan correctly diagnosed 27 of 36 patients (75%) with cancer, gave a false negative in 25% and a false positive in 31%. Ultrasonography gave a correct diagnosis in 18 of 27 patients with cancer (67%), a false negative in 33% and a false positive in 28%. Endoscopic retrograde cholangiopancreatography diagnosed correctly 8 of 11 cases (73%) of cancer, there were false negative diagnoses in 3 cases (27%) and false positives in 3 of 14 patients (21%). Duodenal aspiration techniques gave a very low percentage of correct diagnoses. Chronic pancreatitis most commonly gave rise to a false positive diagnosis. Serum alkaline phosphatase was elevated in 82% of patients, gave 18% false negatives and 33% false positives. Carcinoembryonic antigen (CEA) was elevated (greater than 2.5 ng/ml) in most of the pancreas cancer patients but also in patients with other cancers and with non-cancerous diseases. In our hands, CTT, CA, alkaline phosphatase, 75Se-methionine and ultrasonography, in descending order, have given the highest percentage of correct diagnoses but false positive and false negative diagnoses prevented any single test from being conclusive.

Feasibility of fecal occult-blood testing for detection of colorectal neoplasia: debits and credits

A screening program for colorectal cancer and adenomas has been applied to 6,579 mostly asymptomatic men and women age 40 years and older utilizing fecal occult-blood testing followed by investigation of patients with positive slides by air-contrast barium enema and colonoscopy. A control population of 7,325 patients had sigmoidoscopy only and no occult-blood testing. Approximately 1% of the patients had positive slides; most patients had only one or two slides positive. Approximately 50% of patients with positive slides had significant neoplastic lesions, including 23 patients with large adenomas and 7 patients with cancers. Pathological staging of cancers was more favorable in the screened asymptomatic group as compared with the control group. Neoplastic lesions seen on sigmoidoscopy in screened patients who had negative fecal occult-blood tests included 2 cancers and 15 large adenomas. Reasons for false negativity include possible conversion of initially positive slides to negative. Screening for colorectal cancer and adenomas with fecal occult-blood testing appears to be feasible approach with good patient compliance, and manageable rate of positive slides productive of a high percentage of neoplastic lesions. The number of false-positives seems to be low. False negativity has been observed and will require further study.

Carcinoembryonic antigen in colonic lavage

Colonoscopic lavage was performed for assay of carcinoembryonic antigen (CEA) concentration in patients with small and large colonic adenomas, in patients with adenocarcinoma of the colon, and in normal controls. CEA concentration was considerably higher in colonoscopic lavage as compared to plasma. CEA concentration in normal controls and in patients with colonic adenomas less than 1 cm in size were not significantly different. CEA concentrations in patients with colonic adenomas greater than 1 cm in size and in patients with adenocarcinoma of the colon were significantly higher than those observed in patients with small adenomas and in the normal controls. In all except 2 patients, plasma CEA concentrations were normal. Assay of CEA concentrations in colonic lavage may have potential application in the further assessment of the mucosa at risk for colon adenomas and for colon cancer. It does not appear to be accurate enough for diagnosis of colon cancer in individual patients.

Detecting early colon cancer

Techniques enabling detection of early colon cancer already exist, but to be more productive in terms of improving survival they must be applied in a meaningful sequence and repeated regularly in high-risk patients. Positive findings in specific screening steps based on well-known risk factors in colon cancer always call for aggressive follow-up. The advantages and disadvantages of the various techniques are discussed.

Radioautographic observations of a 19-month-old ileal conduit

The influence of an altered environment of the cellular kinetics and histological appearance of ileal mucosa used as a urinary bladder was investigated in a patient with a conduit of 1 year and 7 months' duration. After injection of 10 mc of 3H-TdR, multiple biopsies were taken spanning a 3-day period. No increase in inflammatory cell numbers was seen and villous atrophy was minimal. A generation time or total cell cycle time of 36 hr was observed, with a G1 phase of 22 hr and an S phase of 11 hr. At 1 hr 2.4 3H-TdR-labeled cells per crypt column and a mitotic index of 1.4% were obtained. The complet labeled mitosis curve obtained on the epithelial cells of the 19-month-old ileal conduit mucosa demonstrated a retention of the kinetics and histological characteristics of normal ileal mucosa, contrary to previously documented findings.