Neutrophil precursor generation: effects of culture conditions

The influence of feeding schedules on the expansion and differentiation of enriched PB CD34+ cells (84.9+/-14.7% purity) was studied after 12-13 days of serum-free liquid culture. CD34+ cell cultures were initiated (n=6) on day 0 (2 x 10(5) cells) in X-VIVO 10 medium containing 1% human albumin (HA) and 100 ng/ml each of rIL-3, rIL-6, rSCF, and rG-CSF. The cultures were supplemented on days 3, 6, and 9 as follows: condition 1, unfed (static culture); condition 2, 100 ng/ml rG-CSF; condition 3, split 1:2 medium + 100 ng/ml each rIL-3, rIL-6, rSCF, and rG-CSF; condition 4, split 1:2 medium + 100 ng/ml rG-CSF. The proliferative capacities (fold increase) of condition 2 (49.1+/-21.3), condition 3 (75.6+/-33.4), and condition 4 (63.1+/-23.8) cultures were significantly higher (p < 0.05) than that of the condition 1 unfed (35.5+/-14.0) cultures. Flow cytometric analysis (CD15-FITC/CD11b-PE) showed that the highest CD15+ cell purity (neutrophil precursors) was found in the condition 3 (1.18 x 10(7)+/-4.29 x 10(6)) cultures, followed by condition 4 (9.84 x 10(6)+/-3.57 x 10(6)), condition 2 (7.54 x 10(6)+/-2.06 x 10(6)), and condition 1 (4.78 x 10(6)+/-9.80 x 10(5)), respectively. The average cloning efficiency of the day 0 enriched CD34+ cells, 15.1%+/-10.3%, decreased to less than 0.2% in all of the day 12-13 cultures. These data suggest that feeding CD34+ cell cultures with rG-CSF alone, medium + rG-CSF, or medium + rIL3, rIL-6, rSCF, and rG-CSF enhances CD15+ neutrophil precursor (promyelocytes, myelocytes, metamyelocytes) production in vitro.

Small brain neuropeptides

Recent Advances in Arthropod Endocrinology Edited by Geoffrey M. Coast and Simon G. Webster. Cambridge, Cambridge University Press, 1998, $110.00 (xviii+406 pages), ISBN 0-521-59113-9.

Tirilazad widens the therapeutic window for riluzole-induced attenuation of progressive cortical degeneration in an infant rat model of the shaken baby syndrome

Our infant rat model of traumatic subarchnoid hemorrhage combines violent shaking and hypoxia to produce subdural hemorrhaging and progressive cortical degeneration similar to that seen in victims of the shaken baby syndrome. Anesthetized, 6-day-old male rats were subjected to one episode of shaking under hypoxic conditions. Brain histologies revealed moderate-to-severe cortical hemorrhaging at 48 h postinjury and progressive cortical degeneration, as indicated by a 15.3% and 20.2% reduction in cortical wet weight, at 7 and 14 days postinjury, respectively. The purpose of the present study was to assess the effects of two antioxidant lipid peroxidation inhibitors (tirilazad mesylate and PNU-101033E), and the glutamate release inhibitor (riluzole), upon the brain pathology seen in this model. A significant, 54.3-75.3%, reduction in cortical hemorrhaging was observed in rats that were treated with a total of three doses of tirilazad (10 mg/kg, i.p.): 10 min before or 5-30 min after injury, and again at 2 and 24 h postinjury (p < 0.01 vs. vehicle). However, treatment with tirilazad or the more potent, brain-penetrating pyrrolopyrimidine, PNU-101033E (10 min before plus 2, 24, 48, and 72 h after), did not attenuate the progressive cortical degeneration typically seen at 14 days postinjury. These results suggest that free radicals play an important role in the pathophysiology of secondary brain hemorrhaging due to shaking + hypoxia, but may not be critical in the mediation of the subsequent neurodegeneration. Rather, glutamate neurotoxicity may be a key factor here. This is suggested by our observation that the glutamate release inhibitor, riluzole, significantly reduced cortical degeneration when it was administered up to 1 h postinjury in the present model. Specifically, the cortical wet weights of rats treated with 8 mg/kg riluzole (i.p.) 10 min before or 1 h after shaking + hypoxia (and again at 24 h postinjury) were 95.3% and 97.4% of noninjured controls, respectively, at 14 days postinjury (p < 0.02 vs. vehicle). Riluzole treatment beyond 1 h (e.g., 2 or 4 h postinjury) did not reduce the neurodegeneration. Lastly, we attempted to demonstrate that the therapeutic window for riluzole-induced attenuation of cortical degeneration could be extended beyond 1 h through the use of combination therapy. In this experiment, rat pups were treated with 10 mg/kg tirilazad (i.p.) at 30 min postinjury followed by 8 mg/kg riluzole (i.p.) at 4 and 24 h postinjury. At 14 days postinjury, the cortical wet weights of these rats were 94.5% of noninjured controls, thus demonstrating significant neuroprotection (p < 0.05 vs. vehicle) and a widening of the therapeutic window from 1 to 4 h in length. These results suggest that early attenuation of free radical-induced lipid peroxidation may slow down the biochemical cascade of events related to glutamate-induced excitotoxicity and, in doing so, prolong the time during which a glutamate release inhibitor, such as riluzole, is effective.

Infant rat model of the shaken baby syndrome: preliminary characterization and evidence for the role of free radicals in cortical hemorrhaging and progressive neuronal degeneration

Infants subjected to repeated episodes of violent shaking develop brain damage characterized by intracranial hemorrhage and progressive cortical atrophy. We have developed an animal model that mimics this pathological state and investigated its etiology and treatment. Anesthetized male rats, 6 days of age, were subjected to one episode of shaking per day for 3 consecutive days. Separate groups of rats were sacrificed 1 h postinjury on the third day of shaking for HPLC quantification of cortical .OH and vitamin E levels, and histological assessment of cortical hemorrhaging. Additional groups were sacrificed 7 or 14 days postinjury to demonstrate progressive neuronal degeneration via cortical wet weight comparisons. In comparison to noninjured shams, the results indicated that cortical vitamin E and .OH levels rose 53.7% (p < 0.005) and 457.1% (p < 0.001), respectively, in shaken infant rats. Brain histologies revealed a moderate-to-severe degree of cortical hemorrhaging in these animals 1 h postinjury. By 7 and 14 days postinjury, there was a 13.3% and 28.7% (p < 0.0001 vs. sham) loss of cortical tissue in shaken infants, respectively, indicating progressive neuronal degeneration. Treatment with 10 mg/kg (ip) of the 21-aminosteroid antioxidant, tirilazad mesylate, 10 min before and 2 h after each episode of shaking, resulted in a 53.1% attenuation of cortical .OH levels and a 34.9% decrease in brain hemorrhaging (p < 0.05 vs. vehicle). Tirilazad treatment did not, however, significantly effect cortical vitamin E concentrations at 1 h postinjury or the extent of progressive neuronal degeneration at either 7 or 14 days postinjury. The present animal model mimics the brain pathology seen in abused children. Our observation that tirilazad mesylate, an antioxidant-lipid peroxidation inhibitor, significantly reduces cortical .OH levels and brain hemorrhaging in shaken infant rats supports a role for oxygen radicals in the pathophysiology of this type of CNS injury. The failure of tirilazad to block progressive cortical degeneration suggests that mechanisms other than free radicals may be of prime importance in the mediation of this aspect of the pathology.

The role of iron in neurotoxicity: a study of novel antimalarial drugs

The antimalarial drug artemisinin and its derivatives display neurotoxicity in animal studies in vivo and in neuronal cells in vitro. Their toxicity may be due to an interaction of iron with the endoperoxide bridge of the derivative to produce toxic free radicals and/or other toxic metabolites. In this study, 0.3 microM artemether (AEM) in the presence of 2 microM haemin significantly inhibited the outgrowth of neurites from differentiating NB2a neuroblastoma cells by up to 76%. The antioxidants ascorbic acid and glutathione completely protected against this toxicity at a concentration of 100 microM. AEM was found to be partially converted to two isomeric products, which were identified as the tetrahydrofuran acetate isomer of AEM and 3alpha-hydroxydesoxyartemether.

Adaptation of neuromuscular activation patterns during treadmill walking after long-duration space flight

The precise neuromuscular control needed for optimal locomotion, particularly around heel strike and toe off, is known to he compromised after short duration (8- to 15-day) space flight. We hypothesized here that longer exposure to weightlessness would result in maladaptive neuromuscular activation during postflight treadmill walking. We also hypothesized that space flight would affect the ability of the sensory-motor control system to generate adaptive neuromuscular activation patterns in response to changes in visual target distance during postflight treadmill walking. Seven crewmembers, who completed 3- to 6-month missions, walked on a motorized treadmill while visually fixating on a target placed 30 cm (NEAR) or 2 m (FAR) from the subject's eyes. Electronic foot switch data and surface electromyography were collected from selected muscles of the right lower limb. Results indicate that the phasic features of neuromuscular activation were moderately affected and the relative amplitude of activity in the tibialis anterior and rectus femoris around toe off changed after space flight. Changes also were evident after space flight in how these muscles adapted to the shift in visual target distance.

Percutaneous penetration of Aldara cream, 5% during the topical treatment of genital and perianal warts

Objective: The objective of this single-center, open-label trial was to evaluate the percutaneous penetration of Aldara (imiquimod) cream, 5% when applied topically to patients with anogenital warts using a more frequent/aggressive dosing regimen.Methods: Ten otherwise healthy males and six otherwise healthy, nonpregnant, nonlactating females with histology results suggestive of, or diagnostic of, human papilloma virus/condyloma acuminata were enrolled. Females were required to be practicing an acceptable form of contraception control. Patients applied cream daily (8 +/- 2 hours) until complete wart clearance, or for a maximum of 16 weeks. Following the initial dose, at approximately week 4, and at the end-of-treatment, patients were confined for 42 hours in order to obtain a series of blood and urine samples. These samples were analyzed for levels of imiquimod and two metabolites, S-26704 and S-27700. Biological marker levels were not included as a part of this trial.Results: No quantifiable (>/=5 ng/mL) levels of imiquimod or the two metabolites were observed in any of the serum samples collected. Five patients had quantifiable (>/=10 ng/mL) imiquimod, S-26704, or both in urine. No quantifiable levels of S-27700 were observed. Complete clearance of warts occurred in 40% of male patients and 83% of female patients. Erythema was the most frequently observed local skin reaction and was moderate in intensity, although 6 of 16 patients reported a severe erythema reaction at some point in the study. Application site reactions (itching, burning and pain) were the most frequently reported adverse events.Conclusion: The lack of quantifiable levels of imiquimod or metabolites in serum, together with sporadically occurring quantifiable but low levels in urine, indicate that systemic exposure, after daily application of Aldara cream to genital/perianal skin, may occur but is minimal; however, pharmacological (immune marker) effects were not evaluated because cytokine measurements were not obtained. A future trial assessing cytokine levels after topical Aldara therapy with minimal systemic levels of imiquimod would help assess systemic drug and pharmacological effects and utility of this product in pregnant women.

The accuracy of patients' judgments of disease probability and test sensitivity and specificity

BACKGROUND

We studied patients' understanding of the characteristics of diagnostic tests for six common conditions to determine what patients know about diagnostic uncertainties before they communicate with a doctor. We compared the accuracy of patients' estimates of disease probabilities and diagnostic test characteristics for diseases with which they did or did not have prior experience.

METHODS

To measure patients' understanding of the uncertainty of diagnostic test results, questionnaires describing diseases were given to patients in clinic waiting rooms. For each of six diseases, a 2-page questionnaire presented a case history of the disease and its diagnostic test, and asked respondents to estimate the probability that the case patient has the suspected disease, the sensitivity of test, the specificity of test, and the probability that the patient has the disease if the test result is positive. It also asked whether the patient, a close friend, or family member had ever been thought to have this disease.

RESULTS

One hundred eighty-four patients in the clinic waiting room responded for at least one disease. Although patients judged the disease probabilities to be higher after a positive diagnostic test, each of their four judgments was essentially the same for all diseases, including those with high and low prior probabilities, and with accurate and inaccurate tests. Past experience with the disease was associated with only a minimal increase in the accuracy of patient knowledge.

CONCLUSIONS

Patients' ignorance of the uncertainties of diseases demonstrates the need for patient education when a disease is suspected. The lack of relation between knowledge and experience suggests that this need is not being effectively met. To convey the rates or probabilities, and to help the patients understand what the probabilities are based on, a physician should speak in terms that patients can easily understand.

Polyurethane foams: effects of specimen size when determining cushioning stiffness

Polyurethane (PU) foams are used as inexpensive materials for reducing interface pressure in a number of rehabilitative applications, particularly seating and prosthetic limb interfaces. Specimens of three different PU foams were cut to four different sizes and compressed according to ASTM protocols to determine their stiffness capabilities. It was found that the test results varied according to the relationship between the size of the test specimen and the test indenter. It is recommended that investigators create a testing situation that reflects their application when determining the cushioning capabilities of these materials.

Hand-assisted laparoscopic distal pancreatectomy for pancreatic cystadenoma

A cystic lesion in the body of the pancreas was detected during staging workup of a 59-year-old woman with T-cell lymphoma of the tongue. After six cycles of chemotherapy the pancreatic lesion was unchanged. Suggestive ulceration of the vulva with edema appeared at the end of chemotherapy. After right vulvar excision, distal pancreatic resection with splenectomy was carried out by a hand-assisted laparoscopic technique utilizing a small muscle-splitting right lower quadrant incision. This allowed for palpation of the peritoneal cavity for evidence of tumor and allowed for safe and expeditious pancreatectomy. The pancreatic tumor was found to be a serous cystadenoma without evidence of malignancy. T-cell lymphoma was identified in the spleen and the vulva. The patient was discharged home on the fifth postoperative day and returned to normal activity within 2 weeks after operation. Two months after the surgery, computed tomography demonstrated a 3-cm pseudocyst in the region of the tail of the pancreas. As the patient was asymptomatic, this required no further therapy. Minimally invasive surgery together with hand assistance combines the advantages of both laparotomy and laparoscopy in the surgical management of selected lesions in the pancreas.

Mental health and health care utilization in geriatric primary care patients

OBJECTIVE

This study examines the effect of mental health factors on health care utilization in a group of community dwelling elderly subjects followed in a primary care setting.

METHOD

Data on utilization was obtained prospectively from computerized billing records for a one-year period following completion of a structured survey. Relationships between variables were characterized by Spearman's rank correlation. Multivariate linear regression modeling was employed to relate health care utilization, as measured by total cost, to the baseline variables.

RESULTS

No significant relationship was found between mental health measures and health care utilization as measured by total costs in this elderly population. However, total costs were found to be related to medical comorbidity and total daily medication use.

CONCLUSION

The present study did not find the relationship of psychiatric distress and increased use of health care services to apply to a group of community dwelling elderly. Future research will need to focus on larger data sets and improvement of models that attempt to examine the relationships between mental health and health care utilization in the elderly.

Effect of onychomycosis on quality of life

BACKGROUND

Onychomycosis impairs normal nail functions, causes considerable pain, interferes with daily activities, and has negative psychosocial effects.

OBJECTIVE

Our purpose was to determine patients' perception of onychomycosis on the quality of life.

METHODS

A total of 258 patients with confirmed onychomycosis were surveyed by telephone at three centers. Responses to a standardized quality-of-life questionnaire were analyzed for patient demographics, physical and functional impact, psychosocial impact, and economic impact.

RESULTS

Highest positive responses were nail-trimming problems (76%), embarrassment (74%), pain (48%), nail pressure (40%), and discomfort wearing shoes (38%). Ability to pick up small objects was impaired in 41% of subjects with fingernail involvement. More than 58 onychomycosis-related sick days and 468 medical visits (1.8 per subject) were reported during a 6-month period.

CONCLUSION

Onychomycosis has significant social, psychologic, health, and occupational effects. Relevance of quality-of-life issues to overall health, earning potential, and social functioning should prompt reconsideration of the value of aggressive treatment of and financial coverage for onychomycosis.

Malignant epithelial tumors of the lacrimal gland: a clinicopathologic study of 21 cases

OBJECTIVE

To analyze 120 lacrimal gland masses collected during a 23-year period in the Ophthalmic Pathology Laboratory at the Cullen Eye Institute, Houston, Tex.

METHODS

Of the 120 lacrimal gland tumors, we focused on a detailed clinicopathologic study of 21 malignant epithelial tumors. Follow-up was available in 19 (90%) of 21 cases.

RESULTS

About two thirds of the masses (75 cases) were inflammatory, one third (41 cases) were of epithelial origin, and 3% (4 cases) were malignant lymphomas. Of the epithelial tumors, 17 (41%) were benign mixed tumors, 12 (29%) were adenoid cystic carcinomas arising de novo, 2 (5%) were adenocarcinoma arising de novo, 7 (17%) were malignant mixed tumors, and 3 (7%) were metastatic carcinoma. All of the patients with adenoid cystic carcinoma had local recurrences, and 60% of the patients died of their tumors (mean survival, 5 years); only 2 patients were alive 13 and 16 years after the initial surgery, both of whom had radical surgical procedures for recurrence following orbital exenteration.

CONCLUSION

The histopathologic classification and management of these tumors are discussed. This study supports the dismal prognosis of adenoid cystic carcinoma arising de novo.

Isolation and initial characterisation of complement components C3 and C4 of the nurse shark and the channel catfish

Complement components C3 and C4 have been isolated from the serum of the nurse shark (Ginglymostoma cirratum) and of the channel catfish (Ictalurus punctatus). As in the higher vertebrates, the fish C4 proteins have three-chain structures while the C3 proteins have two-chain structures. All four proteins have intra-chain thioesters located within their highest molecular mass polypeptides. N-terminal sequence analysis of the polypeptides has confirmed the identity of the proteins. In all cases except the catfish C3 alpha-chain, which appears to have a blocked N-terminus, sequence similarities are apparent in comparisons with the chains of C3 and C4 from higher vertebrates. We have confirmed that the activity/protein previously designated C2n is the nurse shark analogue of mammalian C4. This is the first report of structural evidence for C4 in both the bony and cartilaginous fish.

Outpatient geriatric evaluation and management

OBJECTIVE

To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults.

PARTICIPANTS

Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (P(ra) > .40) in the future (n = 248).

INTERVENTION

Outpatient GEM.

MEASUREMENTS

Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians.

RESULTS

At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated.

CONCLUSIONS

This model of outpatient GEM provided 6 months of targeted intensive care at a reasonable cost. The satisfaction ratings of patients and their primary physicians were high.

Evaluation of the human hair root for DNA typing subsequent to microscopic comparison

Telogen human hairs are one of the most common useful evidence findings at crime scenes and/or on homicide victims. Occasionally, the microscopic characterization of the found telogen hair is the only physical evidence association to a victim or suspect. Recently efforts to characterize these hairs by mitochondrial DNA (mtDNA) methods have progressed. The nature of the telogen hair root morphology and ultrastructure has, however, been largely ignored. Examiners have recognized these hairs are unlikely to be typable by nuclear DNA (nuDNA) methods. Most forensic biologists have little knowledge of the complex cellular composition of anagen, catagen, and telogen hair roots or their morphogenesis. This paper reviews ex situ human hair root morphology as it relates to the likelihood of successful nuclear DNA typing. Dermatology texts of hair root morphology always demonstrate their microscopic appearance in the skin. This study investigates the use of fluorescence in situ hybridization (FISH) methods to sex type telogen head hairs, and it further investigates hair root morphology as it relates to the potential nuclear DNA content of evidence hairs. There is a need for the use of appropriate, consensus terminology for describing hair root morphology. There is also a need for standardized laboratory light microscopic methods in evaluating a hair root for DNA typing. FISH was found to be an unsuitable technique for sex determination of telogen hair clubs. It was determined that anagen/catagen hair roots without translucent sheath material are excellent candidates for nuDNA PCR-based typing and that hairs with telogen club root material only should not be submitted for nuDNA typing attempts.

Psychotherapeutic agents in older adults. Compliance: problems and opportunities

Many studies have demonstrated the problems patients have with medications. In these studies, the elderly and patients utilizing psychiatric medications are often cited as having the greatest noncompliance. This article reviews the extent of noncompliance in this population and the effect of noncompliance on disease management. Factors related to the health care provider, the patient, and the type of therapy that lead to noncompliance are reviewed. Opportunities and intervention techniques are provided to improve patient outcomes.

Hand-assisted laparoscopic splenectomy for isolated splenic metastasis from an ovarian carcinoma: a case report with review of the literature

A 56-year-old woman was found to have a solitary metastasis to the spleen from ovarian cancer. A hand-assisted laparoscopic splenectomy was carried out. The operative technique and advantages of this technique are discussed. Laparoscopy with mini laparotomy allows for manual manipulation of the spleen with the ability to control bleeding, and facilitates mobilization and removal of the specimen. Postoperative recovery is rapid. Review of the literature indicates that secondary metastasis to the spleen is quite common.

[Laparoscopic antireflux procedures]

Laparoscopic antireflux surgery is rapidly replacing traditional operations for the treatment of medically refractory gastroesophageal reflux disease. These procedures are technically demanding. Troublesome side effects can be minimized by carefully selecting patients and using a meticulous and appropriate technique. Extensive follow-up data are now emerging and indicate that these procedures can offer long-term control of symptoms with few permanent side effects.

Identification of the leader-body junctions for the viral subgenomic mRNAs and organization of the simian hemorrhagic fever virus genome: evidence for gene duplication during arterivirus evolution

Simian hemorrhagic fever virus (SHFV) was recently reclassified and assigned to the new virus family Arteriviridae. During replication, arteriviruses produce a 3' coterminal, nested set of subgenomic mRNAs (sgRNAs). These sgRNAs arise by discontinuous transcription, and each contains a 5' leader sequence which is joined to the body of the mRNA through a conserved junction sequence. Only the 5'-most open reading frame (ORF) is believed to be transcribed from each sgRNA. The SHFV genome encodes nine ORFs that are presumed to be expressed from sgRNAs. However, reverse transcription-PCR analysis with leader- and ORF-specific primers identified only eight sgRNA species. The consensus sequence 5'-UCNUUAACC-3' was identified as the junction motif. Our data suggest that sgRNA 2 may be bicistronic, expressing both ORF 2a and ORF 2b. SHFV encodes three more ORFs on its genome than the other arteriviruses. Comparative sequence analysis suggested that SHFV ORFs 2a, 2b, and 3 are related to ORFs 2 through 4 of the other arteriviruses. Evidence which suggests that SHFV ORFs 4 through 6 are related to ORFs 2a through 3 and may have resulted from a recombination event during virus evolution is presented.

Management of ingested foreign bodies within the appendix: a case report with review of the literature

A case is reported of an elective appendectomy in a patient with known ingestion of a sharp foreign body. The metal drill bit was ingested unintentionally 3 months before presentation at our institution. Plain abdominal films demonstrated the foreign body in the right lower abdominal quadrant. Because the gold dental drill bit was sharp and thought to be lodged in the terminal ileum or cecum, an attempt was made to remove the object during colonoscopy. This attempt was unsuccessful because no drill bit could be detected in the colon or terminal ileum. A laparoscopic exploration was performed, and the foreign body was found to lie in the appendix, after bowel manipulation under fluoroscopic guidance and with direct laparoscopic visualization. A laparoscopic assisted appendectomy was performed. On pathologic examination the drill bit was embedded in the tip of the appendix with signs of intramucosal acute inflammation. Management and indication for surgery of foreign bodies in the appendix are discussed, and we review the related literature. This is the second reported case of a dental drill bit in the appendix causing appendicitis.

Factors that predict malignant thyroid lesions when fine-needle aspiration is "suspicious for follicular neoplasm"

OBJECTIVE

To assess clinical factors that may improve the ability to predict the presence of a malignant lesion in thyroid nodules that are found to be "suspicious for follicular neoplasm" by fine-needle aspiration (FNA) cytology.

MATERIAL AND METHODS

We undertook a retrospective review of the medical records of all patients at the three Mayo Clinic facilities who underwent a thyroid surgical procedure between January 1992 and December 1994 and had a preoperative FNA report of "suspicious for follicular neoplasm." Patient and nodule characteristics were analyzed statistically for associations with the presence of cancer.

RESULTS

The study cohort consisted of 219 patients with a mean age of 54.3 years. Eighty-four percent of resections were done for benign disease. Of the 35 malignant lesions, 9 were incidental papillary cancers separate from the primary nodule; thus, only 26 cancers were found in the index nodule, and only 19 (9% of the total group) were follicular carcinomas. Clinical findings associated with a malignant index nodule were larger diameter, fixation of the mass, and younger age of the patient.

CONCLUSION

Clinical characteristics may be used for more accurate assessment of the risk of the presence of a malignant lesion when FNA cytology of a thyroid nodule is reported as "suspicious for follicular neoplasm."

Management of the failed antireflux operation

A further operation is required in a small proportion of patients who have had prior antireflux surgery. This has a surprisingly good chance for success in appropriately evaluated patients. The surgeon must make very specific decisions regarding the surgical approach. The use of laparoscopy for redo surgery is being defined.