Alcohol has no effect on hepatitis C virus replication: a meta-analysis

BACKGROUND

Patients with chronic hepatitis C virus (HCV) infection who consume large quantities of alcohol have more severe liver disease compared with HCV patients without a history of alcohol consumption. The mechanism by which alcohol worsens HCV related liver disease is not properly understood. One possibility is that alcohol stimulates HCV replication, and the present meta-analysis was performed to examine this issue.

METHODS

The effect of alcohol on viral titres was assessed in three ways: comparison of the heaviest drinkers with non-drinkers; effect of graded doses of alcohol; and effect of abstinence in the same individual.

RESULTS

A total of 14 studies were identified. Comparison of patients with the highest alcohol use with the abstinent group showed a significant association with viral load in three studies, five studies had a positive direction, while the remaining four studies found a negative relationship. Analysis of the combined results showed no association between alcohol consumption and virus levels (p = 0.29). Assessment of graded doses of alcohol also showed no significant difference between non-drinkers and moderate drinkers (p = 0.50), between non-drinkers and heavy drinkers (p = 0.35), or between moderate drinkers and heavy drinkers (p = 0.32). Five studies examined the influence of abstinence on viral titres but none provided sufficient data for statistical analysis.

CONCLUSIONS

The present study has failed to show an association between alcohol use and HCV viral titres. These observations raise the possibility that the hepatic damage caused by alcohol and HCV may be purely additive, involving different mechanisms and pathways.

Risk Factors for Candida tropicalis fungemia in patients with cancer

The risk factors for and presentation of Candida tropicalis fungemia, in comparison with those of Candida albicans, have been incompletely characterized. We compared 43 cases of C. tropicalis fungemia with 148 cases of C. albicans fungemia. In univariate analysis, patients with C. tropicalis fungemia were more likely to have leukemia (P=.0006), prolonged neutropenia (P=.03), and a positive blood culture for more days (P=.02). The 2 groups did not differ with regard to baseline Acute Physiology and Chronic Health Evaluation (APACHE) II score, frequency of catheter-associated fungemia, or response to antifungals. In multivariate analysis, patients with C. tropicalis fungemia were more likely to have leukemia (P=.02), previous neutropenia (P=.002), and a longer stay in the intensive care unit during the infectious episode (P=.01). Also, the response of the breakthrough C. tropicalis fungemia was lower (P=.05). In conclusion, the host determinants associated with susceptibility to C. tropicalis are leukemia and prolonged neutropenia.

Longitudinal follow-up of depressive symptoms among normal versus cognitively impaired elderly

OBJECTIVES

This prospectively designed longitudinal study assesses prevalence, incidence and prognosis of depressive symptoms among cognitively normal elderly volunteers compared with patients with mild cognitive impairment (MCI), dementia of Alzheimer type (DAT), and vascular dementia (VAD). Possible relationships between depressive symptoms, cognitive performance, disease types, and effects of antidepressant treatment were analyzed.

METHODS

Two hundred and ninety four subjects exhibiting different levels of cognitive performance were admitted to this study. Demographics, cardiovascular and neurodegenerative risk factors, together with measures of neuropsychological test performance, were obtained at sequential visits. Depressive symptoms were selectively treated with antidepressant medications.

RESULTS

One hundred and forty six subjects with normal cognition, 19 subjects with MCI, 42 patients with DAT, and 32 patients with VAD were followed for a mean of 3.5 years. With the passage of time, there were trends showing prevalence of depressive symptoms to decrease among DAT and to increase among VAD patients. VAD patients exhibited the highest incidences of new-onset depressive symptoms, followed in incidence by DAT and MCI groups. Depressive symptoms among VAD and MCI patients were more persistent and refractory to antidepressant medications than for DAT patients. Trends suggested that antidepressant treatment might benefit MCI and VAD subjects more than DAT patients. Motivationally related depressive symptoms accounted for major components of elevated Hamilton depression rating scale scores.

CONCLUSIONS

Depressive symptoms among DAT patients have higher rates of spontaneous resolution, without requiring intensive drug treatment, than among VAD patients in whom depressive symptoms are more persistent and refractory to drug treatment. Early depressive symptoms among subjects with MCI may represent a preclinical sign and should be considered as a risk factor for impending DAT or VAD among the elderly.

Comparison of carpal canal pressure in paraplegic and nonparaplegic subjects: clinical implications

The purpose of this study was to evaluate the pressure within the carpal tunnel that was generated with certain tasks in paraplegic versus nonparaplegic subjects. Four groups of subjects were evaluated: 10 wrists in six paraplegic subjects with carpal tunnel syndrome, 11 wrists in six paraplegics without the syndrome, 12 wrists in nine nonparaplegics with the syndrome, and 17 wrists in 11 nonparaplegics without the syndrome. Carpal canal pressures were measured in the wrists in three positions (neutral, 45-degree flexion, 45-degree extension) and during two dynamic tasks [wheelchair propulsion and RAISE (relief of anatomic ischial skin embarrassment) maneuver]. External force resistors were placed over the carpal canal and correlated with internal tunnel pressures. At each wrist position, paraplegics with carpal tunnel syndrome consistently had higher carpal canal pressure than did the other groups at the corresponding wrist position; statistical significance was evident with regard to the neutral wrist position (p < 0.05). Within each group of subjects, wrist extension and wrist flexion produced a statistically significant increase in carpal canal pressure (p < 0.05), compared with the neutral wrist position. Dynamic tasks (wheelchair propulsion and the RAISE maneuver) significantly elevated the carpal canal pressure in paraplegics with carpal tunnel syndrome, compared with the other groups (p < 0.05). Lastly, there is a linear positive correlation between carpal canal pressure and external force resistance.

Depressive symptoms among cognitively normal versus cognitively impaired elderly subjects

OBJECTIVES

The present cross-sectional study analyzed the prevalence and severity of depressive symptoms among patients with Alzheimer's disease (DAT), vascular dementia (VAD), and among the cognitively normal elderly. Putative risk factors contributing to depression were likewise evaluated.

METHODS

Seventy-six DAT patients, 51 VAD patients, and 121 cognitively normal subjects were admitted to the study. Questionnaires concerning demography and their vascular and familial risk factors together with results of neuropsychological testing by combined Mini-Mental Status Examinations (MMSE), Cognitive Capacity Screening Examinations (CCSE), and Hamilton Depression Rating Scales (HDRS) were obtained so that resulting data would be statistically analyzed.

RESULTS

Prevalence of depressive symptoms among VAD, DAT, and cognitively normal elderly were 31.4%, 19.9%, and 13.2%, respectively. 25.5% of VAD and 13.2% of DAT patients had depression of mild to moderate degrees. Regression analysis revealed that diagnosis of VAD and DAT, heart disease, and past history of depression was significantly associated with high HDRS scores. There was no correlation between degree of depression and severity of cognitive impairments.

CONCLUSION

Mild to moderate depression is a common comorbidity with organic dementia, especially VAD, but associated depression is independent of severity of cognitive impairments.

Validating mini-mental status, cognitive capacity screening and Hamilton depression scales utilizing subjects with vascular headaches

INTRODUCTION

The Mini-Mental State Examination (MMSE) and Cognitive Capacity Screening Examination (CCSE) are easily and rapidly administered tests for quantifying the general cognitive status of young as well as geriatric subjects. Likewise, the Hamilton Depression Rating Scale (HDRS) is a brief instrument for quantifying depression that may confound cognitive test performances. Testing by means of all three scales concurrently provides useful information for longitudinal research among the elderly.

OBJECTIVES

To validate the combined longitudinal use of MMSE, CCSE and HDRS among a specific cohort of normal subjects with vascular headaches characterized by known well-established temporary cognitive decline occurring only during temporary intervals with headache.

METHODS

The MMSE, CCSE and HDRS were serially tested at 3-12 monthly intervals among 196 healthy subjects attending our out-patient headache clinic who suffered from migraine or cluster headaches. Stability and specificity of MMSE, CCSE and HDRS were evaluated by comparing consecutive normative scores during headache-free intervals. Sensitivity of MMSE and CCSE for detecting temporary cognitive decline were evaluated by comparing scores during headache and headache-free intervals.

RESULTS

CCSE, MMSE and HDRS gave stable headache-free normative values over intervals of 3-10 years among 182 subjects. Among 77 subjects during headache intervals, temporary cognitive decline were confirmed by both CCSE and MMSE (p < 0.0001). When cutoff points for both CCSE and MMSE normal scores were placed at >/= 27, specificity for detecting cognitively normal values for CCSE and MMSE when headache-free were 92.2 and 89.6%, respectively (p > 0.05), while sensitivity for detecting cognitively decline during headache intervals were 83.7 and 49%, respectively (p < 0.001). Compared with scoring by a single rater, reliability estimates for all three rating scales were slightly lower when tested by different raters, but these differences were not significant.

CONCLUSIONS

CCSE is reliable and more sensitive than MMSE for detecting cognitive decline.

Treatment of nosocomial postoperative pneumonia in cancer patients: a prospective randomized study

BACKGROUND

Nosocomial pneumonia continues to be associated with high morbidity and mortality in cancer patients.

METHODS

In an attempt to find an optimal treatment for this infection, nonneutropenic cancer patients with postoperative nosocomial pneumonia were randomized to receive either piperacillin/tazobactam (P/T) 4.5 g i.v. every 6 hours (30 patients) or clindamycin (Cl) 900 mg plus aztreonam (Az) 2 g i.v. every 8 hours (22 patients). Amikacin 500 mg i.v. every 12 hours was given to all patients for the first 48 hours.

RESULTS

The two groups were comparable for the characteristics of pneumonia that included gram-negative etiology and duration of intubation. Response rates were 83% for patients who received P/T and 86% for those who received Cl/Az (P > .99). There were no serious adverse events; however, at our center the cost of the P/T regimen was $73.86 compared with $99.15 for the Cl/Az regimen.

CONCLUSIONS

The two regimens had comparable high efficacy, and P/T had a slight cost advantage. Either of these antibiotic regimens combined with an aminoglycoside could lead to favorable outcome in cancer patients at high risk for nosocomial pneumonia.

Concurrent chemotherapy and "concomitant boost" radiotherapy for unresectable head and neck cancer

PURPOSE

For patients with advanced head and neck cancer, various combined chemoradiotherapy regimens have been used to improve local control. This study was carried out to assess the outcome of concomitant chemotherapy with a "concomitant boost" radiotherapy in the treatment of advanced unresectable head and neck cancer patients.

MATERIALS AND METHODS

Forty-eight patients were treated with combined chemoradiotherapy between the years of 1990 and 1995. Cisplatinum (100 mg/m2) was given intravenously during week 1 and week 5. A "concomitant boost" external beam radiotherapy approach was used with twice-daily treatment delivered during the last 2 weeks. A total of 70 Gy was delivered over 6 weeks. Median follow-up was 23.5 months (2-79 months).

RESULTS

Thirty-one (65%) and 17 (35%) patients achieved complete and partial response, respectively. Median survival in complete responders has not been reached. Overall survival at 2 years, 3 years, and 5 years were 58.7%, 52.8%, and 42.4%, respectively. Median overall survival was 38.8 months. Acute confluent mucositis (Radiation Therapy Oncology [RTOG] grade 3) developed in 50% of patients, but there was no severe long-term treatment-related toxicity.

CONCLUSION

This combined chemoradiotherapy approach is safe and efficacious for advanced unresectable head and neck cancer. Treatment-related toxicity was acceptable with 50% of patients developing acute confluent mucositis. There was no severe long-term treatment-related toxicity.

Reversible cognitive decline accompanies migraine and cluster headaches

Vascular headaches, including migraine, cluster, and migrainous transformation to chronic daily headaches, are disabling. During and shortly after headache intervals, difficulties are reported in concentration, comprehension, and communication, not accounted for by nausea, photophobia, or sonophobia. These interfere with interpersonal relations and performance at work with economic loss. The hypothesis tested and reported here is that cognitive impairments comprise an important part of vascular headache diatheses. One hundred ninety-six otherwise normative subjects suffering from migraine or cluster, but not tension-type, headaches (136 women, 63 men; mean age, 46 years) participated in an outpatient prospective trial. One hundred thirty-three patients had migraine without aura, 39 migraine with aura, 11 periodic cluster (by IHS criteria), and 13 had migrainous transformation into chronic daily headaches. Neuropsychological testing was compared with and without headaches, by combined Mini-Mental Status Examination (MMSE), Cognitive Capacity Screening Examination (CCSE), and Hamilton Depression Rating Scale (HDRS). During headache intervals, significant decline was measured in both CCSE and MMSE scores (P <. 001) without HDRS change in all types of vascular headache and independent of headache severity, which often improved, or associated physical symptoms. Cognitive decline was promptly relieved by serotonin agonists and sleep. Disorders of cerebral serotoninergic projection systems appear to cause these reversible cognitive impairments.

Physical and psychosocial symptoms among 88 volunteer subjects compared with patients seeking plastic surgery procedures to the breast

In an investigation of the relationship between macromastia and physical and psychosocial symptoms, 88 female university students, 21 augmentation mammaplasty patients, and 31 breast reduction patients graded somatic and psychosocial symptoms. The intent of the study was to discover which complaints were most common among women presenting for reduction mammaplasty and to determine whether height/weight index and brassiere chest measurement and cup size might affect their symptoms. Both the student group and the augmentation mammaplasty patients differed significantly from the breast reduction patients. Eighty-one percent of the reduction patients complained of neck and back pain. Seventy-seven percent complained of shoulder pain, 58 percent complained of chafing or rash; 45 percent reported significant limitation in their activity; and 52 percent were unhappy with their appearance (p < 0.001 compared with augmentation and student groups). Physical symptoms were related to height/weight index and bra chest and cup sizes in each of the three participating groups. It was found that patients who present for symptom-related reduction mammaplasty have a disease-specific group of physical and psychosocial complaints that are more directly related to large breast size than to being overweight.

Prospective study of fatigue in localized prostate cancer patients undergoing radiotherapy

The objectives were to (1) prospectively evaluate fatigue utilizing validated instruments in patients with localized prostate cancer, and (2) examine the relationships between fatigue, depression, quality of life, and sleep disturbance. The instruments used included: Piper Fatigue Scale, Beck Depression Inventory, Epworth Sleepiness Scale, and Functional Assessment of Cancer Therapy for Prostate Scale. Data on cancer stage, prostate specific antigen levels, hematocrit, patient's body weight and radiation dosage were recorded. Patients were evaluated preradiotherapy, middle of radiotherapy, completion of radiotherapy, and at 4-5 weeks follow-up. Thirty-six veterans with localized prostate cancer were studied. Mean age was 66.9 years (range 55-79). Duration of treatment was 7-8 weeks. Univariate procedure and Wilcoxon Signed Rank-test were used to examine changes in pretreatment scores for each of the three subsequent study periods. To adjust for multiple comparisons Bonferroni test was used. Spearman Correlations were calculated among parameters. No significant changes were noted in mean scores of hematocrit and body weight during the study period. On the Piper Fatigue Scale, adjusted for multiple comparisons, the median scores were significantly higher at completion of radiotherapy as compared with preradiotherapy values. Three patients (8%) were experienced fatigue according to Piper Fatigue Scale before treatment as compared to nine patients (25%) at completion of radiotherapy. On Prostate Cancer Specific and Physical Well Being subscales of the Functional Assessment for Prostate Cancer Therapy, the scores were significantly lower at middle and completion of radiotherapy than at pretreatment. At preradiotherapy, middle of radiotherapy, completion of radiotherapy and follow-up evaluation, patients scoring higher on the Piper Fatigue Scale were more likely to report a poorer quality of Physical Well Being on Functional Assessment of Cancer Therapy for Prostates. No significant changes were noted in the Beck Depression Inventory and Epworth Sleepiness Scale scores during treatment. Eight patients scored 10 or more on the Beck Depression Inventory before starting radiotherapy, suggesting depressive symptomatology. Of these, only seven patients scored 10 or more at completion of treatment. The incidence of fatigue is lower in our study than in previously published data. A relationship exists between fatigue scores and physical well being subscale scores. Higher scores on the Piper Fatigue Scale at the completion of radiotherapy, as well as no changes on depression and sleepiness scales, suggest that fatigue may not be the result of depression or sleep disturbance. Based upon our previous work, we propose that the physical expression of fatigue may be secondary to a decline in neuromuscular efficiency and enhanced muscle fatigue.

Prospective study of fatigue in localized prostate cancer patients undergoing radiotherapy

The objectives were to (1) prospectively evaluate fatigue utilizing validated instruments in patients with localized prostate cancer, and (2) examine the relationships between fatigue, depression, quality of life, and sleep disturbance. The instruments used included: Piper Fatigue Scale, Beck Depression Inventory, Epworth Sleepiness Scale, and Functional Assessment of Cancer Therapy for Prostate Scale. Data on cancer stage, prostate specific antigen levels, hematocrit, patient's body weight and radiation dosage were recorded. Patients were evaluated preradiotherapy, middle of radiotherapy, completion of radiotherapy, and at 4-5 weeks follow-up. Thirty-six veterans with localized prostate cancer were studied. Mean age was 66.9 years (range 55-79). Duration of treatment was 7-8 weeks. Univariate procedure and Wilcoxon Signed Rank-test were used to examine changes in pretreatment scores for each of the three subsequent study periods. To adjust for multiple comparisons Bonferroni test was used. Spearman Correlations were calculated among parameters. No significant changes were noted in mean scores of hematocrit and body weight during the study period. On the Piper Fatigue Scale, adjusted for multiple comparisons, the median scores were significantly higher at completion of radiotherapy as compared with preradiotherapy values. Three patients (8%) were experienced fatigue according to Piper Fatigue Scale before treatment as compared to nine patients (25%) at completion of radiotherapy. On Prostate Cancer Specific and Physical Well Being subscales of the Functional Assessment for Prostate Cancer Therapy, the scores were significantly lower at middle and completion of radiotherapy than at pretreatment. At preradiotherapy, middle of radiotherapy, completion of radiotherapy and follow-up evaluation, patients scoring higher on the Piper Fatigue Scale were more likely to report a poorer quality of Physical Well Being on Functional Assessment of Cancer Therapy for Prostates. No significant changes were noted in the Beck Depression Inventory and Epworth Sleepiness Scale scores during treatment. Eight patients scored 10 or more on the Beck Depression Inventory before starting radiotherapy, suggesting depressive symptomatology. Of these, only seven patients scored 10 or more at completion of treatment. The incidence of fatigue is lower in our study than in previously published data. A relationship exists between fatigue scores and physical well being subscale scores. Higher scores on the Piper Fatigue Scale at the completion of radiotherapy, as well as no changes on depression and sleepiness scales, suggest that fatigue may not be the result of depression or sleep disturbance. Based upon our previous work, we propose that the physical expression of fatigue may be secondary to a decline in neuromuscular efficiency and enhanced muscle fatigue.

Evaluation of results and treatment variables for pressure ulcers in 48 veteran spinal cord-injured patients

This retrospective study of 48 spinal cord-injured patients with pressure ulcers seen at a tertiary referral Veterans Hospital spinal cord injury unit between 1992 and 1997 correlates a number of variables (co-morbid conditions, nutritional status, smoking history, type of repair performed, type of bed used postoperatively, ulcer location and severity, duration of postoperative antibiotic therapy, time elapsed before sitting rehabilitation began, and length of hospital stay) with ulcer repair outcome measures, including postoperative systemic and wound-healing complications, recurrence rates, and the development of new ulcers at different sites. Surgical complication rates were high, occurring in 19 patients (39.6%), and ulcer recurrence or new ulcer development occurred in 38 patients (79.2%). Correlations were found between ulcer location and postoperative wound separation and the length of hospitalization. The hospital course was shorter if the ulcer was new rather than recurrent. Other than the finding that chronic smokers had longer courses of antibiotic therapy, smoking did not correlate statistically with other outcome variables, including wound-healing complications. No significant correlations were found between any postoperative systemic or wound complications, ulcer recurrence, or new ulcer development and patient age, level of spinal cord injury, number of ulcers and grade, laboratory values, mental status, cardiac or pulmonary disease, diabetes, and presence or absence of osteomyelitis.

Natural variability of circulating levels of cytokines and cytokine receptors in patients with heart failure: implications for clinical trials

OBJECTIVES

The purpose of this study was to examine the variability in cytokines and cytokine receptors in patients with heart failure in comparison with a group of healthy control subjects who were free of cardiovascular disease.

BACKGROUND

Despite increasing interest in cytokines as mediators of disease progression in heart failure and the recent interest in suppressing cytokines in clinical studies, the extent of variability in cytokines and cytokine receptors is largely unknown. This information is important for interpreting the results of studies in which changes in cytokine levels are measured in response to a specific form of therapy.

METHODS

Circulating levels of tumor necrosis factor-alpha (TNF-alpha), and soluble TNF receptors (types 1 and 2), as well as interleukin (IL)-6 and IL-6 receptor were measured on a daily, weekly and monthly basis in heart failure patients (New York Heart Association class IIIa and IIIb; n = 10) and healthy volunteer subjects (n = 10). Measurements of cytokines and cytokine receptors were performed on plasma samples by enzyme-linked immunoassay. The daily, weekly and monthly degree of variability in cytokine and cytokine receptor levels was assessed by determining the coefficient of variation each point in time.

RESULTS

The coefficient of variation for TNF-alpha and IL-6 levels increased over time in patients with heart failure; moreover, the coefficient of variation in heart failure subjects was significantly greater for IL-6 than for TNF-alpha. The coefficient of variation in cytokine receptor levels was minimal, and did not differ significantly between heart failure and control subjects.

CONCLUSIONS

In patients with heart failure the degree of natural variability in circulating cytokine levels increases with time, and is greater for IL-6 than for TNF-alpha. Accordingly, the results of the present study suggest that the sample size needed to show a statistically significant change in the circulating level of a given cytokine will vary depending on the specific cytokine that is being measured, as well as the time period over which that cytokine is being assayed.

The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: a meta-analysis

Because of the growing concern surrounding the integrity and life span of silicone gel breast implants and the reported variations in the diagnostic accuracy of various imaging techniques in identifying ruptured implants, the authors undertook a meta-analysis of articles in the scientific literature to examine these concerns. They were able to include reports from the literature that detailed the condition and removal of 1,099 breast implants during the past 7 years. The median life span of a silicone gel implant was estimated to be 16.4 years. Of the implants, 79.1% were intact at 10 years, falling to 48.7% by 15 years. The sensitivities and specificities of three imaging modalities used in the diagnosis of implant rupture (mammography, ultrasonography, and magnetic resonance imaging [MRI]) were also evaluated and compared statistically in an effort to discover which of the three techniques might serve as the most reliable screening tool in the diagnosis of gel implant rupture. The sensitivity of mammography for finding a ruptured implant is 28.4% with a specificity of 92.9%. Ultrasonography has a sensitivity and specificity of 59.0% and 76.8% respectively compared with MRI, which was 78.1% and 80.0% respectively. For implants in place for 10 years, one would need to image 3.3 implants by ultrasound to identify a single possible rupture. However, because of the 76.8% specificity, 8.1 implants would need to be imaged to find a confirmed intraoperative rupture. This was similar to MRI, in which 3.1 implants would need to be imaged to detect one suspected rupture, and 6.1 implants would need to be imaged to find one intraoperatively confirmed rupture. The authors do not recommend either ultrasound or MRI as a screening tool based on their meta-analysis.

Division of the transverse carpal ligament and flexor tendon excursion: open and endoscopic carpal tunnel release

Ten fresh cadaver upper extremities from 10 different subjects were used in this study of the effect of both open and endoscopic carpal tunnel release on flexor tendon excursion. The amount of excursion necessary to bring each finger from the fully extended to the fully flexed position with the fingertip just touching the palm was measured with the extremity mounted in a device that moved the wrist from extension through flexion. Endoscopic carpal tunnel release, open release, and transverse carpal ligament reconstruction were performed with tendon excursion measurements made in each of four wrist positions after each procedure. Fingertip to palm distance was also measured. The measurements of flexor tendon excursion in neutral wrist position with intact transverse carpal ligament served as the norm for each finger and as the denominator in the ratio of postoperative to preoperative excursion distances. The study confirmed the importance of the transverse carpal ligament as a flexor pulley; transection of the ligament increased the amount of flexor tendon excursion necessary to achieve finger flexion and fingertip-to-palm contact. Tendon excursion/digital flexion improved after transposition flap repair. Neither open nor endoscopic carpal tunnel release conferred any particular benefit to flexor tendon excursion postoperatively. The proximal palmar aponeurosis does not seem to have the same pulley effect as the transverse fibers of the distal palm.

Caring for terminally ill persons: comparative analysis of attitudes (thanatophobia) of practicing physicians, student nurses, and medical students

To investigate why some caregivers desire to avoid patients with terminal illnesses, a thanatophobia scale assessing caregivers' uncomfortable feelings and sense of helplessness was developed and evaluated among practicing physicians and student nurses and medical students. As a group, student nurses scored lower on the thanatophobia scale than practicing physicians and medical students. Higher scores on intolerance to clinical uncertainty were associated with higher thanatophobia scores in all groups. Scores for depressed mood, decreased sensitivity, and Machiavellianism were statistically significant predictors in some groups. Higher thanatophobia scores also predicted lower scores for ratings of self-esteem in caring for elderly patients. Among senior medical students, those with lower thanatophobia scores tended to enter primary care residencies. Health professional educators may find this scale helpful both in pinpointing sources of caregivers' angst and useful in counseling students in management of terminally ill persons.

Malignant meningioma: an indication for initial aggressive surgery and adjuvant radiotherapy

Malignant meningiomas constitute a rare subset of meningiomas and display a marked propensity for postsurgical recurrence. This retrospective study evaluates the various parameters which alter the recurrence rate. The records of all malignant meningioma patients treated from 1984 through 1992 were reviewed, and the time to recurrence or current patient status was determined, and the influence of various patient and disease parameters were analyzed. Thirty-eight patients were treated with 48 malignant meningioma resections performed (28 total and 20 subtotal), 25 at initial presentation and 23 for recurrent disease; 19 patients received postoperative radiotherapy. Subtypes included 32 anaplastic meningioma, 11 hemangiopericytoma, 2 meningiosarcoma, and 3 papillary meningioma. Followup ranged from 3 to 144 months, with five patients excluded from analysis. Actuarial disease free/progression free survival (DFS) at 5 years was 39% following total resection versus 0% after subtotal resection (p=0.001). For all totally excised lesions, the 5-yr DFS was improved from 28% for surgery alone to 57% with adjuvant radiotherapy (p=NS). Adjuvant irradiation following initial resection increased the 5-yr DFS rates from 15% to 80% (p=0.002). When administered for recurrent lesions, adjuvant radiotherapy improved the 2-yr DFS from 50% to 89% (p=0.015), but had no impact on 5-yr DFS. Multivariate analysis indicates extent of resection, adjuvant radiotherapy, and recurrence status are independent prognostic factors. Malignant meningiomas display a tendency for post surgical recurrence, with recurrence significantly increased for multicentric and recurrent disease. Complete surgical resection and the administration of adjuvant irradiation following initial resection are crucial to long-term control.

Temporal changes in grip and pinch strength after open carpal tunnel release and the effect of ligament reconstruction

Symptoms of pain and weakness are nearly ubiquitous after carpal tunnel release. This study investigates the length of time before restoration of grip and pinch strength after open carpal tunnel release, in a population of patients without workers' compensation-related injuries. Two different forms of carpal ligament reconstruction were carried out in 2 groups of patients, and a third group underwent no ligament reconstruction. Grip and pinch strengths were measured for participants in each group both preoperatively and at set postoperative intervals. Mean changes in strength were calculated and analysis of variance used to determine statistical significance of the changes. Grip strength at 6 weeks after surgery in the group that underwent transposition flap repair exceeded preoperative grip strength values and all 3 groups surpassed preoperative grip strength measurements at 12 weeks. By 6 weeks after surgery, all pinch measurements for 3 groups equaled or exceeded preoperative pinch measurements. The transposition flap repair group recovered faster than did the other 2 groups and surpassed those groups in maximum grip and pinch strength at 12 weeks. These results suggest that transverse carpal ligament reconstruction, particularly the transposition flap technique, after open carpal tunnel release confers a mechanical advantage and that the transverse carpal ligament is an important pulley in flexor tendon excursion.

The effect of division of the transverse carpal ligament on flexor tendon excursion

The effect of the transverse carpal ligament (TCL) as a pulley was evaluated by measuring flexor tendon excursion after ligament division and by changing wrist position through a range of flexion and extension. Eight fresh cadaver upper extremities were mounted in a device and tendon excursions from full extension to fingertip-palm contact were measured for each flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendon. Measurements were performed with the wrist at 30 degrees extension, neutral, 30 degrees flexion, and 60 degrees flexion. The TCL was then sectioned, the skin was sutured, and the measurements were repeated. Two forms of carpal ligament repair were then done--transposition flap and aponeurotic repairs--and measurements were again repeated. With increasing wrist flexion, greater excursion differences were noted. Analysis of variance revealed that for both FDS and FDP, a significant difference in excursion occurred at 60 degrees wrist flexion and 30 degrees wrist extension with no ligament reconstruction or aponeurotic repair, compared to values prior to carpal tunnel release (p < .05) and to transposition ligament repair (p < .05).

Transverse carpal ligament: its effect on flexor tendon excursion, morphologic changes of the carpal canal, and on pinch and grip strengths after open carpal tunnel release

A three-part study is described that examines postoperative weakness after open carpal tunnel release and investigates the role of the transverse carpal ligament in the digital flexor pulley system. The effect of this ligament on flexor tendon excursion is evaluated in a cadaver study. Magnetic resonance imaging analysis is used to determine whether division of the transverse carpal ligament promotes volar migration of the median nerve and flexor tendons. Finally, the effects of ligament division and various methods of transverse carpal ligament reconstruction on the return of grip and pinch strengths after open carpal tunnel release are evaluated. The authors were able to determine that transverse carpal ligament reconstruction, particularly the transposition flap repair technique, after open carpal tunnel release confers a mechanical advantage and that the transverse carpal ligament is an important pulley for flexor tendon excursion. Based on the magnetic resonance imaging studies, volar displacement of carpal contents is reduced in patients undergoing transverse carpal ligament reconstruction by means of a transposition flap compared with those undergoing no ligament reconstruction and those undergoing reconstruction using the palmar aponeurosis. Postoperative grip and pinch strength values for the transposition flap repair group surpassed those of the other two groups at 12 weeks.

Correlation of histologic subtypes of primary basal cell carcinoma and number of Mohs stages required to achieve a tumor-free plane

BACKGROUND

Certain histologic subtypes of basal cell carcinoma (BCC) behave more aggressively and require more aggressive treatment.

OBJECTIVE

The aim of this study was to see whether certain subtypes of BCC require more Mohs stages to achieve tumor-free margins.

METHODS

A retrospective study of 342 primary BCCs treated with Mohs micrographic surgery (MMS) was performed identifying the histologic subtype of BCC present and the number of stages required to clear the tumor.

RESULTS

The aggressive subtypes (infiltrative, morpheaform, micronodular, and mixed) were most frequently found when high numbers of Mohs stages were required for cure.

CONCLUSION

The more aggressive subtypes of BCC require more MMS stages to achieve tumor-free margins, which is consistent with the concept that these subtypes usually require more aggressive treatment from the start.

Aesthetic outcome of breast implant removal in 85 consecutive patients

As we began to see increasing numbers of women concerned about their gel-filled breast implants, we became aware that we could not advise them with any degree of confidence what they might expect in terms of aesthetic result after implant removal. We decided to review the records and outcomes over a 2-year period of a number of patients who underwent implant removal. Eighty-five consecutive patients were reviewed, 69 of whom had undergone cosmetic augmentation and 16 of whom had breast reconstruction with silicone gel implant(s). Thirty-nine of the 69 cosmetic augmentation patients had removal of implants alone, and 27 had removal accompanied by mastopexy. Three had reaugmentation with saline-filled implants; one had replacement with saline-filled implants. Fifteen of the 16 reconstruction patients underwent autogenous tissue transfer. Preoperative and postoperative photographs of all patients were mixed randomly and rated by two independent raters in four aesthetic categories on a five-point scoring system. Repeatability was measured several weeks later, when each rater scored randomly selected photographs from this patient pool. The patients also performed their own outcome evaluations by means of questionnaire. We discovered that cosmetic augmentation patients who undergo implant removal only often suffer adverse aesthetic results. The postremoval appearance of many cosmetic augmentation patients actually will be improved over their preoperative appearance when mastopexy is performed in conjunction with implant removal. The study demonstrated that patients with certain body types could expect a particular outcome; i.e., women with asthenic builds and older patients with lax, striated breast skin generally had unsatisfactory aesthetic outcomes with implant removal only. Patients selected for autogenous breast reconstruction had favorable results, with extended latissimus dorsi and TRAM flaps yielding equally good outcomes. The study allows us to offer patients an optimistic view of postoperative results following breast implant removal. We have begun to advise selected patients that implant removal accompanied by mastopexy provides a more pleasing aesthetic outcome than implant removal alone.

Sleep-related erections: absence of change following presleep sexual arousal

We examined the effects of a brief period of sexual arousal before sleep on sleep-related erections (SREs) to add to our knowledge concerning those factors that affect SREs. Twelve subjects watched a 5 minute sexually explicit video before sleep. On other evenings they watched a dysphoric arousal video or a lecture (neutral) video. Sleep and SREs were recorded throughout the following night. Although the brief sexual arousal video produced a full or near full erection in all subjects, no significant effect on subsequent SREs occurred. We conclude that the control of SREs in young healthy subjects is insulated against the effect of a brief period of sexual arousal before sleep.

Parietal cell vagotomy performed with fundoplication for esophageal reflux

BACKGROUND

Reduction of acid secretion is an important aspect of medical treatment of reflux esophagitis. Truncal vagotomy and drainage procedures used in conjunction with antireflux procedures to reduce acid secretion in patients with gastroesophageal reflux were unsatisfactory. This study reviews the results of parietal cell vagotomy used in conjunction with a 360-degree fundoplication to determine if reduction of acid by this form of vagotomy was beneficial to patients with gastroesophageal reflux.

METHODS

Between March 1973 and May 1993, 94 private and 64 Veterans Administration patients underwent parietal cell vagotomy and Nissen type fundoplication for esophageal reflux. Esophagogastroduodenoscopy (EGD), gastric analysis, cine-esophagogram, and 24-hour esophageal pH and motility studies were performed preoperatively on VA patients. Private patients underwent EGD, cine-esophagogram, and sometimes pH and motility studies. Similar studies were performed postoperatively if the patient permitted. The major technical alteration made during the study was the addition of posterior gastropexy to the operations performed between March 1978 and January 1987. Patients were considered failures if dysphagia and reflux symptoms were moderate but operation not contemplated (Visick III) or symptoms were severe and reoperation had been performed or was contemplated (Visick IV).

RESULTS

There were no operative deaths. There were 25 operative failures; dysphagia contributed to failure in 4, reflux in 11, and dysphagia and reflux in 10 patients. Reoperation was required in 6 patients. There was no statistical difference in acid secretion inhibition for patients with or without postoperative reflux symptoms. The cumulative probability for operative failure was 9.3 +/- SE 4.2% for patients who underwent posterior gastropexy and 22.9 +/- SE 4.6% (P <0.02) for those who did not.

CONCLUSIONS

Parietal cell vagotomy with Nissen fundoplication is a safe operation. The exposure created by PCV protected the vagi from injury. The study design made it impossible to determine whether PCV improved the results of fundoplication but the failure rate was significantly (P <0.02) reduced by the addition of posterior gastropexy. This may have lessened the risk of disintegration of the wrap that might be more likely to occur after PCV.

Superficial versus deep: options in venous drainage of the radial forearm free flap

We performed a fresh cadaver dissection study of the superficial venous system (cephalic vein and its branches) and the deep venous system (venae comitantes) of the radial forearm to assess the suitability of each system for venous anastomosis during free tissue transfer. We used methyl methacrylate to evaluate vessel diameters and anatomic variability of both venous systems. Colored radiopaque injectate allowed us to combine anatomic dissection with tissue radiographs. We discovered the cephalic vein to invariably be of larger caliber than the venae comitantes. Ensuring capture of the cephalic vein in the flap necessitated additional dorsoradial subcutaneous dissection beyond the boundaries of the skin flap in four of ten specimens. The vessel diameters of the venae comitantes in four cadavers were less than 2 mm. Proximal confluence of the two venae comitantes, and communication between the deep and superficial venous systems were encountered in only four cases. In these cases, had an anastomotic site been chosen proximal to such a communication to ensure greater vessel caliber, pedicle length probably would have made free tissue transfer unwieldy. We recommend mapping the course of the cephalic vein before flap elevation and maintaining a wide proximal subcutaneous pedicle to capture the best possible superficial drainage system. If the superficial venous system has been damaged (as by previous intravenous catheterization), one may not necessarily be able to rely on the vessel caliber of the deep venae comitantes for microvenous anastomosis.

Diagnostic value of clinical examination and various imaging techniques for breast implant rupture as determined in 81 patients having implant removal

To determine sensitivity and specificity of magnetic resonance imaging (MRI) and ultrasonography (US) in the detection of breast implant rupture, and also to determine the relative merits of clinical examination and mammography, we studied 81 patients (160 implants). All patients had implants removed, thus allowing confirmation of the presence or absence of rupture. Clinical examination positively identified only one patient with implant rupture, and mammography detected only two implant ruptures (both extracapsular). The sensitivity for US was 70% and specificity was 90%, while for MRI it was 75.6% and 94%, respectively. These differences between MRI and US were not statistically significant. Combining the results of US and MRI did not seem to add to the diagnostic discrimination. The most cost-effective method of diagnosing implant rupture was US in our study.

Anatomic delineation of the ulnar nerve and ulnar artery in relation to the carpal tunnel by axial magnetic resonance imaging scanning

In a number of publications the distal branches of both the ulnar artery and ulnar nerve have been identified as being positioned ulnar to the hook of the hamate. We undertook a magnetic resonance imaging project in patients who presented for carpal tunnel release to determine how far radially vital structures of Guyon's canal may be located and if they may overlap the carpal tunnel at the hook of the hamate. Cross-sectional magnetic resonance imaging scans of 20 patients were performed prior to carpal tunnel release with the wrist positioned in neutral, flexed, and extended positions. Linear measurements were made either radial or ulnar to the hook of the hamate taken as the reference point. In the neutral position, the ulnar nerve was found to be, on average, 3.6 mm ulnar to the hook of the hamate (range of 5.8 mm radial to 7.5 mm ulnar). The ulnar artery averaged 0.7 mm to the radial side of the hook of the hamate (range 7.8 mm radial to 2.8 mm ulnar). Guyon's canal extended 28% of the way across the carpal ligament (range 9 to 63%). With the wrist in flexion and extension, there was an ulnar displacement and a radial displacement, respectively, of these structures relative to the hook of the hamate.

Hemostasis at skin graft donor sites: evaluation of topical agents

Blood loss from split-thickness skin graft donor sites may be significant. Various topical agents have been used to decrease this blood loss, including thrombin and epinephrine solutions of varying concentrations. We describe a K-Y jelly/epinephrine mixture that serves both as a lubricant for the dermatome and as a hemostatic agent. This mixture, in comparison with other topical agents, produces rapid hemostasis and offers the advantages of easy use, ready availability, and low cost. The blood loss savings based on this hemostatic technique is quantifiable and significant.

Is obstetrics-gynecology a primary care specialty?

Suddenly everyone wants more primary care physicians. For several years, we collected data from senior medical students to relate their attitudes and beliefs about several clinical problems common to primary care to their choices of residencies. Because the Texas Medical Association's Special Committee on Primary Care included obstetrics-gynecology as a primary care specialty, we reviewed our data to see if the personal traits and professional role characteristics of seniors choosing obstetrics-gynecology differed materially from those of seniors choosing family medicine, internal medicine, or pediatrics. Results of this analysis put obstetrics-gynecology about as firmly in the primary care group as if the experimental design had planned it that way.

Transconjunctival versus transcutaneous lower eyelid blepharoplasty: a prospective study

Debate continues over the relative merits of transconjunctival and the more customary subciliary transcutaneous approaches for lower lid blepharoplasty. Ten consecutive patients presented for blepharoplasty, and in all patients the transcutaneous subciliary musculocutaneous flap approach was used on the left lower eyelid and the transconjunctival preseptal approach was used on the right. Patients served as their own controls. Follow-up was evaluated clinically by patient questionnaire and by standardized photographs preoperatively and at 5 days, 1 month, 3 months, and 6 months postoperatively. Photographs were graded independently by four blinded examiners. No statistical difference was identified in measured fornix depth between preoperative patients and postoperatively on each side. Average fat removed from each side was the same, and no patient had an identified "missed fat compartment." Three patients had mild bilateral scleral show postoperatively, and a fourth developed it on the left (transcutaneous) side. However, overall grading on both sides was universally very good with no significant difference on the two sides--0.68 on the right and 0.60 on the left (maximum worst grade could be 5.0 and best grade 0). The potential for external scarring was never a perceived problem in the transcutaneous technique.

Clinical relevance of positive breast periprosthetic cultures without overt infection

The true incidence of positive breast periprosthetic cultures in the absence of overt infection is not clearly established. We retrospectively reviewed data from 389 implants that were removed for reasons other than clinical infection. Many of these patients presented with a variety of musculoskeletal ailments. Others had symptomatic capsular contracture as the presenting complaint. In a few a known implant rupture was the reason for explantation. We identified a positive culture rate of 23.5 percent from capsule tissue. Most of these organisms were coagulase-negative staphylococci and anaerobic diphtheroids, but fungi and other organisms (generally felt to be more pathogenic than the less virulent coagulase-negative staphylococci) also were cultured. In an attempt to identify the clinical relevance of these positive cultures, we statistically evaluated the culture results for associations with capsular contracture, implant rupture, type of implant, and location of implant. Of these, the only statistically significant correlation was between positive culture result and symptomatic capsular contracture (Baker class IV).

The hemodynamic and hematologic effects of cigarette smoking versus a nicotine patch

Patients who smoke have higher complication rates than nonsmokers in the postoperative period. The authors designed an experimental protocol for habitual smokers (n = 30) to determine the specific hemodynamic and hematologic adverse effects possibly caused by nicotine and whether the method of nicotine delivery and systemic nicotine levels achieved might influence these adverse effects. During the 5-day study, subjects were asked to refrain from smoking, and testing sessions were conducted as follows: on day 1, the subjects smoked two cigarettes immediately before testing; on day 3 (control day), testing was done after not smoking for 48 hours and then the subjects were instructed to wear a transdermal nicotine patch (PROSTEP 22 mg/day) for 24 hours and replace it with another so that, on day 5, testing took place after the subjects had worn the patch for approximately 34 hours. At each testing session, digital artery pulse amplitude and a number of clinical and serum blood level parameters were measured. Relative digital blood flow after smoking (69.2 +/- 5.8%) and with the patch (80.4 +/- 7.6%) was lower than on the control day (100.0 +/- 0.0%). The nicotine patch, unlike smoking, had no effect on vasopressin or fibrinogen concentrations, hematocrit, or white cell or platelet counts; both smoking and the patch resulted in elevated norepinephrine levels.

Vasoactive effects of smoking as mediated through nicotinic stimulation of sympathetic nerve fibers

Patients who smoke have higher complication rates than nonsmokers following many surgical procedures. It is not known if the adverse effects of smoking are caused by a nicotine effect or by some other potentially harmful agents that exist in tobacco smoke. It is also not known if these vasoactive effects are mediated through sympathetic nerve fibers (via nicotinic receptors in ganglia) or through elevated circulating levels of vasoactive hormones. We designed a 5-day protocol to measure relative blood flow both before and after a digital sympathetic block in the digits of subjects who were regular smokers following both smoking and wearing of a transdermal nicotine patch. Suitable pulse/wave tracings were recorded on 23 subjects. We also measured serum levels of nicotine, cotinine, vasopressin, norepinephrine, epinephrine, dopamine, and carboxyhemoglobin on each test day. Data for these serum levels were available in 30 test subjects. Digital sympathetic block had a significant beneficial effect in reversing the decreased digital blood flow that occurred after smoking (and also with use of the nicotine patch), despite the elevated circulating levels of vasopressin and norepinephrine seen with smoking. The vasoactive effects of smoking are probably due to the nicotinic effects on sympathetic fibers at the ganglionic levels.

Histologic patterns of basal cell carcinoma based upon patient immunostatus

BACKGROUND

The biologic behavior of basal cell carcinoma (BCC) seems to be dictated by the histologic subtype. Moreover, BCCs in immunosuppressed patients appear to show a more aggressive biologic behavior.

OBJECTIVE

The purpose of this study was to retrospectively investigate different histologic subtypes of BCC to determine whether a particular subtype would predominate in immunosuppressed patients.

METHODS

The histologic patterns of 112 primary BCCs from 77 immunosuppressed patients and 60 primary BCCs from 46 patients who are endogenously immunocompromised, due to diabetes mellitus and/or chronic renal failure, were examined. The results were compared with 488 primary BCCs of 318 immunocompetent patients.

RESULTS

The nodular subtype was the predominant pattern among all patients. However, a statistical difference was found in the immunosuppressed patients in that there was a lower percentage of nodular pattern (P = .0038), and a higher percentage of infiltrative pattern (P = .0002). The higher frequency of the infiltrative pattern in the immunosuppressed group was particularly prominent among chronic alcoholics.

CONCLUSION

In immunosuppressed patients, the higher frequency of the infiltrative subtype of BCC, particularly among chronic alcoholics, may have a predictive role in the management of these cases.

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy

OBJECTIVE

The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers.

BACKGROUND DATA

Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers.

METHODS

A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification.

RESULTS

There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation.

CONCLUSION

This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.

Some selected psychological and social characteristics of veteran psychiatric inpatients without stable housing

In this study were compared scores on selected MMPI subscales and demographic variables from 58 veterans with stable housing and 54 veterans without stable housing. Both groups were selected from the same inpatient psychiatric treatment program at the Houston VA Medical Center. The MMPI was administered and a number of demographic variables were collected from patients' archival computerized records. Comparison of MMPI scores indicated that patients without housing had marginally significantly higher scores on the clinical research subscale PD4A (Social Alienation). They were also significantly less likely to be married or employed. Logistic regression analysis indicated that, when multiple predictors were considered, marital status was the only significant risk factor for absence of stable housing. Results underscore the relevance of social services to treatment, discharge, and rehabilitation planning when working with veterans without stable housing.

Some outcome predictors for use in vocational rehabilitation planning

This study examined some predictor variables for positive outcome with a state vocational rehabilitation agency. Referrals to the agency from VA Counseling Psychology were analyzed to develop guidelines for identifying clients with good probability for positive outcome in their vocational rehabilitation planning. All subjects had a history of substance-abuse treatment at the Houston VA Medical Center. Analyses suggested a number of factors are relevant when assessing potential for successful vocational rehabilitation. Provision of drug-free housing, recent work history, and discharge status from a substance-abuse program were identified as relevant factors.

Utility of magnetic resonance imaging and ultrasonography in diagnosing breast implant rupture

We prospectively evaluated 81 patients (with 160 implants) who subsequently had implants removed to determine sensitivity and specificity of both magnetic resonance imaging and ultrasonography. Positive and negative predictive values were also calculated to determine whether a statistically beneficial interaction existed when ultrasonography and magnetic resonance imaging were used in combination to examine an implant. Finally, the misdiagnoses were retrospectively evaluated to identify the pitfalls of the investigations. Positive diagnostic criteria were described. The sensitivity and specificity of ultrasonography were 47% and 83%, respectively, and of MRI, 46% and 88%, respectively. On retrospective review by the radiologist, the sensitivity and specificity of ultrasonography were 70% and 90%, respectively, and of magnetic resonance imaging, 75.6% and 94%, respectively. Although definite conclusions could not be obtained, there did not seem to be an additive benefit from using both ultrasonography and magnetic resonance imaging.

Education and occupation as risk factors for dementias of the Alzheimer and ischemic vascular types

Education and occupation as sociodemographic risk factors for dementias of the Alzheimer (DAT) and ischemic vascular types (IVD) were evaluated by two case series studies. Cases were compared to well-evaluated individuals identified as healthy normals acting as controls. There were 150 patients with probable DAT, 102 patients with probable IVD, and 188 neurologically and cognitively normal subjects. Logistic regression indicated that for DAT, education with occupation was the best predictor (OR, 1.51; 95% CI, 1.23-1.87). For IVD, the two predictors were: education with occupation (OR, 1.84; 95% CI 1.38-4.50) and education with gender (OR, 3.40; 95% CI, 1.29-8.92). We conclude that risk of dementia is increased in those with limited educational background and occupational achievement.

A review of 198 patients (389 implants) who had breast implants removed

Because of the large number of women now returning to their plastic surgeons with concerns about their breast implants many years after surgery, we are afforded an ideal opportunity to evaluate these patients over the long-term. This study reviewed 198 patients (389 implants) who underwent explantation by two surgeons over a 2-year period, correlating prosthesis type, location, and length of time since implantation with two adverse endpoints, implant rupture and symptomatic capsular contracture. Significant findings included a relatively high rate of implant rupture in patients whose implants had been in place over 20 years, an increased incidence of both symptomatic capsular contracture and implant rupture in single lumen gel implants and a positive correlation between severity of capsular contracture and implant rupture.

National survey on physicians' attitudes toward social and sexual contact with patients

To determine the attitudes of physicians toward social and sexual contact with patients, we mailed a self-report survey to a nationwide randomized sample including general practitioners, internists, obstetrician-gynecologists, and ophthalmologists. The 777 physicians who responded specified whether or not behavior such as hugging, dating, and sexual contact with their own patients may be appropriate. Less than 1% of all respondents thought that sexual contact with patients was appropriate during patient consultations. Three percent of internists and obstetrician-gynecologists considered sexual contact with patients appropriate when concurrent with treatment but outside of patient consultation, as compared with 9% of general practitioners and 12% of ophthalmologists (X2 = 17.8, df = 3, P < .001). Nearly 50% of general practitioners and more than 50% of all other physicians thought that sexual contact might be appropriate after termination of treatment of a patient. These findings may facilitate professional discussion on standards for social and sexual contact with patients.

Twenty years after parietal cell vagotomy or selective vagotomy antrectomy for treatment of duodenal ulcer. Final report

OBJECTIVE

This study was a prospective, randomized evaluation of parietal cell vagotomy (PCV) and selective vagotomy-antrectomy (SV-A) in the treatment of duodenal ulcer.

BACKGROUND DATA

Operative treatment of duodenal ulcer is associated with mortality and mechanical and metabolic morbidity. At the time that surgeons appear to have succeeded in developing operations with low morbidity and mortality, the number of patients requiring elective operation has decreased partly because of the simultaneous, dramatic improvement in medical therapy. Nevertheless, surgical therapy still is important, especially in certain socioeconomic environments.

METHODS

After a pilot study of PCV, 200 patients with duodenal ulcers were randomized to PCV or SV-A. One surgeon was responsible for the operations and follow-up studies. An attempt was made to evaluate all patients annually in the hospital. Gastric analyses were performed on each visit, for which the patient gave his/her consent.

RESULTS

There was no operative mortality. The recurrence rate-by-life table analysis was less (p < 0.003) after SV-A than PCV. Dumping was greater (p < 0.001), and there was no difference in the frequency of diarrhea after SV-A compared with PCV. The percentage of patients with grades Visick I or Visick II was not different for the two operations, but more patients were graded Visick I after PCV than after SV-A.

CONCLUSIONS

Selective vagotomy-antrectomy and parietal cell vagotomy are effective and safe operations, when used appropriately. Selective vagotomy-antrectomy is preferable for patients with pyloric and prepyloric ulcers and pyloric obstruction. Parietal cell vagotomy is the authors' choice for duodenal ulcer patients because of the occasional patient who becomes disabled by SV-A.

Predicting the results and outcome of patients who undergo abdominal CT scanning while in the surgical intensive care unit

Postlaparotomy patients who remain in the Surgical Intensive Care Unit (SICU) are frequently suspected of harboring an intra-abdominal abscess (IAA). Computed Tomography (CT) of the abdomen has been advanced as an accurate method to diagnose an IAA. To determine the clinical parameters predictive of CT scan results, and the survival of such patients, this study reviewed a consecutive series of 29 postlaparotomy patients who were evaluated by abdominal CT scan while in the SICU. An IAA was identified significantly more frequently by CT when patients were explored for a GI malignancy (70% vs 30%; P < 0.05) and when patients were operated upon electively (11.1% vs 20.0%; P < 0.05). Postoperatively, alert patients were significantly more likely to have a CT scan positive for an IAA than were patients who were lethargic or nonresponsive (90% vs 10%; P < 0.05). Laboratory data, including radiographic studies, were not predictive of the CT scan results. A negative CT scan modified therapy in only 10.5 per cent of patients, while a positive scan altered therapy in 70 per cent of patients (P < 0.05). The overall survival for this group was 48.1 per cent. The identification of an IAA by CT scan did not significantly improve survival (42% with an IAA vs 40% without an IAA). APACHY II scores were significantly increased in nonsurvivors (17.4 +/- 6.0 survivors vs 23.76 +/- 7.8 nonsurvivors; P < 0.05). Our data indicate that in critically ill postlaparotomy SICU patients who were evaluated by abdominal CT scanning, there are some clinical clues that tend to predict whether or not CT scanning will identify an IAA.(ABSTRACT TRUNCATED AT 250 WORDS)