Validation of the 2022 National Comprehensive Cancer Network Risk Stratification for Cutaneous Squamous Cell Carcinoma

Importance

The 2022 National Comprehensive Cancer Network (NCCN) reclassified cutaneous squamous cell carcinoma (CSCC) into low-, high-, and very high-risk groups to better risk stratify tumors. Mohs micrographic surgery (Mohs) or peripheral and deep en face margin assessment (PDEMA) became preferred surgical modalities for high- and very high-risk tumors. This new risk stratification and the recommendation for Mohs or PDEMA in high- and very high-risk groups have not been validated.

Objective

To compare outcomes in very high-, high-, and low-risk NCCN groups of CSCCs and in CSCCs treated with Mohs or PDEMA compared with wide local excision (WLE).

Design, Setting, and Participants

This retrospective cohort study of CSCCs was performed in 2 tertiary care academic medical centers. Patients 18 years or older and diagnosed between January 1, 1996, and December 31, 2019, at Brigham and Women's Hospital and Cleveland Clinic Foundation were included. Data were analyzed from October 20, 2021, to March 29, 2023.

Exposures

NCCN risk group, Mohs or PDEMA, and WLE.

Main Outcomes and Measures

Local recurrence (LR), nodal metastasis (NM), distant metastasis (DM), and disease-specific death (DSD).

Results

A total of 10 196 tumors from 8727 patients were stratified by NCCN guidelines into low-, high-, and very high-risk groups (6003 [59.0%] men; mean [SD] age, 72.4 [11.8] years). Compared with the low-risk group, the high- and very high-risk groups demonstrated a greater risk of LR (high-risk subhazard ratio [SHR], 1.99 [95% CI, 1.21-3.27; P = .007]; very high-risk SHR, 12.66 [95% CI, 7.86-20.39; P < .001]), NM (high-risk SHR, 4.26 [95% CI, 1.28-14.23; P = .02]; very high-risk SHR, 62.98 [95% CI, 19.24-206.17; P < .001]), DM (high-risk SHR, 2.2 × 107 [95% CI, 4.7 × 103-1.1 × 1011; P < .001]; very high-risk SHR, 6.3 × 108 [95% CI, 1.4 × 105-2.9 × 1012; P < .001]), and DSD (high-risk SHR, 4.02 [95% CI, 1.18-13.71; P = .03]; very high-risk SHR, 93.87 [95% CI, 29.19-301.85; P < .001]). Adjusted 5-year cumulative incidence was significantly higher in very high- vs high- and low-risk groups for LR (9.4% [95% CI, 9.2%-14.0%] vs 1.5% [95% CI, 1.4%-2.1%] and 0.8% [95% CI, 0.5%-1.2%], respectively), NM (7.3% [95% CI, 6.8%-10.9%] vs 0.5% [95% CI, 0.4%-0.8%] and 0.1% [95% CI, 0.03%-0.3%], respectively), DM (3.9% [95% CI, 2.6%-5.6%] vs 0.1% [95% CI, 0.04%-0.2%] and 0.01% [95% CI, not applicable], respectively), and DSD (10.5% [95% CI, 10.3%-15.4%] vs 0.5% [95% CI, 0.4%-0.8%] and 0.1% [95% CI, 0.04%-0.3%], respectively). Compared with CSCCs treated with WLE, those treated with Mohs or PDEMA had lower risk of LR (SHR, 0.65 [95% CI, 0.46-0.90]; P = .009), DM (SHR, 0.38 [95% CI, 0.18-0.83]; P = .02), and DSD (SHR, 0.55 [95% CI, 0.36-0.84]; P = .006).

Conclusions and Relevance

The findings of this cohort study suggest that the NCCN high- and very high-risk groups identify CSCCs at greatest risk for developing poor outcomes. Further, Mohs or PDEMA resulted in lower LR, DM, and DSD compared with WLE.

Development and validation of a brief screener for posttraumatic stress disorder risk in emergency medical settings

OBJECTIVE

Predicting risk of posttraumatic stress disorder (PTSD) in the acute care setting is challenging given the pace and acute care demands in the emergency department (ED) and the infeasibility of using time-consuming assessments. Currently, no accurate brief screening for long-term PTSD risk is routinely used in the ED. One instrument widely used in the ED is the 27-item Immediate Stress Reaction Checklist (ISRC). The aim of this study was to develop a short screener using a machine learning approach and to investigate whether accurate PTSD prediction in the ED can be achieved with substantially fewer items than the IRSC.

METHOD

This prospective longitudinal cohort study examined the development and validation of a brief screening instrument in two independent samples, a model development sample (N = 253) and an external validation sample (N = 93). We used a feature selection algorithm to identify a minimal subset of features of the ISRC and tested this subset in a predictive model to investigate if we can accurately predict long-term PTSD outcomes.

RESULTS

We were able to identify a reduced subset of 5 highly predictive features of the ISRC in the model development sample (AUC = 0.80), and we were able to validate those findings in the external validation sample (AUC = 0.84) to discriminate non-remitting vs. resilient trajectories.

CONCLUSION

This study developed and validated a brief 5-item screener in the ED setting, which may help to improve the diagnostic process of PTSD in the acute care setting and help ED clinicians plan follow-up care when patients are still in contact with the healthcare system. This could reduce the burden on patients and decrease the risk of chronic PTSD.

Community Violence Exposure is Associated with Hippocampus-Insula Resting State Functional Connectivity in Urban Youth

Our previous work has linked childhood violence exposure in Black youth to functional changes in the hippocampus, a brain region sensitive to stress. However, different contexts of violence exposure (e.g., community, home, school) may have differential effects on circuitry. We investigated the unique effect of community violence in predicting resting-state functional connectivity (rsFC) in the hippocampus. Fifty-two (26F) violence-exposed Black youth ages 8-15 performed resting-state functional neuroimaging scans while looking at a fixation cross for seven minutes with eyes open. Seed-based analyses were conducted to examine the association between total violence exposure and rsFC of the hippocampus to the whole brain. Follow-up hierarchical regression analysis were performed to specifically investigate community violence. Violence exposure was associated with higher hippocampus rsFC with a core node of the Default Mode Network (i.e., posterior cingulate cortex) and lower hippocampal rsFC with a core node of the Salience Network (i.e., insula). Community violence uniquely associated with lower hippocampus-insula rsFC, after controlling for home and school violence, sex and age. Age-related decreases in hippocampus-insula rsFC were also present in youth with lower violence exposure, but not in youth with higher violence exposure. This is one of the first studies to investigate the unique impact of community violence, above home and school violence, on threat circuitry. Our data suggest functional alterations in the hippocampus in violence-exposed youth, and that violence in the community may be a more salient form of threat exposure compared to other forms of violence experienced by youth.

Diabetic ketoacidosis and mortality in COVID-19 infection

Aim

- Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients.

Methods

- Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19.

Results

- Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40–1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06–1.08) and need for pressors (HR 2.33, 95% CI 1.82–2.98). Glucocorticoid use was protective in patients with and without DKA.

Conclusion

- The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

Do Postoperative Antibiotics Affect Outcomes in Mohs Reconstructive Surgery?

OBJECTIVES/HYPOTHESIS

The prescribing of postoperative antibiotics for patients undergoing Mohs reconstructive surgery has increased in the last decade, while antibiotic resistance has been increasing. We hypothesized that routine prescribing of postoperative antibiotics after Mohs reconstruction does not decrease the risk of surgical site infection.

STUDY DESIGN

Retrospective, single-institution cohort study.

METHODS

This study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 29, 2019. The main outcomes assessed included postoperative surgical site infections, partial or full flap/graft necrosis, hematoma, and dehiscence.

RESULTS

A total of 900 defects in 800 patients (mean age [range] = 65.3 [21-96], 54.60% female) were identified over the 7-year period. Patient-specific variables reviewed included comorbidities, age, and smoking status. Surgery-specific variables analyzed included defect characteristics, time interval between Mohs micrographic surgery and reconstruction, reconstructive modalities, and use of postoperative antibiotics. All patients received peri-incisional antibiotics. On regression analysis, use of cartilage grafts (odds ratio [OR]: 6.53; 95% CI: 2.1-20.6; P = .001), current smoking status (OR: 6.67; 95% CI: 2.09-21.30; P = .001), full-thickness defects (OR: 1.2; 95% CI: 1.0-3.4; P = .045), and interpolated flap reconstruction (OR: 3.4; 95% CI: 1.0-11.5; P = .049) were associated with an increased risk of postoperative infections. Smoking and cartilage grafting remained significant on bivariable regression modeling. Use of perioperative antibiotics was not associated with a decreased risk of infection (OR: 1.82; 95% CI: 0.23-14.21; P = .568).

CONCLUSIONS

We found no association between postoperative infections after Mohs reconstructive surgery and the use of postoperative antibiotics. These data support a more targeted approach to antibiotic prescribing in Mohs reconstructive surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E434-E439, 2021.

Endocervical and Neutrophil Lipoxygenases Coordinate Neutrophil Transepithelial Migration to Neisseria gonorrhoeae

Background

Infection with Neisseria gonorrhoeae (GC) is characterized by robust neutrophil influx that is insufficient to clear the bacteria. Sustained neutrophilic inflammation contributes to serious clinical sequelae that particularly affect women, including pelvic inflammatory disease and infertility.

Methods

We established a 3-component system using GC, End1 polarized human endocervical cells, and primary human neutrophils to investigate neutrophil transepithelial migration following infection.

Results

Neutrophil migration across endocervical monolayers increased with the infectious dose and required GC-epithelial cell contact. Epithelial protein kinase C, cytosolic phospholipase A2, 12R-lipoxygenase (LOX), and eLOX3 hepoxilin synthase were required for neutrophil transmigration to GC, and migration was abrogated by blocking the MRP2 efflux pump and by adding recombinant soluble epoxide hydrolase. These results are all consistent with epithelial cell production of the neutrophil chemoattractant hepoxilin A3 (HXA3). Neutrophil transmigration was also accompanied by increasing apical concentrations of leukotriene B4 (LTB4). Neutrophil 5-lipoxygenase and active BLT1 receptor were required for apical LTB4 and neutrophil migration.

Conclusions

Our data support a model in which GC-endocervical cell contact infection stimulates HXA3 production, driving neutrophil migration that is amplified by neutrophil-derived LTB4. Therapeutic targeting of these pathways could limit inflammation and deleterious clinical sequelae in women with gonorrhea.

A thermonuclease of Neisseria gonorrhoeae enhances bacterial escape from killing by neutrophil extracellular traps

Acute gonorrhea is characterized by neutrophilic inflammation that is insufficient to clear Neisseria gonorrhoeae. Activated neutrophils release extracellular traps (NETs), which are composed of chromatin and decorated with antimicrobial proteins. The N. gonorrhoeae NG0969 open reading frame contains a gene (nuc) that encodes a putatively secreted thermonuclease (Nuc) that contributes to biofilm remodeling. Here, we report that Nuc degrades NETs to help N. gonorrhoeae resist killing by neutrophils. Primary human neutrophils released NETs after exposure to N. gonorrhoeae, but NET integrity declined over time with Nuc-containing bacteria. Recombinant Nuc and conditioned medium from Nuc-containing N. gonorrhoeae degraded human neutrophil DNA and NETs. NETs were found to have antimicrobial activity against N. gonorrhoeae, and Nuc expression enhanced N. gonorrhoeae survival in the presence of neutrophils that released NETs. We propose that Nuc enables N. gonorrhoeae to escape trapping and killing by NETs during symptomatic infection, highlighting Nuc as a multifunctional virulence factor for N. gonorrhoeae.

Histone deacetylase inhibition induces long-lasting changes in maternal behavior and gene expression in female mice

In many species, including mice, maternal responsiveness is experience-dependent and permanent, lasting for long periods (months to years). We have shown that after brief exposures to pups, virgin female mice continue to respond maternally toward pups for at least one month. Administration of a histone deacetylase inhibitor (HDACi) reduces the amount of maternal experience required to affect maternal behavior and gene expression. In this set of studies, we examined the epigenetic mechanisms that underlie these motivated behaviors. We assessed whether the effects of HDACi persisted 1 month after the initial experience (in the absence of continued pup experience or HDACi treatment) and whether the maintenance of maternal memory was associated with stable changes in gene expression. Using chromatin immunoprecipitation, we examined whether Esr2 and Oxt gene expression might be mediated by recruitment of the histone acetyltransferase cAMP response element binding protein (CBP) to their promoter regions after maternal memory consolidation. We report that HDACi treatment induced long-lasting changes in maternal responsiveness. Maternal learning was associated with increased recruitment of CBP to the Esr2 and Oxt gene promoters during the consolidation of maternal memory as well as a persistent increase in estrogen receptor-β (Esr2) mRNA and decreased expression of the de novo DNA methyltransferase Dnmt3a within the medial preoptic area. The consolidation of the maternal experience may involve the CBP recruitment and stable changes in gene expression, which maintain increased maternal responsiveness for long periods of time.

Conservation of artists' acrylic emulsion paints: XPS, NEXAFS and ATR-FTIR studies of wet cleaning methods

Works of art prepared with acrylic emulsion paints became commercially available in the 1960s. It is increasingly necessary to undertake and optimise cleaning and preventative conservation treatments to ensure their longevity. Model artists' acrylic paint films covered with artificial soiling were thus prepared on a canvas support and exposed to a variety of wet cleaning treatments based on aqueous or hydrocarbon solvent systems. This included some with additives such as chelating agents and/or surfactants, and microemulsion systems made specifically for conservation practice. The impact of cleaning (soiling removal) on the paint film surface was examined visually and correlated with results of attenuated total reflection Fourier transform infrared, XPS and near-edge X-ray absorption fine structure analyses – three spectroscopic techniques with increasing surface sensitivity ranging from approximately − 1000, 10 and 5 nm, respectively. Visual analysis established the relative cleaning efficacy of the wet cleaning treatments in line with previous results. X-ray spectroscopy analysis provided significant additional findings, including evidence for (i) surfactant extraction following aqueous swabbing, (ii) modifications to pigment following cleaning and (iii) cleaning system residues. © 2014 The Authors. Surface and Interface Analysis published by John Wiley & Sons, Ltd.

Experience-facilitated improvements in pup retrieval; evidence for an epigenetic effect

The quality and quantity of maternal care received during infancy are highly predictive of successful infant development. It has been well established, primarily in rats, that the combination of hormonal and infant stimuli at birth modifies neural circuits that regulate maternal responsiveness. During subsequent interactions, infant stimuli are more likely to elicit rapid maternal responsiveness. Some species, such as humans, can display maternal care in the absence of the endocrine events of pregnancy and birth. Similarly, virgin C57BL/6J female mice, display maternal care toward infants, and experience with infants elicits long-lasting increases in maternal care. We hypothesized that these experience-induced changes in behavior may be mediated by chromatin modifications, which in turn change expression of genes that promote maternal care. One site of action is the medial preoptic area (MPOA). To test our hypothesis we treated virgin female mice with sodium butyrate, a histone deacetylase inhibitor. This treatment potentiated maternal responsiveness as well as the expression of several genes: estrogen receptor β (Esr2), oxytocin (Oxt), and cyclicAMP response element binding protein (CREB) binding protein (Crebbp; a histone acetyltransferase) in the MPOA. These data suggest that experience induces high levels of maternal care via epigenetic modifications.

Identification of a calcitonin-like diuretic hormone that functions as an intrinsic modulator of the American lobster, Homarus americanus, cardiac neuromuscular system

In insects, a family of peptides with sequence homology to the vertebrate calcitonins has been implicated in the control of diuresis, a process that includes mixing of the hemolymph. Here, we show that a member of the insect calcitonin-like diuretic hormone (CLDH) family is present in the American lobster, Homarus americanus, serving, at least in part, as a powerful modulator of cardiac output. Specifically, during an ongoing EST project, a transcript encoding a putative H. americanus CLDH precursor was identified; a full-length cDNA was subsequently cloned. In silico analyses of the deduced prepro-hormone predicted the mature structure of the encoded CLDH to be GLDLGLGRGFSGSQAAKHLMGLAAANFAGGPamide (Homam-CLDH), which is identical to a known Tribolium castaneum peptide. RT-PCR tissue profiling suggests that Homam-CLDH is broadly distributed within the lobster nervous system, including the cardiac ganglion (CG), which controls the movement of the neurogenic heart. RT-PCR analysis conducted on pacemaker neuron- and motor neuron-specific cDNAs suggests that the motor neurons are the source of the CLDH message in the CG. Perfusion of Homam-CLDH through the isolated lobster heart produced dose-dependent increases in both contraction frequency and amplitude and a dose-dependent decrease in contraction duration, with threshold concentrations for all parameters in the range 10(-11) to 10(-10) mol l(-1) or less, among the lowest for any peptide on this system. This report is the first documentation of a decapod CLDH, the first demonstration of CLDH bioactivity outside the Insecta, and the first detection of an intrinsic neuropeptide transcript in the crustacean CG.

The peptide hormone pQDLDHVFLRFamide (crustacean myosuppressin) modulates the Homarus americanus cardiac neuromuscular system at multiple sites

pQDLDHVFLRFamide is a highly conserved crustacean neuropeptide with a structure that places it within the myosuppressin subfamily of the FMRFamide-like peptides. Despite its apparent ubiquitous conservation in decapod crustaceans, the paracrine and/or endocrine roles played by pQDLDHVFLRFamide remain largely unknown. We have examined the actions of this peptide on the cardiac neuromuscular system of the American lobster Homarus americanus using four preparations: the intact animal, the heart in vitro, the isolated cardiac ganglion (CG), and a stimulated heart muscle preparation. In the intact animal, injection of myosuppressin caused a decrease in heartbeat frequency. Perfusion of the in vitro heart with pQDLDHVFLRFamide elicited a decrease in the frequency and an increase in the amplitude of heart contractions. In the isolated CG, myosuppressin induced a hyperpolarization of the resting membrane potential of cardiac motor neurons and a decrease in the cycle frequency of their bursting. In the stimulated heart muscle preparation, pQDLDHVFLRFamide increased the amplitude of the induced contractions, suggesting that myosuppressin modulates not only the CG, but also peripheral sites. For at least the in vitro heart and the isolated CG, the effects of myosuppressin were dose-dependent (10(-9) to 10(-6) mol l(-1) tested), with threshold concentrations (10(-8)-10(-7) mol l(-1)) consistent with the peptide serving as a circulating hormone. Although cycle frequency, a parameter directly determined by the CG, consistently decreased when pQDLDHVFLRFamide was applied to all preparation types, the magnitudes of this decrease differed, suggesting the possibility that, because myosuppressin modulates the CG and the periphery, it also alters peripheral feedback to the CG.

Usefulness of preoperative lymphoscintigraphy for the identification of sentinel lymph nodes in melanoma

BACKGROUND

The exact role of lymphoscintigraphy (LS) in the evaluation of sentinel lymph nodes (SLNs) in melanoma is controversial.

METHODS

We reviewed our experience with preoperative LS for the determination of the lymph node drainage pattern of clinically node negative primary melanomas, with attention to the rate of ambiguous drainage and the effect of previous wide local excision (WLE).

RESULTS

The scans of 87 patients who underwent LS at our institution for evaluation of their primary melanomas from 1995 to the present were reviewed. Fourteen of the primary tumor sites were in the head and neck region, 41 were truncal, and 32 were in the extremities. The average tumor thickness was 2.6 mm. Nine of 14 (64%) head/neck lesions and 12 of 41 (29%) truncal lesions displayed ambiguous drainage, as compared with only 2 of 32 (6%) extremity lesions (P <0.05). Forty-one of the 87 patients (47%) had undergone previous WLE of their primary lesion prior to their LS. The number of draining basins for the WLE and the non-WLE groups were not significantly different, and at least one SLN was found for all WLE cases.

CONCLUSIONS

Preoperative LS is important for the treatment planning of SLN biopsy for head/neck and truncal melanomas, but adds little additional information for extremity lesions. Lymph node drainage scans and subsequent SLN biopsies are not contraindicated in the presence of a prior WLE.

Denial of emergency department authorization of potentially high-risk patients by managed care

This study was designed to evaluate patients presenting to a large urban university emergency department (ED) who were subsequently denied authorization for reimbursed care by their managed care provider and to characterize the denial as potentially safe or unsafe based on published triage criteria. A consecutive case surveillance was performed from October 1, 1994 to September 30, 1995 at a university-based ED (30,000 visits per year) for adult patients in inner-city Chicago. Cases were comprised of adult managed care participants whose providers refused by telephone to authorize payment for ED services and who then left the ED without treatment. Chief complaints and vital signs were used to categorize patients as high-risk or nonemergent based on previously published criteria. A total of 2,965 adult managed care patients presented to the ED during the study period, representing 11.1% of the total ED census. Of these patients, 244 (8.2%) were denied authorization for payment of their care. By previously established criteria, 115 (47.1%) were identified as potentially unstable, 61 (53%) due to abnormal vital signs and 54 (47%) with other high-risk indications such as severe pain, chest pain, or abdominal pain. These potentially high-risk patients may subsequently suffer adverse outcomes. Current guidelines used for telephone triage by managed care to divert patients from our ED do not meet previously published safe triage criteria.

Renal transplant nuclear tomography using Tc-99m MAG3

In this study, the authors performed SPECT imaging on 12 renal transplant patients immediately after a routine planar study demonstrated tubular stasis. The stasis allowed the authors to obtain good quality tomograms on all of them. In five patients, the findings on the planar and SPECT studies were identical. In five patients, there was decreased upper pole activity on planar images and SPECT imaging differentiated between attenuation (4 patients) and cortical thinning (1 patient). In the remaining two patients, the SPECT images showed unanticipated information. It is not yet clear if this new information is of clinical value. It was concluded that diagnostic quality nuclear tomograms in renal transplant patients with tubular stasis can be easily and consistently obtained.

Alagille's syndrome. New manifestations

The authors present the case of an infant with Alagille's syndrome who had cholestatic jaundice. The findings on IDA scintigraphy differed in several significant respects from previously reported cases. The hepatobiliary scintigraphic manifestations of Alagille's syndrome are more varied than previously thought.

MAG3 renal transplant tomography SPECT with a non-SPECT agent

The authors encountered a renal transplant patient in whom tubular stasis permitted sufficient time to perform SPECT using Tc-99m MAG3. SPECT revealed a defect that was not apparent on the planar study. Renal biopsy showed acute vascular rejection. On a subsequent Tc-99m MAG3 SPECT study the defect had resolved.

Gastric activity on dipyridamole 201Tl myocardial perfusion imaging: a clinically useful finding

To determine the potential association of increased 201Tl uptake by the stomach with symptoms referable to gastritis, 39 consecutive patients experiencing chest pain syndromes underwent a routine dipyridamole 201Tl pharmacological stress test. With the patient in a fasting state, dipyridamole was infused intravenously (0.56 mg kg-1), shortly followed by 201Tl infusion and subsequent image acquisition for single photon emission tomography (SPET). The original 32 SPET images over 180 degrees of arc were interpreted without knowledge of clinical data, using a 4-point scoring system. Patients with active symptoms of gastro-oesophageal discomfort (n = 17) were found to have significantly greater 201Tl stomach uptake scores, compared to the little or no uptake in the 22 patients without such active symptoms (P = 0.0001). A stepwise logistic regression analysis was used to determine which factor(s) showed independent predictive value of 201Tl gastric uptake. The only two independent variables identified were the presence of active gastritis symptoms and the use of anti-gastritis medications. Elevated gastric 201Tl uptake may be a clinically useful finding indicative of gastric inflammation that may be of value in the differential diagnosis of chest and epigastric discomfort.

Technetium pertechnetate scintigraphy in an ileal duplication of the stomach and duodenum

We report a patient with ileal duplication of the stomach and duodenum that presented with gastrointestinal bleeding. The scan appearance of the duplicated stomach in both shape and temporal course of activity bore a striking resemblance to the patient's homotopic stomach.

Residual spleen found on denatured red blood cell scan following negative colloid scans

The technetium-sulfur colloid liver-spleen examination is widely used to evaluate patients with idiopathic thrombocytopenic purpura for residual splenic tissue following splenectomy. Technetium-labeled heat-damaged red blood cell imaging is another sensitive test for residual splenic tissue. We recently encountered a patient with idiopathic thrombocytopenic purpura who was initially evaluated with a technetium sulfur colloid scan which was negative. A denatured red blood cell scan was subsequently performed which revealed intense focal activity in the region of the splenic bed. Surgery confirmed this to be splenic tissue. Our results emphasize the utility of the denatured red blood cell examination in the setting of strong clinical suspicion for residual splenic tissue following a negative sulfur colloid study.

Control-related cognitions and depression among inpatient children and adolescents

In previous studies, children with numerous depressive symptoms have shown two patterns of control-related cognition: (1) low levels of perceived personal competence, and (2) "contingency uncertainty"--confusion regarding the causes of significant events. The generality of these findings was tested for more seriously disturbed children. Three child inpatient samples, from separate psychiatric hospitals, completed the Children's Depression Inventory (CDI) plus measures of control-related beliefs. In all three samples, the findings resembled those of previous studies: CDI scores were significantly related to low perceived competence and to contingency uncertainty; by contrast, CDI scores were only weakly related to perceived noncontingency. The findings suggest that depressive symptoms in children may be (1) more closely linked to "personal helplessness" than to "universal helplessness," and (2) more closely linked to uncertainty about the causes of events than to firm beliefs in noncontingency. The findings carry implications for etiology and treatment of child depression.

Extraction of a melanoma growth-stimulatory activity from culture medium conditioned by the Hs0294 human melanoma cell line

Extracts of conditioned medium (CM) from Hs0294 human malignant melanoma cells stimulate [3H]thymidine incorporation and an increase in cell number in serum-depleted Hs0294 cells. This activity is acid and heat stable, nonproteolytic, protease sensitive, contains disulfide bonds and elutes broadly from a Bio-Gel P-30 column with an approximate molecular weight range of 6,000 to 25,000. Hs0294 CM also stimulates [3H]thymidine incorporation in nonmalignant human nevus cells and normal rat kidney fibroblast cells but not in human fibroblasts. There was only limited competition with 125I-epidermal growth factor in binding assays. Hs0294 CM extracts stimulate anchorage-independent growth in normal rat kidney fibroblast cells in soft agar but not in Hs0294 cells, nevus cells, or human fibroblasts. This second activity elutes from the Bio-Gel P-30 column in two positions with apparent molecular weights of 27,000 and 11,000.

In vitro growth promotion in human malignant melanoma cells by fibroblast growth factor

Bovine pituitary fibroblast growth factor (FGF) stimulates the incorporation of [3H]thymidine into DNA in serum-depleted cultures of some but not other human melanoma cells. The melanotic malignant melanoma cell line MIRW exhibited a 40% increase in [3H]thymidine incorporation into DNA and a 48% increase in cell number in response to 3.73 x 10(-9) M FGF. This same concentration of FGF produced a 22% increase in [3H]thymidine incorporation in the melanotic melanoma cell line Hs0294. However, FGF had no effect on the amelanotic melanoma cell line Hs0675, early-passage cultures of a human amelanotic melanoma (W-1), or early-passage cultures of a congenital nevus (N-1).

Type A behavior, field dependence, and serum lipids

Given evidence that individual differences on the cognitive style dimension of field dependence/independence are significantly related to sympathetically mediated cardiovascular functioning and lipid metabolism, a correlational study was designed to examine associations between Type A behavior, field dependence, and serum lipids. It was hypothesized that field dependent Type A individuals would exhibit higher levels of total cholesterol and triglycerides than would field independent Type A individuals. Using 82 medical students as subjects, the hypothesis was supported among both males and females for total cholesterol, with a trend in the predicted direction for triglycerides. Field dependent Type A individuals of both sexes were also found to have a higher level of low-density lipoprotein to total cholesterol, when compared to their field independent Type A counterparts. The overall pattern of findings provides suggestive evidence that field dependence is an important mediating personality factor influencing levels of autonomic arousal and coronary risk among Type A individuals. Alternative explanations as to why field dependent Type A individuals may be more chronically aroused in response to environmental stimuli are discussed.

Piroxicam, a structurally novel anti-inflammatory compound. Mode of prostaglandin synthesis inhibition

Piroxicam is a potent inhibitor of prostaglandin biosynthesis. Experiments utilizing cell culture and microsomes derived from various sources have demonstrated that piroxicam is a selective inhibitor of the cyclooxygenase step of arachidonic acid metabolism. Little blocking activity is observed at the phospholipase, thromboxane or prostacyclin synthetase, and arachidonic acid lipoxygenase steps.

Abnormal radionuclide angiogram in cervical lymphadenitis: case report

We have observed increased activity over the neck on radionuclide angiograms of two patients with cervical lymphadenitis. This incidental findings should not be confused with other causes of locally increased perfusion.

Incompatibility of diphenhydramine hydrochloride (Benadryl) with meglumine iodipamide (Cholografin)

Diphenhydramine hydrochloride (Benadryl) and meglumine iodipamide (Cholografin) were mixed in varying proportions and found to consistently form a dense amorphous precipitate. This is not mentioned in the package insert of either agent. All physicians who administer these compounds should be aware of this phenomenon.

Abnormal radionuclide cerebral angiograms and scans due to seizures

The effect of recent seizures on the brain scan was determined in a retrospective study of patients who had had seizures. All patients who underwent brain scanning within eight days of seizures and who did not have a specific intracranial lesion were included. The 99mTc-pertechnetate cerebral angiogram and/or delayed scan was abnormal in 73% of 22 patients. The data suggest that if seizures occur within six days of the brain imaging, the image is likely to be abnormal.

Persistent left superior vena cava demonstrated by radionuclide angiocardiography: case report

This report presents a patient with a persistent left superior vena cava demonstrated by radionuclide angiocardiography. The appearance is characteristic.