Disparities in disease presentation in the four screenable cancers according to health insurance status

OBJECTIVES

Current guidelines support the use of screening for early detection in breast, prostate, colorectal and cervical cancer. The purpose of this study was to evaluate whether insurance status predicts for more advanced disease in these four currently screened cancers.

STUDY DESIGN

The Surveillance, Epidemiology, and End Results (SEER) database was queried for breast, prostate, colorectal and cervix in patients aged 18-64 years. The database was queried from 2007 to 2011, with 425,614 patients with known insurance status included.

METHODS

Multinomial logistic regression was used to evaluate insurance status and cancer presentation.

RESULTS

Under multivariate analysis for breast cancer, uninsured patients more often had invasive disease (odds ratio [OR]: 1.55), T- (OR: 2.00), N- (OR: 1.59) stage, and metastatic disease (OR: 3.48), and were more often high-grade (OR: 1.21). For prostate cancer, uninsured patients again presented more commonly with higher T-stage (OR: 1.45), nodal (OR: 2.90) and metastatic (OR: 4.98) disease, in addition to higher prostate-specific antigen (OR: 2.85) and Gleason score (OR: 1.65). Colorectal cancer had similar findings with uninsured individuals presenting with more invasive disease (OR: 1.78), higher T (OR: 1.86), N (OR: 1.22), and M (OR: 1.58) stage, in addition to higher carcinoembryonic antigen levels (OR: 1.66). Similar results were seen for cervical cancer with uninsured having higher T (OR: 2.03), N (OR: 1.21), and M (OR: 1.45) stage.

CONCLUSION

In the four cancers detected by screening exams, those without health insurance present with more advanced disease, with higher stage and grade, and more elevated tumour markers.

The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis

BACKGROUND

Following neoadjuvant chemotherapy (NAC), the optimal strategies for postmastectomy radiotherapy (PMRT) and regional nodal irradiation (RNI) after breast-conserving surgery (BCS) are controversial. In this analysis, we evaluate the impact of these radiotherapy (RT) approaches for women with clinically node-positive breast cancer treated with NAC in the National Cancer Database (NCDB).

PATIENTS AND METHODS

Women with cT1-3 cN1 M0 breast cancer treated with NAC were divided into four cohorts by surgery [Mastectomy (Mast) versus BCS] and post-chemotherapy pathologic nodal status (ypN0 versus ypN+). Overall survival (OS) was estimated using the Kaplan-Meier method and RT approaches were analyzed using the log-rank test, multivariate Cox models, and propensity score-matched analyses.

RESULTS

From 2003 to 2011, 15 315 cases were identified including 3040 Mast-ypN0, 7243 Mast-ypN+, 2070 BCS-ypN0, and 2962 BCS-ypN+ patients. On univariate analysis, PMRT was associated with improved OS for both Mast-ypN0 (P = 0.019) and Mast-ypN+ (P < 0.001) patients. On multivariate analyses adjusted for factors including age, comorbidity score, cT stage, in-breast pathologic complete response, axillary surgery, ypN stage, estrogen receptor status and hormone therapy, PMRT remained independently associated with improved OS among Mast-ypN0 [hazard ratio (HR) = 0.729, 95% confidence interval (CI) 0.566-0.939, P = 0.015] and Mast-ypN+ patients (HR = 0.772, 95% CI 0.689-0.866, P < 0.001). No differences in OS were observed with the addition of RNI to breast RT for BCS-ypN0 or BCS-ypN+ patients. Propensity score-matched analyses demonstrated identical patterns of significance. On subset analysis, OS was improved with PMRT in each pathologic nodal subgroup (ypN0, ypN1, and ypN2-3) (all P < 0.05).

CONCLUSIONS

In the largest reported analysis of RT for cN1 patients treated with NAC, PMRT was associated with improved OS for all pathologic nodal subgroups. No OS differences were observed with the addition of RNI to breast RT.

A Qualitative Exploration of Community-Based Organization Programs, Resources, and Training to Promote Adolescent Sexual Health

BACKGROUND

Youth development professionals (YDPs) working at community-based organizations (CBOs) can promote adolescent sexual health through programs. This study explored the programs and resources that youth access at CBOs and training YDPs receive.

METHODS

Twenty-one semi-structured interviews were conducted with YDPs. Qualitative content analyses were conducted using NVivo.

RESULTS

Most YDPs (n = 15, 71.4%) described sexuality-related programs for youth. Some YDPs provided informal information (n = 11, 52.4%) and/or referrals for youth (n = 6, 28.6%). Few YDPs (n = 8, 38.1%) were trained to address adolescent sexuality, but some (n = 10, 47.6%) sought outside resources.

CONCLUSIONS

YDPs have a unique opportunity to improve adolescent sexual health and sexuality. Five considerations for organizations that develop programs and training for CBOs are suggested.

Neuroanatomic evidence to explain why bilateral internuclear ophthalmoplegia may result from occlusion of a unilateral pontine branch artery

Microscopic study of serial sections of the pons in two autopsy cases without known neurologic disease showed that the terminal portion of paramedian tegmental pontine arteries may divide to supply the region of the medial longitudinal fasciculus bilaterally. This finding provides the basis for the occurrence of bilateral internuclear ophthalmoplegia with unilateral basilar branch artery occlusion.

Early Arrest of Mental and Motor Development Associated with Bilateral Hippocampal Anoxic Damage

Background:

Clinical-pathological study of the case of a woman with amentia from birth.

Case history:

A 45-year-old woman was institutionalized since the age of two and showed no change in 43 years. She did not stand, walk, talk, use her hands or comprehend. She was placed in a chair each day. She lacked control of bladder and bowel. She showed no mental capability.

Case pathology:

The brain weighed 1250 gm and was normally developed. There were two anoxic-ischemic regions of damage. The hippocampus showed extensive damage bilaterally and the cerebellum showed watershed infarction bilaterally.

Conclusion:

A perinatal anoxic-ischemic episode is suspected. Hippocampal damage was the only finding that might explain the failure of mental and motor development. If this hypothesis is correct, the function of the human hippocampus is broader than currently accepted.

Outcome of surgery for vascular access in patients commencing haemodialysis

OBJECTIVE

assessment of surgical vascular access procedures for haemodialysis.

DESIGN

retrospective cohort audit.

MATERIALS AND METHODS

secondary patency was calculated from surgery until access failure, death, transplant, conversion to peritoneal dialysis, or loss to follow-up. All surgical procedures including immediate failures and failures to mature fistulae were included but not radiological interventions.

RESULTS

four hundred and forty-five operations were undertaken in 197 patients over 87 months comprising 273 access creations and 172 revisions. Median follow-up was 26 months with a mortality of 9.4 deaths per 100 patient-years including eight perioperative deaths. Autogenous access was created in 147 (75%) patients with 142 based on the radial artery whilst 50 prosthetic grafts including 46 PTFE grafts and 40 forearm loops were placed. Patients receiving grafts were more likely to be older, female and die in follow-up. Grafts had higher patencies of 89, 75 and 68% at 1, 2 and 4 years, respectively compared to 69, 63 and 55% for autogenous access. This difference was significant (p=0.049) when the effects of the presence of diabetes and peripheral arterial disease were accounted for but more frequent revisions were required. The final access placed was autogenous in 110 (56%) and prosthetic in 87 (44%) patients.

CONCLUSIONS

in our surgical unit, there was high secondary patency including for prosthetic grafts, high autogenous utilisation and relatively infrequent reintervention.

Reversal of normal pressure hydrocephalus symptoms by subdural collections

BACKGROUND

The pathogenesis of symptoms in normal pressure hydrocephalus (NPH) is unclear. One theory is that in the presence of enlarged lateral ventricles, the ventricular fluid exerts increased force on the ventricular walls, the cerebrospinal fluid pressure remaining normal. This is in accordance with Pascal's principle of F = PxA. It has not been possible to obtain direct evidence for this view.

METHOD

The opportunity to gain insight into the matter arose when it was observed that two patients with symptomatic NPH were relieved of their symptoms when they developed bilateral subdural collections, one after head trauma, the other after ventriculo-peritoneal shunting for NPH.

RESULT

In each case, concomitant with the subdural collections and the reversal of symptoms, the ventricular system became smaller. In the first patient, symptoms returned when the subdural collections were resorbed. In the second patient, symptoms returned when the subdural collections became excessive.

CONCLUSION

Although documentation was less thorough than desired, it was concluded that relief of symptoms was related to the decrease in the ventricular size rather than lowering of the intraventricular pressure, thus providing evidence for operation of the principle F = PxA as the mechanism of symptoms in NPH.

If there were no free will

Electrophysiological findings in humans who are performing voluntary acts, indicate that the intention to act, follows brain activity rather than preceding it. This has implications for voluntary behavior and the doctrine of free will. This essay reviews the fields of human behavior, including medicine, in which this new thesis might have far-reaching significance.

Combined endovascular and open surgery for four-vessel cerebrovascular occlusive disease

PURPOSE

To report a case of bilateral simultaneous percutaneous transluminal angioplasty and stenting of the intracranial vertebral arteries prior to staged bilateral carotid endarterectomy.

CASE REPORT

A 68-year-old man presented with a 3-month history of recurrent, intermittent left-sided weakness and diplopia. Imaging defined bilateral 80% to 99% internal carotid artery stenoses and >90% stenoses of both distal vertebral arteries at the level of the foramen magnum. Bilateral intracranial vertebral artery stenting was performed, followed by staged carotid endarterectomies. No complications occurred, and the patient recovered uneventfully from all 3 procedures. He remains symptom- and event-free 20 months later.

CONCLUSIONS

Our initial success in this case indicates a role for percutaneous transluminal angioplasty and stenting as an alternative to open surgery for intracranial vertebral artery stenosis.

Alien hand phenomena: a review with the addition of six personal cases

This is a comprehensive literature review of the motor abnormalities that have come to be included under the designation of Alien Hand Phenomena (AHP). Some of the disorders are dyspractic in nature - intermanual conflict, mirror movements, interference etc., while others - groping, grasping with inability to release, utilization etc. are frontal lobe reflexes. AHP are mainly associated with two pathological processes: 1) Infarction or hemorrhage in the territory of the anterior cerebral arteries; and 2) Corticobasal degeneration. Included in the review is a description of AHP in six personal cases of corticobasal degeneration. The summary includes a short discussion of the possible anatomy of 'free will' based on AHP.

Prevalence and outcome of activated protein C resistance in patients after peripheral arterial bypass grafts

The association of activated protein C resistance with peripheral arterial bypass graft patency was assessed. A retrospective cohort study of consecutive first-time femoro-popliteal or femoro-distal bypasses performed in patients living within the boundaries of the Area Health Service was performed. Of 242 patients eligible for inclusion, 73 had died, nine refused to participate and 40 were lost to follow-up. Activated protein C resistance was present in nine (7.5%) of the 120 patients tested. In the study group, smoking at the time of surgery, female gender and the use of prosthetic grafts were significantly associated with graft failure on univariate Cox regression analysis, but activated protein C resistance was not. After accounting for confounders, there was a trend (P = 0.098) for activated protein C resistance to be associated with graft failure (OR 2.90, 95% CL 0.82-10.3). Patients who died or who were lost to follow-up had significantly earlier operation dates than those who remained alive or tested for activated protein C resistance. However, there was also a highly significant (P = 0.006) trend for activated protein C resistance in patients who had undergone surgery closer to the end of the study period. Six of the nine patients with activated protein C resistance underwent surgery in the last 10 months of the review period and only three activated protein C resistance patients had a graft patent for more than 8 months. The prevalence of activated protein C resistance in patients undergoing peripheral arterial bypass grafting is greater than in the general population. There was a trend for activated protein C resistance to be associated with graft failure. A significantly higher proportion of patients with activated protein C resistance was found with more recently performed surgery. The observed results could be accounted for by excess mortality in patients with activated protein C resistance. This hypothesis requires testing prospectively.

Hysteria: a delusional state

This paper explores the hypothesis that hysterical symptoms may best be regarded as the product of delusional thinking. Hysteria has generally been interpreted as a process quite distinct from other psychiatric disorders. An attempt is made to bring it within more conventional bounds.

Late-life (migrainous) scintillating zigzags without headache: one person's 27-year experience

BACKGROUND

Episodes of typical scintillating zigzags similar to the visual aura of migraine may occur without headache, especially after the age of 50. There is no record of one individual's long-term experience.

PRESENT MATERIAL

This paper is a personal account of all 41 episodes of scintillating zigzags that occurred between the ages of 59 and 85. Observations were made on several aspects of the visual event itself--evolution, pattern, scotoma, coloration, duration, lateralization, etc. The chronological distribution of spells, circumstances of occurrence, time of day, the season, etc were noted. The study was observational in nature. Documentation of this experience could be of value clinically and scientifically.

RESULTS

The spells occurred irregularly, unrelated to season, time of day, activity at onset, diet, and temperamental state. The characteristic appearance was a flickering zigzag line that began centrally and migrated to the periphery. The display, which was stereotyped, was achromatic. The average duration was 15 minutes. Both visual fields were equally involved, never at the same time. The details of the scintillating zigzag line are actually complex and an account of the observations of others and of the author is included here.

Phantom erection after amputation of penis. Case description and review of the relevant literature on phantoms

BACKGROUND

Perception of a phantom limb is frequent after an amputation of an upper or lower extremity. Phantom penis is reported infrequently.

METHOD

Case description and literature review.

RESULT

The phenomenon of phantom penis followed total penectomy. Several aspects were unusual, particularly the existence with phantom only in the erect state, and associated recrudescence of a preoperative painful ulcer. General features of limb phantoms after amputation are reviewed including a résumé of recent studies of cortical reorganization. The phantom process is analyzed looking for clues to the nature of the underlying neural organization. The puzzle of phantom pain is briefly touched on.

CONCLUSION

The development of the phantom is attributed to activity in the deafferented parietal sensory cortex.

Limitations of intra-arterial thrombolysis

The purpose of this study was to assess the efficacy, costs and complications of acutely ischaemic limbs initially treated with urokinase-induced thrombolysis, and to compare the subsequent patencies of occluded native arteries, vein grafts and prosthetic grafts. Data from 45 consecutive episodes of thrombolysis in 37 patients (37 limbs) were reviewed retrospectively. An initial bolus dose of urokinase was used in all limbs, with pulse-spray in nine 30 limbs received additional infusions of urokinase including six who received initial treatment with pulse-spray. Percutaneous transluminal angioplasty or surgical intervention was undertaken at any stage when considered appropriate. There were 14 occluded native arteries (31%), 12 vein grafts (27%), 16 prosthetic polytetrafluoroethylene grafts (35%), and three composite grafts (7%). Thrombolysis was initially successful in 33 episodes (73%). Of these, no additional procedure was required in three, percutaneous transluminal angioplasty in 23, other surgery in 11 and bypass surgery in seven with more than one additional procedure being undertaken in 10. Of the 12 episodes with initial failure, major surgery was performed in eight and no procedure in four. Lysis-related complications occurred in 19 treatment episodes (42%) with major bleeding in seven (16%), minor bleeding in 10 (22%), distal embolization in 11 (24%) and arterial dissection in two (4%). One amputation (2%) and one death (2%), both directly attributable to thrombolysis, occurred within 1 month of treatment. Complications occurred in 10 of 19 (53%) prosthetic or composite grafts, five of 12 (42%) vein grafts, and four of 14 (29%) native artery occlusions (P = 0.38). The median follow-up of patients remaining alive was 24 months. The overall mean (s.e.m.)patency rate at 6 months of lysed vessels or replacement bypass grafts was 44% (8%). Presentation with a native artery and or graft occlusion was associated with superior long-term patency (any subsequent conduit) compared with presentation with an occluded prosthetic graft (log rank chi2[1] = 7.00, P = 0.008) and reflects the inferior run-off of the latter patients. The average cost of thrombolysis in radiological procedures and disposables alone excluding intensive care and complications was AUD$2440.

Difficulty recalling people's names

BACKGROUND

Difficulty recalling people's names is common in the adult population, especially in the elderly. The subject is scarcely mentioned in the literature. An 82-year-old patient gave the history that for 33 years he had made prospective observations on his own difficulty with people's names.

METHOD

Documentation and analysis of the patient's personal observations in which his ability to recall the names of friends, acquaintances, colleagues, public figures, movie stars and athletes is compared with that of his spouse. A suitable test-battery for the names of famous North American persons was not available.

RESULTS

The patient's capability in recalling people's names was clearly inferior to that of his spouse. The patient's intellect was otherwise intact and the impairment seemed to be isolated to the category of proper-naming. Doubts were raised about the patient's own conclusion that the deficit was progressive.

CONCLUSIONS

A parallel may be drawn between benign difficulty recalling people's names and the acquired categorical deficit for proper naming reported in the literature in recent years. Based on Damasio's concept of anatomically compartmentalized sensory subsystems, it is hypothesized that our patient's symptom represents an innate limited capacity for proper naming.

Hypomanic symptoms caused by herpes simplex encephalitis

This is a case report of a brief episode of rather typical hypomanic symptoms in the acute phase of presumed herpes simplex encephalitis in a young woman. I infer that the hypomanic episode was triggered from the anterior inferomedial temporal lobe or limbic system, the presumed cerebral substrate of the emotions in general, and review the literature relating to the occurrence of hypomania associated with structural disease of the nervous system.

Variation in measurement of ankle-brachial pressure index in routine clinical practice

PURPOSE

The purpose of this study was to determine the variation in ankle-brachial pressure index (ABPI) measurements in routine clinical practice.

METHODS

Analysis was done of preoperative and postoperative ABPIs in 130 limbs contralateral to those undergoing femoral bypass grafting in 123 patients over a 15-month period.

RESULTS

The mean initial ABPI was 0.72 (range 0.22 to 1.10). The range of observed differences between the preoperative and postoperative ABPIs was from -0.33 to +0.25. The mean (+/-SD) difference between the first and second ABPIs was 0.00 (+/-0.11). The 95% confidence limits of the difference were -0.21 to 0.21. There was no trend for the size or direction of the difference in ABPI to vary according to the mean ABPI, brachial blood pressure, or time between tests.

CONCLUSIONS

ABPI is routinely used as an objective measure of peripheral vascular disease. The variation observed in this study is comparable with values obtained in reproducibility studies and is greater than that accepted in clinical practice. The difference between an ABPI measurement and the actual ABPI and the difference between repeat single measurements are not the same and should be distinguished. Vascular laboratories should determine the accuracy of ABPI measurement on a local basis to guarantee and maintain quality assurance.

The incidence of deep venous thrombosis after laparoscopic cholecystectomy

OBJECTIVE

To determine the incidence of deep venous thrombosis (DVT) after laparoscopic cholecystectomy.

DESIGN

Prospective cross-sectional analysis, with a one-month follow-up, conducted in 1994.

SETTING

University teaching hospital.

SUBJECTS

20 patients undergoing elective or urgent laparoscopic cholecystectomy, consecutively recruited.

INTERVENTIONS

Patients received thromboprophylaxis according to the normal practice of the attending surgeon and underwent laparoscopic cholecystectomy. A venous duplex scan was performed before the operation and on Day 1, 7 and 30 after the operation.

MAIN OUTCOME MEASURE

The presence of postoperative DVT.

RESULTS

All patients were given graduated compression stockings to wear and 16 received electrical stimulation of the calf during the operation. Only 16 patients received pharmacological thromboprophylaxis before the operation, but all patients received this after the operation. The median duration of pneumoperitoneum was 80 minutes (40-160 minutes). Eleven of 19 patients completing all the required scans developed venous thrombosis (incidence, 55%); in three the thromboses involved major axial veins. In one patient the Day 7 and Day 30 scans were not performed, but the Day 1 scan was negative. Seven of the 11 thromboses were detected on the Day 1 scan. None of the DVTs were suspected clinically.

CONCLUSIONS

This extremely high incidence of venous thrombosis correlates with the haemodynamic changes which occur in the venous system during pneumoperitoneum. Laparoscopic cholecystectomy should not be considered a procedure with a low risk of DVT, and further studies are needed to determine optimal DVT prophylaxis for laparoscopic surgery.

No additional benefit from laser in balloon angioplasty of the superficial femoral artery

OBJECTIVES

To evaluate the efficacy of the addition of plaque ablation by hot-tip laser to balloon angioplasty.

DESIGN

Prospective randomised clinical trial.

MATERIALS AND METHODS

Patients with either occlusion orf > 50% diameter stenosis less than 3 cm in length in the superficial femoral artery, and with two or three calf vessel run-off were eligible and randomised to receive either balloon angioplasty alone or with laser assistance. Treatment failure in follow-up was defined as reocclusion or recurrence of greater that 50% stenosis at the site of angioplasty.

RESULTS

Ninety limbs (82 patients) were entered into the study. Forty-four patients had mild claudication, 32 more severe symptoms and 6 rest pain or ulceration. More patients with diabetes (5 of 5, p = 0.04, Fisher's exact test) and occlusions (16 of 22, p < 0.05, chi(2)) were randomised to the laser group. Initial technical success was obtained in all lesions. The median duration of follow-up was 1 year. Failure occurred in 40 limbs during follow-up. Three segments, all with initial occlusions and undergoing laser angioplasty re-occluded within 2 days, one requiring immediate thrombectomy. Another 20 limbs underwent further intervention. Overall success (+/- S.D.) (Kaplan-Meier) at 1 year was 67% (+/- 5%) and at 2 years 43% (+/- 7%). Only increased age, initial occlusion, female sex, and not smoking were significantly (p < 0.05, Cox's proportional hazards) associated with failure; on multivariate analysis, age and occlusion were the best independent predictors. There was no significant difference (p > 0.05) in outcome between limbs undergoing laser assisted balloon angioplasty and balloon alone either overall of within the stenosis or occlusion subgroups.

CONCLUSIONS

This study found no significant benefit was gained by the addition of laser to balloon angioplasty and that the long term success was modest for lesions considered to be suitable for angioplasty.

Ruptured abdominal aortic aneurysms: who should be offered surgery?

PURPOSE

Operation for ruptured abdominal aortic aneurysm is generally still associated with a high mortality rate. A review of our experience over a 9-year period was undertaken to identify factors present on admission associated with 30-day operative mortality.

METHODS

A retrospective analysis of 154 patients with ruptured abdominal aortic aneurysm submitted for operation in a university teaching hospital between January 1985 and December 1993 was undertaken.

RESULTS

The hospital mortality rate was 39%. Logistic regression identified a set of five independent preoperative factors associated with mortality: age (> 76 years), creatinine level (> 0.19 mmol/L), loss of consciousness after arrival, Hb (< 9 g%), and electrocardiographic ischemia. In the 52 patients with a single risk factor present, the mortality rate was 37%, with two factors (32 patients) it was 72%, with three or more factors (8 patients), it was 100%, and no patient had all five risk factors. A 16% mortality rate was found in the 62 patients with no risk factors.

CONCLUSION

These risk factors can be easily determined on admission and may be used to help improve patient selection for surgical intervention. The current operative mortality rate for ruptured abdominal aortic aneurysm remains high, and in some cases health care resources are used in a nonproductive fashion. Restricted patient selection and allocation of scarce resources will bring advantages to both the patient and the community.

The economic cost of elective carotid endarterectomy

Cost awareness and accountability for the use of health care resources have become major issues for clinicians. In order to identify the economic costs associated with carotid endarterectomy (CEA), a retrospective review of 50 elective CEA between May 1993 and April 1994 was undertaken. Despite our belief [based on the Australian National Diagnostic Related Groupings (ANDRG)], that our resource utilization had been refined to produce a median length of stay significantly below the New South Wales (NSW) State average, this study has identified several areas of non-productive expenditure. The mean cost of CEA per patient was $7053. This figure includes non-productive expenditure of $793 per patient in the pre-operative period and $395 per patient in the postoperative period. If these costs, which did not contribute to patient care, were removed the mean cost of CEA would be $5865. The major causes of non-productive resource utilization included prolonged pre-operative stay, duplicated or omitted investigations, as well as the use of the Intensive Care Unit for patient monitoring in the postoperative period.

Brain herniation: a revision of classical concepts

This paper is an update on evolving ideas about brain herniations. Following observations on cerebellar pressure coning that raised doubts about its reputed lethal connotations, herniation at the tentorium was re-examined for its role in critically damaging the brain stem. Combining clinical, pathologic, computed tomography and magnetic resonance imaging data, it is concluded that temporal lobe herniation is not the means by which the midbrain sustains irreversible damage in acute cases, but rather lateral displacement of the brain at the tentorium is the prime mover and herniation a harmless accompaniment. Transtentorial herniation has been investigated with computed tomography using the three calcification relationship and descent through the tentorial opening could not be documented. Bilateral brain stem compression in acute bilateral cases must be distinguished from herniation. Upward cerebellar herniation is only the sign of an overfull posterior fossa. Subfalcial herniation is tolerated unless lateral displacement is excessive.

Hunger and the temporal lobe

A boy experienced two episodes of intracerebral hemorrhage in the region of the right anterior temporal lobe. On both occasions, the bleeding was ushered in by an exclamation of intense hunger. The patient provides further evidence for the temporal lobe localization of the sensation of hunger. We describe a model of the neural system subserving feeding that incorporates the cortical locus of hunger.

Alterations in brainstem and cortical organization of rats sustaining prenatal vibrissa follicle lesions

Vibrissa follicles were cauterized in late fetal or newborn rats to determine whether the relationships between brainstem and cortical changes observed after neonatal peripheral damage would also be obtained when vibrissa follicles were cauterized earlier in development. Vibrissa follicles were cauterized between embryonic day 15 (E-15) and the day of birth (P-0). The vibrissa-related representation in the brainstem was examined with cytochrome oxidase histochemistry, and that in the cortex was evaluated with either serotonin immunocytochemistry or anterograde labeling with Di-I when animals reached 6-8 days of age. There was a significant relationship between the ages at which lesions were carried out and the extent to which the representations of undamaged vibrissa follicles were altered in the brainstem and cortex. Peripheral lesions carried out between E-15 and E-18 resulted in significant increases in the cross-sectional areas of the patches corresponding to the undamaged vibrissa follicles in both the brainstem and cortex. Lesions at later ages resulted in significant increases only in the cortex. In some animals that sustained peripheral damage on E-20 and all of those that received lesions on P-0, there were aggregates of labeling in cortex that had no counterpart in the brainstem. Prenatal, but not postnatal, vibrissa follicle damage also reduced the overall dimensions of the cortical region devoted to the representation of these receptor organelles. Finally, there was a strong negative correlation between the magnitude of peripheral lesions (i.e., the number of vibrissa follicles ablated) and the extent of the reorganization in the brainstem and cortex.

Bilateral decompressive craniectomy for worsening coma in acute subarachnoid hemorrhage. Observations in support of the procedure

Bilateral craniectomy in a woman comatose and decerebrate after a subarachnoid hemorrhage, resulted in normal mentation in 3 days. The dramatic recovery is unmatched in our experience. The rationale rested on clinicopathologic studies showing that in such cases brain swelling was the cause of death, the brain being otherwise intact. Emergency surgery to relieve the tamponade seemed reasonable. The question is whether the procedure has a role in those patients who fail to respond to current therapeutic measures. The arguments in favor, presented herein, are illustrated by three pathologic studies selected from our longtime experience.

Concerning mind

The nature of the human mind is addressed from a neurological viewpoint. First from reported observations on subjects born blind with congenital cataract, who acquired vision after surgery, the concept of the primacy of somatosensation is developed. Therefrom some principles of the organization of higher sensory functions in the dominant parietal, occipital and temporal lobes are deduced. Sentience is traced to somatosensation. Some characteristics of the mind and of thinking are described. The non-existence of the unconscious is inferred. The question of free will is approached. Using neurological experience it is demonstrated that a good case for operation of a free will is difficult to establish. Positing the absence of a free will may be beneficial in the analysis and management of behavior. Finally the opportunity to study the nature and mechanism of the emotions in clinical neurology is outlined.

Complex hallucinatory state occurring postsurgery: a case report

A patient had unpleasant complex hallucinatory activity beginning 36 h postsurgery that lasted 48 h. Closing the eyes precipitated a flood of visual imagery that immediately roused the patient and prevented sleep. The imagery was predominantly visual, but there were auditory and narrative components suggesting a relationship to dreaming. An electroencephalogram showed that the hallucinatory activity was related to a recurring sequence of drowsiness, a few vertex slow waves, a myoclonic jerk, and arousal. Morphine was a prime suspect as the causative agent. The basic disturbance probably lay in the sleep-dream system. The syndrome has not been fully defined in the past.

Measurement of the ultrasonic intima-media complex thickness in normal subjects

PURPOSE

The evolution of atherosclerosis can be studied before development of symptomatic plaque by evaluating morphologic changes of the intima-media (I-M) complex, seen on high-resolution ultrasonography of the arterial wall. These qualitative changes require large alterations in vessel wall appearance to recognize progression of atherosclerosis. It has been suggested that measurement of the thickness of the I-M complex may be a quantitative and more sensitive method of assessing these early atherosclerotic changes.

METHODS

High-resolution ultrasonography has been used to measure the thickness of the I-M complex in 140 symptom-free subjects.

RESULTS

The mean thickness of the I-M complex of the common carotid arteries was linearly related to the age (r = 0.77; p < 0.001), pack-years of smoking (r = 0.39; p < 0.05), the systolic blood pressure (r = 0.51, p < 0.01), and to the arterial ultrasound score (r = 0.85). The arterial ultrasound score has previously been shown to correlate with the presence of asymptomatic myocardial ischemia and with the development of cardiovascular symptoms. The mean thickness of the I-M complex in subjects without plaque (in the common carotid or common femoral artery bifurcations) was significantly thinner than in subjects with plaque (p < 0.001).

CONCLUSION

The thickness of the I-M complex of the common carotid arteries is a measure of the risk for the development of cardiovascular symptoms in symptom-free individuals.

The visual variant of Alzheimer's disease: a clinicopathologic case study

A 59-year-old man developed problems with reading and driving. When first examined, he had great difficulty locating and identifying items by sight. Visual acuity was normal, but contrast sensitivity for low spatial frequencies was severely impaired. The peripheral visual fields were moderately constricted with depressed flicker fusion frequencies, more on the right. Color identification was preserved. The difficulties in identifying and locating objects by sight were aggravated by increasing the complexity and multiplicity of the items in the field of vision and by changing the ambient illumination. Intellect and memory were relatively intact, except for difficulty with calculations. Over a 12-year course the visual defects steadily worsened, and eventually memory and language skills failed. Social manners, perseverance, and affect remained normal. Postmortem examination showed cortical atrophy, predominantly posterior, with abundant neurofibrillary tangles and senile plaques. The density of the tangles was correlated with the severity of the atrophy, being highest in the occipitoparietal areas and lowest in the frontal lobes. Alzheimer's disease can preferentially affect the posterior cerebral hemispheres and cause a dementia presenting with, and dominated by, visual disturbances.

Information content of dentists' Yellow Pages advertising

Content analysis was performed on 1,007 Yellow Pages dental display ads to investigate whether such advertisements include the information important to consumers. The authors found a significant information gap between what consumers considered important when selecting a dentist and the information provided in the advertisements. The research was supported in part by a grant to Caroline Fisher from the American Marketing Association.

Amnestic syndrome associated with propranolol toxicity: a case report

An elderly woman developed an Alzheimer-like subacute dementia as a result of propranolol toxicity. Analysis of the manifestations showed that severe impairment of memory accounted for virtually all of the abnormalities. There is evidence that cerebral reactions to drug toxicity can exhibit patterns that suggest highly selective involvement of functional subdivisions of the brain.

The combination of liquid crystal thermography and duplex scanning in the diagnosis of deep vein thrombosis

One hundred patients with clinically suspected deep vein thrombosis (DVT) were studied by liquid crystal thermography (LCT), duplex scanning and venography. Liquid crystal thermography was found to have a negative predictive value of 97% if performed within 1 week of the onset of symptoms. Duplex scanning had a sensitivity of 93% and specificity of 91% for all thrombi (proximal and calf). On the basis of these results a plan of investigation has been formulated that would avoid duplex scanning and venography in 39 of the 100 patients. Duplex scanning alone would be appropriate in 56 of the remaining 61 patients. Only six patients would be unsuitable for duplex scanning because of a very tense tender leg and require venography. The plan would miss one calf thrombus and result in treating three patients unnecessarily. This policy would be not only effective but also cost-effective.

Concerning the mechanism of recovery in stroke hemiplegia

Two patients with pure motor hemiplegia were regaining strength in the affected limbs when a pure motor stroke developed on the opposite side. At the same time as the new hemiplegia appeared, the recovering side became re-paralyzed, suggesting that activity in the contralateral corticospinal tract had participated in the recovery process. Pathological studies were confirmatory. The literature pertaining to contralateral motor compensation is reviewed.