Extracardiac 18F-florbetapir imaging in patients with systemic amyloidosis: more than hearts and minds

Purpose

¹⁸F-Florbetapir has been reported to show cardiac uptake in patients with systemic light-chain amyloidosis (AL). This study systematically assessed uptake of ¹⁸F-florbetapir in patients with proven systemic amyloidosis at sites outside the heart.

Methods

Seventeen patients with proven cardiac amyloidosis underwent ¹⁸F-florbetapir PET/CT imaging, 15 with AL and 2 with transthyretin amyloidosis (ATTR). Three patients had repeat scans. All patients had protocolized assessment at the UK National Amyloidosis Centre including imaging with ¹²³I-serum amyloid P component (SAP). ¹⁸F-Florbetapir images were assessed for areas of increased tracer accumulation and time–uptake curves in terms of standardized uptake values (SUV_mean) were produced.

Results

All 17 patients showed ¹⁸F-florbetapir uptake at one or more extracardiac sites. Uptake was seen in the spleen in 6 patients (35%; 6 of 9, 67%, with splenic involvement on ¹²³I-SAP scintigraphy), in the fat in 11 (65%), in the tongue in 8 (47%), in the parotids in 8 (47%), in the masticatory muscles in 7 (41%), in the lungs in 3 (18%), and in the kidney in 2 (12%) on the late half-body images. The ¹⁸F-florbetapir spleen retention index (SRI) was calculated. SRI >0.045 had 100% sensitivity/sensitivity (in relation to ¹²³I-SAP splenic uptake, the current standard) in detecting splenic amyloid on dynamic imaging and a sensitivity of 66.7% and a specificity of 100% on the late half-body images. Intense lung uptake was seen in three patients, one of whom had lung interstitial infiltration suggestive of amyloid deposition on previous high-resolution CT. Repeat imaging showed a stable appearance in all three patients suggesting no early impact of treatment response.

Conclusion

¹⁸F-Florbetapir PET/CT is a promising tool for the detection of extracardiac sites of amyloid deposition. The combination of uptake in the heart and uptake in the spleen on ¹⁸F-florbetapir PET/CT, a hallmark of AL, suggests that this tracer holds promise as a screening tool for AL.

Electronic supplementary material

The online version of this article (10.1007/s00259-018-3995-2) contains supplementary material, which is available to authorized users.

Pulmonary vascular morphology as an imaging biomarker in chronic thromboembolic pulmonary hypertension

Patients with chronic thromboembolic pulmonary hypertension (CTEPH) have morphologic changes to the pulmonary vasculature. These include pruning of the distal vessels, dilation of the proximal vessels, and increased vascular tortuosity. Advances in image processing and computer vision enable objective detection and quantification of these processes in clinically acquired computed tomographic (CT) scans. Three-dimensional reconstructions of the pulmonary vasculature were created from the CT angiograms of 18 patients with CTEPH diagnosed using imaging and hemodynamics as well as 15 control patients referred to our Dyspnea Clinic and found to have no evidence of pulmonary vascular disease. Compared to controls, CTEPH patients exhibited greater pruning of the distal vasculature (median density of small-vessel volume: 2.7 [interquartile range (IQR): 2.5-3.0] vs. 3.2 [3.0-3.8]; P = 0.008), greater dilation of proximal arteries (median fraction of blood in large arteries: 0.35 [IQR: 0.30-0.41] vs. 0.23 [0.21-0.31]; P = 0.0005), and increased tortuosity in the pulmonary arterial tree (median: 4.92% [IQR: 4.85%-5.21%] vs. 4.63% [4.39%-4.92%]; P = 0.004). CTEPH was not associated with dilation of proximal veins or increased tortuosity in the venous system. Distal pruning of the vasculature was correlated with the cardiac index (R = 0.51, P = 0.04). Quantitative models derived from CT scans can be used to measure changes in vascular morphology previously described subjectively in CTEPH. These measurements are also correlated with invasive metrics of pulmonary hemodynamics, suggesting that they may be used to assess disease severity. Further work in a larger cohort may enable the use of such measures as a biomarker for diagnostic, phenotyping, and prognostic purposes.

T-lymphocyte populations following a period of high volume training in female soccer players

PURPOSE

To investigate the T-lymphocyte response to a period of increased training volume in trained females compared to habitual activity in female controls.

METHODS

Thirteen trained female (19.8 ± 1.9 yrs) soccer players were monitored during a two-week long high volume training period (increased by 39%) and thirteen female untrained (20.5 ± 2.2 yrs) controls were monitored during two-weeks of habitual activity. Blood lymphocytes, collected at rest, were isolated before and after the two-week period. Isolated lymphocytes were assessed for the cell surface expression of the co-receptor CD28, a marker of T-lymphocyte naivety, and CD57 a marker used to identify highly-differentiated T-lymphocytes. Co-expression of these markers was identified on helper CD4(+) and cytotoxic CD8(+) T-lymphocytes. In addition a further population of γδ(+) T-lymphocytes were identified. Plasma was used to determine Cytomegalovirus (CMV) serostatus.

RESULTS

No difference was observed in the T-lymphocyte populations following the two-week period of increased volume training. At baseline the number of total CD3(+), cytotoxic CD8(+), naïve (CD8(+) CD28(+) CD57(-)), intermediate (CD8(+) CD28(+) CD57(+)) T-lymphocytes and the number and proportion of γδ(+) T-lymphocytes were greater in the trained compared to the untrained females (p<0.05). The proportion of CD4(+)T-lymphocytes was greater in the untrained compared to the trained (p<0.05), in turn the CD4(+):CD8(+) ratio was also greater in the untrained females (p<0.05). Inclusion of percentage body fat as a covariate removed the main effect of training status in all T-lymphocyte sub-populations, with the exception of the γδ(+) T-lymphocyte population. 8% of the untrained group was defined as positive for CMV whereas 23% of the trained group was positive for CMV. However, CMV was not a significant covariate in the analysis of T-lymphocyte proportions.

CONCLUSION

The period of high volume training had no effect on T-lymphocyte populations in trained females. However, baseline training status differences were evident between groups. This indicates that long-term exercise training, as opposed to short-term changes in exercise volume, appears to elicit discernible changes in the composition of the blood T-lymphocyte pool.

EMPHYSEMA QUANTIFICATION IN A MULTI-SCANNER HRCT COHORT USING LOCAL INTENSITY DISTRIBUTIONS

This article investigates the suitability of local intensity distributions to analyze six emphysema classes in 342 CT scans obtained from 16 sites hosting scanners by 3 vendors and a total of 9 specific models in subjects with Chronic Obstructive Pulmonary Disease (COPD). We propose using kernel density estimation to deal with the inherent sparsity of local intensity histograms obtained from scarcely populated regions of interest. We validate our approach by leave-one-subject-out classification experiments and full-lung analyses. We compare our results with recently published LBP texture-based methodology. We demonstrate the efficacy of using intensity information alone in multi-scanner cohorts, which is a simpler, more intuitive approach.

A study of the headgroup motion of sphingomyelin using 31P NMR and an analytically soluble model

A 31P NMR investigation has been carried out of the headgroup dynamics of sphingomyelin molecules in bilayers for the L alpha and L beta' phases. The resulting line shapes have been analysed in terms of a reduced-parameter model, using van Faassen's method for obtaining an analytic solution to first-order stochastic differential equations to simulate the line shapes of oriented and non-oriented samples. Our treatment results in good fits to measured data but using fewer parameters than traditional methods. Angles and correlation times (tau parallel and tau perpendicular) describing the geometry and dynamics of the headgroup are obtained by optimising the agreement between simulated and experimental data. The results are contrasted with those obtained for the lecithins DMPC and DPPC using a similar analysis. Not only are tau parallel and tau perpendicular now equal in value for the L alpha phase, but this value is also found to be nearly four times larger than the longest correlation time for the lecithins. We interpret this as evidence of inter- and intramolecular hydrogen bonding in the L(alpha) phase of sphingomyelin. In the L beta' phase of sphingomyelin, however, although tau(parallel) and tau(perpendicular) remain equal their value is now 32% smaller than that of the lecithins in the same phase. This indicates less difference between the fluidities in the headgroup region of the two phases of sphingomyelin as compared to that of the lecithins. Another significant difference between the L beta' phases is that the tilt angle for sphingomyelin is found to be nearly twice as large as for the lecithins. We argue that these combined observations point to the existence of hydrogen bonding in this phase also. Again in contrast to our previous work on lecithins, our results provide evidence of a negative diamagnetic anisotropy in sphingomyelin molecules, even in the L beta' phase. This is provided for in our model by the assumption that our unoriented samples consist of prolate ellipsoidal liposomes whose major axes are oriented parallel to the static magnetic field. The apparently different diamagnetic behaviour of sphingomyelin in the present work is due to the higher static field used rather than any intrinsic difference in this respect between sphingomyelin and the lecithins DMPC and DPPC.

The natural history of trunk list, its associated disability and the influence of McKenzie management

Lumbosacral list is a clinical sign that is frequently associated with low back pain and intervertebral disc lesions. This study examines the influence of McKenzie management on the natural history of trunk list. Patients with trunk list and low back pain were randomised into two groups: a control group receiving non-specific back massage and general back care advice, and a group treated according to the McKenzie protocol. Trunk list was measured over a period of 90 days and patients completed Oswestry Disability Questionnaires. There was a significantly greater resolution of list after 90 days in the group receiving McKenzie treatment compared to the control group. There was poor correlation between list magnitude and Oswestry scores. These data support previous observations that trunk list is not necessarily related to the degree of physical disability. The McKenzie method of assessment and treatment may assist in the resolution of trunk list, but it was ineffective in improving clinical condition.

Steroid receptors in surgical pathology. With special reference to small mammographically detected breast lesions

The cellular receptors for estrogen, progesterone, and other steroid hormones appear in the cytosol fraction of homogenated specimens of hormonal target tissues. These receptors have traditionally been detected and quantitated by biochemical techniques that involve binding tritium-labelled marker steroids to the receptor proteins. An important recent development has been the creation of various monoclonal antibody reagents that specifically recognize antigenic determinants on receptor molecules.

A comparison of methods for measuring trunk list. A simple plumbline is the best

STUDY DESIGN

Trunk list was measured using three different techniques to compare accuracy, precision, and ease of use.

OBJECTIVE

To obtain a reproducible technique for further studies of the nature, cause, and clinical relevance of trunk list.

SUMMARY OF BACKGROUND DATA

Gravity-induced trunk list is a clinical sign that is frequently observed in patients with low back pain and has been associated with intervertebral disc lesions.

METHODS

Patients with trunk list participated in a comparison of three techniques to determine list magnitude and direction. Paired measurements of trunk list were obtained from each patient using three techniques: a plumbline, a projected shadow, and the 3SPACE Isotrak (McDonnell Douglas Electronics Company, Colchester, VT). In addition, intra- and interobserver reliability of list measurement was assessed by comparison of paired measurements by each of two observers.

RESULTS

List measurements assessed by the plumbline and the projected shadow techniques were not significantly different, but the Isotrak produced data that differed significantly (P < 0.05) from both of these techniques. Comparison of intra- and interobserver repeatability of list measurement using the plumbline technique indicated no significant difference between repeated measures by each observer or between two observers.

CONCLUSIONS

A plumbline is the most useful instrument for measuring static trunk list, but its limitations and the need for standardization of measurement technique must be recognized.

Placental transport and fetal utilization of leucine in a model of fetal growth retardation

Placental transport and fetal utilization of leucine were studied at 130 days of gestation in six control ewes and in seven ewes in which intrauterine growth retardation (IUGR) had been induced by exposure to heat stress. Leucine fluxes were measured during simultaneous intravenous infusion of L-[1-13C]leucine into the mother and L-[1-14C] leucine into the fetus. In the IUGR group, the following leucine fluxes, expressed as micromol/min/kg fetus, were reduced compared with control: net uterine uptake (3.44 vs. 8.56, P<0.01), uteroplacental utilization (0.0 vs. 4.7, P<0.01), fetal disposal rate (6.4 vs. 8.9, P<0.001), flux from placenta to fetus (5.0 vs. 7.1, P<0.01), direct transport from mother to fetus (1.6 vs. 3.4, P<0.01), flux from fetus to placenta (1.5 vs. 3.2, P<0.001), and oxidation of fetal leucine by fetus plus placenta (2.1 vs. 3.2, P<0.02). Uterine uptake, uteroplacental utilization, and direct transport were also significantly reduced per gram placenta. We conclude that maternal leucine flux into the IUGR placenta is markedly reduced. Most of the reduced flux is routed into fetal metabolism via a decrease in placental leucine utilization and a decrease in the leucine flux from fetus to placenta.

Problems with tracheoesophageal fistula voice restoration in totally laryngectomized patients. A review of 95 cases

OBJECTIVES

Tracheoesophageal fistula (TEF) construction, performed during or after total laryngectomy, is used for voice and speech restoration but has been associated with mild to severe complications. Our goal was to study the successes and complications in the application of this technique to restore voice function after laryngectomy in 95 consecutive patients.

RESEARCH DESIGN

Retrospective cohort study with a mean follow-up time of 3.5 years.

SETTING

Five medical facilities in northern California: the Veterans Affairs Medical Centers in San Francisco and Martinez, the Kaiser Permanente Medical Center in Oakland, and private practice offices in San Francisco and Pinole.

PATIENTS

Ninety-five patients (90 men and five women) who had undergone total laryngectomy with subsequent or primary TEF construction. Patients' ages ranged from 35 to 80 years.

INTERVENTIONS

Three- or two-layer closure was used, depending on whether TEF construction was done as a secondary or a primary procedure. Most patients underwent radiation therapy, and most used surface or intraoral electrolarynx devices before TEF construction. Insufflation tests were performed by clinicians, or self-insufflation tests were performed by the patient. Patients' voices were recorded and analyzed. In many cases, respiratory and pulmonary function studies were performed before and after total laryngectomy or TEF. Blom-Singer and Groningen voice prostheses were used.

MAIN OUTCOME MEASURES

Voice restoration was considered successful when the patient was able to communicate effectively via the TEF.

RESULTS

Approximately 92% of patients who underwent TEF construction and had voice prostheses placed were considered to be successfully rehabilitated. Complications ranged from mild to severe and included problems with predictive values obtained during insufflation, fistula retention, TEF angulation shifts, fungal colonization of the prosthesis, valve retention problems, difficulty with digital occlusion, pressure necrosis, postradiation necrosis, dysphagia, phonatory gagging, emesis, gastric distention, pouching, stenosis, infection, hypertrophy, shunt insufficiency, persistent spasm, myotomy, inadvertent fistula closure, and aspiration of the prosthesis.

CONCLUSIONS

Acoustic measures indicate that speech produced with the TEF compares better with normal laryngeal speech than does esophageal or electronic speech. Thus, TEF should remain the preferred procedure to rehabilitate patients undergoing total laryngectomy.

Ventricular dysphonia: a profile of 40 cases

Ventricular dysphonia is a poorly understood disorder involving ventricular fold participation during phonation. A population of ventricular dysphonia patients was evaluated using phonatory function studies such as laryngovideostroboscopy, advanced acoustic analysis, and electroglottography to identify shared epidemiologic characteristics and to discuss possible neuromuscular mechanisms and causes. Forty patients with ventricular dysphonia were studied and epidemiologic, acoustic, and histologic data were analyzed. In almost all cases, the authors found abnormalities affecting the glottis caused by a related medical condition. The abnormalities included true vocal cord (TVC) aperiodicity in 100% of the patients, TVC asymmetry in 65%, a laryngeal mass or foreign body (usually Teflon) in 35%, TVC erythema or edema in 32.5%, and TVC bowing in 22.5%. Ventricular dysphonia seems to be primarily a compensatory mechanism for glottic dysfunction. Therapy is based on identifying and correcting the underlying abnormalities. Laryngovideostroboscopy is a particularly important tool in examining chronic dysphonia.

Fine-needle aspiration in the diagnosis of salivary gland disorders in the community hospital setting

From 1983 to 1988, 47 patients with salivary gland disorders were assessed with fine-needle aspiration (FNA) before surgery. The preoperative fine-needle diagnoses were then compared with the postoperative pathologic findings. In the same period, 63 patients from two other community hospitals who had been evaluated preoperatively with FNA were studied retrospectively. The overall sensitivity of FNA for salivary neoplasms was 80.6%. Fine-needle aspiration was more sensitive in identifying benign tumors (88.4%) than malignant neoplasms (58.3%) and was least sensitive in identifying nonneoplastic salivary diseases (35.3%). Pleomorphic adenomas were correctly identified preoperatively in 96.2% of cases, whereas for malignant neoplasms, the diagnostic accuracy was highest for mucoepidermoid carcinoma (50%). To demonstrate the strengths of FNA as a diagnostic tool, as well as to delineate its limitations, we present our 5-year experience. Our FNA results are similar to those reported by the major European and American referral centers. Because our medical centers are community based, our results may more accurately reflect those seen by otolaryngologists in private practice. To date, no evidence of tumor seeding along the FNA tract has been reported.

A technique for fabrication of a custom tracheostomy prosthesis

A technique is described for using an endotracheal tube to make an impression of the intratracheal anatomy for fabrication of a custom-fitted tracheostomy prosthesis.

Primary pulmonary hypertension: a look at the future

Primary pulmonary hypertension is a well described but poorly understood illness. It is a disease of the small muscular pulmonary arteries in which proliferative lesions involving endothelial cells, smooth muscle cells and fibroblasts obstruct flow. Aggressive therapy with vasodilator drugs, especially calcium channel blockers, has improved the quality of life in a minority of patients; heart-lung transplantation is feasible for only a few. Rapid developments in the study of vascular biology in the last several years are likely to provide insight into the etiology and pathogenesis of primary pulmonary hypertension. The areas involved include the cell biology of pulmonary vascular endothelial and smooth muscle cells, studies of integrins, endothelial surface charge, angiogenesis and growth factors, endothelial-derived vasoactive substances, the effects of shear and the role of coagulation at the endothelial surface. The future looks bright for understanding and treating this difficult and cryptic illness.

The effects of irradiation on alaryngeal voice of totally laryngectomized patients

The effects of radiation therapy on the ability of totally laryngectomized patients to produce voice and speech were examined using objective non-invasive methods. Moderate to severe losses were noted in patients producing voice with all types of alaryngeal modalities: tracheoesophageal, esophageal, and electrolaryngeal. Voice and speech losses were related to the impaired motility and vibratory capability of the esophageal wall and mucosa, to fibrosis of the submandibular region and to trismus. Tracheoesophageal and esophageal voice was recovered some weeks after completion of irradiation. No voice losses were observed in alaryngeal speakers who did not undergo voice restoration until after irradiation. All irradiated patients also showed various degrees of dysphagia during the treatment.

Alpha-interferon in superficial bladder cancer: a Northern California Oncology Group Study

Thirty-five patients with superficial transitional carcinoma of the bladder were treated intravesically with escalating doses of recombinant alpha-2-interferon administered weekly for 8 weeks. Of the 19 patients with high-grade intraepithelial neoplasia (17 carcinoma in situ [CIS], two severe dysplasia, all cytology positive), six (32%) had complete resolution of all histologic and cytologic evidence of disease (complete response). An additional three patients (16%) had complete resolution of CIS, but the interval appearance of a low-grade transitional cell neoplasm. Five (26%) had a partial response (complete resolution of all evidence of CIS on multiple bladder biopsies but persistently positive cytologic preparations). Sixteen patients with recurrent papillary tumors and extensive prior therapy were also treated. Four (25%) had a complete response. Twenty-three of the 35 patients had prior intravesical therapy. Seven of the 23 (30%) patients with prior intravesical chemotherapy or immunotherapy had a complete or partial response to interferon, while eight of the 12 patients (67%) without prior intravesical treatment responded. These responses were achieved with minimal local and systemic toxicity. Of the ten complete responders, five remain in continuous unmaintained remission for 18+ to 37+ months. Intracavitary alpha-2-interferon is an effective new treatment for some patients with bladder cancer.

Division of the external urethral sphincter in the treatment of the paraplegic bladder: a preliminary report on a new procedure

Division or resection of the external sphincter is a new operation designed to relieve retention of urine (or a high residue) in patients with an open bladder-neck and a narrow, rigid external sphincter area and in whom subarachnoid alcohol block, pudendal neurectomy or a bladder-neck resection have failed to help. The operation converts a chronic retention to an easily expressible bladder. Ten patients are reported. The operation technique is described. During the post-operative period care is necessary in preventing or dealing with clot-retention and with severe infection due to absorption of organisms in the urethra. The operation should not be attempted in patients with grossly dilated upper urinary tracts and in those with uncontrollable infection. The eight surviving patients have been spared the catheter life and, possibly, subsequent damage to the upper urinary tract.

Fungal colonization of tracheoesophageal voice prosthesis

Laryngectomized patients fitted with tracheoesophageal (TE) puncture voice prosthesis may experience frequent failures in adequate production of neophonation. In some cases, these phonatory problems result from obstruction of the voice prosthesis with various deposits. The nature of these deposits was studied with mycologic techniques and by light and scanning electron microscopy. Candida albicans and other fungal species were identified.

An interim prosthesis for the glossectomy patient

The use of a simple patient-held prosthesis for improving speech in a patient with mandible and tongue resections has been described. As subjectively perceived and objectively verified, speech intelligibility improved in a test patient. There were no apparent risks or lengthy therapy. The ease of fabrication and low cost indicate that this prosthesis may be of value in aiding the speech of glossectomy patients.

Nature of the glomerular capillary injury in human membranous glomerulopathy

A differential solute clearance technique was used to evaluate glomerular capillary wall function in 20 patients with membranous glomerulopathy and massive proteinuria. The clearance of inulin, the filtration fraction, and the fractional clearance of uncharged dextrans of a radius of 28-48 A were depressed significantly below control values in 20 healthy volunteers (P less than 0.01). In contrast, the fractional clearance of dextrans of radius greater than 50 A was elevated markedly. A theoretical model of solute transport that depicts the major portion of the glomerular capillary wall as an isoporous membrane and the minor portion as a nondiscriminatory shunt pathway revealed the calculated glomerular ultrafiltration coefficient to be five times lower and mean pore radius of the major membrane component to be 4 A smaller than control values. However, the fraction of filtrate volume permeating the shunt pathway was three- to fourfold above control values and correlated strongly in individual patients with the fractional clearance of albumin (r = 0.76) and of IgG (r = 0.80). Lowering renal plasma flow by 24% during indomethacin therapy in seven patients resulted in a 74% reduction in proteinuria accompanied by a corresponding diminution of filtrate formed through the shunt pathway. Morphometric analysis of glomerular ultrastructure revealed the magnitude of depression of the glomerular filtration rate and of urinary protein leakage to be related strongly to changes in the epithelial layer of the glomerular capillary wall, but not to the density of subepithelial immune deposits. We conclude that glomerular capillaries in membranous glomerulopathy are characterized by a loss of ultrafiltration capacity and of barrier size-selectivity, and that subepithelial immune deposits do not provide a structural basis for these functional alterations.

Sex chromosome fragment in a phenotypically normal female. Significance of occult Y-related material

The authors report a 15-year-old short, nonvirilized, prepubertal female whose peripheral karyotype revealed a mosaicism in which 62 percent of the cells had a karyotype of 45X, and the other 38 percent had a karyotype of 46X plus a small unidentified marker chromosome. Since the authors were unable to determine from the karyotype whether this marker was derived from an X or a Y chromosome and because of the high risk for neoplasia in abnormal gonads containing Y material, she underwent surgical exploration, with removal of gonadal tissue. Microscopic examination of the streak gonads revealed a mixture of dysgenetic ovarian and testicular type tissues. The presence of testicular-like tubules strongly implied the presence of Y material in the genotype. Review of the literature reveals at least 19 similar cases in which presumed sex chromosomal markers or fragments were found in phenotypically normal females. Because of the risk of gonadal neoplasia in patients with occult Y chromosomal material, gonadectomy is indicated when the origin of the marker chromosome is uncertain.

Nonimmune hydrops fetalis in association with hemangioma of the umbilical cord

Nonimmune hydrops fetalis is becoming the predominant form of fetal hydrops due to the declining frequency of Rh isoimmunization. Reported is the preterm delivery of a hydropic twin with umbilical cord and cutaneous hemangiomata. The unusual umbilical angiomatous malformation was associated with marked edema of the cord. This produced an ultrasonographic abnormality detected antenatally as a multicystic mass in close approximation to the fetal abdomen. The hydropic twin responded to aggressive neonatal management. It appears that hemangiomata of the umbilical cord may be causally related to fetal hydrops and may represent another entry in the differential diagnosis of this disorder.

Treatment of intractable lupus nephritis with total lymphoid irradiation

Ten patients with lupus nephritis and marked proteinuria (3.9 g or more/d) that did not respond adequately to treatment with prednisone alone or prednisone in combination with azathioprine were treated with total lymphoid irradiation in an uncontrolled feasibility study. Within 6 weeks after the start of total lymphoid irradiation, the serum albumin level rose in all patients in association with a reduction in the serum level of anti-DNA antibodies, an increase in the serum complement level, or both. Improvement in these variables persisted in eight patients followed for more than 1 year, with the stabilization or reduction of the serum creatinine level. Urinary leakage of albumin was substantially reduced in all patients. Side effects associated with radiotherapy included transient constitutional complaints in ten patients, transient blood element depressions in three, localized viral and bacterial infections in four, and ovarian failure in one. The results suggest that total lymphoid irradiation may provide an alternative to cytotoxic drugs in the treatment of lupus nephritis.

Primary mucinous adenocarcinoma of the endometrium. A clinicopathologic and histochemical study

Of 256 patients with carcinoma confined to the uterine corpus at the time of hysterectomy treated in the period 1959-1975 at Stanford University Hospital, 98 patients (38%) had neoplasms which demonstrated at least focal intracytoplasmic mucin. In 21 carcinomas (9%), intracytoplasmic mucin production was the dominant form of differentiation--a group which we designate primary mucinous carcinoma of the endometrium. Freedom from relapse and frequency of myometrial invasion were not statistically different for patients whose neoplasms contained intracytoplasmic mucin, regardless of the amount of mucin present, when compared with cases of nonmucin-containing carcinoma. Using histochemical methods, it was impossible reliably to distinguish between the intracytoplasmic mucin produced by carcinomas arising in endometrium and that produced by carcinomas primary in the endocervix. Differential biopsy and fractional curettage are stressed as useful tools in making this clinically important distinction. Since both benign mucinous metaplasia and mucinous carcinoma may arise in the endometrium, it is important to establish histopathologic criteria by which the malignant lesions may be recognized. The use of criteria illustrated in this paper (which include architectural complexity of proliferation, epithelial stratification, loss of epithelial polarity, and nuclear atypicality) resulted in the recognition of mucin producing proliferations which as a group manifest a 50% incidence of myometrial invasion.

An analysis of policies regulating medication in Ohio public schools

The development of medicines, state and federal laws requiring the enrollment and mainstreaming of handicapped students and the use of behavior modifying drugs has resulted in more requests by parents to have medication administered to their children during school hours. The problem in schools without immediate access to nurses is to accommodate students who need medication while at the same time avoid the dangers that are inherent in administering medication to children. The purpose of this investigation was to determine what guidelines are being followed in Ohio schools on the storage and administration of prescribed medication. Policies and regulations on the administration of medication, solicited from a random sample of Ohio school districts, were found to be not in keeping with pertinent legislation, litigation and recommended procedures. The investigation of the sample districts revealed enough inadequacies to suggest that: 1) many Ohio school districts need formal policies and regulations in the administration of medication; and 2) Ohio school districts having policies and regulations in the administration of medication should seriously consider eliminating whatever inadequacies exist for the safety and well-being of students and staff. A sample board policy statement, regulations for administering prescription and nonprescription medication in schools, a request form and a model statute designed to protect the employee from tort liability as a result of ordinary negligence in the administration of medication were developed in keeping with the findings of this study and are recommended for consideration as models by school districts nationwide.

Effect of naloxone on the pulmonary vascular responses to graded levels of intracranial hypertension in anesthetized sheep

We increased intracranial pressure (ICP) in anesthetized sheep for 3 h by connecting the cisterna magna to an elevated reservoir of buffered saline. We monitored systemic and pulmonary vascular pressures, pulmonary blood flow, and the flow of lymph from the lungs. The volume and protein concentration of the lymph were used to assess changes in lung vascular permeability-surface area. Extravascular lung water was measured postmortem, and in vivo indicator dilution studies were used to measure permeability-surface area product (PS urea) of the lung circulation for a small hydrophillic molecule (14C-urea) and extravascular water volume (VH2O). These studies were done in 16 sheep with ICP raised to 0, 60, or 100 mmHg. Thirteen other sheep received naloxone before and during elevation of ICP to 0, 60, or 100 mmHg. Elevation of ICP increased pulmonary artery pressure (

CONTROL

16 +/- 3 cmH2O; ICP: 60 mmHg = 16 +/- 2 cmH2O; ICP: 100 mmHg = 23 +/- 2 cmH2O), cardiac output (

CONTROL

2.7 +/- 0.1 L/min; ICP: 60 mmHg = 3.3 +/- 0.05, p less than 0.05; ICP: 100 mmHg = 5.3 +/- 1.0, p less than 0.05), lung lymph flow (

CONTROL

94 +/- 8% baseline; ICP: 60 mmHg = 193 +/- 25% baseline, p less than 0.05; ICP: 100 mmHg = 285 +/- 38% baseline, p less than 0.05), PS urea (

CONTROL

7.0 +/- 0.5 ml/s; ICP: 60 mmHg = 11.0 +/- 3.7 ml/s; ICP: 100 mmHg = 12.4 +/- 1.3 ml/s, p less than 0.05), and VH2O (CONTROL: 93 +/- 8% baseline; ICP: 60 mmHg = 112 +/- 6% of baseline; ICP: 100 mmHg = 129 +/- 13% of baseline, p less than 0.05) proportional to the level of ICP. Sheep with ICP raised to 100 mmHg had modestly increased lung water (pulmonary edema).(ABSTRACT TRUNCATED AT 250 WORDS)

Surreptitious diuretic ingestion and pseudo-Bartter's syndrome

A patient with profound hypokalemia satisfied the criteria for Bartter's syndrome, including hyperreninemia, aldosteronism, normal blood pressure, and hyperplasia of the juxtaglomerular apparatus. Two screening tests of urine and one of plasma for diuretic agents gave negative results. A third urinary sample gave negative results for thiazide but positive for furosemide; the fourth and fifth samples gave negative results for furosemide but positive for thiazide. Urinary prostaglandin excretion was normal. We conclude that this apparent case of Bartter's syndrome was caused by long term surreptitious diuretic ingestion and suggest this may occur more frequently than is generally appreciated.

Neoplasms arising in congenital giant nevi: morphologic study of seven cases and a review of the literature

Congenital giant nevi are complex cutaneous malformations composed of melanocytic and occasionally neural supportive elements. Malignant neoplasms arising in this setting are not uncommon, and their histologic appearances often differ significantly from the typical pattern of malignant melanoma. We report six patients with neoplasms arising in congenital giant nevi and one patient with a neoplasm arising in an extensive congenital blue nevus, and present a description of the neoplastic patterns encountered. These patterns include 1) poorly differentiated small round cell cancer, 2) malignant cellular blue nevus, 3) spindle-cell malignant tumor with lamellar cell (pseudomeissnerian) differentiation, 4) so-called minimal deviation melanoma, 5) heterologous malignant mesenchymal differentiation including rhabdomyosarcoma and liposarcoma, and 6) undifferentiated spindle cell cancer. We have reviewed the literature in order to address the question of frequency of malignant transformation in congenital giant nevi, the reported experience with the morphology of these cancers, and the histogenesis of these sometimes complex neoplasms as it is illuminated by our current understanding of the embryology of the neural crest.

Division of the external urethral sphincter in the neuropathic bladder: a twenty years' review

It is now twenty years since the authors first performed division of the external sphincter region in the treatment of the neuropathic bladder. Although a ten year report was published in 1967, it was decided to review all the patients at the end of the twenty year period. The rationale of the operation in the upper motor neurone lesion has been confirmed by modern investigative techniques, while it appears from recent work that the success of the procedure in the lower motor neurone case is due to division of plain muscle which is subjected to excessive sympathetic stimulation. It is the authors' firm conviction that long term catheterization, whether permanent or intermittent is a confession of failure and can be avoided in the vast majority of patients. The operation has proved of permanent benefit especially with the regard to the elimination of residual urine. Further, hydronephrosis, and renal infection and failure, are also benefited in many cases. These factors are of great importance in a condition in which late morbidity and mortality has been usually due to renal causes.

Clinical decision analysis. The hazard of using additional data

Acquisition of laboratory data bearing on a clinical problem may make patient care worse rather than better. The hazards of obtaining new information, that go beyond the monetary costs and risks to physical well-being, are frequently not appreciated by physicians. In the complex and many-faceted practice of medicine, intuition, even when expressed by experienced clinicians, may lead to faulty judgments. Decision analysis gives a systematic exposition of clinical management, and lessens, if not eliminates, the influence of biased and unreliable intuition. With practice, most physicians could employ decision analysis to help solve moderately complicated problems at the bedside or in the office. Use of this tactic will make gaps in knowledge explicit, and may thereby stimulate investigations to ensure better clinical judgments in the future.

Production of parathyroid hormone by laryngeal cancer. Report of a case

Nonparathyroid humoral hypercalcemia is becoming an increasingly more common problem associated with carcinoma. Carcinomas of the head and neck may elaborate parathormone or parathormone-like humors that in the absence of bone metastases, renal disease, parathytoid tumors, or secondary hyperparathyroidism may produce hypercalcemia, which if unrecognized, complicates and prevents the appropriate management of the patient. This report deals with the production of parathyroid hormone and the first reported case, to our knowledge, of carcinoma of the larynx associated with nonparathyroid hypercalcemia.

Vesical dysfunction due to prolapsed disc

Neural disturbance of micturition may occur as a result of a prolapsed intervertebral disc. Single nerve root lesions are unlikely to cause bladder dysfunction; a massive central protrusion producing total blockage of the vertebral canal or multiple disc lesions are more likely to cause disturbance of voiding. High lesions are more prone to cause severe bladder dysfunction. Vesical dysfunction may sometimes be present without the typical back and leg pain.Provided a gynaecological cause is excluded, any young or middle-aged woman developing incontinence and retention with a sterile urine must be fully investigated to exclude a disc lesion. Once the disc has been removed, bladder function will improve, but in some cases recovery will be slow. Rarely some patients have permanent bladder dysfunction following a disc operation.