Bess Kaiser Hospital

We analyzed data from 107 consecutive patients with clinical stage B prostate cancer in an attempt to identify those at high risk for having involved margins or nodal metastasis. Each patient underwent transrectal ultrasound-guided sextant biopsies of the prostate. Patient age, surgical approach to prostatectomy, pre-biopsy prostate specific antigen (PSA) level, and number, location and maximum Gleason score of positive biopsies were statistically evaluated for all patients groups. Prostate volume and PSA density (PSAD) were calculated for all patients undergoing prostatectomy. Of the 101 patients who underwent radical prostatectomy 64 had negative margins, 37 had at least 1 positive margin and 11 of the 37 had more than 1 positive margin. Involved margins were most common at the apex (62%) and mid portion (59%) of the gland. Prostatectomy was not performed on 6 patients with nodal metastases evident on frozen section examination. Therefore, 43 patients are considered to be at high risk for having residual disease after surgery. The mean PSAD, PSA level and number of positive biopsies were significant (p < 0.05) predictors of tumor extension to the surgical margin. The mean number of positive biopsies, biopsy Gleason score and PSA level were significantly greater (p < 0.05) in patients with nodal metastases. Only 15% of the patients with a single positive biopsy had positive margins versus 47% of those with multiple positive biopsies (p < 0.05). Of the patients with tumor positive nodes on frozen section 67% had 5 or more positive biopsies, whereas only 9% of all others had that many positive biopsies (p < 0.05). The number of positive biopsy sites, PSAD and PSA level were significantly associated with tumor at the surgical margin or metastatic to the pelvic nodes.

“Thought-disorder” in schizophrenia was initially a psychiatric concept derived from clinical observation. As crystallized in standard psychiatric authorities, say Mayer-Gross, Slater and Roth (1954) the primary features of the talk (and inferentially the thinking) of thought-disordered schizophrenic patients are: ( i ) Inconsequential following of side issues. ( ii ) Tendencies for the thought to be directed by alliterations, analogies, clang associations, associations with accidents of the speaker's environment, symbolic meanings, and the condensation of several (perhaps mutually contradictory) ideas into one. ( iii ) Words used out of context, e.g. concrete meanings taken where abstract meanings would be appropriate. ( iv ) Clinging to unimportant detail. ( v ) The use of laconic answers, e.g. I don't know, maybe, perhaps—indicative of emptiness and vagueness of ideas. ( vi ) Thought is generally marked by gaps, poverty, indefiniteness and vagueness. ( vii ) Indications of thought-blocking. ( viii ) Indications of pressure of thoughts.

Juvenile xanthogranuloma (JXG) is a benign histiocytic proliferation of uncertain histogenesis which usually resolves spontaneously. Histopathologically, classic lesions are characterized by diffuse proliferations of foamy histiocytes, many of which may be multinucleated (Touton cells), admixed with lymphocytes and eosinophils. Histologic variants of JXG, perhaps representing evolving lesions, may lack these typical histopathological features, showing diffuse infiltrates of non-foamy mononuclear histiocytes without Touton cells, posing problems in differentiation from other histiocytic or melanocytic proliferations. Immunohistochemically, JXG is characterized by variable expressions of several histiocytic markers as well as the absence of staining for S100 protein. To assess better the spectrum of histopathological and immunohistochemical features of JXG, we studied nine cases of classic or histologic variant of JXG. The cases were evaluated by light microscopy and with an extensive battery of antibodies. All 9 cases, regardless of their light microscopic appearance, showed markedly positive staining with histiocytic markers including CD68, HAM56, cathepsin B and vimentin, but did not stain for S100 protein. Antibodies to factor XIIIa stained positively in 8 cases while staining for other markers was variable. Our results suggest that the histiocytes in JXG lesions have macrophagic differentiation, probably representing a reactive process to an unknown stimulus.

Wolfe defined four different classes of breast parenchymal patterns and claimed that they were associated with different risks for the subsequent development of breast cancer. Egan and Mosteller suggested that these patterns did not constitute a true risk factor, rather the effect was caused by the greater difficulty of detecting breast cancers in the dense (P2, DY) patterns compared with the fatty (N1, P1) patterns. Similarly, Mendell believed that a bias was introduced into Wolfe's work by requiring a negative mammogram before a patient entered the study. This study of 221 prevalent and 706 incident cancers followed for up to 10 years indicates that a masking effect does exist, but that it operates in addition to a difference in risk of breast cancer within the four Wolfe classes. Wolfe's hypothesis is found to be valid.

The objective of this study was to change procedures in our medical center regarding frenotomy for ankyloglossia (tongue-tie). The medical and breastfeeding outcomes of 36 fullterm infants who received frenotomies were studied. The information was used to develop frenotomy eligibility standards that would guide other physicians and insure timely treatment to avoid breastfeeding cessation.

Data collected between 1973 and 1984 on 696 incident cases of breast cancer and 1,376 matched controls from four Breast Cancer Detection Demonstration Project clinics in the United States were used to assess the role of mammographic parenchymal pattern as a risk factor and its relationship with other, accepted, risk factors. The data confirm previous reports of the influence of benign breast biopsy, age at first live birth, family history of breast cancer, and duration of menstruation on the incidence of breast cancer. Height is also found to be an influential factor. Parenchymal pattern is found to be a risk factor with effects comparable in magnitude to the other factors studied. It operates separately from them, except for its relationship with height and weight. After adjustment for parenchymal pattern, weight is seen to have a significant effect on breast cancer incidence, and height is no longer needed in a model for risk. A model which simultaneously incorporates all of the risk factors considered, including parenchymal pattern, is presented. While these factors are of interest in the epidemiology of breast cancer, it is demonstrated that they are insufficient to allow reliable prediction of the disease in an individual woman.

Malignant nerve sheath tumors comprise approximately 5% of all soft tissue sarcomas; only 8% to 15% of these tumors arise in the head and neck. Most tumors appear as a rapidly expanding nonpainful mass in the face or lateral neck. Reported association with Von Recklinghausen's disease varies from 26% to 70%. Wide surgical excision is generally the recommended primary treatment. Recently, there has been a trend to include postoperative radiation therapy as a primary modality.

Background Wide variations in disability duration and magnitude have been noted among recipients of workers' compensation for low back pain. Findings from recent studies have indicated that inclusion of a broad array of variables (i.e., physical, occupation, social, economic) is needed to understand differences in workers' responses to occupational low back pain. Methods Workers' compensation and questionnaire data from 340 Oregon workers with low back claims were merged to develop multivariate models predicting: (1) absenteeism days, (2) residual symptoms, (3) functional impairment, and (4) medical costs. Results Forty-two percent of the variation in low back symptoms was explained by: discontinuing physical fitness activities post-injury (β = −.419), self-reported low energy/high fatigue (β = −.227), poorer general heath (β = 0.137), and attorney involvement in claim (β = 0.117), (adjusted R2 => 0.418, p < 0.001). Survival curves revealed significantly longer claim durations among workers who discontinued physical fitness activities post-injury, compared with workers who did not; these differences remained significant even after controlling for severity of the initial injury. Conclusion Continuation of physical fitness activities during the recovery process was found to be a significant predictor in three of four regression models, providing evidence on behalf of a relationship between fitness and positive health outcomes. However, it was not possible to clearly differentiate pre-morbid from post-injury fitness, nor to determine if this relationship was due to a therapeutic effect on the back, the general restorative benefits of remaining active, or represents a proxy variable for workers' self-care efforts during recovery. Am. J. Ind. Med. 34:559–567, 1998. © 1998 Wiley-Liss, Inc.

Six children with lymphoreticular malignancy arising in the pharyngeal tonsils or adenoids are presented. Early clues to the possible malignant nature of the enlargement of tonsils and adenoids in this series include: asymmetric and persistent enlargement, the absence of such manifestations of infection as fever or pain, and the association of atypical adenopathy. Lack of clinical suspicion brings with it the risk of delayed diagnosis and possible compromise of optimal therapy.

BACKGROUND: Carboplatin, which is used in the treatment of several childhood tumors, increasingly has been reported to cause hypersensitivity reactions, the majority reported in adults. Five cases of children with primary brain tumors who were treated with carboplatin and developed acute allergic reactions are presented. METHODS: The clinical history of each patient is described, as is the schedule, cumulative dose, and number of infusions of carboplatin, type of reaction, and retreatment. RESULTS: Four of the five patients had histologically proven low grade astrocytic tumors; three had juvenile pilocytic astrocytomas, and one had a mixed oligoastrocytoma. One patient with neurofibromatosis type I had radiographically-defined bilateral optic nerve gliomas. Three patients had prior chemotherapy, one with cisplatin. All five patients developed hypersensitivity reactions such as urticaria, facial erythema, and facial swelling after multiple infusions of carboplatin. Two were retreated with carboplatin after receiving antihistamines, but still developed a reaction. Carboplatin therapy was discontinued in all patients. CONCLUSION: The purpose of this report is to heighten awareness of this potentially serious complication of carboplatin in children so that potentially dangerous retreatment is avoided. As use of a weekly schedule of carboplatin in children with low grade gliomas increases, with planned therapy extending for more than 50 weeks, more hypersensitivity reactions are anticipated.

This case is presented both because it rarely occurs and because "chance favors the prepared mind." Malignant disease in artificially used skin grafts should be called to the attention of the clinician who manages these problems.

BACKGROUND: A study was carried out to increase familiarity with the aetiology, pathogenesis, and radiographic features that characterise pulmonary gangrene. PATIENTS: Four patients with one of the disorders vasoinvasive aspergillosis, infarcted tuberculous cavity, chronic necrotising aspergillosis, and gangrene due to Pseudomonas aeruginosa were selected because they showed the variations of the typical radiographic pattern and illustrated the pathogenesis. A fifth case is also presented, in which pulmonary gangrene was simulated by the invagination of a loculated pleural effusion into the wall of a contiguous lung abscess. CONCLUSIONS: Evolution of a crescent or rim of air within a homogeneous shadow is the feature that both heralds the development and facilitates the recognition of pulmonary gangrene. It is most often the result of vascular thrombosis induced by the infecting organism. The outcome of treatment is often unfavourable, principally because of the severity of the predisposing systemic or local underlying disorder, although a delay in diagnosis, possibly due to unfamiliarity with the radiographic pattern, may have contributed to the adverse outcome in some instances.

The purpose of this study was to estimate the incidence of clinically identified (i.e., ascertained either because of symptoms or an incidental chest radiograph) sarcoidosis in a geographically and ethnically defined United States population. We employed a research-quality database of a large health maintenance organization (HMO), Kaiser Permanente, Northwest Region (KPNW), which collects morbidity and utilization data for a random sample of members sociodemographically representative of the service area of the HMO, to identify persons with suspected or confirmed sarcoidosis. Nine clinically identified incident cases of sarcoidosis were verified within the 1.87*10(5) person-year sample over a 21-year span, 1967-1987, an estimated annual all-ethnicity incidence rate of 4.8/10(5) (95 percent confidence interval ((CI)): 1.7, 7.9). Among persons of Caucasian ancestry, the estimated annual incidence was 2.8/10(5) (95 percent CI: 0.4, 5.2). If the incidence among Caucasians and the relative risk of developing sarcoidosis among African-Americans in the KPNW population is representative of the U.S. population, we estimate the incidence of clinically identified sarcoidosis in the latter to be 7.3. If, in addition, clinically identified cases constitute 42 percent of those that are clinically ascertainable (i.e., identified by mass population screening in addition to cases detected because of symptoms or incidental chest radiographs), as observed in the Swedish population, our estimate of the U.S. incidence of clinically ascertainable sarcoidosis would be 17.4.

This study is a retrospective examination of data from a prepaid group practice that introduced a change in surgical services so that about 35 per cent of patients having surgery in the operating room were not admitted to the hospital. The study population is the membership of the Oregon Region of the Kaiser Foundation Health Plan for the period 1966 through 1974. The data come from 100 per cent of the hospital admissions and 100 per cent of the ambulatory (nonadmit) surgical procedures. This study examines the costs, quality of care, and satisfaction of providers and patients with ambulatory surgery. Cost savings for the ambulatory procedures averaged +192.19 per procedure (based on 1977 costs). National savings for 1977 were projected at +773,947,208. In addition, ambulatory surgery absorbed an increasing demand for surgical procedures without requiring additional hospital beds. No difference in quality of care were found for inpatients and ambulatory patients (both used the same operating rooms and staff), and both providers and patients were found to be very satisfied with ambulatory surgery services.

Howard, Jan Ph.D.*; Davis, Fred Ph.D.†; Pope, Clyde Ph.D.‡; Ruzek, Sheryl Ph.D.§ Author Information

Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts.

Intravenous amiodarone is one of the most widely used antiarrythmics for the treatment of atrial fibrillation with rapid ventricular response. Peripheral amiodarone infusion, however, often causes pain during infusion and subsequent phlebitis.Data collection on a cardiac telemetry unit revealed a high rate of phlebitis. A multidisciplinary team developed and implemented amiodarone peripheral infusion guidelines. The pre-guideline phlebitis rate was 85% and post-guideline rate was 38%, representing a 47% change or improvement. An additional finding was that the severity of phlebitis was reduced, as well. The results of this study suggest that the implementation of a peripheral amiodarone infusion guideline reduced the incidence and severity of amiodarone-related phlebitis in the cardiac population.

Our purpose was: (1) to determine whether assessment of amniotic fluid index in high risk patients with a reactive nonstress test (NST) allowed improved recognition of the fetus at risk for perinatal morbidity than a reactive NST alone; and (2) to determine the optimal low amniotic fluid index (AFI) which should prompt clinical concern. The last NST performed within a week of delivery and amniotic fluid index were retro-spectively compared with various indices of perinatal morbidity. In fetuses with a reactive NST, decreasing AFI was directly correlated with a risk of 5-minute Apgar score of less than 7 and delivery for fetal distress. When various subgroupings of AFI were compared, 7 cm or greater appeared to have a better inverse correlation with the indices of morbidity than lower cut-off values. The addition of AFI assessment to the standard NST allows better prediction of perinatal morbidity than the NSTs alone. Seven centimeters appears to be a reasonable cut-off for clinical concern.

Genitourinary tumors account for half of all documented cases of pseudohyperparathyroidism. The treatment of hypercalcemia is directed toward immediate correction of the electrolyte imbalance and long-term control. These goals are accomplished with volume repletion, calcium normalization and removal of the tumor. Effective therapy includes saline infusion and furosemide. Additional control is obtained with phosphates and/or indomethachin. In refractory cases actinomycin-D or mithramycin is helpful. The first reported case of urethral cancer and second reported case of testicular seminoma producing this syndrome are added to the literature.

Abstract. Agnogenic myeloid metaplasia (AMM) was recognized 3 years after a diagnosis of sarcoidosis in a 45‐year‐old man. This is the second reported instance of that association, and the 15th reported case in which systemic granulomata have been associated with a myeloproliferative disorder (MPD). In the client population at risk, this connection would be expected to occur by chance once in 1700 years. Therefore, it is unlikely that the association is fortuitous. Systemic granulomata may represent an immunologic response to antigens of neoplastic origin in MPD