Metastatic tumors mimicking gynecologic cancer

Review of the admissions to the Gynecologic Oncology Service at the University of Alabama Medical Center over a 12-year period reveals that 1% of all referrals had nongynecologic malignancies. Duration of symptoms was short; of 40 patients with adequate follow-up, 31 (77%) were dead from their cancer, with a median survival of eight months. The value of diagnostic radiologic procedures was assessed and, while these procedures proved helpful, most patients required a surgical procedure (often a reoperation) to establish the diagnosis.     

Methanol poisoning: a review and case study of four patients from Central Australia

Methanol intoxication, a rare and potentially lethal form of poisoning, usually results from ingestion and occasionally inhalation of methanol. Initial symptoms of blurred vision, elongated anion gap and metabolic acidosis are typically delayed and may not at first be recognised as methanol-related complaints. Once diagnosed, treatment must be prompt and definitive. As well as general supportive care, ethanol infusion, dialysis and alkalinization form the mainstays of treatment.

The cases described in this paper are compared to previous reports from other countries worldwide and contrast the variance in outcome often seen in methanol poisoning. The paper describes two tragic deaths and two lucky survivors, all of whom had consumed a cocktail of methanol and other alcoholic beverages at the same party.

The ICU nurse's role in managing the methanol-intoxicated patient relies on that person's sound knowledge of the unusual biochemical reactions occurring in the body and the need to institute definitive and supportive measures to help both patient and family recover.     

Biomechanical Characteristics of Biplane Multiplanar Tension-Side Fixation for Lapidus Fusion

Although plating on the plantar, tension-side of the metatarsocuneiform joint provides an inherent biomechanical advantage for Lapidus arthrodesis, it has not been widely adopted owing to the morbidity associated with plantar application. To overcome these limitations, a modification to 90-90 locked biplanar plating was developed to provide the biomechanical advantages of multiplanar fixation and tension-side fixation, allowing application through a conventional incision. We tested the hypothesis that biplanar plating with tension-side fixation (low-profile straight dorsal plate and anatomic medial-plantar plate) would demonstrate improved mechanical stability compared with a previously tested 90-90 biplanar construct (small straight plate dorsally and medially) under cyclic loading. Both constructs were tested in static load to failure (3 pairs) and cyclic loading (10 pairs) with plantar cantilever bending using surrogate anatomic bone models. With static ultimate failure, the biplanar plate construct with tension-side fixation failed at a significantly greater failure load than did the straight biplanar plate construct (247.3?±?18.4 N versus 210.9?±?10.4 N; p?=?.04). With cyclic failure testing, the biplanar plate construct with tension-side fixation endured a significantly greater number of cycles (206,738?±?49,103 versus 101,780?±?43,273; p?<?.001) and a significantly greater dynamic failure load (207.5?±?24.3 N versus 162.5?±?20.6 N; p?<?.001) compared with the straight biplanar plate construct. These results have demonstrated that under simulated static and cyclic Lapidus arthrodesis loading, biplanar plating with tension-side fixation provides superior strength compared with the straight biplanar construct. Thus, this construct shows promise for clinical application as a practical approach to tension-side fixation and an early return to weightbearing after Lapidus fusion.     

A near-fatal reaction during granulocyte transfusion of a neonate

Although reactions to granulocyte transfusions in neonates are rarely reported, we observed a near-fatal pulmonary reaction, presumably due to white cell antibodies, in a neonate with Rh hemolytic disease. The hemolytic disease was being treated with exchange transfusions, and at 2 days after the infant's birth, bacterial sepsis was suspected and granulocyte transfusions were begun. The first granulocyte transfusion (Day 3) was uneventful. Five minutes after the beginning of the second granulocyte transfusion (Day 4), severe respiratory distress, hypotension, bradycardia, cyanosis, and acidosis suddenly occurred. The infant's serum obtained after the reaction contained granulocytotoxic and B-lymphocytotoxic antibodies that reacted with leukocytes from the second granulocyte donor. Antibodies could not be detected either in the initial infant serum or in maternal serum. However, an antileukocyte antibody was present in the serum of a parous woman donor. We used plasma from this woman to prepare reconstituted whole blood for the exchange transfusion that we performed immediately preceding the second granulocyte transfusion. Despite the sequence of events, an irrefutable cause-and-effect mechanism could not be established because the properties of the donor and neonatal antibodies were similar, but not identical. However, this catastrophic event emphasizes both the potential for adverse effects of granulocyte transfusions in neonates and the need for caution when transfusing blood from parous women.     

The Effects of Psychological Stress on Electromyographic Activity and Negative Affect in Ambulatory Tension-Type Headache Patients

Fourteen female dental hygiene students (seven with episodic tension-type headache and seven who rarely or never experienced headache) wore an ambulatory electromyographic recorder and completed hourly subjective ratings of pain and negative affective states for six days while they carried out their normal daily activities. Three of the days were designated as high stress days by virtue of the fact that the students were required to take a major course examination or undergo a clinical evaluation on that day. The remaining three days were designated as low stress days by virtue of the fact that no unusual demands were made on the students, and they simply attended lectures as usual. All students showed significantly greater levels of electromyographic activity on the high stress days compared to the low stress days, but there was not a statistically significant difference between the headache and control groups. Headache group subjects reported significantly higher levels of pain compared to the control group, but their pain ratings did not differ between high and low stress days. Subjective ratings of negative affective states (anxiety, anger, sadness, and frustration) were significantly greater on high stress days compared to low stress days. Headache group subjects also exhibited a tendency to report higher levels of negative affective states than did control group subjects, but only in the case of frustration was the .05 level of statistical significance achieved.     

Acute hypoxemic respiratory failure in children: case mix and the utility of respiratory severity indices

Objective: Acute hypoxemic respiratory failure (AHRF) is a common reason for emergency pediatric intensive care. An objective assessment of disease severity from acute physiological parameters would be of value in clinical practice and in the design of clinical trials. We hypothesised that there was a difference in the best early respiratory indices in those who died compared with those who survived. Design: A prospective observational study of 118 consecutive AHRF admissions with data analysis incorporating all blood gases. Setting: A pediatric intensive care unit in a national children's hospital. Interventions: None. Results: Mortality was 26/118, 22 % (95 % confidence interval 18–26 %). There were no significant differences in the best alveolar-arterial oxygen tension gradient (A-aDO₂, torr), oxygenation index (OI), ventilation index (VI), or PaO₂/FIO₂ during the first 2 days of intensive care between the survivors and non-survivors. Only the mean airway pressure (MAP, cm H₂O) used for supportive care was significantly different on days 0 and 1 (p K 0.05) with higher pressure being used in non-survivors. Multiple logistic regression analysis did not identify any gas exchange or ventilator parameter independently associated with mortality. Rather, all deaths were associated with coincident pathology or multi-organ system failure, or perceived treatment futility due to pre-existing diagnoses instead of unsupportable respiratory failure. When using previously published predictors of outcome (VI > 40 and OI > 40; A-aDO₂ > 450 for 24 h; A-aDO₂ > 470 or MAP > 23; or A-aDO₂ > 420) the risk of mortality was overestimated significantly in the current population. Conclusion: The original hypothesis was refuted. It appears that the outcome of AHRF in present day pediatric critical care is principally related to the severity of associated pathology and now no longer solely to the severity of respiratory failure. Further studies in larger series are needed to confirm these findings. Received: 16 December 1997 Accepted: 31 March 1998     

Mouse A6-positive hepatic oval cells also express several hematopoietic stem cell markers

Hepatic oval cells (HOC) are thought to be a type of facultative stem cell that arises as a result of certain forms of hepatic injury. A new and more efficient model has been established to activate the oval cell compartment in mice by incorporating 3,5-diethoxycarbonyl-1,4-dihydro-collidine (DDC) in a standard chow at a concentration of 0.1%. At the present time, very few markers exist for the mouse oval cells. One accepted marker is A6, an uncharacterized epitope recognized by mouse hepatic oval cells and it is accepted to be an oval cell marker. Sca-1 is a cell surface marker used to identify hematopoietic stem cells in conjunction with Thy-1+, CD34+, and lineage-specific markers. Both the CD34 and Sca-1 antigens are not normally expressed in adult liver, but are expressed in fetal liver, presumably on the hematopoietic cells. We report herein that mouse oval cells express high levels of Sca-1 and CD34, as well as CD45 surface proteins. Immunohistochemistry revealed that the cells expressing Sca-1/CD34/CD45 were indeed oval cells because they co-expressed the oval cell-specific marker A6 (94.57% +/- 0.033%), as well as alpha-fetoprotein (AFP) (75.92% +/- 0.071%). By using Sca-1 antibody in conjunction with magnetic activated cell sorting (MACS), followed with a flow cytometric cell sorting (FACS) method for CD34 and CD45, we have developed a rapid oval cell isolation protocol with high yields of greater than 90%. In conclusion, we have an efficient murine model for the production and isolation of large numbers of highly purified oval cells. Our system works with most strains of mouse, which will facilitate both in vivo and in vitro studies of mouse hepatic oval cells.