The spectrum and cost of complicated gallstone disease in California

HYPOTHESIS: We hypothesized that complications of gallstone disease are more common than previously recognized and are related to treatment delay. DESIGN: Retrospective review. PATIENTS: Data for 248 consecutive patients from a university hospital in 1995-1996 and 40,571 patients identified through the 1996 California Office of Statewide Health Planning and Development database who underwent cholecystectomy for gallstone disease were reviewed. MAIN OUTCOME MEASURES: Diagnosis, length of hospital stay, hospital mortality, type of admission, type of surgical procedure, hospital cost, and interval of delay between onset of initial symptoms, ultrasound diagnosis, and cholecystectomy. RESULTS: The spectrum of gallstone disease included biliary colic in 56%, acute cholecystitis in 36%, acute pancreatitis in 4%, choledocholithiasis in 3%, gallbladder cancer in 0.3%, and cholangitis in 0.2%. Community hospitals, public or county hospitals, and academic health centers had a similar distribution of diagnoses. Patients undergoing cholecystectomy for biliary colic had a significantly shorter length of hospital stay, lower operative mortality rate, were more likely to have their operations completed laparoscopically, and had lower hospital charges than patients undergoing cholecystectomy for complications such as acute cholecystitis. Over half of the patients requiring cholecystectomy for complications of gallstones initially presented with biliary colic. Patients with gallstone complications had an average delay from ultrasound confirmation to surgery of 6 months. CONCLUSION: Complications of gallstone disease are (1) common, (2) costly, and (3) potentially preventable.     

Information processing deficits in children with early and continuously treated phenylketonuria?

Thirty-three patients with early and continuously treated classical phenylketonuria (PKU) and 33 controls matched for age, gender, and educational level of both parents, participated in chronometric study exploring elementary mechanisms of information processing. Subjects performed speeded performance tasks designed to systematically vary the load on perceptual, central, and output-related mechanisms of information processing. A preliminary analysis of the data indicated that the overall performance of patients with early and continuously treated PKU practically matched that of the controls on all three tasks. Although this finding must be interpreted with caution as it is based on only preliminary analysis of the data, it suggests that PKU patients who are continuously maintained on a well-controlled phenylalanine-restricted diet are not deficient in the elementary mechanisms of processing. Given the more recent findings indicating that young children with early-treated classical PKU have specific cognitive deficits in the executive function skills, despite relatively strict dietary control, the authors suggest that future studies should focus on these higher-order cognitive processes.     

Immunophenotyping to Detect and Characterize Acute Lymphocytic Leukemia in Testicular Biopsies

This study establishes the utility of immunophenotyping testicular biopsy specimens in patients with acute lymphoid leukemia. The value of immunophenotyping in detecting or excluding leukemic testicular infiltration is demonstrated in six children with acute lymphocytic leukemia. A panel of monoclonal antibodies was employed on snap-frozen testicular biopsies, allowing both detection and immunologic characterization of four neoplastic lymphocytic infiltrates. Two samples were proven both histologically and phenotypically negative for leukemic infiltration. One of the four leukemic cases was clinically silent and might have escaped detection except for phenotyping. One leukemic infiltrate was also suspected to possess a multidrug-resistant phenotype (-glycoprotein +); the latter possibility was excluded by an absence of reactivity with anti-p-glycoprotein monoclonal antibody. Thus, three clinically useful applications are demonstrated: (1) confirmation of testicular leukemic relapse, gaining assertion in histologically uncertain cases; (2) exclusion of clinically suspected disease relevant to cessation of therapy, and (3) detection/exclusion of drug-resistant phenotypes. Unexpectedly, we found expression of plasma cell-associated antigen in testicular germ cells, which may prove to be diagnostically useful in the future evaluation of germ cell tumors.     

A survey of antiemetic use in children with cancer

Pediatric oncologists within Pediatric Oncology Group institutions were surveyed to determine current antiemetic practices for children receiving chemotherapy and the basis for those practices. A mean severity rating for associated nausea and vomiting was calculated and used to rank 31 chemotherapeutic agents commonly used in the treatment of childhood cancer. Antiemetics were used 17%, 79%, and 98% of the time for chemotherapeutic agents with mild, moderate, or severe associated nausea and vomiting, respectively. A median of one, two, and three antiemetics were used for mild, moderate, and severe agents, respectively. Antihistamines and phenothiazines were the drugs most commonly used for agents causing mild or moderate nausea and vomiting, and metoclopramide hydrochloride/antihistamines with lorazepam and/or corticosteroids were used most often for chemotherapeutic agents causing severe nausea and vomiting. Most oncologists based their choice of antiemetics on personal experience. Current literature addressing the treatment of nausea and vomiting in children receiving chemotherapy, as reviewed here, does not always support the present clinical practices.     

Bone marrow monosomy 7: hematologic and clinical manifestations in childhood and adolescence

The hematologic manifestations and clinical course are described for six children and adolescents with bone marrow monosomy 7. One child with secondary acute myelogenous leukemia had monosomy 7 plus a marker chromosome; the remaining patients had marrow monosomy 7 as the only karyotypic abnormality. The hematologic abnormalities were diverse, but the majority of patients had a smoldering preleukemic or myeloproliferative phase. Leukemic blasts were either undifferentiated or demonstrated evidence of myeloid differentiation. All patients responded poorly to antileukemic therapy. Bone marrow monosomy 7 was observed in one patient with severe marrow hypoplasia. Antileukemic therapy in another patient with greater than 30 per cent marrow blasts was associated with the development of a bone marrow myeloproliferative disorder with persistence of the monosomy 7 karyotype. We speculate that monosomy 7 may be a specific marker for a pluripotent hematopoietic stem cell abnormality that is associated with either blastic leukemia or a myeloproliferative disorder.     

Axillary lymph node metastases in breast cancer: preoperative detection with US

The importance of axillary node status in the prognosis of breast cancer led the authors to conduct a prospective study comparing the value of clinical examination with ultrasound (US) performed by a transpectoral approach. All 60 patients examined underwent axillary dissection. Sensitivity was 45.4% for clinical examination versus 72.7% for US. US provides valuable information for breast cancers treated solely by irradiation, after insufficient dissection, and for large tumors not amenable to primary surgery. When the nodal region is treated by surgery and/or radiotherapy, local monitoring with US appears unnecessary owing to the low incidence of nodal recurrence.