FRANTZ'S TUMOUR: PAPILLARY AND CYSTIC CARCINOMA OF THE PANCREAS

Frantz's tumour (papillary and cystic tumour) of the pancreas is a rare neoplasm usually seen in young women. It is of low grade malignancy and deserves special note among pancreatic malignancies as it is frequently amenable to local resection and has a good long-term survival rate after excision. Three such cases have been treated at Westmead Hospital, one young male and two females. In two the disease was confined to the pancreas. In one, local invasion outside the pancreas and trans-coelomic spread to the ovaries was present at the time of diagnosis. Complete surgical removal of macroscopic disease was achieved in all three and all remain disease free between 2 and 4 years post-surgery. All have good exocrine and endocrine pancreatic function. These cases are discussed in detail. The need to be aware of this uncommon variant of pancreatic cancer is stressed. Investigation and treatment options are reviewed. The role of cytology studies in diagnosis and the potential for long-term surgical control of this tumour are highlighted on the basis of our limited experience and that presented in recent surgical literature.     

Early diagnosis of SARS: lessons from the Toronto SARS outbreak

The clinical presentation of SARS is nonspecific and diagnostic tests do not provide accurate results early in the disease course. Initial diagnosis remains reliant on clinical assessment. To identify features of the clinical assessment that are useful in SARS diagnosis, the exposure status and the prevalence and timing of symptoms, signs, laboratory and radiographic findings were determined for all adult patients admitted with suspected SARS during the Toronto SARS outbreak. Findings were compared between patients with laboratory-confirmed SARS and those in whom SARS was excluded by laboratory or public health investigation. Of 364 cases, 273 (75%) had confirmed SARS, 30 (8%) were excluded, and 61 (17%) remained indeterminate. Among confirmed cases, exposure occurred in the healthcare environment (80%) or in the households of affected patients (17%); community or travel-related cases were rare (<3%). Fever occurred in 97% of patients by the time of admission. Respiratory findings including cough, dyspnea and pulmonary infiltrates evolved later and were present in only 59, 37 and 68% of patients, respectively, at admission. Direct exposure, fever on the first day of illness, and elevated temperature, pulmonary infiltrates, lymphopenia and thrombocytopenia at admission were associated with confirmed cases. Rhinorrhea, sore throat, and an elevated neutrophil count at admission were associated with excluded cases. In the absence of fever or significant exposure, SARS is unlikely. Other clinical, laboratory and radiographic findings further raise or lower the likelihood of SARS and provide a rational basis for estimating the likelihood of SARS and directing initial management.     

Phase I trial of piroxicam in 62 dogs bearing naturally occurring tumors

Summary Piroxicam, a nonsteroidal antiinflammatory drug, was given to 62 dogs bearing naturally occurring tumors in a phase I clinical trial. Dose escalation was performed, with oral doses ranging from 0.5 mg/kg every 48 h (q48h) to 1.5 mg/kg q48h being tested. Dose-limiting gastromestinal irritation/ulceration occurred in all four animals that received 1.5 mg/kg q48h. The maximum tolerated dose was 1 mg/kg q48h. Subclinical renal papillary necrosis occurred in two dogs (initial dosages, 1 and 1.5 mg/kg q48h, respectively). Following dose escalation, an additional group of dogs was treated with 0.3 mg/kg piroxicam q24h per os, the accepted canine dosage prior to this trial. Inclusion of this treatment group enabled evaluation of the toxicity of and tumor response to a daily dosage regimen. No complete remissions occurred in this trial. Partial remission was documented in three of ten dogs exhibiting transitional-cell carcinoma, in three of five animals bearing squamous-cell carcinoma, in one of three dogs displaying mammary adenocarcinoma, and in the one dog that exhibited a transmissible venereal tumor. The results of this study support the additional evaluation of piroxicam in a phase II clinical trial in dogs bearing naturally occurring tumors.This investigation was supported by Pfizer Inc.     

Physician variations and the ancillary costs of neonatal intensive care.

OBJECTIVE: To determine to what degree attending physicians contribute to cost variations in the care of ventilator-dependent newborns. DATA SOURCES: Clinical data were merged with hospital financial data describing daily ancillary care costs during the first two weeks of life for 132 extremely low-birthweight newborns. In addition, each patient's chart was reviewed and illness severity graded using both SNAP and CRIB scores. STUDY DESIGN: This was a retrospective cohort of infants with birth weights of less than 1,001 grams and respiratory distress syndrome requiring mechanical ventilation in the first day of life. From birth up to two weeks of life, each received care directed by only one of 11 faculty neonatologists in a single university hospital. Data were analyzed stratified by these physicians. t-Test, ANOVA, and chi-square were used to assess bivariate data. For continuous data, log linear regressions were used. PRINCIPAL FINDINGS: After controlling for illness severity, when stratified by physicians, there were significant variances in the costs of ancillary resources for the study infants (p < .0001). Twenty-nine percent of the variance was attributable to whether or not the hospital day included the use of a ventilator. Physician identity explained only 5.6 percent (p < .0001). CONCLUSIONS: Physician identity was significant but explained less than 6 percent of the total variance in ancillary costs. Whether or not a ventilator was used during care was far more important. We conclude that for very sick babies during the first two weeks of care, reducing variations in ancillary services utilization among neonatologists will yield only modest savings.     

Intractable Diarrhea from Carbamazepine

Diarrhea has been reported as an early, mild, and uncommon complication of carbamazepine (CBZ) therapy. We report three cases of intractable diarrhea induced by CBZ necessitating discontinuation of the drug.     

Correlation between the induction of an immediate early gene, zif/268, and long-term potentiation in the dentate gyrus.

Expression of the immediate early gene zif/268 (also termed NGFI-A, Krox 24, TIS8 and Egr-1) was investigated in awake rats following various long-term potentiation (LTP) induction protocols.zif/268 mRNA (Northern blots) and protein (immunohistochemistry) levels sharply increased following LTP, and followed a time course characteristic of other immediate early genes. When measured across 3 tetanization protocols known to produce differing degrees of LTP persistence,zif/268 induction was found to be more highly correlated with LTP duration than with the magnitude of initial LTP. These data support the hypothesis that the immediate early gene zif/268 plays a role as a third messenger in the cascade of cellular and nuclear events that govern the persistence of LTP.     

Vertically fused tracheal cartilage. An underrecognized anomaly.

Anterior vertical fusion of the tracheal cartilages with normal pars membranacea is a rarely described tracheal anomaly. We report four cases of this anomaly, three associated with craniosynostosis syndromes and one with Goldenhar's syndrome. The anomaly was documented at postmortem examination in one case, both endoscopically and at tracheotomy in two cases, and endoscopically in one case. Documentation from gross postmortem photographs, photomicrographs, and intraoperative endoscopic photographs is presented so that the anatomical aspects of this anomaly can be thoroughly understood and recognized. All four newborn patients developed recurrent lower respiratory tract infections, reactive airway disease, and chronically retained secretions attributable to this anomaly. Neither tracheal stenosis nor stridor was encountered. In the three surviving patients, the infections grew less frequent and less severe in later childhood. These observations suggest that this tracheobronchial anomaly may be associated with a variety of craniofacial syndromes and may alter airflow dynamics in a way that predisposes to retained secretions and chronic pulmonary disease.     

Laparoscopic partial fundoplication vs laparoscopic Nissen-Rosetti fundoplication

Background: Since 1992, all patients at our institution who have met standard accepted criteria for surgical intervention for complicated gastroesophageal reflux disease have been entered into a prospective sequential clinical study to evaluate outcomes of the laparoscopic approach to the Nissen-Rosetti procedure and a modified Toupet procedure. Methods: A standardized workup with upper GI series, esophagography, and endoscopy was used in all patients. Manometry, pH testing, and other special tests were used selectively. A measuring technique was used to determine wrap size without the use of dilators. The short gastric vessels were left intact in all patients. A cosurgeon approach was used, with technical factors described herein. Results: Some 226 of 231 cases were completed laparoscopically (98%)—125 patients in the Nissen-Rosetti group and 101 in the partial fundoplication group. There were no clinical failures in either group. The partial fundoplication group performed better than the Nissen-Rosetti group in all categories of comparison. Return to normal eating habits was much earlier in the partial wrap group (p < 0.0001). Postop distal esophageal sphincter pressures in the two groups were equal at 15 mmHg. Eight patients suffered significant dysphagia requiring endoscopy and dilatation, all in the Nissen-Rosetti group (p < 0.01). Minor complications occurred in 12% of the total group. There was a total surgical revision rate of 3%. There were no gastric or esophageal perforations. Average operative time was 30 min. Average hospital stay was 1.4 days. Hospital charges for the laparoscopic approach averaged $6,000 dollars compared to $12,000 for the open approach. Conclusion: Laparoscopic partial fundoplication is as effective as laparoscopic Nissen-Rosetti fundoplication, with a higher satisfaction rate and fewer side effects. Measuring for wrap and hiatus size eliminates the need for and risk of using stiff dilators. By utilizing cosurgeons and currently available technology, cost, operative time, hospital time, and complications can be reduced to a finite minimum. Received: 12 December 1995/Accepted: 12 August 1996     

Risk of periodontal defects after third molar surgery: An exercise in evidence-based clinical decision-making.

OBJECTIVE: The object of this study was to apply evidence-based principles to answer the question, What is the risk of having periodontal defects on the distal aspect of the mandibular second molar (M2) following third molar (M3) removal? STUDY DESIGN: To identify relevant articles for review, we completed a computerized literature search of Medline. The inclusion criteria for articles included prospective cohort studies or randomized clinical trials with follow-up periods of 6 months or more, and preoperative and postoperative measurements of periodontal probing depths (PDs) or attachment levels (ALs). RESULTS: Eight articles met the inclusion criteria. Overall, the reported mean changes in ALs or PDs on the distal of M2 6 months after M3 removal were clinically insignificant, ie, less than 2 mm. Six months after M3 removal, 52% to 100% of subjects had no change or improvement in ALs or PDs. Given periodontal disease present preoperatively, the number needed to treat (NNT) ranged from 3 to 10. Given healthy periodontal status preoperatively, 48% had worsening of their periodontal measures after M3 removal and the number needed to harm (NNH) was 2. CONCLUSION: Commonly, the second molar periodontal probing depth or attachment levels either remain unchanged or improve after third molar removal. For subjects with healthy second molar periodontium preoperatively, the indication for third molar removal needs to be evaluated carefully as these subjects have an increased risk for worsening of probing depths or attachment levels after third molar removal.