Squamous-cell carcinoma of the anus

Summary The records of 102 patients with squamous-cell carcinoma of the anus are analyzed. A protocol for the evaluation and management of this lesion is outlined. Read before the meeting of the Pennsylvania State Medical Society, Host Farm, Lancaster, Pennsylvania, November 18, 1970.     

Crisis management during anaesthesia: awareness and anaesthesia

Background: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist.

Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for awareness, in the detection and management of potential awareness in association with general anaesthesia.

Method: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

Results: Of the first 4000 reports received by AIMS, there were 21 incidents of patient awareness under general anaesthesia, and 20 of patients being paralysed while awake from "syringe swaps" before induction of anaesthesia. In 12 of the 21 reports there was an obvious cause, most commonly a low concentration of volatile agent (8 of 12 reports). The AIMS "core" crisis management algorithm would have detected the cause of awareness in all of these cases. In nine reports the course of anaesthesia appeared unremarkable, and in these the algorithm would not have been expected to detect or prevent awareness. Volatile agent monitoring would have prevented some cases of awareness, as would bispectral index electroencephalographic (BIS) monitoring. The role of BIS monitoring is still contentious, but it should be considered for high risk patients.

Conclusion: Awareness should be minimised by thorough checking of equipment, particularly vaporisers, and frequent application of a structured scanning routine. Awareness may occur during crisis management and aftermath protocols should include patient follow up to detect and manage awareness when it occurs.

     

Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial

Context  Observational studies have shown that psychosocial factors are associated with increased risk for cardiovascular morbidity and mortality, but the effects of behavioral interventions on psychosocial and medical end points remain uncertain. Objective  To determine the effect of 2 behavioral programs, aerobic exercise training and stress management training, with routine medical care on psychosocial functioning and markers of cardiovascular risk. Design, Setting, and Patients  Randomized controlled trial of 134 patients (92 male and 42 female; aged 40-84 years) with stable ischemic heart disease (IHD) and exercise-induced myocardial ischemia. Conducted from January 1999 to February 2003. Interventions  Routine medical care (usual care); usual care plus supervised aerobic exercise training for 35 minutes 3 times per week for 16 weeks; usual care plus weekly 1.5-hour stress management training for 16 weeks. Main Outcome Measures  Self-reported measures of general distress (General Health Questionnaire [GHQ]) and depression (Beck Depression Inventory [BDI]); left ventricular ejection fraction (LVEF) and wall motion abnormalities (WMA); flow-mediated dilation; and cardiac autonomic control (heart rate variability during deep breathing and baroreflex sensitivity). Results  Patients in the exercise and stress management groups had lower mean (SE) BDI scores (exercise: 8.2 [0.6]; stress management: 8.2 [0.6]) vs usual care (10.1 [0.6]; P = .02); reduced distress by GHQ scores (exercise: 56.3 [0.9]; stress management: 56.8 [0.9]) vs usual care (53.6 [0.9]; P = .02); and smaller reductions in LVEF during mental stress testing (exercise: –0.54% [0.44%]; stress management: –0.34% [0.45%]) vs usual care (–1.69% [0.46%]; P = .03). Exercise and stress management were associated with lower mean (SE) WMA rating scores (exercise: 0.20 [0.07]; stress management: 0.10 [0.07]) in a subset of patients with significant stress-induced WMA at baseline vs usual care (0.36 [0.07]; P = .02). Patients in the exercise and stress management groups had greater mean (SE) improvements in flow-mediated dilation (exercise: mean [SD], 5.6% [0.45%]; stress management: 5.2% [0.47%]) vs usual care patients (4.1% [0.48%]; P = .03). In a subgroup, those receiving stress management showed improved mean (SE) baroreflex sensitivity (8.2 [0.8] ms/mm Hg) vs usual care (5.1 [0.9] ms/mm Hg; P = .02) and significant increases in heart rate variability (193.7 [19.6] ms) vs usual care (132.1 [21.5] ms; P = .04). Conclusion  For patients with stable IHD, exercise and stress management training reduced emotional distress and improved markers of cardiovascular risk more than usual medical care alone.      

Hormonal contraceptive use and the effectiveness of highly active antiretroviral therapy

The role of hormonal contraceptive use in the effectiveness of highly active antiretroviral therapy (HAART) was examined among participants in the Women's Interagency HIV Study who were followed from HAART initiation to 2001. Propensity score selection was used to match 77 hormonal contraceptive users with 77 nonusers on age, race, and pre-HAART CD4-positive T-lymphocyte (CD4+ cell) count and viral load. The authors compared hormonal contraceptive users and nonusers with regard to the CD4+ cell count and viral load responses to HAART upon initiation. Proportional hazards analyses were used to assess the effect of hormonal contraceptive use on times to increases in CD4+ cell count of 50 cells/mm(3) and 100 cells/mm(3) and achievement of an undetectable viral load. There were no statistically significant differences in CD4+ cell counts and log viral load responses by hormone use after HAART initiation, except in log viral load at the third visit after initiation (p = 0.047). Time-dependent hormonal contraceptive use was not a statistically significant predictor of achieving increases in CD4+ cell count of 50 cells/mm(3) and 100 cells/mm(3) or an undetectable viral load (p = 0.517, p = 0.751, and p = 0.218, respectively) after HAART initiation. In conclusion, the authors did not find substantial evidence that use of hormonal contraceptives strongly affected responses to HAART.     

Malignant degeneration in ulcerative colitis

Summary and Conclusions A case of carcinoma of the colon complicating chronic ulcerative colitis of long duration in a 31-year-old patient has been presented. It has been stated once more that there is a much higher incidence of cancer in patients with this disease than in the normal population. The incidence becomes extremely great as the duration of the disease increases. The virulence of malignant disease in chronic ulcerative colitis has been stressed and the poor prognosis emphasized. It is the authors’ considered opinion that the patient with ulcerative colitis should have periodic proctoscopic and roentgenologic examinations and that surgery should be performed whenever localized changes are revealed on roentgenologic examination after the patient has harbored the disease for 5 years or more.     

Polyarteritis nodosa in children: radiological aspects and diagnostic correlation

The radiological findings in 14 children with polyarteritis nodosa (PN) were evaluated in relation to clinical, laboratory, and histological findings. In this series, there were two major groups of radiological findings, one associated with renal insufficiency and the other with intestinal vascular insufficiency. No radiographic finding was pathognomonic. Two patients were suspected of having small bowel intussusception (SBI), and SBI was documented at laparotomy in a third patient. The diagnosis and management of PN in children is dependent upon the correlation of clinical and laboratory findings. Associated pertinent radiological features which may be useful in the management of children with PN are reviewed.     

A simplified method for the diagnosis of cancer of the colon by exfoliative cytology

Summary A simplified method for the cytologic diagnosis of cancer of the colon is presented. A greater clinical trial of this diagnostic method seems warranted. Read at the meeting of the American Proctologic Society, Houston, Texas, April 25 to 27, 1960. Resident in Department of Proctologic Surgery; now practicing in Houston, Texas. Resident in Pathology. Study supported by the William Goldman Cancer Research Fund.