Computer-assisted diagnosis of rheumatic disorders.

A review of the literature regarding computer-assisted diagnosis of rheumatic diseases is presented. After a general outline of the history and goals of computer programs intended to support physicians in the diagnostic process, 14 systems or projects are described. The scope of seven of these is general internal medicine, and the other seven are intended exclusively for rheumatic problems. The majority of these systems are prototypes. To date, none of them is widely used by physicians. Preliminary evaluation studies and/or independent reviews have been reported for all of the systems. The need for further evaluation studies is recognized, and strategies to carry these out are outlined. Furthermore, the potential usefulness for patient care and education is discussed. It is concluded that a new and interesting field is being developed that deserves more attention among rheumatologists.     

The influence of neonatal thymectomy on the development of radiation myelopathy in rats.

To investigate the possible contribution of cellular immunity in the development of radiation injury of the central nervous system, Wag/Rij rats were thymectomized at birth and irradiated to the cervical spinal cord at the age of 3 months. At the time of paralysis or at the end of the follow-up period (when rats were 1-year-old) the animals were sacrificed and the mediastinum was examined histologically. In 95% of the neonatally thymectomized animals no thymus was left. These rats showed a firm impairment of the cellular immunity, as they had a 40% reduction of the T-lymphocytes in the spleen, and a 70% reduction of the mixed lymphocyte reaction, compared to age-matched controls. Both single dose and two-fraction irradiation experiments were performed. No modification of the latency time to develop paralysis was observed comparing thymectomized and age-matched controls. The incidence of foreleg paralysis after cervical spine irradiation (single dose or two-fraction) was identically distributed in the follow-up period for both neonatally thymectomized and control Wag/Rij rats. The ED50 value derived in the single dose experiments was 20.3 Gy for the control animals, and 20.9 Gy for thymectomized rats, and in the two fraction experiments 29 Gy for controls and 29.6 Gy for thymectomized rats. None of these differences are significant. It appears that neonatal thymectomy, in spite of its firm suppression of the cellular immunity, has no major influence on the development of radiation myelopathy in rats.     

Cellular and humoral reactivity pattern to the mycobacterial heat shock protein HSP65 in adjuvant arthritis susceptible and resistant Wistar rats.

We have analyzed the cellular and humoral immunity to the mycobacterial 65 KDa heat shock protein (hsp65) in a group of Freund's Adjuvant-immunized rats with a limited susceptibility to Adjuvant arthritis. According to the arthritis indices during the period of study (35 days), two different groups of rats could be distinguished; a) autoimmune Adjuvant arthritic rats (AA), and b) Non-arthritic animals (NA), including both rats which did not display any disease symptoms and rats suffering mild transient inflammation. The cellular response to the immunizing agent (Mycobacterium tuberculosis) or the mitogen Concanavalin A was comparable between both groups of rats. However, we detected an impaired cellular response to the individual hsp65 antigen in the animals that did not develop the disease. On the contrary, the level of hsp65-specific antibodies was much higher in NA animals than in AA rats suggesting a protective role for the hsp65 specific antibodies.     

Cardiovascular applications of magnetic resonance imaging and phosphorus-31 spectroscopy.

Recent advances in cardiovascular applications of magnetic resonance (MR) imaging and phosphorus-31 spectroscopy are reported. MR velocity mapping is a valuable adjunct to conventional imaging techniques, providing information on flow velocities as well as on absolute blood flow volume in the aorta and pulmonary arteries. Recently, ultrafast MR techniques have become available to evaluate myocardial perfusion with the aid of MR contrast agents as perfusion marker. Dynamic MR imaging is a powerful tool to assess cardiac function and ventricular mass. In particular, right ventricular function and mass can be evaluated with great accuracy, contributing to improved assessment of the significance of disease processes which may affect the right heart. The role of phosphorus-31 spectroscopy of the heart is expanding for the evaluation of ischemic myocardial disease and cardiomyopathies. The phosphocreatine to adenosine triphosphate ratio appears to be a marker of disease in patients with cardiac hypertrophy. In conclusion, MR imaging and phosphorus-31 spectroscopy is gaining widespread acceptance for evaluation of many cardiovascular disease processes.     

Referral pattern of patients with oral mucosal lesions in The Netherlands

The referral pattern of 140 Dutch patients with oral mucosal lesions, who had been referred to a Department of Oral & Maxillofacial Surgery and Oral Pathology, shows that patients with oral mucosal lesions consult the dentist as often as the family doctor as the first source of help or information. Furthermore, family doctors were much more used to refer patients with oral mucosal disease to medical specialists rather than to the dentist or the oral and maxillofacial surgeon.     

Frequent administration of Dabis Maleate, a phase I study.

Dabis Maleate (1,4-bis(2'-chloroethyl)-1,4-diazabicyclo[2.2.1] Heptane dihydrogen dimaleate) (NSC 262666) is an alkylating quaternary nitrogen compound. In a previous phase I study using a once-every-3-weeks administration the dose-limiting toxicity was neurotoxicity and the recommended dose for phase II studies was 750 mg/m2 iv every 3 weeks. In vitro studies suggested a higher activity after more frequent administration, and in vivo studies a better therapeutic index with prolonged infusion. We studied 11 patients with solid tumors. Dose levels tested ranged from 250-750 mg/m2, either as a day 1-3 regimen or weekly, the latter as bolus administration or as prolonged infusion. The dose-limiting toxicity was neurotoxicity consisting of paresthesias and ataxia. Nausea and vomiting were moderate. No other major toxicity was observed. The dose recommended for phase II studies is 500 mg/m2/week as a 6-hour iv infusion for 6 weeks, followed by a 3-week rest period.     

Is there a place for gastroenterostomy in patients with advanced cancer of the head of the pancreas?

There remains doubt about the need for gastroenterostomy in patients with advanced cancer of the pancreatic head, performed either prophylactically or when passage of food becomes impossible. The records of 142 patients admitted for advanced pancreatic cancer to the Erasmus University Hospital over a period of 11 years were reviewed. We concentrated especially on the pre- and postoperative intake of food in cases involving gastroenterostomy and the morbidity and mortality associated with abdominal surgery in these patients. Of 129 patients without symptoms of gastric outlet obstruction at the time of diagnosis, 31 underwent prophylactic gastroenterostomy. The procedure did not prevent gastric outlet obstruction in 4 patients. Of the remaining 98 patients, 15 developed gastric outlet obstruction. Cox proportional hazards analysis showed no significant difference in the interval to the occurrence of a symptomatic obstruction between these two groups, taking into account other covariables. Postoperative complications and mortality regarding a gastroenterostomy were high, ranging from 9% to 41% and 11% to 33%, respectively. Our results do not indicate that prophylactic gastroenterostomy may significantly prevent future gastric outlet obstruction; therefore, as it also increases morbidity, it should not be performed. A gastroenterostomy to relieve symptoms should be considered carefully, as the success rate is low and is accompanied by a considerable incidence of morbidity and mortality.

---

Resumen Persiste la duda sobre la necesidad de practicar gastroenterostomía en pacientes con cáncer avanzado de la cabeza del páncreas, así sea profiláctica o en presencia de obstrucción al paso de los alimentos. Se revisaron las historias de 142 pacientes con cáncer avanzado de la cabeza del páncreas en el Hospital de la Universidad de Erasmo observados en un periodo de 11 años. El estudio se concentré especialmente sobre la ingesta pre y postoperatoria de alimentos en los pacientos con gastroenterostomía y en la morbilidad y mortalidad asociada con la cirugía abdominal. De 129 pacientes libres de síntomas de obstrucción en el momento del diagnóstico, 31 fueron sometidos a gastroenterostomía profiláctica; el procedimiento no logró prevenir la obstrucción gástrica en 4 casos. De los 98 pacientes restantes, 15 desarrollaron obstrucción gástrico. El análisis proporcional de Cox no demostró diferencia significativa en el intervalo transcurrido hasta la aparición de los sintomas entre los dos grupos, tomando en consideración diversas variables. Las tasas de complicaciones y de mortalidad postoperatoria en relación con la gastroenterostomía fueron elevadas, 9–41% y 11–33%, respectivamente. Nuestros resultados no indican que la gastroenterostomía profiláctica pueda prevenir la obstrucción gástrica y, por cuanto incrementa la morbilidad, no debe ser realizada. La gastroenterostomía por razones de sintomatologia debe ser cuidadosamente considerada, puesto que la tasa de éxito es baja y se acompana de considerable morbilidad y mortalidad.

---

Résumé Réaliser une gastroentérostomie de faÇon prophylactique ou seulement lorsque l'alimentation devient impossible chez un patient ayant un cancer de la tÊte du pancréas reste une question sans réponse. Les dossiers de 142 patients ayant un cancer avancé de la tÊte du pancréas, observés à l'HÔpital Universitaire Erasmus en l'espace de 11 ans, ont été revus. Nous avons noté la possibilité d'alimentation en périodes préet postopératoire ainsi que la morbidité et mortalité en rapport avec la chirurgie chez ces patients. Des 129 patients n'ayant pas de symptÔmes d'obstruction postpylorique au moment du diagnostic, 31 ont eu une gastroentérostomie à titre prophylactique. Cette intervention n'a pu prévenir l'obstruction chez 4 de ces patients. Des 98 autres patients, 15 ont développé une obstruction postpylorique. Une analyse multifactorielle selon le modèle de Cox n'a pu démontrer de différence significative entre les deux groupes pour l'intervalle entre le moment du diagnostic et la survenue de l'obstruction. Le taux de complications et de décès postopératoires après gastroentérostomie était élevée, variant respectivement entre 9% et 41% et 11% et 33%. Nos résultats indiquent que la gastroentérostomie à titre prophylactique ne prévient pas la survenue d'une obstruction postpylorique mais qu'elle accroÎt la morbidité. Dans ces conditions, la gastroentérostomie ne devrait Être réalisée qu'en cas d'obstruction symptomatique, mais en sachant qu'elle n'est pas toujours couronnée de succès et que les taux de mortalité et de morbidité ne sont pas nuls.