Multiphasic helical CT criteria for differentiation of recurrent neoplasm and desmoplastic reaction after laparoscopic resection of renal mass lesions

BACKGROUND AND PURPOSE: Differentiation of recurrent neoplasm and desmoplastic reaction following laparoscopic resection of renal mass lesions poses a problem. The usefulness of multiphasic helical CT-generated criteria based on enhancement and morphologic characteristics was investigated. PATIENTS AND METHODS: The findings in 5 female and 12 male patients aged 29 to 68 years having renal-cell carcinoma (11-38 mm; N = 15) or solitary angiomyolipomas (N = 2) treated by laparoscopic resection (N = 15) or open segmental surgery (N = 2) were analyzed. Multiphasic helical CT was performed in the preenhancement, arterial corticomedullary, parenchymal, and excretory phases generating 2.5- to 7-mm slices. RESULTS: Both recurrent neoplasms showed median postcontrast enhancement of 119 HU in the arterial corticomedullary phase; the median enhancement of desmoplastic masses was 48 HU. In the parenchymal and excretory phase, recurrent neoplasms showed progressive loss of enhancement, whereas desmoplastic lesions sustained enhancement at about the same level. Recurrent neoplasms presented a defined mass with characteristic spiculation, whereas desmoplastic reaction was characterized by an ill-defined mass with spidery projections extending to abutting fat and residual fascial planes. On 2- to 3-month follow-up scans, recurrent neoplasms showed progressive increases in size and desmoplastic reaction a sharp decrease. CONCLUSION: Enhancement of the mass at the operative site on arterial corticomedullary-phase CT to >90 HU strongly suggests recurrent renal-cell carcinoma, while progressive decrease in size on 1- to 3-month follow-up CT suggests a desmoplastic reaction.     

Postoperative mortality after nontraumatic lower extremity amputation in patients with renal insufficiency

Mortality rates after lower extremity amputation are extremely high among dialysis patients. However, the impact of milder degrees of renal insufficiency on death rates after lower extremity amputation has not been carefully examined. In this study, the authors used data from the Department of Veterans Affairs' National Surgical Quality Improvement Program (NSQIP) to measure the association between renal dysfunction and 30-d mortality after nontraumatic amputation adjusted for confounders. The study population consisted of 16,994 patients undergoing their first NSQIP recorded amputation from January 1, 1994 through September 30, 2001. Thirty-five percent of all cohort patients had at least moderate renal insufficiency, and 52% of all postoperative deaths occurred in this group. Postoperative mortality was 9% in patients with moderate renal insufficiency, 15% in patients with severe renal insufficiency, and 16% in dialysis patients, compared with 6% in patients with normal or mildly reduced renal function. Renal insufficiency remained associated with death after adjustment for confounders (adjusted odds ratio [OR] 3.36, 95% confidence interval [CI] 2.75 to 4.10 [dialysis patients]; OR 2.54, CI 2.06 to 3.14 [severe renal insufficiency]; and OR 1.52, CI 1.32 to 1.76 [moderate renal insufficiency]). In conclusion, even moderate renal insufficiency is independently associated with postoperative death after lower extremity amputation. This finding highlights the need for a targeted approach to improving the care of patients with renal insufficiency undergoing lower extremity amputation.     

Nutritional indicators, peripheral blood lymphocyte subsets and survival in an institutionalised elderly population

The objectives of this study were to determine the percentage and absolute counts of the peripheral blood lymphocyte subsets, and to examine the relationship between lymphocyte subsets and nutritional status, and total mortality in an institutionalised elderly population. Design The study had a cross-sectional and observational design. The sample of 115 permanent elderly residents was drawn from large geriatric institution in Melbourne, Australia. The main outcome measures were as follows: (i) percentages and absolute counts of lymphocyte subsets, (ii) association between biochemical indices of nutritional status (ferritin, iron and zinc) and peripheral blood lymphocyte subsets, (iii) total mortality during a 22-month period in relation to baseline lymphocyte subset counts. Women had higher absolute counts of various lymphocyte subsets than men. Positive correlations of serum ferritin with the number of CD8 (T-suppressor cell) and of serum iron with CD56 (natural killer, NK cells) were observed in men. In women, serum zinc was positively correlated with the absolute counts of CD3 (total T-cells), CD4 (T-helper cell) and CD19 (total B-cell). The analysis of survival data after 22 months showed that the mean number of CD4 cells of non-survivors (524 +/-292 x10(6)cells/L) was significantly lower than that of survivors (759+/-292 x 10(6) cells/L). The biochemical indicators of iron and zinc status partly account for variations in lymphocyte subset counts, consistent with known effects of iron overload and of zinc deficiency on immunocompetence. The number of CD4 T-cells may be useful in the prediction of total mortality in an institutionalised elderly population.     

Extended spectrum beta-lactamase producing organisms at the University Hospital of the West Indies

Extended spectrum beta-lactamases (ESBL) represent a major group of beta-lactamases that have the ability to inactivate beta-lactam antibiotics containing an oxyimino group such as third generation cephalosporins and monobactams. These enzymes are produced by gram negative organisms, especially members of the Enterobacteriaceae family such as Klebsiella pneumoniae and Escherichia coli. The prevalence of these organisms varies widely internationally, as well as within the same country. This is the first study on ESBL production in K pneumoniae and E coli at the University Hospital of the West Indies, a tertiary care hospital in Jamaica. Two-hundred and sixty-four isolates of K pneumoniae and 300 isolates of E coli were collected over the study period January 2002 to December 2002. Forty-eight (18.2%) K pneumoniae isolates were confirmed to be ESBL producers, while there was no ESBL producing E coli. Infections with ESBL producing organisms can pose a therapeutic challenge, leading to treatment failure if the wrong class of antibiotics is used. With increasing resistance to all classes of antibiotics, there is a narrowing of available treatment options. It is very important that these organisms be monitored and antibiotic policies as well as infection control policies be in place to curtail their spread.     

Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners' accounts

How family doctors conceptualise chronic illness in the consultation has important implications for both the delivery of medical care, and its experience by patients. In this paper, we present the results of a re-analysis of qualitative data collected in a series of studies of British family doctors between 1995 and 2001, to explore the ways in which the legitimacy and authority of medical knowledge and practice are organised and worked out in relation to three kinds of chronic illness (menorrhagia; depression; and chronic low back pain/medically unexplained symptoms). We present a comparative analysis of (a). the moral evaluation of the patient (and judgements about the legitimacy of symptom presentation); (b). the possibilities of disposal; and (c). doctors' empathic responses to the patient, in each of these clinical cases. Our analysis defines some of the fundamental conditions through which general practitioners frame their relationships with patients presenting complex but sometimes diffuse combinations of 'social', 'psychological' and 'medical' symptoms. These are fundamental to, yet barely touched by, the increasingly voluminous literature on how doctors should interact with patients. Moving beyond the individual studies from which our data are drawn, we have outlined some of the highly complex and demanding features of what is often seen as routine and unrewarding medical work, and some of the key requirements for the local negotiation of patients' problems and their meanings (for both patients and doctors) in everyday general practice.     

Fetal serum alpha-fetoprotein in alloimmunised pregnancies

OBJECTIVES: Maternal serum alpha-fetoprotein (AFP) levels have been known to be increased in red blood cell alloimmunisation. Since AFP is now thought be a pro-erythropoietic factor, we wished to evaluate fetal serum levels of AFP in cases of alloimmunised pregnancies. METHODS: We studied AFP levels in 32 fetal serum samples from women with red blood cell alloimmunisation at the time of the first fetal blood sampling. We expressed the levels of AFP and haemoglobin as absolute numbers and as delta values (number of SDs by which the observed value differed from the normal mean for the same gestation). Main outcome measures were fetal serum AFP levels and fetal haemoglobin concentration. RESULTS: Overall, fetal AFP level was higher than normal in the cases (delta values 2.4 +/- 5.5 SD). However, mildly affected non-hydropic cases had higher levels than severely affected fetuses with hydrops. CONCLUSIONS: Fetuses affected by red blood cell alloimmunisation have increased levels of serum AFP but these levels fall back to low levels in severe anaemia especially with hydrops, which could represent the failing of a compensatory erythropoietic mechanism. Our results suggest that fetal haematopoiesis is activated early in red blood cell alloimmunisation but was subsequently impaired.     

Misoprostol for women's health: a review

OBJECTIVE: To review published literature on misoprostol for women's health indications to provide a synthesis of available information and highlight areas in need of additional research. DATA SOURCES: Studies were identified through searches of medical literature databases including MEDLINE, Cochrane Database, and Popline, in addition to a review of references from identified articles. STUDY SELECTION: We included all studies reported in English and published before March 31, 2001, which evaluated the efficacy of misoprostol alone for labor and delivery, evacuation of the uterus after pregnancy failure and induced abortion. Studies were not excluded based on quality or sample size. TABULATION, INTEGRATION, AND RESULTS: Misoprostol shows promise for all of the women's health indications addressed. Currently available data, though, are often hard to interpret because of variations in regimen, dose, and outcome measures. The low cost, ease of administration and storage, and widespread availability of misoprostol make it particularly appealing for developing countries. Because many of the women's health problems for which misoprostol could be prescribed currently cause significant mortality and morbidity, increased access to and information on use of misoprostol could help improve women's health especially where these problems are most severe. CONCLUSION: Further research is needed to identify optimal regimens for misoprostol for obstetric and gynecologic health indications. Registering misoprostol with national drug regulatory authorities for any of several women's health indications could help increase access to and safe use of this drug. Provider training would be a logical subsequent step.     

The effect of in utero exposure to indomethacin on the need for surgical closure of a patent ductus arteriosus in the neonate

OBJECTIVE: Our purpose was to determine the effect of in utero exposure to indomethacin on the need for surgical closure of a patent ductus arteriosus (PDA). STUDY DESIGN: Perinatal variables were compared between infants at <32 weeks who required surgical closure of PDA after failed medical management and those who did not. Statistical analysis was performed by Student t, Mann-Whitney, chi(2), and multiple logistic regression tests. RESULTS: Eight of 77 infants with PDA failed therapy and required surgery. Maternal demographics, gestational age, birth weight, and delivery route were similar in both groups. In utero exposure to indomethacin was more common in neonates requiring surgery versus those who did not, particularly when exposure was for >72 hours (50.0% vs 8.7%, odds ratio 10.5, 95% CI 1.6-72.1, P =.008). CONCLUSION: Need for surgical closure of PDA appears to be increased by in utero indomethacin exposure. These findings should be considered in the overall context of the risk versus benefits of tocolysis.     

Predicting death from HIV/AIDS: a case-control study from Florida public HIV/AIDS clinics

BACKGROUND: After markedly decreasing for 3 years, HIV/AIDS mortality declined only slightly in 1999. METHODS: The authors conducted a case-control study in four Florida urban public health HIV clinics to evaluate modifiable factors associated with HIV/AIDS mortality in a non-research setting. Structured chart review was conducted for 120 case-patients who died in 1999 and for 240 randomly selected control-patients. Risk factors associated with death in univariate analysis were entered into three conceptually related, matched logistic regression models. RESULTS: In the final multivariate model, homelessness (adjusted odds ratio [AOR], 9.98; 95% confidence interval [CI], 2.34-42.5), Medicaid insurance (AOR, 3.10; 95% CI, 1.43-6.74), having a documented adherence problem (AOR, 3.50; 95% CI, 1.64-7.47), injection drug use (AOR, 2.46; 95% CI, 1.11-5.43), non-specific liver failure (AOR, 76.9; 95% CI, 6.79-870.9), interrupted highly active antiretroviral therapy (HAART) secondary to side effects (AOR, 4.00; 95% CI, 1.46-10.9), and not receiving HAART (AOR, 2.62; 95% CI, 1.03-6.68) were independent predictors of mortality. CONCLUSIONS: In addition to medical and clinical indicators, several sociobehavioral-demographic factors remained important throughout the multivariate analysis. Improvement in care should include a focus on social circumstances of infected people. Special attention to the homeless, those with adherence problems, and those with liver disease is clearly indicated.     

Peripheral deletion of autoreactive CD8 T cells by cross presentation of self-antigen occurs by a Bcl-2-inhibitable pathway mediated by Bim

By transgenic expression of ovalbumin (OVA) as a model self antigen in the beta cells of the pancreas, we have shown that self tolerance can be maintained by the cross-presentation of this antigen on dendritic cells in the draining lymph nodes. Such cross-presentation causes initial activation of OVA-specific CD8 T cells, which proliferate but are ultimately deleted; a process referred to as cross-tolerance. Here, we investigated the molecular basis of cross-tolerance. Deletion of CD8 T cells was prevented by overexpression of Bcl-2, indicating that cross-tolerance was mediated by a Bcl-2 inhibitable pathway. Recently, Bim, a pro-apoptotic Bcl-2 family member whose function can be inhibited by Bcl-2, was found to play a critical role in the deletion of autoreactive thymocytes, leading us to examine its role in cross-tolerance. Bim-deficient T cells were not deleted in response to cross-presented self-antigen, strongly implicating Bim as the pro-apoptotic mediator of cross-tolerance.