Granular cell tumor of the vulva: six new cases

Granular cell tumors are rare neoplastic skin and soft tissue lesions: only 1–2% are malignant. Five to sixteen percent occur in the vulva. We present our experience with granular cell tumors of the vulva in six patients, all of whom had wide local excisions and were followed-up in our outpatient clinic for 3–171 months. One died of an unrelated cause. None of the others has evidence of the disease. Rabin Medical Center is affilated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel     

Left ventricular apical ballooning: not an uncommon variant of acute myocardial infarction in women

BACKGROUND: Left ventricular apical ballooning, a new syndrome recently described in Japan, is characterized by chest pain, electrocardiographic changes mimicking acute myocardial infarction, and transient apical dyskinesia with normal coronary arteries. Although several studies have defined the clinical characteristics, the prevalence of this syndrome remains unclear. HYPOTHESIS: This study sought to determine the prevalence of left ventricular apical ballooning syndrome. METHODS: From January 2002 to September 2004, clinical, echocardiographic, and angiographic data of hospitalization and follow-up were collected from 638 consecutive patients referred to our Heart Institute for primary percutaneous intervention. RESULTS: Thirteen patients (2%) were diagnosed with transient left ventricular apical ballooning. All but one patient were women, representing a 6% incidence for the female patients with acute myocardial infarction. A triggering factor was identified in eight. One patient died of cardiogenic shock. Left ventricular systolic function recovered completely within 4-5 weeks in the remaining 12 survivors. CONCLUSION: This syndrome is not uncommon and should be considered particularly in female patients presenting with acute myocardial infarction.     

Nurses as information providers: facilitating understanding and communication of statistical information

Nurses are increasingly being called upon to be the conveyers of important statistical information to patients. This trend is particularly evident in the domains of genetics and cancer screening. These new roles, however, demand new competencies, such as the ability to solve statistical problems, and the skill to communicate the answers effectively, as effective communication is an important ingredient in shared decision making. Genetic testing, perhaps more than other medical domains, relies heavily on the use of statistics. Being able to convey statistical information effectively is vital. In this paper, we illustrate the problems health care professionals have had in tackling and communicating statistical information. We introduce the natural frequencies method of solving Bayesian inference problems and review empirical evidence that shows the superiority of this format. Being able to transform probabilities into natural frequencies facilitates correct Bayesian inferences. It is argued that the conventional approach to educating nurses in Bayesian problem solving should be reconsidered and their statistical curriculum should be supplemented with instruction in using the natural frequency format.     

Gonadotropin-releasing hormone induces apoptosis of prostate cancer cells: role of c-Jun NH2-terminal kinase, protein kinase B, and extracellular signal-regulated kinase pathways

A standard therapy used today for prostate cancer is androgen ablation by gonadotropin-releasing hormone analogs (GnRH-a). Although most patients respond to androgen ablation as an initial systemic therapy, nearly all cases will develop androgen resistance, the management of which is still a major challenge. Here, we report that GnRH-a can directly induce apoptosis of the androgen-independent prostate cancer-derived DU145 and PC3 cell lines. Using specific inhibitors, we found that the apoptotic effect of GnRH-a is mediated by c-Jun NH2-terminal kinase (JNK) and inhibited by the phosphatidylinositol 3'-kinase (PI3K)-protein kinase B (PKB) pathway. Indeed, in DU145 cells, GnRH-a activates the JNK cascade in a c-Src- and MLK3-dependent manner but does not involve protein kinase C and epidermal growth factor receptor. Concomitantly, GnRH-a reduces the activity of the PI3K-PKB pathway, which results in the dephosphorylation of PKB mainly in the nucleus. The reduction of PKB activity releases PKB-induced inhibition of MLK3 and thus further stimulates JNK activity and accelerates the apoptotic effect of GnRH-a. Interestingly, extracellular signal-regulated kinase is also activated by GnRH-a, and this occurs via a pathway that involves matrix metalloproteinases and epidermal growth factor receptor, but its activation does not affect JNK activation and the GnRH-a-induced apoptosis. Our results support a potential use of GnRH-a for the treatment of advanced prostate cancer and suggest that the outcome of this treatment can be amplified by using PI3K-PKB inhibitors.     

Effect of elevated homocysteine levels on clinical restenosis following percutaneous coronary intervention

Since hyperhomocysteinemia confers a prothrombotic effect and promotes proliferation of smooth muscle cells in response to vascular injury, it might be implicated in the pathogenesis of restenosis after percutaneous coronary intervention (PCI). Our study comprised 55 patients who underwent successful PCI in the acute myocardial infarction (AMI) course. Homocysteine levels were determined within 24 h of admission. During a 1-year follow-up, 16 patients (31%) underwent repeated coronary angiography for recurrent angina or re-infarction, which demonstrated re-narrowing of > or =50% at the qualifying PCI site (clinical restenosis). Irrespective of stent deployment, clinical restenosis was not associated with higher homocysteine levels (12 +/- 7 vs. 14 +/- 11 micromol/l, p = 0.77). There was no correlation between homocysteine levels and time to restenosis (r(2) = 0.06, p = 0.35). In conclusion, elevated homocysteine levels do not predict a higher incidence of restenosis after PCI.     

Psychosocial Adaptation to Epilepsy: The Role of Coping Strategies

This article begins by reviewing the literature on the concept of psychosocial adaptation to impairment among persons with epilepsy. Particular attention is devoted to those roots reasoned to lie at the base of psychosocial problems manifested by people with epilepsy. The research literature on coping with epilepsy is then reviewed in two areas: (a) general coping styles and their relationship to psychosocial adaptation, and (b) specific coping strategies and their association with adaptation to epilepsy. Next, clinical implications of these findings are briefly outlined. The article concludes with a discussion of research limitations identified in the conceptualization and measurement of coping, followed by suggestions for future research on coping and adaptation to epilepsy.     

Colonic Epithelial Proliferation Indices Before and After Colon Cancer Removal

Rectal mucosal (epithelial) proliferation labeling indices (LI) have been widely used as a risk marker for colorectal cancer and as an intermediate end-point in chetno-prevention studies. The purpose of this study was to determine whether the presence of cancer preoperatively altered the LI and whether these LI could be used over the long term us a market for colon cancer. We studied 25 patients (18 with colorectal cancer and 7 with benign colonic diseases) who were admitted for colonic resection. Biopsies for thymidine LI were taken before, during, and 4 and 7 months after the operation. The preoperative LI of cancer patients was higher, but not significantly, than that of noncancer patients (5.22 5 3.54 and 4.11 ± 1.34%, respectively, p = 0.28). The intraoperative LI was significantly higher than the preoperative LI (8.08 ± 4.00 and 4.90 ± 3.07%, respectively; p = 0.004). After 4 and 7 months, the LI was not significantly different from the preoperative LI (p= 0.60 and 0.89, respectively). Resection of a colonic segment did not affect the level of proliferation over time. Therefore, it is unlikely that LI can be used as a marker to predict local recurrence after curative resection of colorectal cancer.     

Acute acalculous cholecystitis due to an incarcerated epigastric hernia

A case of a 96 year old woman with an incarcerated gallbladder in an epigastric hernia causing acute acalculous cholecystitis is described. At operation the gallbladder was replaced in its anatomical site and the hernia was repaired. This unique case of acute acalculous cholecystitis demonstrates cystic duct obstruction and cystic vessel compression as possible aetiologies for this pathology.     

Pretreatment tumour volume measurement on high-resolution magnetic resonance imaging as a predictor of survival in cervical cancer

OBJECTIVE: To evaluate pretreatment tumour volume as a predictor of survival in patients with cervical cancer using both endovaginal and external coil magnetic resonance imaging in order to achieve high spatial resolution and delineate small volume disease. DESIGN: A retrosfection case series. SETTING: A tertiary referral centre for gynaecological oncology. POPULATION/SAMPLE: One hundred and six consecutive women with invasive carcinoma of the cervix underwent endovaginal and external coil magnetic resonance imaging on a 0.5-T or 1.5-T scanner. METHODS: T2-W FSE images, sagittal and transverse to the cervix, were obtained and tumour volume was calculated on the sagittal images by the standard technique of multiplying the sum of the areas by the slice thickness. Patients were treated in accordance with normal clinical practice and their subsequent outcome was recorded. The relationships between clinical or imaging parameters and survival were assessed with Cox's proportional hazard method. MAIN OUTCOME MEASURES: Disease-free survival. RESULTS: In 89 of these women, the tumour was Stage I and 88 of the 106 were treated principally by surgery. The median tumour volume was 4.75 cm(3) (upper and lower quartiles 22 and 0.6). The median length of follow up of surviving patients was 223 weeks (quartiles 158 and 274 weeks). Stage, treatment type, lymphovascular space involvement, invasion of the parametrium, closeness of the excision margin, lymph node metastases, and magnetic resonance imaging measurements of tumour volume, parametrial invasion and lymph node disease were all significantly associated with survival in univariate analysis. Only magnetic resonance imaging measurement of tumour volume remained consistently and strongly associated with survival after multivariate analysis of parameters available prior to treatment (P= 0.001, Wald statistic 10.74). A receiver operating characteristic curve of tumour volume and disease-free survival confirmed the utility of this investigation and suggested that a cutoff around 13.0 cm(3) would predict survival with a positive predictive value of 0.93 and a negative predictive value of 0.75. CONCLUSION: Magnetic resonance imaging assessment of tumour volume using both an endovaginal and an external coil approach provides an accurate prediction of prognosis in cervical cancer and defines a population of women at high risk of recurrence and death. The predictive value of this investigation is superior to the clinical and histological parameters previously used. Use of this technique permits a more accurate choice of treatment options. These results suggest that it is the size of tumour burden that determines the outcome rather than invasion beyond the anatomical margins of the uterus.