Change in proptosis following extraocular muscle surgery: effects of muscle recession in thyroid-associated orbitopathy.

PURPOSE: To evaluate the effect of strabismus surgery on proptosis in patients with thyroid-associated orbitopathy. METHODS: The medical records of 22 consecutive patients with thyroid-associated orbitopathy undergoing strabismus surgery were reviewed. Data pertaining to the number of muscles operated on, amount of muscle recession, prior orbital decompression, and exophthalmometry were evaluated. RESULTS: Thirty-eight eyes in 22 patients with thyroid-associated orbitopathy were studied before and after strabismus surgery. The mean change in exophthalmometry following strabismus surgery in all eyes was +0.6 mm (p < 0.01). Eyes with prior decompression averaged a 0.9 mm increase following strabismus surgery (p < 0.01); those without decompression averaged a 0.2 mm decrease (p = 0.658). In eyes that underwent two rectus muscle recessions the increase in Hertel measurements averaged 1.2 mm; when only one muscle was recessed, the average increase was 0.2 mm. In the eyes with muscle recession < or =5 mm, the mean exophthalmometric increase was 0.7 mm. When a muscle recession of more than 5 mm was performed, the exophthalmometry showed a mean increase of 0.5 mm. CONCLUSIONS: Strabismus surgery on patients with thyroid-associated orbitopathy can worsen proptosis, especially in those with prior decompression. When planning for orbital decompression, the surgeon should consider this effect. Moreover, patients should be made aware of the possible changes to their appearance.     

Angiotensin II subtype 1 receptor blockade inhibits Clostridium difficile toxin A-induced intestinal secretion in a rabbit model

Angiotensin II (ANG II) has been described in the regulation of intestinal secretion and absorption via angiotensin subtype 1 (AT(1)) and AT(2) receptors, respectively, in rats. We investigated the role that ANG II plays in the rabbit ileal-loop model of Clostridium difficile infection. Expression of AT(1), the more abundant ANG II receptor, was demonstrated in ileal loops, and an AT(1) receptor blocker, losartan, inhibited hypersecretion induced by C. difficile toxin A (mean volume : length ratio, 0.27+/-0.06 vs. 0.60+/-0.06 mL/cm in controls). Losartan also decreased production of ANG II in the ileum (0.48+/-0.06 vs. 0.87+/-0.12 pg/mg in controls), raising the possibility that ANG II may participate in a positive feedback loop involving the hypersecretory response. Our findings suggest that ANG II plays a significant role in the pathogenesis of C. difficile toxin-induced diarrhea.     

Measuring the effect of a large reduction in welfare payments on mental health service use in welfare-dependent neighborhoods

BACKGROUND: Major social policy changes were implemented in Canada in the last decade with few efforts to examine their potential health effects. OBJECTIVES: We sought to determine the impact of a large reduction in welfare benefits on use of ambulatory physician mental health services in areas with high levels of welfare dependency relative to areas with low levels of welfare dependency. METHODS: The setting was Toronto, Canada. Data sources included census, provincial health insurance, and municipal welfare data. We used generalized estimating equations to compare ambulatory mental health service rates by neighborhood level of welfare dependency before and after a 21.6% reduction in welfare payments. RESULTS: There were no long-term relative differences by welfare dependency in mental health service use before compared with after the policy change. There was a very small short-term increase in mental health visits to generalists in the 6 months after the policy change. We demonstrated a marked gradient in psychiatric service use with low welfare dependency areas having significantly higher rates of use than high welfare dependency areas. CONCLUSIONS: We demonstrated a mismatch between known levels of need for care and levels of psychiatric use. We conclude that where use of services is not tightly linked to need for services, utilization data may be unsuitable for evaluating programs or policies. Social policy changes with potential health effects should have integrated evaluations planned at the time of policy implementation.     

Quantitative trait loci associated with elevated thyroid-stimulating hormone in the Wistar-Kyoto rat

Thyroid hormones are essential for the regulation of developmental and physiological processes. The genetic factors underlying naturally occurring variability in mammalian thyroid function are, however, only partially understood. Genetic control of thyroid function can be studied with animal models such as the inbred Wistar-Kyoto (WKY) rat strain. Previous studies established that WKY rats have elevated TSH, slightly elevated total T3, and normal total T4 levels compared with Wistar controls. The present study confirmed a persistent 24-h elevation of TSH in WKY rats compared with the Fisher 344 (F344) rat, another inbred strain. Acute T3 challenge (25 microg/100 g body weight ip) suppressed serum TSH and T4 levels in both strains. Quantitative trait locus analysis of elevated TSH in a reciprocally bred WKY x F344 F2 population identified one highly significant locus on chromosome 6 (LOD=11.7, TSH-1) and one suggestive locus on chromosome 5 (LOD=2.3, TSH-2). The confidence interval of TSH-1 contains the TSH receptor and type 2 deiodinase genes, and TSH-2 contains the type 1 deiodinase gene. The WKY alleles of each gene contain sequence alterations, but additional studies are indicated to identify the specific gene or genes responsible for altered regulation of the thyroid axis. These findings suggest that one or more genetic alterations within the TSH-1 locus significantly contribute to the altered thyroid function tests of the WKY rat.     

Dietary soy protein and isoflavones have no significant effect on bone and a potentially negative effect on the uterus of sexually mature intact Sprague-Dawley female rats

OBJECTIVE: To evaluate the effect of dietary soy protein and isoflavones on bone and the reproductive tract in premenopausal rats. DESIGN: Three-month-old intact Sprague-Dawley female rats (N = 50) were fed diets containing casein, soy protein, or casein with isoflavone extract for 12 weeks. The amount of casein, soy protein, and extract (per kilogram diet) in each group was: (1) 200 g casein (control); (2) 100 g casein plus 100 g soy protein (low soy); (3) 200 g soy protein (high soy); 4) 200 g casein plus 17.2g extract (low extract); and (5) 200 g casein plus 34.4 g extract (high extract). Diet consumption, body weight, uterine wet weight, urinary deoxypyridinoline concentration, and bone mineral density of the femur and lumbar vertebrae were measured. Femur rigidity was evaluated by histomorphometry. The uterus and vagina were studied histologically. RESULTS: Rats in all treatment groups had lower body weights and lower deoxypyridinoline concentrations compared with controls, but none of the differences was statistically significant. There was no significant difference in femur and lumbar bone mineral density, uterine wet weights, or histomorphometry between the control and treatment groups. Histologically, uteri and vaginae were normal in all groups except that 1 of 10 rats in the high-soy group and 2 of 10 rats in the high-extract group showed extensive squamous metaplasia in the uterine gland. CONCLUSION: These results suggest that dietary isolated soy protein and isoflavones have no effect on bone and the vagina during premenopausal period, but may have an adverse effect on the uterus.     

Perceptions of predisposing and protective factors for perinatal depression in same-sex parents

Increasing numbers of women are choosing to have children in the context of same-sex relationships or as "out" lesbian or bisexual individuals. This study used qualitative methods to assess perceived predisposing and protective factors for perinatal depression in lesbian, gay, bisexual, and queer (LGBQ) women. Two focus groups with LGBQ women were conducted: 1) biological parents of young children and 2) nonbiological parents of young children or whose partners were currently pregnant. Three major themes emerged. Issues related to social support were primary, particularly related to disappointment with the lack of support provided by members of the family of origin. Participants also described issues related to the couple relationship, such as challenges in negotiating parenting roles. Finally, legal and policy barriers (e.g., second parent adoption) were identified as a significant source of stress during the transition to parenthood. Both lack of social support and relationship problems have previously been identified as risk factors for perinatal depression in heterosexual women, and legal and policy barriers may represent a unique risk factor for this population. Therefore, additional study of perinatal mental health among LGBQ women is warranted.     

Clinicopathological features of and risk factors for multiple primary melanomas

Context  The incidence of multiple primary melanomas ranges from 1.3% to 8.0% in large retrospective reviews; however, the impact of certain risk factors is not understood. Objectives  To determine the incidence of multiple primary melanomas (MPM) from a prospective, single-institution, multidisciplinary database, and to describe the clinical and pathological characteristics and risk factors specific to these patients. Design and Setting  Review of a prospectively maintained database at Memorial Sloan-Kettering Cancer Center in New York, NY. Patients  A total of 4484 patients diagnosed with a first primary melanoma between January 1, 1996, and December 31, 2002. Main Outcome Measures  Incidence of and risk factors for MPM. Results  Three hundred eighty-five patients (8.6%) had 2 or more primary melanomas, with an average of 2.3 melanomas per MPM patient. Seventy-eight percent had 2 primary melanomas. For 74% of patients, the initial melanoma was the thickest tumor. Fifty-nine percent presented with their second primary tumor within 1 year. Twenty-one percent of MPM patients had a positive family history of melanoma compared with only 12% of patients with a single primary melanoma (SPM) (P<.001). Thirty-eight percent of MPM patients had dysplastic nevi compared with 18% of SPM patients (P<.001). The estimated cumulative 5-year risk of a second primary tumor for the entire cohort was 11.4%, with almost half of that risk occurring within the first year. For patients with a positive family history or dysplastic nevi, the estimated 5-year risk of MPM was significantly higher at 19.1% and 23.7%, respectively. The most striking increase in incidence for the MPM population was seen for development of a third primary melanoma from the time of second primary melanoma, which was 15.6% at 1 year and 30.9% at 5 years. Conclusions  The incidence of MPM is increased in patients with a positive family history and/or dysplastic nevi. These patients should undergo intensive dermatologic screening and should consider genetic testing.      

Desmoplastic Melanoma: A Pathologically and Clinically Distinct Form of Cutaneous Melanoma

Background Desmoplastic melanoma (DM) is a rare variant characterized by the presence of fusiform melanocytes in a sclerotic stroma. Pathologic heterogeneity within DM may account for the controversy regarding the clinical presentation and prognosis of DM compared with conventional melanoma (CM).Methods We identified 131 patients with a diagnosis of DM seen between 1979 and 2002. Tumors were categorized as either pure DM (pDM; n = 92), if desmoplasia was prominent throughout the entire invasive tumor, or mixed DM (mDM; n = 39), if fibrosis was well developed in only parts of an otherwise non-DM. Differences in clinical behavior among pDM, mDM, and CM (n = 3976) were examined.Results Seventy-three percent of patients with DM had tumors >2 mm in depth, compared with 31% of patients with CM (P < .001). Regional nodal metastasis was uncommon in patients who presented with clinically localized pDM (1%) compared with those with mDM (10%) or CM (6%) (P < .05, pDM vs. CM). Five-year melanoma-specific mortality was lower for patients who presented with pDM compared with mDM (11% vs. 31%; P < .01). Patients with pDM and CM had a similar melanoma-specific mortality despite a 3-fold difference in median tumor depth (3.6 vs. 1.2 mm, respectively).Conclusions DMs can be divided into two subtypes based on a histological quantification of desmoplasia. Tumors with prominent fibrosis (pure subtype) are unlikely to disseminate to regional lymph nodes and are associated with a favorable outcome when compared with those with mixed desmoplasia or CM.