Chondrosarcoma of the scapula: long-term oncologic outcome

BACKGROUND: Chondrosarcoma is the second most common primary sarcoma of bone. It often develops within flat bones, such as the pelvis, ribs, and scapula. In the current study, the authors reviewed the surgical experience and long-term oncologic outcomes of patients with chondrosarcoma arising in the scapula. METHODS: The medical records of 29 consecutive patients with chondrosarcoma of the scapula were reviewed. The patients were treated between 1954 and 1994. All patients had localized disease at the time of presentation. The tumors were classified histologically as Grade 1 (10 patients), Grade 2 (10 patients), Grade 3 (7 patients), dedifferentiated (1 patient), and mesenchymal (1 patient) (using the criteria of Evans et al.). The mean maximal dimension of the tumors was 11 cm. Twenty-five patients underwent limb-sparing surgical resection and 4 patients underwent forequarter amputations. The median follow-up was 13 years (range, 1-35 years). RESULTS: At last follow-up, 22 patients (76%) were free of disease and 7 patients (24%) had died of their disease. Local recurrence occurred in 4 patients at 7 months, 16 months, 40 months, and 43 months, respectively. The local recurrence-free survival rate was 86% at 5 years, 10 years, and 20 years. Disease-specific survival was 83% at 5 years, 74% at 10 years, and 74% at 20 years. Patients who had low-grade chondrosarcomas had better survival compared with patients who had high-grade chondrosarcomas (P = 0.07). CONCLUSIONS: Patients who had localized chondrosarcoma of the scapula had a favorable long-term outcome, most likely due to the unique anatomic features that improved the likelihood of achieving wide surgical margins with limb-sparing surgery, despite the frequent presentation of locally advanced disease.     

The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores

The Female Sexual Function Index (FSFI) is a brief multidimensional scale for assessing sexual function in women. The scale has received initial psychometric evaluation, including studies of reliability, convergent validity, and discriminant validity (Meston, 2003; Rosen et al., 2000). The present study was designed to crossvalidate the FSFI in several samples of women with mixed sexual dysfunctions (N = 568) and to develop diagnostic cut-off scores for potential classification of women's sexual dysfunction. Some of these samples were drawn from our previous validation studies (N = 414), and some were added for purposes of the present study (N = 154). The combined data set consisted of multiple samples of women with sexual dysfunction diagnoses (N = 307), including female sexual arousal disorder (FSAD), hypoactive sexual desire disorder (HSDD), female sexual orgasm disorder (FSOD), dyspareunia/vaginismus (pain), and multiple sexual dysfunctions, in addition to a large sample of nondysfunctional controls (n = 261). We conducted analyses on the individual and combined samples, including replicating the original factor structure using principal components analysis with varimax rotation. We assessed Cronbach's alpha (internal reliability) and interdomain correlations and tested discriminant validity by means of a MANOVA (multivariate analysis of variance; dysfunction diagnosis x FSFI domain), with Bonferroni-corrected post hoc comparisons. We developed diagnostic cut off scores by means of standard receiver operating characteristics-curves and the CART (Classification and Regression Trees) procedure. Principal components analysis replicated the original five-factor structure, including desire/arousal, lubrication, orgasm, pain, and satisfaction. We found the internal reliability for the total FSFI and six domain scores to be good to excellent, with Cronbach alpha's >0.9 for the combined sample and above 0.8 for the sexually dysfunctional and nondysfunctional samples, independently. Discriminant validity testing confirmed the ability of both total and domain scores to differentiate between functional and nondysfunctional women. On the basis of sensitivity and specificity analyses and the CART procedure, we found an FSFI total score of 26.55 to be the optimal cut score for differentiating women with and without sexual dysfunction. On the basis of this cut-off we found 70.7% of women with sexual dysfunction and 88.1% of the sexually functional women in the cross-validation sample to be correctly classified. Addition of the lubrication score in the model resulted in slightly improved specificity (from .707 to .772) at a slight cost of sensitivity (from .881 to .854) for identifying women without sexual dysfunction. We discuss the results in terms of potential strengths and weaknesses of the FSFI, as well in terms of further clinical and research implications.     

Exacerbation of acute pancreatitis by combined cholinergic stimulation and duct obstruction

BACKGROUND: The role of cholinergic pathways in the pathogenesis of bile-pancreatic duct ligation (BPDL)-induced acute pancreatitis in rats remains controversial. We hypothesized that cholinergic stimulation exacerbates acute pancreatic inflammation in the presence of duct obstruction. METHODS: We studied 34 rats divided into 5 groups as follows: (1) sham operation; (2) BPDL; (3) BPDL with duodenal bile-pancreatic juice (BPJ) replacement fresh from a donor rat; (4) BPDL with BPJ replacement as in 3 above, and carbachol (CCh) 5 ug/h subcutaneously; or (5) CCh 5 ug/h subcutaneously only. Rats were killed after 6 hours. RESULTS: The P value was less than .05 by analysis of variance. Pancreatic morphologic changes and zymogen fraction hyperamylasemia seen with duct ligation (2 vs. 1) were ameliorated significantly by duodenal BPJ replacement (3 vs. 2), but not when exogenous CCh was administered (4 vs. 3), whereas CCh alone showed no significant changes compared with sham (5 vs. 1). CONCLUSIONS: Cholinergic stimulation and duct obstruction synergistically amplify acinar hyperstimulation and exacerbate acute pancreatitis.     

Dialysate partitioning in the Genius batch hemodialysis system: effect of temperature and solute concentration

BACKGROUND: The Genius batch system contains a 75-L closed reservoir from which fresh dialysate is extracted at the top, and to which spent dialysate is returned at the bottom. In vivo studies have demonstrated that almost the entire amount of dialysate can be used before contamination of fresh with spent dialysate occurs. The question is raised whether density differences cause this separation, and what the relative contributions of temperature and solute content are. METHODS: As patient substitute, a container filled with dialysate was loaded with various amounts of urea. Temperature differences between spent and fresh dialysate were imposed by not heating the dialysate at the outlet line from the dialyzer (A), heating the outlet to obtain continuously equal temperatures at inlet and outlet (B), or to temperatures as in vivo (C). With a dialysate flow set at 300 mL/min, urea is not expected at the inlet before 250 minutes. RESULTS: With a urea concentration of 33 mg/dL, urea contamination at the dialysate inlet line occurred after 185 +/- 20 (A), 122 +/- 11 (B), and 175 +/- 12 minutes (C) of dialysis, whereas with 67 mg/dL, this happened at 219 +/- 5 (A), 162 +/- 11 (B), and 202 +/- 8 minutes (C). With 100 and 150 mg/dL, urea contamination appeared at 224 +/- 2 (A) and 204 +/- 14 minutes (B), and 227 +/- 5 (A) and 232 +/- 3 minutes (B), respectively. CONCLUSION: Both temperature differences between spent and fresh dialysate and solute content of spent dialysate contribute to dialysate partitioning in the Genius dialysis system.     

Polyclonal rabbit antithymocyte globulin triggers B-cell and plasma cell apoptosis by multiple pathways

BACKGROUND: Polyclonal antithymocyte globulin (ATG) is widely used as an anti-T-cell agent for induction and treatment of acute cellular rejection in solid organ transplantation. The authors recently demonstrated that rabbit (r) ATG can be used in combination with plasmapheresis to effectively treat antibody-mediated renal allograft rejection. This observation suggested that rATG may have anti-B cell activity. METHODS: The authors tested the complement-independent, apoptosis-inducing properties of rATG on CD27- naive B cells, CD40 ligand-activated B cells, and plasma cells in vitro by annexin V staining, subdiploid DNA content, caspase activation, and loss of mitochondrial membrane polarity. Potential surface targets for rATG were assayed by competitive inhibition of monoclonal antibody binding. RESULTS: Rabbit ATG strongly induced apoptosis in vitro against naive, activated B cells and bone marrow resident plasma cells at clinically relevant concentrations (1-100 ng/mL). The authors found rATG activity against numerous B-cell surface proteins and observed that crosslinking of CD30, CD38, CD95, CD80, and HLA-DR likely accounts for this activity. F(ab)2 fragments of rATG showed 90% of the activity of the intact molecule, suggesting participation of the Fc fragment. Inhibition of caspase- and cathepsin-dependent apoptotic pathways partially inhibits rATG-induced B-cell apoptosis. Immunohistochemical staining of pediatric thymi demonstrated the presence of CD20+ B cells and CD138+ plasma cells within the thymic parenchyma, which accounts for the anti-B-cell activity in rATG. CONCLUSIONS: Polyclonal rATG induces complement-independent apoptosis of naive, activated, and plasma B cells. This effect appears to involve the caspase- and cathepsin-mediated apoptosis pathways.     

The contribution of hospital volume, payer status, and other factors on the surgical outcomes of scoliosis patients: a review of 3,606 cases in the State of California

While volume/outcomes relationships have been shown for several areas of orthopaedics, previous studies have not examined this relationship in the area of scoliosis surgery. The Office of Statewide Planning and Development (OSHPD) California inpatient discharge database was used for a retrospective review of all patients 25 years of age or younger with a diagnosis of scoliosis and a spinal fusion procedure from 1995 to 1999 (n = 3,606). Univariate and multivariate analyses were conducted to determine the effect of various factors on in-hospital mortality, surgical complications, reoperations, and length of stay (LOS). Univariate analyses revealed significant effects of age, sex, illness severity, neuromuscular disease, surgical approach, Medicaid status, and annual hospital volume on outcomes (P < 0.05). After controlling for these factors using multivariate regression, patients insured by Medicaid were found to have a significantly greater odds for complications (P = 0.017) and a significantly increased LOS (P < 0.001) compared with patients with all other sources of payment. Additionally, multivariate regression revealed an inverse relationship between annual hospital volume and likelihood of reoperation, as patients treated at hospitals with annual volumes of 5.1 to 25.0, 25.1 to 50.0, and greater than 50.0 spinal fusions all had approximately half the odds of reoperation (P = 0.042, P = 0.004, and P = 0.028 respectively) as patients treated at hospitals with an annual volume of 5.0 or fewer spinal fusions per year. The current data suggest that being insured with Medicaid in the state of California is associated with poorer outcomes after scoliosis surgery. Additionally, this study documents a volume/outcomes relationship in scoliosis surgery.     

The prognostic value of pharmacologic stress myocardial perfusion imaging in patients with permanent pacemakers

BACKGROUND: The aim of this study is to assess the prognostic value of pharmacologic stress (adenosine or dipyridamole) myocardial perfusion imaging in patients with permanent electronic ventricular pacemakers. METHODS AND RESULTS: Between October 1986 and December 1995, 93 patients with pacemakers underwent pharmacologic stress testing with myocardial perfusion single photon emission computed tomography imaging. Follow-up information on 91 patients (98%) was obtained. Mean follow-up was 5.6 +/- 2.4 years. Previously published clinical and image variables were analyzed for their prognostic significance with regard to cardiac death, cardiac death/nonfatal myocardial infarction, and cardiac death/nonfatal myocardial infarction/late revascularization. The presence of a high-risk scan was a significant predictor of subsequent cardiac death by both univariate (chi 2 = 9.4, P < .001) and multivariate analysis (chi 2 = 6.5, P = .01) after adjustment for clinical score. Clinical score was not a significant predictor of cardiac death. CONCLUSION: This study demonstrates that pharmacologic stress myocardial perfusion imaging provides significant prognostic information in patients with permanent pacemakers. In this population, pharmacologic stress myocardial perfusion imaging can differentiate patients at high risk of a subsequent cardiac event from those at low risk. These results support the American College of Cardiology/American Heart Association guideline recommendations for pharmacologic stress perfusion imaging in patients with permanent pacemakers.