Lymphoscintigraphy as a predictor of lymphatic drainage from cutaneous melanoma

Background: If cutaneous lymphoscintigraphy (CL) is accurate in predicting the draining lymph node basins at risk from primary axial melanomas, then regional metastases should only occur in those lymph node basins identified by CL. Methods: This study is a retrospective review of patients undergoing CL for primary axial melanomas from June 1, 1985, until June 31, 1992. Data retrieved included age, gender, number of basins identified, location of basins identified, management of basins, recurrence in lymphatics, development of distant disease, and long-term follow-up. Results: A total of 181 patients underwent elective LND, and 48 patients (27%) had melanoma in the nodes within the dissected basin. Of these 181 patients, seven developed nodal metastases as their site of first recurrence. All seven recurrences were seen at sites dissected or at sites indicated by CL, which the primary surgeon elected not to treat initially. Of the 116 patients observed, 16 (14%) developed lymph node metastases as their first site of recurrence. Fifteen of these 16 patients had their site of lymph node metastases predicted by CL. In this study, CL predicted 98.6% of all lymph node metastases. Conclusions: The high overall reliability of CL as demonstrated by long-term follow-up indicates that the information obtained by CL can be reliably used to guide intervention. Initial evaluation of patients with high-risk cutaneous melanomas at sites with ambiguous lymphatic drainage must include CL in order to determine the draining lymph node basins and to plan therapy. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Search for coloured objects in natural surroundings by people with abnormal colour vision

Background: People with abnormal colour vision often report difficulty seeing coloured berries and flowers in foliage, which suggests they will have a diminished capacity for visual search when target objects are marked out by colour. There is very little experimental evidence of the effect of abnormal colour vision on visual search and none relating to search for objects in natural foliage. Method: We showed 79 subjects with abnormal colour vision (seven protanopes, 10 deuteranopes, 16 protanomals and 46 deuteranomals) and 20 subjects with normal colour vision photographs of natural scenes and asked them to locate clumps of red berries, to trace the length of a red string on grass and to name the season depicted in a photograph taken in the Autumn and the same scene photographed in the Summer. Colour vision was assessed using the Ishihara, the Medmont C100, the Farnsworth D15, the Richmond HRR and the Nagel anomaloscope. Results: All the subjects with abnormal colour vision located fewer clumps of red berries than those with normal colour vision. The subjects who failed the Farnsworth D15 performed significantly worse than those who passed but the distribution of scores in the two groups overlaps. The majority of subjects with abnormal colour vision could not trace the full length of the string: only 38 per cent of anomalous trichromats who passed the Farnsworth D15 test and three per cent of those who failed it were able to trace the full length of the string. Fifty‐five per cent of those classed as having a mild deficiency by the HRR test could trace the whole string. Most dichromats were unable to identify the Autumn season and those who did may have been assisted by guessing. Most (94 per cent) of those who passed the Farnsworth D15 test and all those classified as having a ‘mild’ deficiency by the HRR test could identify the season. Conclusions: All people with abnormal colour vision, even those with a very mild deficiency, have some degree of impairment of their ability to see coloured objects in natural surroundings. A pass at the Farnsworth D15 test or a ‘mild’ classification with the Richmond HRR test identifies those likely to have the least problems with visual search and identification tasks. The results have practical implications for the selection of personnel in occupations that involve visual search in natural terrain.     

Atherosclerosis--multi-organ involvement the rule rather than the exception

Atherosclerosis is a systemic disorder and significant lesions often occur in organ systems other than the symptomatic area. Three groups of patients, those admitted to hospital with either coronary artery disease, carotid artery stenosis or peripheral vascular disease, were examined for concomitant atherosclerotic lesions. Non-invasive tests, namely duplex scanning of the carotid arteries, arm ergometer exercise testing, and segmental pressure of the limbs, were used during evaluation. A clear association between ischaemic heart disease, carotid artery stenosis and femoropopliteal disease was found. Women appear to be more prone to multi-organ involvement than men; their higher average age on admission to hospital is a possible explanation for this in some cases, but not all.     

Medium term outcome for infant repair in tetralogy of Fallot: indicators for timing of surgery

Objective: To assess the impact of early corrective surgery on the short and medium term outcome in tetralogy of Fallot (TOF). Materials and methods: All patients under 12 months of age undergoing correction of isolated TOF between February 1997 and July 2003 were reviewed retrospectively. Outcome data for mortality, post-operative care management, major morbidity and clinical follow-up were analysed. Results: Fifty-two operations were performed. The mean age at surgery was 5 months (range 1–12) of whom 16 (30.8%) were less than 3 months old, including 2 neonates, 22 (42.3%) were 3–6 months old and 14 (26.9%) were 7–12 months old. There was 1 (1.9%) early death caused by a cerebro-vascular accident and 1 (1.9%) late death secondary to acute infective endocarditis. There were no differences in post-operative morbidities attributable to age. Patients under 3 months old required greater duration of post-operative ventilation, ITU stay and in-hospital stay. At a mean follow-up of 4.0 years (range 1.5–8.0), 33 (63.5%) patients had well-tolerated pulmonary regurgitation (PR) and 3 (5.8%) patients required re-operation for right ventricular outflow tract obstruction (RVOTO). All patients had right bundle-branch-block but with QRS < 150 ms. Conclusion: Early definitive repair of TOF can be performed safely on patients under 6 months old. Age at surgery does not appear to affect the medium term haemodynamic outcome. However, early surgery does escalate the need for ICU care. This data suggests repair in asymptomatic patients be delayed until 3–6 months of age.     

Physical and Sexual Abuse and their Relation to Psychiatric Disorder and Suicidal Behavior among Adolescents who are Psychiatrically Hospitalized

Adolescents who were psychiatrically hospitalized ( N = 105) were classified as sexually abused, physically abused, both sexually and physically abused, or not abused, and studied to determine the prevalence of suicidal behavior and psychiatric disorders. Self-reports of hopelessness, depression, coping, and self-concept were also examined. No difference in suicidal behavior or psychiatric disorder, based on abuse history, was found, with one exception. Adolescents who were sexually abused, particularly those who experienced the most severe sexual abuse, used negative coping strategies more often than those not sexually abused. Findings suggest that symptomatology of adolescents who are psychiatrically hospitalized does not differ markedly based on history of abuse.     

Nonepileptic Posttraumatic Seizures

Summary: Purpose: Epileptic posttraumatic seizures (PTSs) are a well-recognized consequence of head injury (HI), but HI and nonepileptic seizures (NESs) have not been related. We describe a significant subset of patients with NESs who had their seizures attributed to HI.
Methods: We reviewed the records of all patients diagnosed with NES at the University of Maryland Medical Center over a 6-year period (1989–1995) and selected patients with seizures attributed to a head injury occurring ≥3 years before the onset of their seizures.
Results: Of 157 patients with video-EEG confirmed NES, 37 (24%) had the onset of their seizures attributed to an HI. Their average age was 34 years (range, 15–56 years); 68% were women. Nonepileptic PTS usually developed within the first year after HI (89%). Convulsive symptoms were present in 54%. Whereas epileptic PTSs characteristically follow severe HI, the majority (78%) of our patients with nonepileptic PTSs sustained only mild HI. Before their HI, 76% of our patients were employed, working in the home, or students, but only 11% could continue those activities after developing nonepileptic PTSs.
Conclusions: Nonepileptic PTSs are frequently mistaken for epileptic PTSs and result in serious disability. The misdiagnosis of nonepileptic PTSs leads to ineffective and inappropriate treatment. Patients with intractable seizures after HIS, articularly mild HIS, should be carefully evaluated for NESs.     

β-Adrenergic agonists suppress chronic/relapsing experimental allergic encephalomyelitis (CREAE) in Lewis rats

Chronic/relapsing experimental allergic encephalomyelitis (CREAE) serves as an animal model for relapsing/remitting multiple sclerosis. Treatment with the β-adrenergic agonist isoproterenol or the β₂-adrenergic agonist terbutaline significantly suppressed both the first acute attack and the number of relapses in CREAE Lewis rats. The number of relapses was decreased even when treatment with β-adrenergic agonist was started after the onset of the first acute attack of CREAE. β-adrenergic receptor number was increased significantly on splenocytes from CREAE rats as compared to healthy controls or CFA-injected rats. Terbutaline treatment of CREAE rats lowered the splenocyte receptor number to normal values.     

The Physiology of Gastrocystoplasty: Once a Stomach, Always a Stomach

To determine the physiology of acid secretion after gastrocystoplasty with the body of the stomach we performed a prospective standardized 3-day study in 13 children (median age 12.5 years) who had undergone bladder augmentation/replacement (median postoperative period 2 years). Urinary pH and titratable acid, and serum gastrin levels were measured after gastric distention with a meal and bladder distention with urethral filling at baseline and after medication with a histamine-2 receptor antagonist or an anticholinergic agent. Five children underwent cystoscopy and biopsy of the gastric and native segments of the gastrocystoplasty.

In the fasting state pH was neutral, there was no titratable acid in the urine and serum gastrin level was normal in all cases. After a meal urinary acid secretion and serum gastrin level increased markedly. After each medication half of the patients demonstrated marked inhibition of urinary acid secretion after a meal while response was partial in the remainder. In none of the patients was there significant alteration in the pattern of gastrin secretion. Bladder distention did not result in urinary acid secretion or gastrin secretion. The cystoscopic and histological appearance of the native bladder and stomach segment of the gastrocystoplasty in the 5 patients was normal. We conclude that the gastric body segment used in gastrocystoplasty continues to secrete acid as though it were part of the stomach. The secretion of acid in the urine can be decreased with histamine-2 receptor antagonist or anticholinergic medication.