Pitfalls in diagnosis of aortic dissection by angiography: Algorithmic approach utilizing CT and MRI

Dissection of the thoracic aorta is a life-threatening event requiring imaging studies to define the level of the tear and the intinmal flap. The “gold standard” has been angiography. This method may fail to demonstrate the dissection, however, due to overlap of the true and false lumens or a very thin flap that is imaged en face rather than tangentially. Computed tomography has a diagnostic accuracy of 95%, but can fail to image the dissection due to technical factors or a thrombosed false hunen. Magnetic resonance imaging requires a hemodynamically stable and cooperative patient. A diagnostic algorithm is proposed for diagnosis of aortic dissection based on renal function and the surgeon's imaging modality preference.     

The decay of house dust mite allergens, Der p I and Der p II, under natural conditions

Background: Fluctuations in the level of mite allergens in domestic house dust are the result of changes in the balance between synthesis, removal and decay. Purely physical forces as well as enzymatic degradation, mediated by house dust inhabiting microbes, may contribute to the decay of allergens in domestic dust. Knowledge about the speed of decay is essential for an understanding of the dynamics of allergen levels. Objective: The present study is a quantitative assessment of the speed of decay at nine combinations of temperature (15°C, 20°C and 25°C) and relative humidity (33%, 55% and 75%). Methods: Samples of mite infested material of an old rug were stored at these temperature/relative humidity-combinations for 6, 12 or 18 months, after the mites were killed by cither a freezing treatment or an acaricide (lindane). The microbes living in the rug presumably survive these treatments. Concentrations of Der p I and Der p II + Der f II. in extracts of the rug material, were measured by a radio immunoassay. Results: No significant changes in the levels of Der p I and Der p II +Der f II, could be detected even after 1¹/₂ year at a high temperature and humidity. Conclusion: These findings incidate that mite allergens can be extremely stable under normal domestic circumstances.     

Retention: An unresolved workforce issue affecting rural occupational therapy services

Failure to retain health professionals in rural areas contributes to the poor health status of these communities through an inability to deliver reliable and consistent services. Considerable attention has been focused on factors affecting recruitment of health professionals. Far less is known about factors affecting the retention of occupational therapists. This was the focus of this study. Ethnographic interviews were used to explore the experiences of 10 occupational therapists who had left rural practice. Six themes emerged from the participants' experiences, from when they first considered rural practice to reflections following their departure from it. These themes were initial appeal, facing the challenge, rural practice issues, the social sphere, reasons for leaving and the value of rural experience. These factors gave rise to a proposed Model of Retention Equilibrium, which suggests that retention can be improved by addressing the imbalance between incentives to leave and incentives to stay. The model provides a useful framework for occupational therapists contemplating rural practice, as well as for health services managers responsible for service delivery in rural areas.     

Lymphoid follicular hyperplasia–a distinctive feature of diversion colitis

Diversion colitis refers to the inflammatory changes that occur in the defunctioned segment of the large intesting following diversion of the faecal stream. We report the histological features in the defunctioned rectums from seven patients: one each with severe constipation and Behcet's disease, two with Crohn's disease with rectal sparing and three with ulcerative colitis. The appearances of diversion colitis in a previously normal rectum are compared with diversion colitis with superimposed inflammatory bowel disease. Lymphoid follicular hyperplasia was found in all cases. This was marked in patients with inflammatory bowel disease. with or without initial rectal involvement. Other changes comprised surface epithelial degeneration and ulceration, mucosal inflammation including crypt abscesses, and crypt branching. Inflammatory and crypt changes were mild, except in ulcerative colitis where changes were marked and resembled those of the proximal colon. Lymphoid hyperplasia is a distinctive feature in diversion colitis. The term follicular proctitis, previously used to indicate chronic ulcerative colitis exclusively, should be re-examined.     

Necrotizing sialometaplasia (adenometaplasia) of the trachea

Necrotizing sialometaplasia is a benign condition first described in minor salivary glands of the soft palate with morphological changes which can be misinterpreted as squamous-cell carcinoma. Similar lesions have been subsequently reported in other locations including major salivary glands, lip, breast and skin (the term syringometaplasia has been applied for the latter). We report three cases of such a process involving submucosal glands in the trachea following prolonged translaryngeal intubation.     

Lymphocyte predominance Hodgkin's disease (nodular paragranuloma)–a bcl-2 negative germinal centre lymphoma

Hodin's disease, lymphocyte predominance type (nodular paragranuloma), is of germinal centre origin and the tumours cells have a B-cell phenotype. As the t(14;18) translocation, and the subsequent expression of bcl-2 protein by germinal centre cells, is the most characteristic finding of centroblastic-centrocytic lymphoma, we have tested a series of 11 cases of lymphocyte predominance Hodgkin's disease, using Southern blot analysis for the major breakpoint region and the minor breakpoint cluster region, polymerase chain reaction with primers for the major and minor breakpoint cluster region, and immunohistological studies with a monoclonal antibody specific for the bcl-2 protein. All three techniques gave negative results in the cases of Hodgkin's disease, establishing a clear differentiation from centroblastic-centrocytic lymphoma. These findings are useful in the differential diagnosis between the two entities and raise the question of the non-clonal nature of lymphocyte predominance Hodgkin's disease.     

Anesthetic considerations of an infant with Beckwith-Wiedemann syndrome

The case of a 3-day-old infant with Beckwith-Wiedemann syndrome who required anesthetic care during closure of an abdominal wall defect is presented. Beckwith-Wiedemann syndrome comprises a constellation of clinical features, including macroglossia, macrosomia, omphalocele, visceromegaly, mild microcephaly, facial nevus flammeus, horizontal earlobe creases, and renal medullary dysplasia. Due to the high rate of omphalocele in this syndrome, anesthetic care is frequently required during the neonatal period. Many of these infants (greater than 50%) are born prematurely. Therefore, their anesthetic care may be further complicated by associated diseases of prematurity, such as hyaline membrane disease. Additional anesthetic implications of this syndrome relate to the occurrence and management of hypoglycemia and polycythemia. Careful intraoperative management of glucose homeostasis is particularly important, since eventual neurologic outcome and intelligence will be normal provided prolonged neonatal hypoglycemia is avoided. Preoperative evaluation of the cardiac and genitourinary system, including echocardiography and renal ultrasound, are recommended because of the frequent occurrence of associated anomalies with omphalocele.     

Haemangiopericytomas: the prognostic value of immunohistochemical staining with a monoclonal antibody to proliferating cell nuclear antigen (PCNA)

Forty-two cases of haemangiopericytoma were studied retrospectively using immunohistochemical staining with PC10, a monoclonal antibody to PCNA. The percentage of tumour cells with positive staining for PCNA was found to correlate well with histological grading. Clinical follow-up data were available in 25 adults and showed no known deaths in 11 cases with a low proportion (less than 14%) of positive cells. Out of 14 cases with a high number (greater than or equal to 14%) of positive cells, seven patients are known to have died, two had metastases, and in a further two there have been multiple recurrences of tumour. DNA flow cytometry was performed on 26 cases but this showed no correlation with PC10 staining or clinical outcome. Staining with PC10 may be of particular value in the identification of patients at greatest risk of rapid tumour metastasis and early death.     

Antisocial personality disorder, HIV risk behavior and retention in methadone maintenance therapy

In a sample of 55 consecutive methadone maintenance admissions to our clinic, 42% were diagnosed with antisocial personality disorder (ASPD) using the National Institute of Mental Health Diagnostic Interview Schedule NIMH DIS. Individuals with ASPD exhibited greater risk for HIV infection as defined by more sexual contacts, needle use and equipment sharing. Data at 1 year follow-up were obtained on this group of patients. The objective was to compare the ASPD and non-ASPD groups with regards to demographics, drug abuse history, outcome and retention in treatment. There were no significant differences between the groups on any demographic or treatment outcome variables. Survival analysis indicated that there were no group differences in treatment retention. In conclusion, although there were no differences in treatment outcome between ASPD and non-ASPD groups it is possible that ASPD patients who drop out of treatment will be at higher risk for contracting and spreading HIV within the IV drug using population. These data also suggest that in this population the diagnosis of ASPD using primarily behavioral traits as measured in the NIMH-DIS-III, has little utility in predicting treatment outcome.     

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the firs, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0–10 years old (40 per cent) and moderate to major burns in the age group 21–30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.