Value of spiral CT in hemodynamically stable patients following blunt chest trauma

Introduction: Features of spiral CT (SCT) — fast scanning, dynamic injection of contrast allowing optimal vessel opacification, and supplemental multiplanar imaging — promises to provide increased accuracy in the diagnosis of acute and non acute thoracic vascular disease. Recent work demonstrating the cost effective triage of hemodynamically stable patients after blunt chest trauma for angiography based on dynamic CT findings has prompted an investigation into the accuracy of SCT in this clinical setting. Methods: A retrospective review of all patients seen in the emergency department over the period of one year for aortic, thoracic, or blunt chest trauma evaluation was performed (74 patients) and all SCT scans available were reviewed and data reformatted for optimal delineation of pathology using maximum intensity projection and multiplanar reformation. The accuracy and predictive positive and negative values of SCT were calculated with respect to angiography, surgical, and/or clinical follow up evaluation. Results: Twenty three (31%) patients went directly to angiography owing to mediastinal widening on chest film and hemodynamic instability, of which four were positive and required emergent surgery. Seven hemodynamically stable patients (9%) had noncontrast SCT owing to mediastinal widening on chest film, all of which had angiography with none having great vessel trauma. Fourty four hemodynamically stable patients (60%) had contrast enhanced SCT (ceSCT), of which five (11%) were abnormal and underwent angiography, four of these were positive for aortic damage, one for a subclavian artery laceration. Of the remaining 39 patients who had normal ceSCT; five had angiography, all of which were normal. Of the remaining 34 patients that had normal ceSCT none had adverse outcome on clinical follow-up, minimum of 12 months. Conclusion: The predictive positive value for aortic trauma of ceSCT in blunt trauma is 80%, with a predictive negative value of 100%, indicating that it is feasible for SCT to be a first line exam in blunt chest trauma in the future.     

Simple algorithms for the management of genital ulcers: evaluation in a primary health care centre in Kigali, Rwanda.

A cross-sectional study was conducted among 395 patients presenting with genital ulcers at a primary health care centre in Kigali, Rwanda. Using clinical data and the results of a rapid plasma reagin (RPR) test, we simulated the diagnostic outcome of two simple WHO flowcharts for the management of genital ulcers. These outcomes and a clinical diagnosis were then compared with the laboratory diagnosis based on culture for genital herpes and Haemophilus ducreyi and serology for syphilis. The prevalence of HIV infection was high (73%) but there was no difference between HIV-positive and HIV-negative patients in the clinical presentation and etiology of genital ulcer disease. The proportion of correctly managed chancroid and/or syphilis cases was 99% using a syndromic approach, 82.1% using a hierarchical algorithm including an RPR test, and 38.3% with a clinical diagnosis. In situations where no laboratory support is available, a simple syndromic approach is preferable to the clinical approach for the management of genital ulcer. If an RPR test can be included in the diagnostic strategy, patients with a reactive RPR test should be treated for both syphilis and chancroid infection.     

American Associatin of Anatomists. Eighty Sixth Annual Session,Cornell University Medical College,New York,New York,April 9, 10, 11, 12, 1973. Officers,abstracts, demonstrations

A method for producing flexible silicone rubber casts of the airways of the lungs in-situ is described. Casts are made to correspond to lung volumes occurring during normal breathing. The lung is prepared for casting by replacing the air within with CO₂ followed by filling with degassed physiological saline. The saline dissolves the CO₂ gas within the airways allowing for a bubble-free finished cast. Casting compound is then slowly injected through the trachea. The saline diffuses out of the lung and passes out of the thorax through several small slits in the thoracic wall. After the injection is completed, the cast lung is allowed to cure in-situ before it is removed and the tissue digested away. Finished casts have an overall shape corresponding closely to the shape of the thorax. Casts produced by this in-situ method appear to have more realistic geometrical relationships than those produced from excised lungs.     

Early experience influences adult retention of aversively motivated tasks in normal,but not DSP4-treated rats

Sprague-Dawley rat pups were injected with DSP4 or water within 48 hr of birth and tested as adults in an inhibitory avoidance task and in a Y-maze discrimination reversal task. Half of the animals were also tested as juveniles during postnatal weeks 4–5, in tasks assessing odor preferences and general investigatory behavior. Controls, but not drug-treated adults, which received the juvenile testing, showed significantly better retention on both tasks than either controls or drug-treated animals not tested as juveniles. Neonatal DSP4 significantly reduced norepinephrine concentrations in the hippocampus and frontal cortex, but not the heart. The results suggest that central norepinephrine may modulate the effects of early experience on adult learning.     

Self-reported comfort in athletic training of gender-specific and non-gender-specific injuries and issues

Context: To assist athletes in maintaining optimal health, athletic trainers must work with athletes of both sexes.Objective: To examine athletic trainers'' comfort levels in providing care for gender-specific and non-gender-specific injuries and issues.Design: We mailed 235 Gender Comfort in Athletic Training Questionnaires to program directors, who were asked to distribute and collect them.Setting: We randomly selected 21 athletic training education program directors and invited them by e-mail to participate in the study. Fourteen program directors representing the 10 National Athletic Trainers'' Association districts agreed to participate.Patients or Other Participants: A total of 192 participants returned completed questionnaires, for a response rate of 82% (103 women, 89 men; 101 senior athletic training students, 91 certified athletic trainers).Main Outcome Measure(s): The questionnaire consisted of 17 injuries and issues common to both female and male athlete scenarios. Three gender-specific items were added to each scenario. Responses were scored on a 5-point scale anchored by 1 (very uncomfortable) and 5 (very comfortable). Participants were asked to indicate the reason for any degree of discomfort. Internal consistency, determined by the Cronbach alpha, was .92 for the female athlete scenario and .93 for the male athlete scenario.Results: We found significant differences between women and men certified athletic trainers for the female and male athlete scenarios. Overall, women were more comfortable caring for female injuries and issues, whereas men were more comfortable caring for male injuries and issues. Certified athletic trainers reported more comfort overall than athletic training students. The most common underlying reason reported for discomfort in caring for female and male injuries and issues was experience level.Conclusions: Athletic training education programs should provide early and more deliberate experiences with injuries and issues of a more intimate nature, including those that are gender specific and non-gender specific. These experiences may increase athletic trainers'' level of comfort in providing care to athletes of the opposite sex.     

Pegaspargase versus asparaginase in adult ALL: a pharmacoeconomic assessment

Asparaginase is an effective treatment for patients with acute lymphocytic leukemia (ALL). Unfortunately, asparaginase therapy is associated with a high incidence of hypersensitivity reactions (up to 73%), including life-threatening anaphylaxis, and its half-life of approximately 20 hours necessitates daily administration. Pegaspargase, a modification of L-asparaginase, has a longer half-life (357 hours), a decreased incidence of hypersensitivity reactions, and when doses every 14 days, provides comparable efficacy to asparaginase; however, it is much more expensive per single-dose vial ($980.00 vs $52.38). To determine the pharmacoeconomic impact of the two agents, we conducted a cost-minimization analysis for three common adult ALL protocols. Results showed that pegaspargase was significantly less costly to payers on an inpatient or outpatient basis and warranted addition to our formulary.     

Interventional catheter magnetic resonance angiography with a conventional 1.5-T magnet: work in progress

Magnetic resonance contrast enhancement depends on the relative timing of image acquisition. Limited human trials have demonstrated efficacy of intra-arterial gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA) in delineating vascular anatomy with X-rays. The present study assessed the ability of dynamic MR during intra-arterial Gd-DTPA administration to demonstrate vascular anatomy compared to conventional angiography as the gold standard. As interventional MR techniques using dedicated magnets proliferate, the ability to perform invasive MR angiography with a conventional magnet would be of great utility at established sites. Four subjects referred for different types of angiography underwent dynamic MR studies, including one with iliac artery stenting (Palmaz P204, Johnson and Johnson). All were examined with conventional angiography, and again after dynamic intra-arterial (IA) Gd-DTPA infusion. Coronal MRI images of the body were acquired using a 1.5-T superconducting magnet (three with a GE Signa, one with Philips NT), fast spoiled gradient echo (FSPGR); echo time (TE) = 4.2 msec, repetition time (TR) = 68-150 msec, flip = 75 degrees, 0-600 s after dilute Gd-DTPA IA bolus injection during sequential breath-hold acquisitions of 13-32 s each. All arteries were detected with dynamic MR. The FSPGR MRI with IA Gd-DTPA administration can provide adequate time and spatial resolution to demonstrate arterial anatomy and arterial stent patency.     

Use of three-dimensional MR angiography for tracking a contrast bolus in the carotid artery

Contrast-bolus tracking in the carotid bifurcation was accomplished using an MR angiographic technique with a 3D turbo field-echo readout (TR/TE = 6/3, flip angle = 50 degrees) modified by a keyhole scheme. Optimal visibility of the contrast bolus was achieved by digital subtraction from a reference volume. This technique reliably time-resolves the carotid arteries from the jugular veins.     

Combination of fludarabine and mitoxantrone in untreated stages III and IV low-grade lymphoma: S9501.

PURPOSE: To determine the efficacy of combination fludarabine and mitoxantrone (FN) in untreated stages III and IV low-grade lymphoma. The major end point was to estimate progression-free survival (PFS) in all eligible patients. PATIENTS AND METHODS: Seventy-eight eligible patients were registered. Chemotherapy courses were administered every 4 weeks with mitoxantrone 10 mg/m2 on day 1 and fludarabine 25 mg/m2 on days 1, 2, and 3 for a total of six to eight cycles. Pneumocystis carinii prophylaxis was required. RESULTS: Seventy-three patients (94%) attained an objective response. Complete remission was demonstrated in 34 patients (44%) and partial remission was demonstrated in 39 patients (50%). With a median follow-up time of 5.5 years, the median PFS was 32 months, with a 4-year PFS rate of 38%. Median survival has not been reached and 88% of all patients are alive at 4 years. The application of the International Prognostic Index and serologic staging showed significant differences in PFS in all risk groups, whereas overall survival was markedly worse for the highest-risk group in either prognostic model. Three prior Southwest Oncology Group trials using a regimen of cyclophosphamide, doxorubicin, vincristine, and prednisone or a combination of prednisone, vincristine, methotrexate, cytarabine, cyclophosphamide, etoposide, nitrogen mustard, vincristine, procarbazine, and prednisone in similar patient populations demonstrated comparable clinical outcome, although the 4-year survival for FN was better. FN was well tolerated, but mild to severe reversible myelosuppression was noted. Other complications were rare. CONCLUSION: FN is an effective, safe chemotherapy combination for patients with advanced-stage, low-grade lymphoma. Clinical outcomes were comparable to prior published data using anthracycline-based regimens.