Persistent truncus arteriosus--an autopsy study of 16 cases.

Sixteen specimens of heart with persistent truncus arteriosus were studied to evaluate the anatomic features. Using the Collet and Edwards classification, type I truncus arteriosus was the most frequent (62.5%). Using Van Praagh's classification type A1 was the most common (43.7%). There were two cases which could not be classified according to the Collet and Edwards classification. The truncal valve was tricuspid in 75% of the cases and bicuspid in the remaining 25%. In all 6 cases with interruption of the aorta, the truncal valve was committed to the right ventricle. The ventricular septal defect was subtruncal in all except 1 case. There was variation in the thickness of the posterior limb of the septal band and the ventriculo-infundibular fold. Absence of the ventriculo-infundibular fold in 3 cases led to truncal tricuspid continuity. Right-sided aortic arch and interruption of the aorta were frequently associated arch anomalies.


Enalapril and exercise-induced hyperkalemia. A study of patients randomized to double-blind treatment with enalapril or placebo after acute myocardial infarction.

During exercise a marked increase in plasma potassium in healthy subjects has repeatedly been demonstrated. In patients on treatment with angiotensin-converting enzyme inhibitors this may be further augmented. Therefore, the aim of present study was to evaluate the effect of enalapril on exercise-induced hyperkalemia. This was done in patients with acute myocardial infarction randomized to double-blind treatment with enalapril 10-20 mg per day (n = 7) or placebo (n = 6) within 24 h of onset of chest pain, and the results were compared with data from healthy control subjects (n = 11). Baseline plasma potassium did not differ between the three groups; i.e. 4.2, 4.0, and 4.1 mmol/l, respectively. An incremental, symptom-limited, bicycle exercise test was done one month after the myocardial infarction, and blood samples were taken for determination of plasma potassium. The exercise-induced increase in plasma potassium was not higher in the enalapril group as compared to the placebo and control groups, and there was no difference between the enalapril and placebo group, the specific values being 0.6 vs. 0.6 and 0.7 mmol/l, respectively. No difference was observed in the slope (dK/dt) between the 3 groups. In conclusion, enalapril at a dosage of 10-20 mg per day does not provoke any augmentation of the increase in plasma potassium during exercise.


Calcitonin gene-related peptide: a haemodynamic study of a novel vasodilator in patients with severe chronic heart failure.

The haemodynamic and neurohumeral response to a novel vasodilator calcitonin gene-related peptide was assessed in 11 patients with severe chronic heart failure. To assess tolerance, a continuous 48-h infusion (n = 6) was compared with a regimen of two successive 8-h infusions (n = 5). Haemodynamic response profiles were similar for both regimens, though the continuous infusion was poorly tolerated. Reductions in afterload reflected by changes in systemic vascular resistance and systemic blood pressure led to increases in cardiac index of at least 24%. Increments in heart rate accounted for much of the increase in cardiac output, there being no significant change in stroke volume index. The response was maintained over the 48-h study period with no tachyphylaxis. Renin and angiotensin levels increased significantly after 24 h. Calcitonin gene-related peptide exerts a favourable haemodynamic response in patients with severe heart failure. The dose used in this study, however, caused troublesome side-effects, particularly when given by continuous infusion. Further studies are required to establish the therapeutic range of this new peptide.


Arrhythmias during dipyridamole test. Report of 3 cases.

The authors report three cases in which the dipyridamole test provoked: (1) junctional rhythm with AV dissociation; (2) sinus arrest; (3) 2:1 AV block. The three cases described above draw attention to the possible effect of dipyridamole on the AV conduction, which is not yet completely known. This unwanted effect suggests that careful ECG monitoring should be performed during the dipyridamole test.


Myocarditis: a rare complication during Legionella infection.

Legionella often causes systemic manifestations. The clinical spectrum now includes cardiac legionellosis. The first case of myocarditis was reported by Gross in 1981. To date few additional cases have been described. Myocardial involvement might be more frequent than supposed in legionnaires' disease.


Multiple intracavitary cardiac masses; an uncommon presentation of African Burkitt's lymphoma.

A 29-yr-old patient is described, who presented with rapid general deterioration and right heart failure. Two-dimensional echocardiography revealed massive intracardiac tumor involving the right atrium, the right ventricle and the left atrium. At histology the diagnosis of Burkitt's lymphoma was made. This report presents what we believe to be the first case of a patient with primary cardiac manifestations and multiple intracardiac masses in this disease.


Hypnosis: wherefore art thou?

The present paper focuses on the influences of social-political needs of various groups with interests in hypnosis (i.e., stage hypnotists, lay hypnotists, licensed practitioners, and researchers). While hypnosis is a specific topic of interest to groups with varying needs, it also serves as an example for other topics in psychology that may overlap the needs of other groups--especially practitioners and researchers. The identity given to hypnosis varies depending upon which particular group of persons is offering the identity, and the nature of the identity reflects each group's biases and needs. These various identities, however, are not always acceptable, in part or in whole, by the other groups, as the needs of one or more may be in conflict with those of others.


Theorizing about hypnosis in either/or terms.

The present paper addresses 3 issues raised by Coe (1992). First, it maintains that the "altered state" issue of the 1960s remains buried in current dichotomous classifications of hypnosis theories as involving either "special processes" or the social-psychological position. Given the current diversity of the field, it appears imprudent to classify theorizing in either/or terms; additionally, despite a history of using the term "altered state" in a circular way, it is not an inherently circular formulation. It can be used descriptively simply to point to the observation that some individuals in hypnosis report subjective alterations. A second issue broached concerns the metaphorical status of the term "hypnosis"; it is accepted as a misleading metaphor inherited from 19th century investigators such as Braid, Faria, Puységur, and Liébeault. Provided that is is recognized that this metaphor refers to a "domain" (E.R. Hilgard, 1973) of characteristically elicited behaviors, no problem ensues in retaining this metaphor derived from nocturnal sleep. A subsequent discussion of current conceptualizations of hypnosis indicates considerable agreement among investigators; there is much consensus that hypnosis is an individual differences phenomenon, in which imagination may, in some individuals, become so intense and so vivid, as to take on "reality value," to the extent that a hypnotized person may have difficulty in distinguishing fantasy from reality. The S abilities of imagery/imagination, absorption, dissociation, and automaticity (which may be proved to be an index of dissociation) are proposed as being the main ingredients of the hypnotic experience. Finally, a synergistic approach is proposed as a means of progressing beyond the current impasse of either/or theorizing.


Imagination and dissociation in hypnotic responding.

A neodissociative model of mind is better equipped than a social-psychological model to deal with the complexities of hypnosis, and of human behavior generally. It recognizes, as Coe's (1992) model does not, that behavior can be more automatically activated than strategically enacted. In particular, Coe's emphasis on human behavior as purposeful and goal directed does not distinguish between goal-directed behavior that serves a purpose, and goal-directed behavior that is performed on purpose. It is this distinction that permits goal-directed behavior to be dissociated from a person's conscious plans and intentions. In addition to offering a critique of Coe's "limited process" view of hypnosis, 4 main points are made in the interest of developing a slightly modified, neodissociation view of hypnosis. First, it is argued that goal-directed fantasies are more limited in their ability to mediate hypnotic responding than is commonly appreciated; as well, they do not seem to account for the nonvolitional quality of hypnotic responding. Second, it is argued that hypnotic ability is not unidimensional, with compliance and social influence more apt to account for the low than for the high hypnotizable's responsiveness to suggestion. Third, compared to low hypnotizables, the hypnotic responsiveness of high hypnotizables seems more likely to result from dissociated control. In other words, for high hypnotizables, hypnotic suggestions may often directly activate subsystems of cognitive control. Consequently, the need for executive initiative and effort to produce hypnotically suggested behavior is minimized, and such responses are therefore experienced as nonvolitional. Fourth and finally, while goal-directed fantasies typically accompany hypnotically suggested responses, they are in many cases more a marker of dissociated control than a mediator of suggested effects.


Social constructions of hypnosis.

Both clinical and experimental views of hypnosis are social constructions that reflect the biases and interests of practitioners and scientists. Each perspective offers useful metaphors for hypnosis. Underlying clinical uses of the term hypnosis are states of mind associated with imaginative reverie and automatic behavior based on procedural knowledge. Social discourse and narratives shape hypnotic experience, but they are themselves influenced by mechanisms of attention and automaticity. Study of hypnosis must proceed on both social and psychological fronts to account for the experience and clinical efficacy of hypnosis.


Hypnosis: a sesquicentennial essay.

The present paper views Coe's (1992) reflections on the sociopolitical interests in clinical and experimental hypnosis against the background of Braid's Neurypnology of 1843. Topics considered are: the significance of the label "hypnosis"; the controversy over state; the tension between credulity and skepticism; the problem of dissociation and automaticity; current theoretical conflicts; and the relationships between practitioners and researchers.


The 1988-1989 measles epidemic in Hungary: assessment of vaccine failure.

Hungary has had a successful measles vaccination programme, achieving over 93% coverage in targeted groups. However, from September 1988 until December 1989, 17,938 measles cases were reported among the civilian population (attack rate [AR] = 169 per 100,000 population) with the majority of cases occurring in vaccinated people. National surveillance data were analysed to determine reasons for the outbreak and risk factors for vaccine failure. People born during 1971 and 1972 had been targeted for vaccination during campaigns in April and September of 1973 and had the highest AR (1332 and 1632 per 100,000, respectively). Epidemiological studies of vaccine efficacy conducted among secondary school students corroborated these findings. Among 754 secondary school students, those vaccinated during the April 1973 campaign were at highest risk compared with those vaccinated at routine health care after 1974 (relative risk = 10.9, 95% confidence interval [Cl]: 2.5-47.9). Among 341 primary school students, one-dose recipients were at higher risk compared with two-dose recipients controlling for age at and time elapsed since vaccination (P = 0.04).


The measurement and interpretation of age-specific vaccine efficacy.

The age-specific efficacy of a vaccine depends upon the mechanism of vaccine action and the force of infection in the unvaccinated subpopulation. Consequently, inferences concerning the persistence of vaccine-induced immunity cannot in general be made directly from age-specific vaccine efficacy estimates. The definition, estimation and interpretation of age-specific vaccine efficacy measures are discussed using simple models of vaccine action. The methods are applied to data on measles and pertussis vaccines.


Risk factors for the development of persistent diarrhoea and malnutrition in Burmese children.

To identify socioeconomic and behavioural risk factors for development of persistent diarrhoea and malnutrition in children, a case-control study was carried out in Burma. Cases were 67 children 1-59 months old hospitalized for diarrhoea lasting > 14 days and complicated by severe malnutrition; for each case, a healthy control child was selected who was age- and sex-matched from the same neighbourhood. Homes of cases and controls were visited for interviews and for direct observation of household child-care practices. Risk factors were catalogued and calculations made for relative risk and etiologic fractions. Risk factors that were associated with persistent diarrhoea and malnutrition included low family income, low education of mothers, unhygienic latrines, flies in the house and on the child, dirty appearance of child and mother, mother not using soap and water when washing child's hands, defaecation of child on floor, breastfeeding on demand, child eating food from floor, not feeding recommended weaning foods, and lack of knowledge by mother about causes of diarrhoea and about foods that prevent malnutrition. These results indicated that persistent diarrhoea and malnutrition in Burma is caused by a complex of several interrelated socioeconomic factors, unsanitary behaviour pertaining to personal hygiene, the practice of demand breastfeeding and lack of certain weaning foods, and low education of mothers who showed less knowledge about causes of diarrhoea and prevention of malnutrition.


Intention-to-treat analysis: implications for quantitative and qualitative research.

Intention-to-treat analysis is an important aspect of randomized controlled trials of health care interventions. The concept is now widely accepted in theory, but not always implemented in practice. Failure to analyse by intention-to-treat can give misleading and indeed life-threatening interpretations. In some studies, a case is put for estimating the effect that would have been observed if all patients had received the allocated treatment. Situations where this is valid are rare, but an example is given of such an exceptional study. The relevance of the intention-to-treat concept is not always taken into account in qualitative research. Interviews with new mothers who delivered their babies at home in a hypothetical controlled trial of home versus hospital confinement would provide fascinating accounts of the pleasure of successful delivery at home. But by definition the interviews would exclude the hazard and drama of necessary transfers to hospital due to complications in late pregnancy and early labour. The intention-to-treat approach would avoid this bias.


Cigarette smoking and breast cancer.

An epidemiological case-control study was conducted in New York State, with 1617 primary breast cancer patients and an equal number of controls, to examine the relationship between cigarette smoking and breast cancer. Results showed no overall association between ever smokers versus never smokers and breast cancer risk (odds ratio [OR] = 1.03, 95% confidence interval [CI]: 0.90-1.19), nor was there any dose response trend observed with increased levels of smoking. In addition, no association was found with risk and age started smoking, age stopped smoking, amount smoked or total years smoked. Controlling for previously identified risk factors for breast cancer in the analysis did not significantly alter these relationships. Previous studies have found a difference in menopausal age among smokers compared to nonsmokers. The mean menopausal age was only slightly lower in smokers than in never smokers for both cases and controls. Breast cancer risk was observed to be close to unity for premenopausal women (OR = 0.97, 95% CI: 0.74-1.34) and postmenopausal women (OR = 1.06, 95% CI: 0.91-1.26). A recent study suggested breast cancer risk was more strongly related to starting smoking at a young age among women who smoked at least 25 or more cigarettes per day in the most recent year of smoking. This hypothesis was not supported by these data.


Cigarette smoking and body weight in the Cancer Prevention Study I.

To investigate the generality of the association of heavy cigarette smoking with increased body weight, the relation of number of cigarettes smoked per day to relative body weight was examined in baseline data for 891,589 participants in a prospective study initiated in 1959. Although the relative weight of cigarette smokers was consistently lower than that of never and exsmokers, men and women smoking two or more packs of cigarettes per day were more likely to be categorized as moderately or severely overweight and less likely to be categorized as underweight than those smoking 10-20 cigarettes per day, despite somewhat greater educational attainment by heavier smokers. These analyses offer support for the temporal generality of the relation between heavier cigarette smoking and greater body weight, and suggest that this phenomenon cannot be explained by historic trends in the socioeconomic stratification of smoking prevalence or smoking dose.


Cigarette smoking among junior high school students in Beijing, China, 1988.

Prevalence, behavioural patterns and risk factors of cigarette smoking were studied in a sample of 8437 junior high school students in Beijing in 1988. Smoking at least occasionally was reported by 34.4% of boys and 3.9% of girls, though the intensity tended to be low. Smoking prevalence increased with age among boys. Inhaling smoke into the lungs was practised by 68.2% of the boys who smoked and 37.3% of the girls. 'Believing that one looks elegant when smoking', 'trying to be fashionable' and 'seeking stimulation' were the most important reasons for smoking. Of the boys 83.5% and of the girls 86.5% usually smoked with friends or schoolmates. Many more boys (19.2%) than girls (1.7%) smoked at home. Examinations of risk factors for teenage smoking showed that it was associated with a combination of familial, psychological and socio-school factors, with peer group pressure being the most important one.


Smoking habits in Denmark from 1953 to 1991: a comparative analysis of results from three nationwide health surveys among adult Danes in 1953-1954, 1986-1987 and 1990-1991.

Changes in smoking habits in Denmark from 1953 to 1991 are described on the basis of data from three nationwide population surveys on health and morbidity. The data on smoking habits were collected at personal interviews with 34,018, 4753 and 4818 subjects aged more than 15 years in 1953-1954, 1986-1987 and 1990-1991, respectively. Among men, the proportion of smokers has fallen from 78% to 47%, but among women it has remained constant at around 40%. The greatest decrease occurred among younger men. The proportion of heavy smokers (> or = 15 g tobacco a day) has remained constant at around 25% in men, but in women it has increased from 3% to 14%. There is a correlation between occupational status and smoking; the proportion of smokers being highest among the unemployed, early retirement pensioners and unskilled workers, and lowest among upper-level salaried employees. Today, more smokers started smoking before the age of 15 years. Possible explanations of the changes include public debate, campaigns concerning the health risks of tobacco, and a change in the roles of the sexes. Since today's smokers are characterized by smoking onset before age 15 years it is proposed that future initiatives to reduce smoking must focus on the psychosocial factors related to early onset of smoking.


Mortality from ovarian cancer among women with many children.

The exposure range for number of children as a risk factor for ovarian cancer has been severely restricted in most studies. This study is the first to describe the effect of many children, i.e. six or more, on the risk for death from ovarian cancer. The association between number of children in the current marriage given at the Norwegian Census in 1970 and mortality from ovarian cancer was investigated in a prospective study of 800,814 women followed over 15 years. Among postmenopausal women a strong negative trend between number of children and mortality from ovarian cancer was found; women with 8-11 children had a relative risk (RR) of 0.30 (95% confidence interval (CI): 0.17-0.54). For postmenopausal women the rate differences according to parity were constant across age strata indicating an additive model. No significant effect was found for age at first birth or social class. The study indicates that low parity could be the major risk factor for death from postmenopausal ovarian cancer.


Familial aggregation of oesophageal cancer in Yangcheng County, Shanxi Province, China.

Oesophageal cancer is the second most common cause of cancer death in China and is particularly prevalent in northern China. Genetic factors have been studied less than environmental factors in the aetiology of this disease. This study was conducted to evaluate familial aggregation of oesophageal cancer. All households in Yangcheng County were interviewed in 1979 to determine family history of oesophageal cancer. In 1989, vital status for all family members from three Yangcheng villages was determined and re-interviews were conducted among families who reported a positive family history of oesophageal cancer in 1979. Risk of oesophageal cancer was evaluated by comparing family and individual rates of oesophageal cancer during the 1979-1989 interval stratified by the number of family members with oesophageal cancer prior to 1979. More families with prior oesophageal cancer history reported new oesophageal cancer deaths during the follow-up period than families without prior history (19% versus 5%). Oesophageal cancer rates increased with increasing positivity of family history, and adjustment for other risk factors did not substantially alter this result. We conclude that these data provide evidence for familial aggregation of oesophageal cancer.


Trends in coronary risk factors in Italy. Responsible Investigators of the RF2, OB43 and MICOL Research Groups.

Three large-scale epidemiological surveys covering some major coronary risk factors were conducted in Italy in population samples of men and women aged 30-59 years. The first survey was carried out in 1978-1979 (RF2 study; nine samples in eight regions; 2561 men and 2912 women); the second in 1983-1984 (OB43 study; nine samples in the same eight regions; 2267 men and 2398 women); and the third one in 1985-1987 (MICOL study; 18 samples in 10 regions; 14,411 men and 12,611 women). Time trends in mean age standardized risk factors levels showed slight but systematic decreases in blood pressure, cigarette smoking (only in men), and body mass index (only in women); whereas no substantial changes were observed in serum cholesterol levels. The combined multiple coronary risk estimated by a model produced in a previous study, showed a decline between 1978-1979 and 1983-1984 of 5.5% in men and 13.4% in women. These changes were compared with the official coronary death rates between 1984 and 1987 in the whole country and in the regions where the samples were located. The expected/observed ratio computed in different ways ranged from 0.54 to 0.88 for men and was over 1 for women. Changes in the levels of major risk factors and changes in coronary mortality seem biologically coherent at least in men.


Serum lipids and their correlates in Chinese urban and rural populations of Beijing and Guangzhou. PRC-USA Cardiovascular and Cardiopulmonary Epidemiology Research Group.

In 1983 and 1984, surveys were conducted in four Chinese population samples, urban and rural for both Beijing and Guangzhou, as part of PRC-USA collaborative research in cardiovascular and cardiopulmonary epidemiology. Serum total cholesterol (TC), HDL-cholesterol (HDL-C), and triglycerides (TG) were measured in 4280 men and 4695 women aged 35-54 years, in laboratories standardized by the US Centers for Disease Control. Age-adjusted mean serum TC was higher in urban than rural samples and generally higher in Beijing than Guangzhou, ranging from 155 mg/dL for Guangzhou rural women to 187 mg/dl for Guangzhou urban women. Group mean values of HDL-C varied from 48 to 59 mg/dl, higher in Beijing than Guangzhou, and higher in women than men. TC/HDL-C ratio ranged from 3.05 to 3.82. Serum TG values were higher for Beijing than Guangzhou; the lowest group mean values of 78 mg/dl and 75 mg/dl were in rural Guangzhou men and women. Mean body mass index (BMI) was uniformly low, ranging from 20 kg/m2 for rural Guangzhou to 24 kg/m2 for urban Beijing. Multiple regression analyses showed that BMI was positively and independently related to serum TC, LDL-C, TG, and TC/HDL-C, and inversely related to HDL-C. Smoking was positively related in both sexes to TG and TC/HDL-C, and inversely related to HDL-C. Smoking was also positively related to TC and LDL-C in men. In men, alcohol was positively related to TC and HDL-C, and was inversely related to TG and TC/HDL-C. Heavy manual work was inversely related to TC, LDL-C, and TC/HDL-C in men, but not related to lipids in women. Thus, for these Chinese population samples, despite their lower serum TC and BMI, the correlates of serum lipids are similar to those in western populations. These variables accounted for only part of the observed urban-rural and north-south differences in serum lipids among these Chinese population samples. The significance of the relatively low serum TC and TG and high HDL-C in relation to low cardiovascular disease in Chinese populations is the object of further investigation in follow-up studies.


Sudden and unexplained deaths in sleep (Laitai) of young men in rural northeastern Thailand.

Sudden and unexplained death in sleep (SUDS) is a significant cause of death of young adults in several Asian populations, but its distribution and incidence are not well known. We conducted a survey by mail of SUDS (known as 'laitai' in the local dialect) that occurred in adults during 1988-1989 in 3867 villages in northeastern Thailand with a total population of 5.42 million. Headmen of 2651 villages (68.6%) returned the questionnaire and sudden deaths of adults 20-49 years old were reported in 396 of these villages. The validity of reports was assessed by interviewing next of kin and witnesses in a sample of 92 villages reporting sudden deaths; 60 of 127 reports of SUDS from these villages were verified (47.2%). Officials and villagers in seven villages that did not respond to the questionnaire were also interviewed and no cases of sudden death were found. The verified SUDS victims were all men wth a mean age of 35.9 years (SD 7.8). A family history of SUDS was reported in 40.3% of index cases and 18.3% had brothers who had died similarly; no such deaths were reported among sisters. The estimated annual rate of death from SUDS among men 20-49 years was 25.9 per 100,000 person years (95% confidence interval (CI): 21.0-30.7). The sudden deaths were seasonal with 38% occurring during March-May and 10% during September-October (chi 2 = 9.45, P = 0.02). Sudden death in sleep is a leading cause of death of young men in rural northeastern Thailand and the characteristics of Thai victims are similar to those of other Asian victims of this unexplained syndrome.


Early childhood mortality in a Brazilian cohort: the roles of birthweight and socioeconomic status.

The deaths of children aged 1-4 years were studied in a cohort of 5914 Brazilian liveborns. A total of 29 early childhood deaths were recorded (cumulative mortality risk of approximately 6 per 1000), 17 of which (59%) were due to infectious diseases. The death rate was highest in the second year. Deaths were highly concentrated in children from low income (< US $50/month) families, where the cumulative risk of early childhood death was about 10 per 1000; on the other hand, there were no deaths among the 616 children from families with a monthly income of US $300 or more. Birthweight was also associated with mortality: the cumulative risk of children weighing less than 2000 g at birth was 21 per 1000, compared to 4 per 1000 among those with birthweights of 3500 g or more. Simultaneous adjustment for income and birthweight did not substantially change these differentials. These findings confirm the strong association between early childhood mortality and socioeconomic conditions, but also make evident the long-term effects of low birthweight.


Classification of nutritional status as 'Z score' or per cent of reference median--does it alter mortality prediction in malnourished children?

The objective of the study was to evaluate, using a prospective cohort study, whether classification of nutritional status by 'Z score' or per cent of reference median alters the prediction of death in malnourished children. The subjects were children with diarrhoea requiring hospitalization due to moderate or severe dehydration and/or associated complications. There were 382 participants under 5 years of age, of whom 37 died (cases), 320 were discharged in a satisfactory condition (controls) and 25 left before diarrhoea was completely cured (lost to follow-up--excluded). Rehydrated weight and recumbent length (under 2 years) or standing height were recorded and the three indices (weight for age, height for age and weight for height) derived as both 'Z scores' and per cents of reference National Centre for Health Statistics (NCHS) medians. Logistic regression, sensitivity specificity curves and Zda test for normalized distances were used to compare the relative utility of these two classification methods in identifying children with a high risk of dying. The per cent of reference median and 'Z scores' were highly correlated (r = 0.9540, 0.9787 and 0.9667, respectively). Both methods yielded virtually identical results in predicting death of malnourished children for all the three indices. It was concluded that 'Z score' and per cent classification of nutrition are equally efficient in predicting death of malnourished children.


Foods predictive of nutrient intake in Chinese diet in Taiwan: I. Total calories, protein, fat and fatty acids.

Dietary consumption data obtained by food weighing for 539 households in Taiwan in 1980-1981 were used to search for foods predictive of nutrient intake. The average per capita nutrient intake in each household was calculated for total calories, protein, fat and fatty acids (saturated fatty acids, oleic acid and unsaturated fatty acids). Stepwise multiple regression analysis was carried out to reveal the relative importance of each of 405 food items in the dietary survey data for predicting nutrient intake. We found that as few as seven to 20 food items could account for a large proportion of the variability of macronutrient intake in this population. These lists of foods were the minimum needed to categorize an individual's nutrient intake for epidemiological studies in Taiwan. The types and amounts of cooking oils (important predictors of fat and calories) added to the dishes were found to vary from family to family, and should be considered in designing dietary questionnaires for Chinese in other societies.


Foods predictive of nutrient intake in Chinese diet in Taiwan: II. Vitamin A, vitamin B1, vitamin B2, vitamin C and calcium.

Dietary consumption data obtained by food weighing for 539 households in Taiwan in 1980-1981 were used to search for predictor foods of individual intake of several vitamins and calcium. Stepwise multiple regression analysis was carried out on food items that were univariately and significantly associated with nutrient intakes, to screen for the important predictors. Less than ten foods were enough to explain more than 90% of the interperson variation for vitamin A, vitamin B1, and vitamin B2. For vitamin C and calcium, 20 food items could explain only 87% of the variation. Salt, brown sugar, and soy bean sauce were selected among calcium predictors. The information on foods predictive of nutrient intake is useful in designing food frequency questionnaires and materials for nutrition education. Although this paper provides such information for Chinese living in Taiwan, some issues described (such as the need to assess spices) may have been overlooked and could be generalized to populations using stir-frying as a major cooking method.


Determinants of delayed initiation of breastfeeding: a community and hospital study from Guinea-Bissau.

A prospective study on the timing of breastfeeding start in Bissau was undertaken in a periurban community (n = 734), and at the Central Hospital (n = 414). Only single, full-term, healthy children born by the vaginal route were included, the purpose being to characterize mothers who delay breastfeeding start for reasons not related to disease. Multivariate failure-time analysis (Cox' regression) was used to relate the child's age at breastfeeding start to a set of independent variables. In the community, those tending to delay breastfeeding start were mothers from the largest ethnic group in the country, mothers who had given birth at times other than the evening hours (6-12 pm) and mothers who had not attended antenatal clinics. At the hospital, delayed initiation was found among young mothers and mothers from one sparsely represented ethnic group. The most important determinant of delayed breastfeeding start was negative cultural ideas about colostrum.


Maternal height and age: risk factors for cephalopelvic disproportion in Zimbabwe.

Maternal age and stature are among several factors used to screen pregnant women for potential risk of labour complications. In a population-based case-control study in Harare, Zimbabwe, multivariate analysis was carried out to evaluate the importance of maternal age and height as risk factors for cephalopelvic disproportion (CPD). Using data abstracted from the medical records of 203 women with operative deliveries due to CPD and 299 women with normal unassisted vaginal deliveries, multiple logistic regression models were developed. Although maternal age < 18 years was not a significant risk factor in this study (perhaps because there were few women in this age group), advanced maternal age (> or = 35 years) was associated with a relative risk of 2.7 compared to women 20-34, after adjusting for other demographic and obstetric factors. Maternal height < 160 cm was associated with a twofold increased risk of CPD as compared to taller women.


Association between glucose-6-phosphate dehydrogenase deficiency and neonatal jaundice: interaction with multiple risk factors.

This nonconcurrent cohort study was carried out to evaluate the association of neonatal jaundice with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency and its interactions with other risk factors. The G-6-PD enzyme activity of 12,379 neonates was screened by a semi-quantitative fluorometric assay and double-checked by a quantitative method to identify a G-6-PD deficient cohort of 333 neonates. Matched with these on birth date, sex and delivery hospital were a G-6-PD normal cohort of 653 neonates. Neonatal jaundice was defined by a peak serum bilirubin (PSB) level of > or = 15 mg/dl. A significant association between G-6-PD deficiency and neonatal jaundice was observed in male but not female neonates. There was an inverse dose-response relation between G-6-PD activity and neonatal jaundice among male neonates. Both hypoxia/asphyxia and maternal hepatitis B surface antigen (HBsAg) carrier status were associated with an increased risk of neonatal jaundice among G-6-PD deficient but not G-6-PD normal male neonates. Based on multiple regression analyses, an additively synergistic effect on PSB level and severe jaundice (PSB > or = 20 mg/dl) was observed for G-6-PD deficiency and maternal HBsAg carrier status.


Dietary factors and fracture in postmenopausal women: a case-control study.

This case-control study examined the effect of diet on the risk of postmenopausal fracture of the hip and wrist. Cases, women aged 50-84 years, were admitted to one of four Metropolitan Toronto hospitals during the period September 1983 through May 1985. Controls were women of the same age, admitted to the same hospitals, and seen for orthopaedic or general surgical complaints. Data were collected through the use of a standardized structured questionnaire administered by trained female interviewers, and included dietary, sociodemographic, medical, and behavioural variables. Data analysis was conducted on 102 hip fracture cases, 154 wrist fracture cases, and 277 controls. Higher dietary calcium intake only slightly increased the risk of hip fracture; however, it was associated with a significantly decreased risk for fracture of the wrist, at the level > or = 1 g/day. Coffee and tea consumption appeared to be unrelated to fracture risk. Finally, alcohol intake was associated with a statistically nonsignificant increased risk in both fracture types. These findings point to the importance of dietary factors on fracture risk, and indicate a need for future studies to stratify analysis on the basis of fracture type.


Epidemiology of prostatic disorders in the city of Barcelona.

Although disorders of the prostate are among the most prevalent problems in elderly males, little is known about their epidemiological characteristics. The 1986 Barcelona Health Interview Survey (BHIS), a cross-sectional study of a random sample of the noninstitutionalized population of the city, was used to estimate the prevalence of prostatic disorders (PD) and to analyse sociodemographic characteristics, self-perceived health, and use of health services among males reporting PD. Ninety-eight out of 1218 males over 45 years old (8%) reported having PD, the prevalence increasing substantially with age. A pattern of increasing prevalence with decreasing occupational class was found. As compared to subjects not reporting PD, individuals reporting PD reported slightly more restricted activity days (prevalence odds ratio [POR] = 1.28; 95% confidence interval [CI]: 0.52-2.80), more chronic disorders (POR = 4.75; 95% CI: 2.04-13.53), and worse self-perceived health (POR = 1.55; 95% CI: 0.92-2.58). Medical visits and hospitalizations were also higher in the prostatic group (P < 0.05). Men reporting PD appear to constitute a subgroup with increased morbidity and health services use.


Reliability and validity of self-reported physical activity in Latinos.

The reliability and validity of six self-report physical activity measures were assessed in Latino adults. Validity was assessed by caltrac activity monitors, 'significant others', and construct analyses. Vigorous activity measures had higher reliability and validity (e.g. r > 0.40, P < 0.05) than moderate intensity measures. Though measures varied in their validity, the use of standard physical activity measures with Latinos was supported, and recommendations for specific measures were provided.


Personal factors related to the perception of occupational exposure: an application of a job exposure matrix.

Whether certain personal characteristics influence the perception of exposure to dusts, gases or fumes was assessed in 6803 men and 6765 women drawn from nonmanual worker households in seven French cities. Factors modifying the strength of the association between two estimates of exposure (here a job exposure matrix estimate and exposure reported by the subjects) are potential recall determinants of exposure. This association was significantly stronger in men than in women, suggesting a better perception of exposure in men. The strength of the association between both estimates of exposure increased significantly among men according to educational level. Smoking habits had no effect on the perception of exposure. The perception of exposure did not vary significantly according to respiratory symptoms in women. In men, subjects without chronic cough or chronic bronchitis had a significantly higher perception of exposure than the others, but no difference was shown for wheezing, dyspnoea or asthma.


Contraception and prevalence of sexually transmitted diseases among adolescents and young adults in Uganda.

The study is aimed at (i) exploring the knowledge and attitudes of adolescents (15-19 years old) and young adults (20-24 years old) towards sex and contraception (condoms) and (ii) determining their level of knowledge and attitudes towards sexually transmitted diseases (STD) as well as the prevalence of the latter among the sexually active adolescents and young adults. A sample of 4510 respondents (1545 males and 2965 females) aged 15-24 years from urban and rural areas were interviewed. The majority of adolescents and young adults surveyed have a negative attitude towards the use of condoms although most of them agreed that they prevent STD. Over 95% of the respondents have heard about STD and their level of knowledge is relatively high; slightly higher for urban residents and for young males. Approximately 21% of the male and 8% of the female respondents admitted having ever contracted STD. The gap between contraceptive knowledge and practice is rather wide. Only a small proportion of the respondents were using condoms at the time of the survey.


The effects of breastfeeding and presence of antibody to p40tax protein of human T cell lymphotropic virus type-I on mother to child transmission.

We examined the effects of various factors, including duration of breastfeeding, the status of mother's anti-p40tax, and titre of mother's anti-human T cell lymphototropic virus type-I (HTLV-I) on mother to child transmission of HTLV-I in 76 HTLV-I carrier mothers and 175 of their children. The overall prevalence of anti-HTLV-I among children was 16.0%. The prevalence of anti-HTLV-I among children breastfed for over 3 months was significantly higher (27.6%) than that of those breastfed for under 3 months (5.1%; P = 0.012). Of the 78 bottle-fed children, 10 (12.8%) were positive for anti-HTLV-I. In the children breastfed for over 3 months, the prevalence of anti-HTLV-I among 37 children of anti-p40tax positive mothers was 37.8% and that of 21 children of anti-p40tax negative mothers was 9.5%, a significant difference (P = 0.044). These data suggest that about 13% of bottle-fed children born to carrier mothers are infected with HTLV-I by routes other than breast milk, and that the mother's anti-p40tax can serve as a marker of infectivity of HTLV-I in the case of breastfeeding for over 3 months.


HTLV among Israeli intravenous drug abusers.

Since human T lymphotropic virus (HTLV) infection was recently described in Israel and other Middle Eastern countries, we have investigated the presence of HTLV type 1 and type 2 in a group of 299 intravenous (IV) drug abusers who were seen at a large methadone clinic in the Tel Aviv area in 1986-1987. We found that 1.3% were seropositive to HTLV. Further testing revealed that HTLV1 was the only HTLV serotype. In addition, no coinfection HIV1/HTLV1 and no HIV2 infection were detected. Since all HTLV seropositives were born in Middle Eastern countries, did not travel outside Israel and were not infected by HIV1 or by HTLV type 2, it is possible that the source of HTLV1 infection in that group was in an endemic reservoir of HTLV1 in Israel. The detection of HTLV1 among IV drug abusers and among other groups in Israel necessitates more extensive HTLV testing in at-risk populations.


The epidemiology of subacute sclerosing panencephalitis in England and Wales 1970-1989.

Two hundred and ninety cases of subacute sclerosing panencephalitis (SSPE) registered in England and Wales from 1970 to 1989 were followed at 6-monthly intervals. Male to female ratio was 2.8:1. Age at onset increased significantly over the period. Measles was recorded for 81% of cases; in nearly half this had occurred under 2 years. Measles vaccine was documented in 20 cases; in 10 measles was also documented and it could not be positively excluded in the remainder. The calculated risk of SSPE following measles was 4.0/100,000 cases compared with the risk after vaccine of 0.14/100,000 doses. Measles under 1 year carried a risk 16 times greater than measles over 5 years. There was an excess of cases in third and subsequent children. The incidence was higher in the northwest than in the southeast of the country. Survival time varied from 4 weeks to 16 years and was shorter when measles had occurred over the mean age of 2.5 years. Of the cases 9% had a history of mental retardation before the onset of SSPE. The incidence of SSPE has fallen following the reduction in measles resulting from vaccination. However, because of the median 8-year interval between measles and onset of SSPE, further cases arising from measles during the study period must still be expected, particularly in adolescents.


Measurement of visceral blood flow with magnetic resonance imaging.

With the increasing application of magnetic resonance imaging (MRI) and MR angiography in parenchymal liver disease, methods are becoming more widely available for noninvasive measurement of visceral blood flow. Amplitude-based (time-of-flight) and phase-based techniques have proved effective for measurement of portal blood flow, and phase-sensitive methods are applicable to arterial flow measurements. Because respiratory motion degrades the quality of examinations in the abdomen, it is desirable to use methods that can generate flow information in a breath-hold period. Although substantial technical difficulties persist for quantitative arterial flow measurements in the abdomen, the technical requirements for venous flow are less stringent, and important clinical information can be derived using straightforward techniques. The authors describe the principles of flow measurement using time-of-flight and phase methods in visceral arteries and veins, and discuss their practical implementation. Clinical applications are discussed, based on the experience of the authors and others working in the field.


Quantitative imaging of renal blood flow and function.

Noninvasive renal blood flow quantitation has been historically difficult, although radionuclide imaging methods for measuring related parameters of renal function such as glomerular filtration rate and effective renal plasma flow have been successful. Radionuclide methods have long played an important role in the evaluation of renal function, but recent advances in other modalities such as positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging (MRI) have the potential to provide information not available with nuclear medicine techniques. The high spatial resolution provided by these modalities, coupled with dynamic imaging of contrast agents or radioactive tracers, potentially could allow detailed clinical evaluation of regional renal function and blood flow. A specialized MR technique, diffusion-weighted imaging, also shows promise for providing information not otherwise available concerning the renal microcirculation. This report provides a brief review of the available clinical techniques for the evaluation of renal blood flow and function as well as new methods under investigation.


Perfusion/diffusion quantitation with magnetic resonance imaging.

Quantitation of perfusion and diffusion in tissues using magnetic resonance imaging (MRI) techniques is an active area of research in many laboratories. Several different approaches have been taken to address the problem of determining microcirculatory flow or perfusion in the body with MRI. Methods have been developed that depend on pulse sequence designs to sensitize the acquisitions to proton movement that is part of physiologic perfusion. Other methods that are being studied take a different approach by using injected MR contrast agents coupled with high temporal resolution acquisitions to produce time-density curves that can be related to perfusion in the tissues of interest. Yet other approaches use blood as the tracer itself to provide a means of determining perfusion. All of these techniques and others provide quantitative information related to microcirculatory flow in tissues.


Perfusion quantitation by ultrafast computed tomography.

Flow measurements can be made with computed tomography (CT) scanners using iodinated, nonionic contrast media as a first-pass indicator. Ultrafast CT (UFCT) is an ideal machine to make these measurements because of its short scan time (50 mseconds) and interscan delay (< or = 0.6 seconds). Additionally, UFCT can acquire data at up to eight cross-sectional levels without moving the patient. Direct application of indicator dilution principles permit measurement of cardiac output and has been validated in both animals and humans. However, measurement of myocardial perfusion, an initial design goal of the UFCT scanner, has been difficult. Experiments in animals have consistently underestimated flow at high flow rates. Methods to improve accuracy include better accounting for tissue blood volume and minimizing image artifacts.


Perfusion quantitation using positron emission tomography.

Positron emission tomography (PET) is assuming increasing importance as a clinical and investigative functional imaging modality. Cerebral blood flow determination with PET is now more easily performed due to improvement in tomography design, increased speed and ease of data analysis, and improvement in radiopharmaceutical synthesis and delivery. This article reviews the historic development of the PET, the evolution of cerebral blood flow measurement techniques with PET, technical considerations in PET imaging, radiopharmaceuticals for cerebral blood flow determination, and tracer kinetic models used for cerebral blood flow determination. Representative examples of PET cerebral blood flow imaging are shown and the evolving applications to brain mapping are discussed.


Magnetic resonance angiography techniques.

After a radio frequency pulse, the decay of the magnetic resonance (MR) signal is described by two relaxation processes, T1 and T2. T1 describes the rate at which the magnetization realigns itself along the external magnetic field direction (ML), and T2 describes the rate of decay of the magnetization component along the transverse axis (MT). Magnetic resonance angiography (MRA) sequences have been developed that encode flow as changes in the apparent T1 or T2 of the moving blood relative to stationary tissues. MRA sequences typically use either time-of-flight (TOF) techniques to encode T1 or phase-contrast techniques to encode T2. TOF techniques encode flow as an apparent T1 shortening through the wash-in of fully relaxed blood from outside the image volume. The shorter T1 produces an enhancement of vascular structures relative to stationary tissues. TOF methods may use either sequential two-dimensional, three-dimensional, or multi-slab three-dimensional imaging sequences to produce a three-dimensional MRA data set. Phase-contrast methods use additional magnetic field gradients to encode flow as shifts in the phase of MT. Both TOF and phase-contrast methods use maximum intensity projection (MIP) images displayed in a cine format to aid in the visualization of three-dimensional vascular structures.


Intracranial magnetic resonance imaging.

Magnetic resonance angiography (MRA) is currently being incorporated into the routine MR evaluations of patients with suspected cerebrovascular disease. Currently, MRA serves as a useful adjunct to routine parenchymal spin-echo imaging of the head. Intracranial MRA is predominantly used as a screening test for cerebrovascular disease in situations where the clinical suspicion and/or the patient's physical condition does not warrant a conventional arteriogram. Clinical experience to date suggests that MRA can play a significant role in the evaluation of patients with suspected intracranial aneurysms, arteriovenous fistulae, large vessel occlusive disease, and dural sinus occlusion/thrombosis. MRA has not yet reached the point where it can replace conventional catheter angiography. This is most apparent when trying to evaluate 1) larger vessels which are typically difficult to visualize due to higher order motion terms (eg, carotid siphon); 2) the smaller cortical branches with relatively slow flow that would be necessary to see in patients with suspected vasculitis; and 3) any situation in which dynamic information is important such as with mass lesions or vascular malformations. These limitations must be taken into account when deciding on the appropriate imaging study for an individual patient. Large-scale, well-controlled prospective clinical trials will ultimately determine the role intracranial MRA will play in the evaluation of patients with suspected cerebrovascular disease.


Measurement of myocardial perfusion and cardiac output using intravenous injection methods by ultrafast (cine) computed tomography.

Ultrafast (or cine) computed tomography (CT) uses a novel scanning electron beam technology to obtain multi-level images of the beating heart in rapid succession. Recent investigations have demonstrated that it can be used to define the transit of iodinated contrast media through the cardiac chambers and myocardium. Using classical indicator dilution principles and rapid intravenous injection of iodinated contrast media, ultrafast CT can quantify cardiac output and, to a limited extent, myocardial perfusion. A caveat to the application requires that careful calibration be made on a subject-by-subject basis prior to quantification of cardiac output. Although global myocardial perfusion and flow reserve can be evaluated by ultrafast CT, spatially variable imaging artifacts may limit the application in all regions of the left ventricular myocardium. Advances in study design, image reconstruction and post-image processing continue. Ultrafast CT technology offers a means to define cardiac anatomy, function and flow in man rapidly, conveniently and accurately in a noninvasive fashion employing intravenous contrast media injection.


Functional brain mapping using magnetic resonance imaging. Signal changes accompanying visual stimulation.

Easily detectable (5%-20%) transient increases in the intensity of water proton magnetic resonance (MR) signals in human primary visual cortex were observed during visual stimulation in gradient echo images at 4-T field strength. The signal intensity increases were predominantly restricted to areas containing gray matter and were used to produce high-spatial-resolution human functional brain maps. Time dependence of the functional brain maps also was monitored during visual stimulation using images acquired every approximately 5 seconds; these images with high spatial and temporal resolution demonstrated that photic stimulation first resulted in signal increases in a large area of the visual cortex followed by a reduction in the size of the area, and that signal intensity increases in the gray matter were time dependent. Reducing the image acquisition echo times reduced the amplitude of the fractional signal change, suggesting that it is produced by a change in T2 or T2*. The amplitude, sign, and echo time dependence of these intrinsic signal changes are consistent with the idea that neural activation increases regional cerebral with the idea that neural activation increases regional cerebral blood flow (rCBF) with a concomitant increase in venous blood oxygenation.


Magnetic resonance imaging mapping of brain function. Human visual cortex.

Magnetic resonance imaging (MRI) studies of human brain activity are described. Task-induced changes in brain cognitive state were measured using high-speed MRI techniques sensitive to changes in cerebral blood volume (CBV), blood flow (CBF), and blood oxygenation. These techniques were used to generate the first functional MRI maps of human task activation, by using a visual stimulus paradigm. The methodology of MRI brain mapping and results from the investigation of the functional organization and frequency response of human primary visual cortex (V1) are presented.


Theoretical principles of perfusion imaging. Application to magnetic resonance imaging.

Perfusion magnetic resonance imaging (MRI) offers relative safety (no ionizing radiation), high spatial/temporal resolution, multi-orientation imaging capability, and relative low cost when compared with sophisticated techniques, such as positron emission tomography (PET). Several methods have been recently proposed to image perfusion. Some techniques mimic conventional nuclear medicine principles, but use radioactively inert tracers. Other approaches directly use blood as an endogenous natural tracer. Such methods are totally noninvasive, and offer original insights, for instance by monitoring variations in blood oxygenation in human brain cortex during activation tasks. These methods are presented and compared. Emphasis is given on advantages and drawbacks, and potential clinical applications.


Measurement of blood flow and perfusion in the cardiovascular system.

Complete evaluation of cardiovascular disease by a single imaging technique requires measurement of bulk flow in blood vessels and estimation of relative or ideally absolute perfusion at the tissue level. Magnetic resonance (MR) measurement of blood flow in arteries and veins has been done using the velocity-encoded phase cine gradient echo technique. This technique has been applied with cine MR to measure normal and pathologically high velocities. Measurement of relative perfusion in the myocardium has used the intravenous injection of T1 relaxation enhancing and magnetic susceptibility MR contrast media with rapid image acquisition using echoplanar imaging. MR images (MRIs) acquired during steady-state distribution or during the first passage of these contrast media have depicted ischemic myocardial regions.


Cardiopulmonary vascular imaging.

Magnetic resonance angiography (MRA) effectively maximizes the flow sensitivity of MR imaging (MRI) to display the body's vasculature. Although MRA has proven quite effective in imaging the intracranial and extracranial vessels, cardiopulmonary MRA faces several additional inherent challenges. Cardiorespiratory motion, vessel pulsatility, and irregular flow patterns all degrade image quality and necessitate appropriate compensation schemes. Although preliminary cardiopulmonary MRA methods appear promising, near instantaneous scan times may be necessary to fully maximize the potential of this technique. Multislice spin-echo and gradient-echo techniques have also proven effective. These methods may compensate for cardiac motion through either ECG-gating or referencing, and may maximize the signal characteristics from the intrinsic slow blood flow of the pulmonary vasculature. Phase velocity mapping techniques, which have proven capable of quantifying blood flow in the body, appear equally promising in preliminary studies in evaluating the cardiopulmonary vascular system. Because of the nature of blood flow dynamics in the cardiopulmonary vascular system, spin-echo (SE), gradient refocussed echo (GRE), and possibly phase mapping technique appear well suited for evaluating these regions.


Magnetic resonance angiography. Application to the peripheral circulation.

Magnetic resonance angiography (MRA) for application in the musculoskeletal system is progressing at a rapid pace. The clinical role of this new technique is still being developed, although a number of uses have already become well recognized, and MRA is diffusing into clinical practice. This article describes the basic fundamentals of MRA as it applies to the peripheral circulation and to the evaluation of potential clinical procedures.


Time-of-flight magnetic resonance angiography of the aorta and renal arteries.

The evaluation of the aorta and renal arteries with time-of-flight (TOF) magnetic resonance angiographic (MRA) techniques has been the subject of several recent investigations, with both sequential two-dimensional and three-dimensional methods described. Although the data are preliminary, these techniques appear to allow the noninvasive evaluation of a variety of vascular abnormalities, including renal artery stenosis and occlusion. This report outlines the theoretical considerations of TOF MRA of the abdomen, and discusses differential characteristics of the available techniques along with their advantages and limitations.


Magnetic resonance angiography of the pelvis and lower extremities. Works in progress.

Two-dimensional time-of-flight (TOF) magnetic resonance angiography (MRA) of the lower extremities has recently been rediscovered as a technique that can be used to find small vessels in the foot and leg for surgical revascularization in patients with severe peripheral vascular disease. The purpose of this article is to acquaint the reader with some of the common problems that may be encountered in this imaging technique and to show their derivations and solutions were applicable. In addition, the authors show receiver operator curve analysis of one radiologist's ability to determine the location and patency of arteries using this technique to be outstanding (AZ, 0.9737). This represents a promising new technique for imaging the arterial system in patients with severe peripheral vascular disease.


Magnetic resonance angiography and measurement of blood flow in the peripheral vessels.

Peripheral vascular disease has been evaluated using conventional imaging techniques such as contrast angiography to demonstrate the morphology and duplex sonography to evaluate the hemodynamic significance of a stenosis. Two-dimensional time-of-flight (TOF) magnetic resonance angiography (MRA) provides useful anatomic information in both normal and diseased popliteal and tibioperoneal vascular segments, whereas corresponding velocity-encoded cine MR determined velocities and waveforms correlate well with those determined using color-coded sonography and showed excellent interstudy reproducibility. Velocity-encoded cine MR may be useful in assessing the hemodynamic significance of a peripheral vascular stenosis whose severity might be overestimated by using MRA alone. When two-dimensional TOF MRA is combined in a complementary manner with velocity-encoded cine MR, the anatomic information from contrast angiography and the physiologic information from duplex sonography can be obtained during the course of one MR examination.


Radiosensitivity and responsiveness to recombinant interleukin-2 of effector cells of graft vs. host disease and mixed lymphocyte reaction in mice.

Synergistic effects of recombinant interleukin-2 (IL-2) or irradiated spleen cells were investigated in vivo and in vitro. Irradiated (750 cGy) C57BL/6 spleen cells infused to sublethally irradiated (500 cGy) BALB/c mice treated with IL-2 (1,000 U 3 times/day) caused graft vs. host-like disease (GVHD) in 3 of 11 mice. Similarly irradiated allogenic spleen cells caused no GVHD in irradiated recipients not administered IL-2. No sign of autologous GVHD was found in mice that received irradiated syngeneic spleen cells with IL-2. Addition of recombinant IL-2 in vitro to mixed lymphocyte reactions (MLR) using irradiated (500 cGy) allogeneic responder spleen cells augmented the 3H-TdR uptake fourfold compared to cultures without IL-2, but was 44-fold below the allogeneic response of nonirradiated C57BL/6 spleen cells. Il-2-induced cell proliferation was also noted in syngeneic MLR, but did not lead to GVHD in in vivo experiments. The data suggest that IL-2 may potentiate GVHD and alloreactivity induced by an adequate number of irradiated, nondividing but viable allogeneic spleen cells and/or that secretion of IL-2 by alloactivated T lymphocytes, supplied exogenously in the present study, may play a role in the GVHD syndrome. Since neither viable but nonreplicating T cells nor IL-2 alone caused GVHD, it is suggested that endogenously produced IL-2 by alloactivated T lymphocytes may be important in the development of the GVHD syndrome, independent of its main function of enhancing T lymphocyte proliferation. On the other hand, the lack of GVHD following administration of high numbers of irradiated or nonirradiated syngeneic spleen cells with IL-2 implies that allogeneic T lymphocytes and not IL-2 activated MHC-nonrestricted cytotoxic cells play a role in inducing the GVHD syndrome in vivo.


Mycobacterium xenopi, a potential human pathogen.

Mycobacterium xenopi is infrequently recognized as a cause of pulmonary disease. During a 12-year survey (1978-89),. 108 strains of this Mycobacterium were isolated from 90 persons and 6 hot water samples. From 87 patients 89 occasional strains of M. xenopi were isolated, and 3 patients were diagnosed as having pulmonary mycobacteriosis caused by it. The treatment and the response in these three cases were variable, depending on clinical conditions and sensitivity to drugs. Most of the strains isolated came from patients hospitalized at the Barzilai Hospital, Ashkelon, therefore a local environmental contamination was suspected. The suspicion was confirmed by the isolation of this thermophile organism from the hot water samples of the above hospital.


Causes of death in patients with end-stage renal disease treated by dialysis in a center in Israel.

The causes of death in 84 end-stage renal failure patients, treated with dialysis, who died during a 66-month period were reviewed retrospectively. Cardiac and infectious diseases were the main cause of death (27% each). These two constituted 44% of causes of death in hemodialysis and 75% in continuous ambulatory peritoneal dialysis patients. Malignant disease (7%) and hyperkalemia (5%) were responsible for death only in hemodialysis patients. Patients who died following hyperkalemia were younger than 50 years old. Patients who died from malignant disease were dialyzed for more than 3 years. In summary, the mode of dialysis therapy, age at start of therapy, time on dialysis, and previous cardiac disease may play a role in determining the causes of death in dialysis patients.


Delayed operation for acute pancreatitis.

A retrospective study of 72 patients with acute biliary pancreatitis admitted to our department between 1982 and 1988 was carried out to evaluate our policy of delaying surgery in such cases. Of the 57 patients who underwent surgery, 17 were operated upon within 1 to 14 days of admission ("early operation"), and 40 patients were managed conservatively and readmitted for elective surgery about 6 weeks after resolution of the acute attack. Higher mortality and morbidity rates were observed in the "early operation" group (18% and 18% compared to 0% and 10%, respectively, P < 0.05). However, all deaths occurred in septic patients over the age of 70 who were operated on due to failure of maximal intensive medical therapy. Advanced age and early operation were found to be significant predictors of hospital mortality (P < 0.01). The two groups had similar mean hospital stay; 12 patients (30%) suffered an attack while waiting for elective surgery, however in only 3 (8%) the second attack occurred within 4 weeks of discharge from hospital. We conclude that a "delayed" operation for biliary pancreatitis is an acceptable option, and that recurrent attacks of acute pancreatitis in the time interval before the operation are avoidable if the operation is performed within 6 weeks of the initial acute attack.


Prevalence of asthma in Israeli schoolchildren. A comparative study of Jewish and Arab populations.

The prevalence of asthma in 2,160 schoolchildren from Arab and Jewish rural and urban communities in central Israel, was determined by means of questionnaire. For the purposes of the study, asthmatic children were defined as those suffering from two or more asthmatic episodes which had been diagnosed by their physicians and had necessitated anti-asthmatic therapy. Doubtful cases were classified after personal interviewing and physical examination. The overall prevalence of asthma was 6.38%. In the Arab rural sample, it was 2.86%, significantly lower than the other groups studied: Arab urban 6.63% (P < 0.001), Jewish urban 9.2% and Jewish rural 8.66% (P < 0.001). The relatively low prevalence in the Arab rural sample is in accordance with the rarity of asthma reported from less advanced societies in other countries. The reasoning for the low asthmatic morbidity found in this group is not clear.


Low concentrations of lithium and cyclooxygenase inhibitors enhance endothelin-1 (ET-1)-induced contractions in human temporal artery, but not in porcine ophthalmic artery.

Endothelins are a recently discovered group of potent vasoconstrictor peptides synthesized by endothelial cells and other tissues in various species, which seem to participate in the regulation of vascular tonus. Abnormalities in vasoactivity in the head may be an important event in headache pathophysiology, although the mechanisms responsible for such constrictions and/or dilations are not known. The endothelium and its constrictor peptide, endothelin, may play a key role in such mechanisms. Of the various drugs used in the treatment of headache, lithium is an accepted treatment for cluster headache, and indomethacin is the drug of choice for the associated condition chronic paroxysmal hemicrania. The mechanism of action of these drugs in these headaches is not known. Due to the possible involvement of endothelin in headache disorders, the objective of this study was to verify the effects of lithium and cyclooxygenase inhibitors (indomethacin, acetylsalicylic acid and naproxen) on endothelin-1 (ET-1)-induced contractions in isolated human temporal arteries and porcine ophthalmic arteries. It was found that all drugs increased the (ET-1)-induced contractions in human temporal arteries. Conversely, there were no significant changes induced by the drugs in porcine ophthalmic arteries. These results are consistent with the variation of activity often seen in different vascular beds and between species. The potential importance of such reactions for the understanding of vascular changes putatively involved in headache development and treatment is discussed.


5-HT2 serotonin receptor on blood platelet of migraine patients.

Several lines of evidence have previously suggested that platelets might play a primary or secondary role in migraine pathogenesis, and that in addition serotonin receptors on human platelets might be involved in those processes. By using [3H]-spiperone as a radioligand and ketanserin to determine the non-specific binding, the numbers of 5-HT2 serotonin receptors on platelet membrane obtained from normal healthy and migraine subjects were determined. We found a significant decrease (p < 0.02) in the maximal receptor numbers (Bmax) on platelet membrane of migraine patients (Bmax = 33.01 +/- 5.57 fmol/mg protein) when compared to the normal healthy group (Bmax = 86.59 +/- 9.09 fmol/mg protein) whereas the dissociation equilibrium constant (Kd) values (2.47 +/- 0.44 nM and 3.41 +/- 0.95 nM for the normal and migraine subjects, respectively) remained unchanged. The platelet response showed a higher degree of aggregability in migraine subjects, whereas the platelet counts were the same. This finding implies that serotonin receptors on the platelet may reflect some aspect of the pathogenesis of migraine headache.


MRI of intracranial arteries in nitroglycerin induced cluster headache attacks.

Eight patients with episodic cluster headache, five in active episode, three out of episode, were investigated as to diameters of intracranial arteries before and after nitroglycerin (NG) administration. The diameter of all intracranial carotids were increased about 10 minutes after NG, although more in the patients in episode than in patients out of episode. The dilatation remained for the next 60 minutes in the patients who did not get a cluster headache attack. There was a normalization of the diameters of the internal carotid arteries compared to the initial values, at maximum pain in all patients who got a cluster headache attack. Similar changes were also found in the basilar arteries. The findings support the hypothesis of a constriction of intracranial arteries at maximum pain in cluster headache attacks to stop the pain.


SUNCT syndrome: VII. Ocular and related variables.

SUNCT is a unilateral headache syndrome with shortlasting attacks, accompanied by e.g. conjunctival injection and lacrimation on the painful side. Intraocular pressure (IOP), corneal indentation pulse (CIP) amplitudes, episcleral venous pressure, and corneal, tympanic, and facial temperature have been studied in 6 SUNCT patients. IOP and CIP amplitudes increased on the painful side during headache paroxysms, while episcleral venous pressure remained unchanged. Corneal temperature seemed to increase during attack on both sides. However, the number of observations during attacks is scanty. Outside of attacks, the corneal temperature on the symptomatic side seemed to be higher when compared with the non-symptomatic side (generally > or = 0.5 degrees C), provided that the attack frequency was high. The facial temperature seemed to be even on both sides or slightly higher on the symptomatic than on the non-symptomatic side in the periocular area. This pattern seems to be different from the one in trigeminal neuralgia, in which the temperature has been reported to be lowest on the painful side of the face. During attacks, there seemed to be a tendency for the temperature to increase in the periocular area, but not over the mandible or in the neck. The results obtained could be caused by increased blood supply to the eye (and the surrounding skin) on the symptomatic side because of vasodilatation during repeated pain attacks. As far as the ocular changes are concerned, probably the arteriolar side of the vascular bed is involved.


Posttraumatic headache: permanency and relationship to legal settlement.

In our increasingly litigious society there is persistence of an attitude that posttraumatic headache (or other injuries) will either improve or disappear following resolution of a claim. In some states (Florida) in order for a person to initiate a claim, an injury must be considered permanent. This is often a difficult task with a subjective symptom. This retrospective study was performed to evaluate the reliability of criteria used to diagnose a "permanent" posttraumatic headache and whether these headaches stay "permanent" after legal settlement. Data was obtained by a structured telephone interview of fifty adult outpatients diagnosed as having permanent posttraumatic headache and their litigation settled at least one year previously. Patients with previous headaches, other accidents or head injuries were excluded. The average length of time from settlement to interview was 23 months. Forty-six had been in automobile accidents and four either had falls or blunt trauma to the head. (Eight cases involved Workman's Compensation). Criteria used at this clinic for determining permanency were either posttraumatic headache persisting for longer than one year with no evidence of further improvement (43 patients) or patients with headaches persisting longer than 6 months with a plateau (no change) in their pattern for three months or more with an adequate trial of treatment (in our judgement). These criteria did seem reliable. All fifty patients interviewed continued to report persistent headache symptoms one year or more following legal settlement. Improvement in headache pattern after legal settlement was only reported by four patients.


The relationship of anger, depression, and perceived disability among headache patients.

Depression is a common concomitant of headache. Conflict with regard to anger or the expression of anger has also been discussed in terms of its relationships to headache. The direction of the relationship between headaches and depression and/or anger is not clear from available research literature. Thus, the present study proposed to examine the interrelationships among measures of anger expression, depression and self-reported disability in a sample of chronic headache patients. It was predicted that there would be significant correlations between depression and perceived disability, and anger held in and perceived disability. Finally, it was predicted that anger held in would be shown to impact perceived disability by way of its relationship to depression. Path analysis was employed to investigate the relationships among the variables. Results showed a significant and positive relationship between depression and perceived disability, which supported the first hypothesis. Anger expression was not significantly related to perceived disability. Therefore, the second hypothesis was not supported. Anger-in, however, was strongly and positively related to depression. Although the causal direction of the relationships cannot be stated with certainty, the suppression of anger appears to be a moderating variable that amplifies the experience of depression among chronic headache patients.


Cluster headache following head injury: a case report and review of the literature.

A relation between head trauma and cluster headache is frequently described in the literature. The percentage of cluster patients with a history of head injury is approximately 16.5 when several large studies are reviewed. The present paper reports another case where there is close proximity between head injury and the onset of cluster headache. A review of the literature attempts to document the supposition that there is indeed a causal or precipitous role for head injury in cluster cephalgia pathogenesis.


MRI in migraineurs.

Forty-six migraineurs and 69 age- and sex-matched controls referred for MRI scans of the brain were evaluated for the incidence of intracranial pathology. Axial long TR/short TE and long TR/long TE and sagittal short TR/short TE scans were performed in all patients. Enhancement with Gd-DTPA was performed in all controls and in nine migraineurs. Six of 46 (13%) of the migraineurs had white matter lesions versus three of 69 (4.3%) of the controls. The white matter lesions in migraineurs were seen in a younger age group than in the controls. These findings agree with recent MRI studies. Ischemia or an immune-based white matter demyelination are possible mechanisms for the white matter lesions.


Tizanidine in chronic tension-type headache: a placebo controlled double-blind cross-over study.

The efficacy of tizanidine in chronic tension-type headache was compared with placebo in a randomized, double-blind and cross-over study in 37 women aged 20 to 59 years with a history of headache for 7 months to 30 years (median 5 years). The treatment periods were 6 weeks with an intervening 2 week wash-out period. The treatment was started with 6 mg/day divided into three doses, and the daily dose could be increased to 18 mg/day depending on the treatment response. The effect of the treatment was measured by visual analogue scale, verbal rating scale, number of days free of headache, number of analgesics needed, and the dose of trial medication needed. In all these measurements, tizanidine was statistically significantly more effective than placebo. The pre-trial Beck Depression Inventory score did not predict the response to treatment, neither did the level of electromyographic activity of the trapezius muscle. Side-effects, drowsiness and dry mouth were significantly more common during tizanidine treatment but they were usually mild. The results of the present trial suggest that tizanidine is effective in the treatment of chronic tension-type headache in women.


Management of acute intractable headaches using i.v. therapy in an office setting.

Twenty-seven consecutive patients with acute intractable headaches were treated in an office setting with an intravenous protocol of an antiemetic, hydrocortisone sodium succinate, and dihydroergotamine (DHE). All patients had significant pain relief within 45 minutes. Patients who were not pain-free post-treatment uniformly reported decreasing pain at the time of departure from the office. No patients required further treatment (including narcotic medication) for acute headache. All patients were followed for at least 24 hours. Adverse reactions were transient and mild. Akathisia was not uncommon and has probably been underestimated in previous studies.


Overexpression of p53 in head and neck cancer.

The putative tumor suppressor gene p53 plays a key role in the regulation of cell proliferation. Functional loss of p53 protein through mutation or viral oncogene-complexing can result in p53 protein overexpression detectable by immunocytochemistry, which in turn has been associated with markers of poor prognosis in some cancers. We report here an analysis of p53 overexpression in fixed, embedded specimens from 81 prospectively collected head and neck tumors, both benign and malignant, including 55 squamous cell carcinomas, using monoclonal pAb1801. Sixty-two percent of the squamous cell carcinomas from the head and neck region overexpressed p53, whereas none of the benign tumors or adjacent normal tissues overexpressed p53. Overexpression of p53 was strongly associated (p < 0.01, two-tailed chi-square) with a histologic malignancy grading scale previously shown to have prognostic capabilities. We conclude that p53 overexpression is one of the most common abnormalities identified in head and neck cancer, and may be a useful marker in the study of multistep progression of tumorigenesis.


Dual free flap transfer using forearm flap for mandibular reconstruction.

To reconstruct a composite mandibular defect, we have simultaneously transferred a vascularized bone graft or osteocutaneous flap together with a forearm flap. The radial forearm flap, being thin, pliable, and having a long vascular stalk, served as mucosal lining and/or an interpositional flap acting as a vascular bridge. Between 1982 and 1989, we used this procedure in 17 patients with a mandibular defect or deformity which developed following treatment of oral cancer. Our clinical experience has demonstrated that this dual free tissue transfer has many advantages. It is useful for obtaining a good alveolar ridge in patients with a composite mandibular defect. It is applicable in cases where only a single pair of recipient vessels are present and may be useful when the recipient vessels are positioned some distance from the defect.


DNA ploidy analysis of squamous cell head and neck cancer to identify distant metastasis from second primary.

We conducted an investigation by flow cytometry to determine whether lung cancer in eight patients with oral cancer represented a metastasis or a second primary. One patient had the same aneuploid cell population at both sites which indicated the lung lesion to be a metastasis. Two patients had a diploid lesion at both sites. In these patients, a second primary could not be distinguished from a distant metastasis because (notwithstanding both lesions being diploid) the tumors may have a different DNA content but at a level too low for flow cytometric detection. Five cases had differing DNA indices, which could represent a second primary as well as the emergence of a new clone during tumor progression and metastasis. It appears that DNA flow cytometry can identify tumors that are the same if both have the same aneuploid pattern, but it cannot prove that they are different.


Epithelial membrane antigen and S-100 protein-labeled cells in primary and metastatic laryngeal carcinomas.

Immunohistochemical studies were done on the expression of S-100 protein-labeled cells in human laryngeal carcinoma of epithelial membrane antigen (EMA) and on the population density. EMA was detected in 65 of 76 (86%) squamous cell carcinomas and was usually more extensively positive in well and moderately differentiated carcinomas. Thus, EMA can serve as a marker of malignancy in laryngeal carcinomas. The population density of S-100 protein-labeled cells was high in well-differentiated tissues. In the metastatic tumors, the number of S-100 protein-labeled cells decreased as compared to findings in the primary tumors. As a statistically significant difference in survival curve was noted between groups with low and intermediate density of S-100 protein-labeled cells, the infiltration of S-100 protein-labeled cells seems to be associated with a better prognosis.


Metastatic thyroid cancer as an incidental finding during neck dissection: significance and management.

Occult thyroid cancer is an occasional incidental finding during surgery for other indications and is usually considered of minor clinical significance; however, the appropriate approach for incidentally found metastatic thyroid cancer is less clear especially when it occurs in the context of another malignancy that has more aggressive potential. Among 2,855 patients treated for squamous cancer of the tongue at The University of Texas M. D. Anderson Cancer Center, eight patients had coexisting differentiated thyroid cancer metastatic to cervical lymph nodes which was found incidentally during regional lymph node dissection. The eight patients included three women and five men with a median age of 47 years (range, 32-62 years); tumors were of the papillary variety in four patients and follicular in the other four. In one patient, no gross or microscopic primary tumor could be identified after thyroidectomy; in another patient, no gross tumor was evident, but whole organ section revealed an area of fibrosis consistent with a primary lesion. Two patients had primary lesions less than 1 cm in maximal diameter. In four patients who had no surgery, physical exam and radiologic evaluation failed to show any intrathyroidal lesions. Clinically relevant thyroid cancer did not develop in any of those patients during the duration of documented follow-up (1-15 years). Three patients died of progressive tongue cancer, one patient of unrelated pulmonary disease, and four patients remain alive without evidence of disease for 1 to 15 years of available follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)


Pathogenesis and surgical treatment of migraine and neurovascular headaches with rhinogenic trigger.

Patients (299) with various types of headaches (migraines, cluster headaches, and so-called idiopathic headaches) were operated on between 1973 and 1991. Septal correction, resection of the middle concha, ethmoidectomy, and sphenoidectomy on the corresponding headache side or occasionally on both sides were carried out. Most patients (235; 78.5%) were totally asymptomatic postoperatively; 34 (11.5%) had a sensation of pressure in the head on rare occasions but no further migraines, and 30 (11%) continued to experience headaches that occurred only rarely and were mild and of short duration.


Esthesioneuroblastoma and neck metastasis.

Esthesioneuroblastoma (ENB) is a rare malignant neoplasm arising from the cribriform olfactory epithelium. Its aggressive biologic behavior is characterized by inapparent submucosal spread, local recurrence, atypical distant metastases, and poor long-term prognosis. Historically, the suspicion of neck metastasis has not been associated with ENB. A retrospective review of all ENB patients treated at the University of North Carolina Hospitals since 1972 has revealed an unusually high incidence of cervical metastases (four of four patients). This prompted a review of the ENB surgical literature. All English-literature series published since the widespread use of craniofacial surgery with accruals of eight or more patients were examined for reports of neck metastasis. Although the cumulative cervical metastatic rate reached 27% (55 of 207 patients), most authors failed to recognize the potential risk of cervical metastasis in ENB. Furthermore, in patients suffering from Kadish stage C disease, the cervical metastatic rate climbed to 44% (25 of 57 Kadish stage C patients). This further emphasizes the importance of the neck as a high-risk metastatic site. These findings suggest that cervical metastases may be an important consideration in the evaluation and treatment of patients suffering from ENB. Strategies for evaluation and management of the neck are discussed.


Temporomandibular arthritis in familial Mediterranean fever.

Temporomandibular joint arthritis is a rare manifestation of familial Mediterranean fever and should be considered in patients of Mediterranean origin. Recently we treated four patients suffering from this condition, and intra-articular corticosteroid injection resulted in rapid resolution of the pain and disability in two. Computed tomography confirmed the usefulness of this therapeutic modality.


[Mechanism of the interaction of leukocytes and dermal endothelial cells in cutaneous inflammation].

The infiltration of specific leucocyte populations into inflamed cutaneous tissue is dependent on their interactions with dermal endothelial cells. The dynamic multistep process of vasodilatation, adhesion, transendothelial migration, and penetration through the basal membrane is controlled by a considerable number of soluble mediators and cell adhesion molecules. In this process, dermal endothelium plays a critical role as a gate-keeper who regulates adhesion and penetration of neutrophils, lymphocytes, or monocytes by selection and activation of specific leucocyte subpopulations. In this review, the presently known functions of the involved cell adhesion molecules of the integrin, selectin, and immunoglobulin superfamily, as well as their interactions and their regulation by cytokines and other mediators are summarized.


Sister chromatid exchange frequencies in carcinoma of the human oral cavity: effect of treatment.

Spontaneous and mitomycin-C-induced sister chromatid exchange frequencies were studied in the lymphocytes of 25 oral cancer patients. For these patients, the mean spontaneous SCE value was 8.31 (+/- SD), which was significantly higher than the value of 6.60 (+/- SD) obtained for the controls (p < 0.001). But there was no significant difference between the Mitomycin C induced mean SCE values of oral cancer patients and controls. Seven of these 25 oral cancer patients were selected for second sampling after surgical removal of the tumor. Six of these seven patients showed a decrease in mean SCE/cell value following surgery, which was almost equal to the SCE values obtained for the controls. This indicates that the increased spontaneous SCE rates in oral cancer patients might be due to the metabolic stress imposed by the tumor on the host body or by some clastogenic product of the malignant cells. Surgical removal of the tumour might have resulted in normalization of the lymphocytic SCE rates in postoperatively studied patients.


Fine-needle aspiration of parotid gland lesions.

The results of 49 specimens obtained by fine-needle aspiration biopsy of parotid gland lesions were compared with the pathologic diagnoses of the surgically resected specimens. Cytologically, 33 lesions were diagnosed as benign, with 30 of these confirmed histologically and three false-negative results. Fourteen cytologic specimens were called malignant or suspicious for malignancy, with 11 of these confirmed histologically and three false-positive results. The concurrence rate for distinguishing benign from malignant disease was 87.2%. The sensitivity for malignancy was 78.6% and the specificity 90.9%. The pathology of the misdiagnosed lesions will be reviewed. Based on our data and a review of the literature, we conclude that fine needle aspiration biopsy of parotid gland masses, with the observation of certain caveats, is a helpful adjunctive test for diagnosis and treatment planning.


[Cyclosporin A in the therapy of inflammatory dermatoses].

The experience reported in the literature with cyclosporin A (CyA) in the treatment of various inflammatory and autoimmune dermatological diseases is reviewed and compared with the authors' own experience of treating 36 patients presenting with psoriatic arthritis [8], generalized pustular psoriasis [2], palmoplantar pustular psoriasis [12], Behçet's disease [2], disseminated circumscribed scleroderma [2], acrodermatitis continua suppurativa [2], pemphigus vulgaris [1], lupus erythematosus [3], pyoderma gangrenosum [1], severe atopic eczema [2], and actinic reticuloid [1]. On the basis of the authors' own experience and the reported results, treatment with CyA appears to be primarily indicated in pyoderma gangrenosum, circumscribed scleroderma, psoriatic arthritis and acrodermatitis continua suppurativa. In diseases such as actinic reticuloid, Behçet's disease, localized and generalized pustular psoriasis, treatment with CyA leads to good results with an acceptable risk-benefit ratio. In our view, it is doubtful whether treatment with CyA alone is indicated in alopecia areata, lichen ruber, dermatomyositis, atopic eczema, systemic scleroderma, bullous diseases, and lupus erythematosus, and in the last two it should be given only in combination with systemic steroids. Literature reports provide no support for the use of CyA in ichthyosis vulgaris, pityriasis rubra pilaris, and cutaneous T-cell lymphomas. The risk-benefit ratio of CyA treatment should be carefully considered, especially in diseases that are not life-threatening.


Double skin island pectoralis major myocutaneous flap with nipple-areola complex preservation: a case report.

A horizontal double skin island pectoralis major myocutaneous flap with preservation of nipple-areola complex is described, a different modification used to reconstruct a complex defect following radical resection of a locally advanced gingival carcinoma. The skin islands are horizontally separated by a distance of 2.5 cm but rely on one vascular pedicle for their blood supply. The muscle between the skin islands provides the soft tissue bulk between the internal mucosal and external skin lining. The need for a separate segmental flap or a split-thickness skin graft for mucosal lining was eliminated.


Thoracic duct cyst: an unusual supraclavicular mass.

Lesions of the thoracic duct may occur either in the neck or the mediastinum. The majority of lesions that present in the neck consist of chylous fistulae and are secondary to neck surgery. Cysts of the thoracic duct are very rare and are usually reported as a disease entity of the mediastinum. There are only two reported cases in the literature of thoracic duct cysts occurring in the neck. The third case of a thoracic duct cyst located primarily in the neck is reported. Thoracic duct cysts in the neck must be differentiated from other cysts of the neck, because not recognizing the inferior attachment to the thoracic duct, may result in the disastrous consequence of a chylothorax. Diagnosis can easily be made by fine-needle aspiration with biochemical analysis. Computerized axial tomography (CAT) is useful in defining the anatomic boundaries. A weakness in the wall of the thoracic duct, either on a congenital or degenerative basis, has been postulated as the etiology. The natural history of these lesions remains unknown. Smaller lesions may be followed at routine intervals. Larger lesions should be surgically removed because of the possible complications that may ensue as a result of traumatic rupture or inflammation.


[Combination therapy with interferon alfa 2a and PUVA in cutaneous T-cell lymphoma].

Eleven patients with cutaneous T-cell lymphoma stages Ib-IV a were treated with a combination of interferon alfa-2a and photochemotherapy. The diagnosis was confirmed by histological and immunohistological investigations. During the initial treatment, interferon alfa-2a was given at a maximum dose of 9 million IU 3 times a week. Few patients received for a short time 9 million IU daily s.c. The total dose amounted to an average of 125 million IU. Simultaneously, photochemotherapy with a maximum single dose of 2 J/cm2 was applied. The total dose ranged between 7 and 62.9 J/cm2, which corresponds to an average dose of 22.6 J/cm2. After achieving a complete or partial remission the dose of interferon was reduced to 1.5 or 3 million IU, which was then maintained for long-term treatment 2 or 3 times a week. Photochemotherapy was given twice weekly for a minimum of 2 months and then stopped, depending on the course of the disease. The success of therapy was judged from the clinical and histological picture. The combination treatment was well tolerated and led to complete remission in 5 patients (45%) and a partial remission in 6 patients (55%) after the initial therapy which lasted for an average of 48 days. During the follow-up period, which now amounts to 2-13 months with under 1.5 or 3 million IU interferon, three patients have shown disease progression. One patient responded well to newly applied photochemotherapy and in two patients local tumors regressed after radiation.


Spontaneous rupture of the common carotid artery: a case report.

Spontaneous rupture of the common carotid artery is an extremely rare vascular disorder in the head and neck region. Pseudoaneurysm can be formed by arterial rupture, presenting clinically as an expanding mass lesion. A 37-year-old fisherman suffered from the spontaneous rupture of the left common carotid artery and resultant pseudoaneurysm was radiologically recognized. Surgical exploration revealed a 0.5-cm rent in the common carotid artery, 2 cm proximal to the bifurcation. The lesion was successfully managed with polypropylene sutures during temporary clamping of the carotid artery. The literature is reviewed and the principles of management are discussed.


[Lichen ruber hypertrophicus with verrucous carcinoma].

A 51-year-old patient presented with aggregated papules and with a central, partly erosive plaque on the left lower leg. Histological examination revealed hypertrophic lichen planus peripherally and a verrucous carcinoma within the centre. The lesion was removed surgically. Shortly after wards an atrophic lichen planus developed exclusively within the skin graft, which was effectively treated with topical steroid cream. The patient remained disease-free for 2 years. The literature relating to malignant transformation of cutaneous lichen planus was reviewed. In most cases, as in the present one, the hypertrophic form of lichen planus and the verrucous type of carcinoma (Ackerman) are reported. Recent investigations have revealed human papilloma virus types 6 and 11 within such lesions.