Management of papillary carcinoma arising in thyroglossal-duct anlage. Cysts of the thyroglossal duct are common congenital abnormalities. They present as asymptomatic midline cervical swellings. The risk of malignant change is low; only 103 cases have been reported in the world literature, 85% of which were papillary adenocarcinomas. The appropriate treatment for this condition remains controversial. The authors describe three patients who had papillary carcinoma contained within a thyroglossal-duct rest. All were treated by cyst resection and thyroid suppression, but without thyroidectomy and radioactive thyroid ablation. Postoperatively, all patients remained disease free, with no recurrence at follow-up ranging from 10 to 29 years. Isolated papillary carcinomas arising from primitive thyroid remnants, associated with a palpably normal thyroid gland at surgery and a negative thyroid scan, can be treated adequately by excising the thyroglossal mass.


Nontertiary surgery in Manitoba: comparison of provincial and teaching-hospital data. Do the teaching hospitals in Manitoba provide a suitable spectrum and sufficient numbers of operations to prepare surgeons for practice in Manitoban communities? To answer these questions, the author reviewed the types and frequencies of all operations performed in Manitoba during 1985 and 1986 and compared them with all operations performed in the two Manitoba teaching hospitals for the same years. The 189,380 operations studied were categorized according to the surgical specialist who usually performed each operation in the teaching hospitals. For some procedures commonly performed in the province as a whole, there were too few operations performed in the teaching hospitals to provide sufficient experience for the trainees. A breakdown of nontertiary operations performed in Manitoba revealed that 39% were in the category of general surgery, 29% were in gynecology and operative obstetrics, 17% were in orthopedics, 10% were in urology and 4% were in plastic surgery. The author concludes that a surgeon going to a smaller community as the only surgical specialist requires training of a broader scope than is provided currently in the standard general-surgery training programs in Manitoba.


A technical-skills course for 1st-year residents in general surgery: a descriptive study. The proper teaching of operative skills to surgical residents is increasingly constrained by operative time, complex procedures and medicolegal concerns. A technical-skills program was developed and introduced over a 3-year period to 28 1st-year residents in general surgery. To introduce the residents to the principles of surgical techniques in a simulated environment outside the operating room, the program consisted of a combination of two didactic sessions and six "wet labs" taking 3 to 4 hours per week for 8 weeks between January and March each year. The didactic sessions included instruction on suture material and the use of stapling devices; the "wet lab" used a "hands-on" approach. Educational objectives in the "wet lab" included instruction on preparation of the patient and draping, aseptic technique, principles of bowel anastomosis, incisions, instrument use and handling, principles of hemostasis, intraoperative surgical emergencies, surgical assisting and overall conduct in the operating room. The residents' surgical technique and skills improved over the course period. The overall value, teaching and understanding of surgical principles were rated highly. Problems cited during resident feedback were the use of live animals and insufficient time to practise. The efficacy of a surgical-skills program has been demonstrated, but its effectiveness requires further evaluation.


The Advanced Trauma Life Support course for senior medical students. The authors conducted the Advanced Trauma Life Support (ATLS) Course for 90 students who were in their 4th year of medicine at the University of Manitoba. The impact of the course was evaluated through questionnaires completed by students, instructors and emergency-room physicians. The students' performances were also compared with those of 96 practising physicians who took the ATLS course in Manitoba. The failure rate for students (3.3%) was not statistically different from that for practising physicians (4.2%). Overall, the students' performances in the written test were better (55% of students scored over 90% on the test compared with 15% of practising physicians). The student-to-faculty ratio was 1.5:1 and included 21 physician-instructors. Ninety-five percent of the faculty and students suggested that this course should be mandatory in the 4th year curriculum of medicine and that the course improves trauma care provided by the students and interns by increasing their confidence and improving communication with specialist surgeons. However, 10% of the faculty suggested that more time should be allocated to the surgical-skills practicum. The authors' experience with this program suggests that the ATLS course should be uniformly incorporated in the Canadian undergraduate 4th year medical curriculum and that techniques used in this course should be considered in other areas of the undergraduate medical curriculum.


A family exhibiting carotid body tumours. The authors describe the surgery carried out for 11 carotid body tumours (CBTs) that were found in three generations of a Greek family. Eight patients with CBTs were operated upon at St. Joseph's Health Centre, Toronto, within 1 year. Three patients had bilateral CBTs, which were removed in two stages. Only one of the CBTs occurred in a female. Seven CBTs were excised by meticulous subadventitial dissection. In the eighth, a previous attempt at removal in another hospital had proved unsuccessful, and excision of the tumour required ligation of the external carotid artery and partial excision of the carotid bulb. The authors conclude that most CBTs can be excised directly without ligation, shunts or bypasses. In eight operations carried out on five patients, the only complication was a transient neuropraxia of the hypoglossal nerve that resolved within 2 weeks.


Bronchogenic cyst masquerading as a chronic post-traumatic pseudoaneurysm of the aortic isthmus. The serious nature of false aneurysms that develop in the aortic isthmus after blunt chest trauma is well known. The authors describe the case of a 33-year-old woman who presented with symptoms of chronic post-traumatic pseudoaneurysm of the aorta 3 months after blunt chest trauma. Radiologic investigations could not substantiate an aortic disruption. A bronchogenic cyst masquerading as a false aneurysm of the aorta was identified at thoracotomy. Bronchogenic cysts are one of the most common causes of primary mid-mediastinal masses and should be considered as potential causes of mid-mediastinal enlargement. However, this consideration should not delay urgent surgery if vascular damage cannot be ruled out.


Surgical management of fulminant pseudomembranous colitis. The presentation of pseudomembranous colitis ranges from mild self-limiting diarrhea to fulminant colitis with overwhelming sepsis. The management of the severe forms of this disease, including the role of surgical intervention, is poorly defined. To evaluate the management and outcome in severe cases, the authors reviewed the records of six patients (four women, two men) seen at The Toronto Hospital between 1985 and 1989 with pseudomembranous colitis manifesting as fulminant colitis. The patients ranged in age from 19 to 69 years (mean 52 years). All presented with nonbloody diarrhea, had peritoneal signs and were severely dehydrated, and all had received antibiotics between 4 days and 6 weeks before the onset of symptoms. The mean preoperative leukocyte count was 40.9 x 10(9)/L. Radiologically, the colon appeared to be dilated in three patients. Two patients were operated on immediately. The other four were treated medically, but three of them required surgery within 24 hours of presentation. Four (67%) of the six patients died. All four had been treated surgically. The mean age of the survivors was 28 years compared with 64 years for those who died. Pseudomembranous colitis can present as severe acute colitis and can carry a high mortality, especially in the aged. Surgical treatment may be required in those who fail to respond to medical management or have peritoneal signs.


Surgical treatment in non-neoplastic parotid disease: indications and results. Non-neoplastic disease of the parotid gland is an important entity, requiring differential diagnosis and management. The incidence of non-neoplastic parotid disease (NNPD) is increasing and makes up about 25% of cases for which parotidectomy is indicated. NNPD can be categorized as type I (asymptomatic soft diffuse enlargement or circumscribed firm nodular enlargement) or type II (inflammatory lesions with recurrent pain and swelling, obstructive or nonobstructive). Concern over possible malignancy is highest in type I nodular lesions and least in type II lesions. Operative treatment may be indicated for exclusion of tumour, relief of recurrent pain and swelling and patient anxiety. In 62 patients with NNPD who were operated on, the relevant clinical factors included radiation, diabetes, tuberculosis, Sjögren's syndrome and pulmonary sarcoidosis. Superficial parotidectomy was effective, being associated with low morbidity, and can be recommended as acceptable treatment, providing there is a complete patient history and operation is carried out by a surgeon experienced in parotid surgery.


Risk of breast cancer in women with breast cysts. To study the occurrence of breast cancer in women with breast cysts. Prospective follow-up study. Office surgical practice. All 742 women referred to the practice with breast cysts diagnosed by means of aspiration or, occasionally, biopsy between 1969 and 1985. The incidence of breast cancer and the number of years between diagnosis of breast cyst and diagnosis of cancer. The observed number of cases of breast cancer was compared with the expected number, calculated from Ontario rates of breast cancer. Fifteen of the women died but did not have breast cancer. No follow-up information was available for five women. Another 38 were lost to follow-up; they did not have breast cancer at the last contact, after 2 to 17 years of follow-up. These patients were withdrawn from the study in the year in which they died or were last observed. By 1990, 34 (5%) of the women had breast cancer. The overall ratio of observed:expected cases of cancer was 3.04 (95% confidence interval 2.09 to 4.28). Breast cancer developed after 7.5 years, but the average length of follow-up was only 10.1 years. Only 3.8% of 374 women after 10 years and 5.4% of 141 women after 15 years had breast cancer. Women who have a gross breast cyst are at moderately increased risk of breast cancer, which usually develops only after many years.


Non-insulin-dependent diabetes mellitus in Indian children in Manitoba. To report on our 7-year experience with non-insulin-dependent diabetes mellitus (NIDDM) in native Indian children in Manitoba and to raise the awareness of physicians about the difficulties in the classification and management of hyperglycemia in Indian children. Case series. All Indian children under 15 years of age referred for evaluation and management of diabetes to the diabetes clinic at the Children's Hospital of Winnipeg between 1984 and 1990 who did not have a history of diabetic ketoacidosis. Sixteen girls and four boys aged 7 to 14 years at the time of diagnosis were identified as having NIDDM. All 16 children whose family history could be confirmed had at least one parent with NIDDM. Five of the 20 complained of polyuria or nocturia; the remainder presented with asymptomatic glycosuria. At the time of diagnosis the random serum glucose level varied from 15.0 to 30.8 mmol/L, the fasting serum insulin level from 45 to 300 pmol/L and the total glycated hemoglobin level from 7.1% to 23.3%. Twelve of the children had been followed for at least 4 years. Six of the 12 had received insulin therapy at some time, including during pregnancy. At the time of writing, none was receiving therapy with insulin or orally given hypoglycemic drugs. All were encouraged to follow a weight-reduction diet and exercise regimen. During follow-up the mean total glycated hemoglobin level for each patient varied from 9.1% to 20.9%; none maintained a glycated hemoglobin level in the normal range. NIDDM occurs in Indian children under 15 years of age. The clinical features at presentation occasionally mimic those of insulin-dependent diabetes. A strong family history of NIDDM and lack of diabetic ketoacidosis during follow-up support the diagnosis of NIDDM. Adherence to a diet and exercise regimen has been poor. The conventional diabetes education approach may not be appropriate for this population.


Risk language preferred by mothers in considering a hypothetical new vaccine for their children. To determine the type of risk language preferred by mothers considering the use of hypothetical new vaccine for their children and to compare their choice with what their physicians perceived they would prefer. Mail survey. Thirteen family practices in southwestern Ontario. Women with at least one child between the ages of 6 months and 5 years and their physicians. Preferred risk language and physicians' predictions about patient preference. Of the 226 women sent the questionnaire 208 (92%) responded. Of the 192 who indicated their risk language preference 118 (61%) chose a numeric statement. Of the 11 physicians who answered the question 8 (73%) predicted that their parents would prefer non-numeric statements. Although the women in the study were more likely to be married, were better educated and had higher family incomes than women of the same age in the Ontario population, risk language preference was not found to be related to any of those demographic characteristics. Physicians must be prepared to outline the risks associated with vaccination in both quantitative and qualitative terms.


Burns associated with fondues.

Burns associated with fondues. To describe the causes of burns associated with fondues. Descriptive case series. All 17 patients admitted to a burn centre between Apr. 1, 1985, and Mar. 31, 1990, whose burns were associated with fondue. Eleven agreed to complete a telephone interview. The age of the 17 patients varied from 2 to 56 (mean 27) years. Two causes were identified: spilling of the contents of the fondue pot and explosion of the fondue fuel when added to the burner during a meal. The telephone interview revealed that eight people other than the respondents were burned during the same accidents. Although we identified only badly burned patients the problem may be more extensive. The knowledge of specific causes of burns from handling fondue equipment indicates that preventive action should be undertaken. More epidemiologic information is needed to obtain a precise estimate of the magnitude of this public health problem.


Dangers of immunosuppressive therapy in hepatitis B virus carriers. To identify the risk of hepatic failure in hepatitis B virus (HBV) carriers given intermittent immunosuppressive therapy. The key words "immunosuppression" and "hepatitis B" were used to search MEDLINE for relevant articles in English published from 1970 to 1990; the bibliographies of these articles were reviewed for additional publications. Also included were articles published in 1991. Articles were included if they documented the use of immunosuppressive drugs to treat chronic hepatitis B or another condition in patients at high risk for the HBV carrier state. Long-term immunosuppressive therapy has not improved the survival of patients with chronic hepatitis B. The withdrawal of such therapy from HBV carriers has resulted in a flare-up of potentially fatal hepatitis in 20% to 50%, regardless of whether underlying liver disease was present. The presence of replicating viral DNA in the serum of HBV carriers may identify those who are at high risk of the deleterious effects of immunosuppressive therapy. Long-term immunosuppressive therapy is not advised for liver disease in HBV carriers. For other conditions in such people continuous rather than intermittent therapy is safer. Patients at high risk for hepatitis B should be screened for this virus when immunosuppressive therapy is contemplated.


Economic impact of HIV infection and coronary heart disease in immigrants to Canada. To compare the direct health care costs of illnesses associated with the human immunodeficiency virus (HIV) and of coronary heart disease (CHD) in immigrants to Canada. Comparative cost analysis. All people who immigrated to Canada in 1988. The numbers with HIV infection and CHD were estimated from country-specific HIV seroprevalence data and national CHD mortality statistics and data from the Framingham study. Health care costs, projected over the 10 years after immigration, were calculated on the basis of data from the Hospital Medical Records Institute and provincial fee schedules. Of the 161,929 immigrants in 1988, 484 were estimated to be HIV positive. The total cost of treatment of HIV-related illnesses from 1989 to 1998 (discounted at 3%) would be $18.5 million: $17.1 million would be spent on the outpatient and inpatient care of the HIV-positive immigrants, $1.0 million on care of the subsequently infected sexual partners and $0.4 million on care of the HIV-positive children born to seropositive immigrant women. In comparison, CHD would develop in 2558 immigrants during the same 10-year period. The total CHD costs would be $21.6 million: $8.4 million would be spent on treating myocardial infarction, $3.2 million on coronary artery bypass grafting, $1.6 million on pacemaker insertion and $8.4 million on treating other CHD events. The economic impact of HIV infection in immigrants to Canada is similar to that of CHD. This comparison identifies an important shortcoming in current immigration policy: economic considerations can be arbitrarily applied to certain diseases, thereby discriminating against specific groups of immigrants.


Sexual assault tracking study: who gets lost to follow-up? To determine whether loss to follow-up can be predicted in patients who present to an emergency sexual assault assessment service and to generate hypotheses regarding the prediction of loss to follow-up on the basis of patient characteristics, assault characteristics and the services provided. Prospective, exploratory study. Emergency department functioning as a regional sexual assault centre in a tertiary care hospital. All 294 women over the age of 16 years who presented to the emergency department with a complaint of sexual assault and consented to be followed up. Telephone interviews at 24 to 48 hours and 1 month after presentation; face-to-face interviews after 1 week, 3 months and 6 months. Follow-up status (tracked versus lost to follow-up), State-Trait Anxiety Inventory (STAI-Y), Beck Depression Scale (Beck) and Rape Trauma Symptom Rating Scale (RTSRS). At 24 to 48 hours 136 (46%) of the patients could not be reached. Only 61 (21%) were still tracked at 6 months. Loss to follow-up at 1 month accurately predicted loss to follow-up at 6 months in 209 (98%) of 214 patients. For tracked patients the STAI-Y and Beck scores improved over 6 months. These scores at 1 week did not predict follow-up status at 6 months, but the numbers were small. Subjects with a higher RTSRS score at 24 to 48 hours were most likely to remain tracked throughout the 6 months. Decisions regarding how vigorously to track patients with a complaint of sexual assault can tentatively be based on the characteristics of the victim and of the assault. We hypothesize that the characteristics predicting loss to follow-up include denial and avoidance behaviour, lack of a telephone number or forwarding address, history of a psychiatric condition, a disability (e.g., deafness), characterization as a "street person," a high degree of violence or injury in the assault, and threat by the assailant. Although a predictive model requires further data, crisis intervention services in an emergency department are essential, given the large number of patients lost to follow-up.


Ethical dilemmas in the care of premature infants. Advanced technology has improved the survival rate of infants of low birthweight and gestational age, but at the cost of long periods of hospitalization and unpredictable long-term prognosis. The neonatal clinical nurse specialist (CNS) has a responsibility to assist the staff and family in dealing with the ethical dilemmas that surround these patients. This article will present a brief history of neonatal care and decision making and will address the issues of uncertain outcome, treatment judgment standards, withdrawing vs. withholding aggressive treatment, and economic impact. The role of the CNS in educating and supporting the staff and family to assume a larger part in ethical choices is also discussed.


HIV-infected client care: case management and the HIV team. No one discipline can meet the complex needs of the HIV-infected client. Because of the diverse nature of disease manifestations, an HIV Team concept is promoted. The clinical nurse specialist (CNS) is uniquely prepared to initiate the team and support holistic client care through case management. Current HIV statistics with implications for the rural community are provided, and reasons for the lack of community involvement with HIV care are suggested. The case study illustrates complex needs of an HIV-infected woman, as well as issues that evolve during HIV-infected client care. Interventions that promote care for persons living with HIV in addition to support of involved health care workers are addressed. Practical suggestions for initiating this process are included.


Development of a model of transitional care for the HIV-positive child and family. The provision of high-quality, cost-effective care to Human Immunodeficiency Virus (HIV)-infected adults and children is a national priority. During 1991 the number of infected children is expected to increase to over 3,000, with at least 2,000 additional cases manifesting some symptoms of HIV infection. Serious questions exist about the ability of these children's families to acquire the health care services that both they and their children require. This paper will present preliminary findings of a study that describes the physical, behavioral, and developmental responses of children who have a diagnosis of perinatally acquired HIV, as well as the caretaking concerns of the custodial family. Building on this work, a model of transitional home care for these children and their families using pediatric clinical nurse specialist (PCNS) follow-up care will be described.


A comparison of patient/nurse perceptions about current and future recovery status. Research comparing patient and caregiver perceptions suggests that caregivers tend to be negatively biased in their assessment of patients. That is, they are more likely to judge the patients' status more negatively than the patients themselves. The data analyses, however, have not always been as informative about the extent of disagreement. Our data on the extent to which patients who had a myocardial infarction and their nurses' assessments differed suggest that, in the case of the patients' current status, there were no differences in the aggregate between patients' and nurses' assessments. Examination of the discrepancies between the pairs, however, suggests that in some cases nurses are more negative in their assessments than their patients. In the case of beliefs about the future, nurses were significantly more negative, in the aggregate, than patients, and the extent of this difference is further elaborated in the examination of the discrepancies. Nevertheless, with respect to both current and future status, the correlations between patients and nurses were low, indicating little, if any, shared variation. Because this study did not examine the relationship between either patients' or nurses' perceptions of recovery status, and the patients' actual recovery status, further research is needed to further determine the implications of this work. The meaning of these results for clinical nurse specialists (CNS) is discussed.


A strategy for staff development: self-care and self-esteem as necessary partners. Using an inservice education approach, the clinical nurse specialist can play an important role in the development of nursing staff. This article presents 10 self-care strategies (valuing strategies) that, if integrated into a nurse's personal and professional life, can increase self-esteem and healthy self-care practices. Self-care and self-esteem are described as "necessary partners." These self-care strategies can be presented to a variety of nursing groups. Utilizing experimental group exercises can enhance the learning for such lifestyle changes.


Catherine's home visit.

Catherine's home visit. The following vignette tells the story of a young couple and their newborn son whose impoverished circumstances momentarily unnerve a nursing student making her first home visit. The story illustrates the transcendant power of a bouquet of flowers in a Japanese photograph.


Costs and benefits of clinical nurse specialists. The emphasis on cost containment during the 1980s has given way to a renewed interest in the quality of health care services that can be delivered at a reasonable cost. In this climate, clinical nurse specialists (CNSs) have an excellent opportunity to demonstrate the cost-effectiveness of their work. In order to do so, costs and benefits of CNS services must be measured and compared.


Reminiscing therapy: a CNS intervention. The role of the clinical nurse specialist (CNS) has expanded over the years. The CNS is prepared through education and training with group process to initiate and implement a reminiscing group for the elderly. Life review and reminiscing are dynamic occurrences in which the individual is an active agent. The implementation of the program with documentation can be kept simple. A nondirective approach may be used to allow the participants to form the group in the manner that is most comfortable for them. By using reminiscing techniques, the CNS can enhance the quality of the elderly's later years, as well as facilitate their last developmental task.


Emergence of lasers in podiatric surgery. This article was meant to introduce the reader to the basics of podiatric laser use. In a field as complex as laser surgery, it would be impossible to present an in depth discussion on any particular area. Instead, the intent was to offer a general overview and leave the specifics to the appropriate articles within this issue. It is the author's hope that the reader has attained an appreciation for the integration of the laser into podiatry. Laser surgery is not proffered as a panacea of treatment. Rather, it is an alternative treatment modality that is both beneficial and effective within the scope of its indications and limitations. As a profession, podiatrists need to cooperate to further define and redefine laser usage; as a medical specialty, podiatrists need to participate and enhance communication with other medical specialties to help develop more advanced laser uses. The uses and indications presented here and elsewhere throughout this issue are proven methods of efficacious treatment. It is only the unconvincable cynic who could or would deny the established benefits of podiatric laser surgery.


Light, lasers, and beam delivery systems. From a clinical standpoint, laser light differs from ordinary light in two important ways: (1) laser light, unlike ordinary light, is monochromatic; (2) laser light is highly directional, making it possible to efficiently collect and focus the light. Laser light is produced through a process known as stimulated emission. Tissue effects produced by laser light are governed by the light's wavelength. Recently, hollow, flexible fibers have been introduced for CO2 laser beam delivery; compared with existing beam delivery systems, the flexible fiber provides the clinician with increased tactile sensitivity and effective access into restricted spaces.


Physics of laser beam interactions with living tissue. This article examines fundamental laser physics and the manner in which the laser transfers energy to the surface of the body and how living cells react. Topics include the significance of absorption and scattering coefficients, assumptions for analysis of laser-beam interactions with living tissue, depth of vaporization of tissue, and mass of tissue vaporized.


Principles of laser surgery. Advantages and disadvantages. An attempt has been made in this article to present an honest and accurate state-of-art narrative of laser surgery for pedal conditions. The theory of operation, physiologic effects and procedural comparisons have been presented regarding those procedures and lasers that are available for use by podiatric surgeons and others treating the foot and leg. Although some information described within this article is anecdotal, it is elaborated with representative expert material from the scientific literature. Overall, a sound theoretic understanding of the mode of action of lasers and extensive training and experience is encouraged when engaging in this exciting discipline of surgery.


Histopathology of soft tissue lesions of the foot. Unfortunately, strict regional considerations of neoplasia affecting the hands of feet are not numerous, and detailed accounts of neoplasia confined either to the hands or feet have been published only periodically. This article attempts to remedy the dearth of information by providing a sampling of the types of tumors that affect the foot with photographs and an emphasis on key histologic characteristics.


Carbon dioxide laser excision of benign pedal lesions. The CO2 laser is a very important tool to remove benign pedal lesions. It certainly is not the only method, but once the technique is developed by the surgeon, it becomes easier to remove these lesions and, consequently, the results become better. In dealing with the mucoid cysts, the laser surgery is second to none and even if it has to be repeated there is basically no disability for the patient. This is also true with fibromas because many types of fibromas would require suturing that would create an inconvenience for the patient. With the use of the laser, sutures are not required and the patients recover much faster. In dealing with plantar fibromatosis, ganglionic cysts, and lipomas, the convalescence is probably about the same with CO2 laser as with conventional removal, especially when deep resection is necessary and suturing of the skin is required. With plantar fibromata surgery, the resultant long-term scarring is much less with the CO2 laser, especially when followed up with the appropriate injectables. CO2 laser surgery performed on the punctata aeriata, interdigital clavus formations, and hypertrophic scars are not always as successful but offer the surgeon another modality in taking care of the patient's problems without the need for extensive surgery.


Laser onychology.

Laser onychology. Laser techniques for nail pathology have existed for over a decade. Published reports concerning onychologic techniques and results are growing along with other medical laser literature. In this article, the author has presented techniques with which he and podiatric colleagues at Wenske Laser Center have operational familiarity. Preoperative concerns have been emphasized and potential complications and prevention are discussed. Widely variant results are identified. Laser onychologic procedures are technique intensive. Research is needed, therefore, to identify factors that might lead to technical improvements so that results may be enhanced. Perhaps in the future laser onychology shall exist as a subspecialty to podiatry and dermatology, much as endodontics is to dentistry. It is hoped that this work might contribute in some small way to that development.


Carbon dioxide laser treatment of pedal verrucae. Physicians always are pursuing improved results. In the case of pedal verrucae, the varying treatment modalities that have evolved are the product of a search, so far less than successful, for one that is virtually 100% effective. HPV is an extremely resilient and elusive organism, possessing the capabilities of lying dormant and suddenly springing to the surface of the skin. Although no single treatment modality has been shown to be a panacea, the authors believe that, among the various treatment alternatives available, the CO2 laser offers the best surgical prospect for eliminating the verruca and minimizing the sequelae of recurrence and postoperative pain.


Treatment of Morton's neuroma with the carbon dioxide laser. Morton's neuroma is one of the most common causes of nerve pain in the foot. This article describes the treatment of this condition with carbon dioxide laser surgery, presenting the disadvantages and advantages of this method. This method has proven to be effective; postoperative pain and healing time are decreased and patients are able to resume normal ambulation faster than with conventional scalpel surgery.


Various laser modalities in the treatment of cutaneous lesions. This article discusses the various lasers used to treat cutaneous lesions on the foot sequentially along the electromagnetic spectrum, beginning with ultraviolet lasers and ending with the infrared carbon dioxide laser. Also included is a brief history of the use of lasers for cutaneous diseases.


Management of nucleated plantar keratomas with a carbon dioxide laser. Laser enucleation of superficial epidermal keratoses and ablation of dermal and subdermal lesions is an effective method for long-term relief from painful plantar lesions. This technique also provides gross visualization of the remaining tissues, a specimen for microscopic evaluation, and a definitive diagnosis. The procedure is relatively atraumatic with a minimal amount of postoperative pain, disability and scarring, and a high percentage of acceptable results.


The efficacy of carbon dioxide laser surgery for adjunct ulcer therapy. This article focuses on the application of the carbon dioxide (CO2) laser at various levels of power density to achieve a level of efficacy in tissue ablation for cutaneous and deep indolent ulcerations that afflict the lower extremities. This article also supports theories of the CO2 laser generating a sterile nonpathogenic environment within ulcers. A cross section of various ulcer types are used to determine duration of healing.


Laser's use in bone and joint surgery.

Laser's use in bone and joint surgery. The use of various lasers in medicine and surgery has progressed considerably. Obviously, the sheer number of lasers being used both clinically and experimentally indicates a great potential for further advancement and refinement in technique and surgical outcomes. Although the medical field has come very far accepting and using the laser, there is still a long way to go.


Carbon dioxide laser studies of defects in articular cartilage. With this further refinement, the author and colleagues hope to establish a reliable method of calculating the depth of penetration necessary to induce a deficit that will cause chondrogenesis in a predictable, reliable fashion. It is hoped that this will allow for consistent results so this technique may be used for the treatment of cartilage degeneration and certain arthritides. In addition, it is hoped that the fibrous cartilage regenerated from the experiments with animals will produce viable information that will lead to extensive human applications in the near future. The author also hopes that many joint destructive procedures such as arthroplasties and some implant procedures may be eliminated, and that this investigation will lead to advances that will eliminate much of the morbidity of arthritis.


Laser treatment of hypertrophic synovitis. Hypertrophic synovitis is fairly common in the foot and ankle as a result of an injury or in reaction to silicone implants. Laser treatment of this condition is accomplished in conjunction with standard surgical techniques. The advantages of this method are clear: hemostasis, reduction of postoperative edema, less scar tissue, and the potential for reduced postoperative pain.


Complications of laser surgery: safety, risks, and the plume. The prevalence of the CO2 laser in medicine today has brought more information to the patient than any other modality to treat different ailments. More laser surgeons are reporting their experiences. Like any new instrument or technique, there are advantages and disadvantages to its use. This article presented a review of different laser-associated problems and issues, as well as methods to correct them if they arise. The knowledge of complications and safety are constant changing. The surgeon needs to know what can happen, both good and bad, in order to inform and treat the patient properly. Although the laser has been used in podiatry for the past decade, it can still be considered to be in its infancy. It is a wonderful tool for patient care, but more research and experience are necessary to use it to its maximal potential.


Surgery of the achilles tendon and posterior muscle group. Ankle equinus is defined as an inability to dorsiflex the foot at the ankle a minimum of 10 degrees with the knee in full extension. Numerous causes have been presented, and proper evaluation and diagnosis is critical before a surgical procedure can be selected. Gross spastic contractures will be managed differently than the more subtle forms of limitation of ankle dorsiflexion. Lastly, it should be remembered that the desired increase in range of motion will be accompanied by a decrease in strength of the posterior group, which will vary with the procedure and age of the patient.


Systemic complications of human immunodeficiency virus infection. HIV infection causes a wide spectrum of complications affecting all organ systems. These complications may be primary to the direct infection of a specific organ system by HIV or secondary to the immunodeficiency associated with HIV infection. These complications may be specific to certain stages of HIV infection. Selected common complications of HIV infection include pulmonary, neurologic, GI, dermatologic, oral, ocular, endocrine, and hematologic complications.


Pedal infectious disease associated with acquired immunodeficiency syndrome. AIDS is a disease that quickly takes the lives of individuals of all ages and in all countries. Therefore, it is the responsibility of podiatrists to recognize the primary manifestations of this disease, to take the proper precautions to guard against the spread of this disease, to direct attention to areas in need of proper diagnosis, and to provide effective treatment to those with the disease and to those yet undetected.


Kaposi's sarcoma in the foot. A retrospective study. Kaposi's sarcoma has been found to be present in a significant number of patients infected with HIV. A report of 162 cases of biopsied specimens has been presented with a review of previous studies. Diagnosis, cause and treatment have been discussed, leading to the conclusion that the podiatrist must be well versed in his understanding of Kaposi's sarcoma in order to recognize, treat, and alert the patient to the diagnosis of AIDS.


Pharmacologic treatment of the patient with acquired immunodeficiency syndrome. A pharmacologic revolution has occurred over the past 10 years with regards to antiviral therapy, specifically medications directed against HIV. This plethora of new information must be disseminated effectively throughout the medical community. HIV infection and its numerous manifestations, both pedal and systemic, are challenging and often difficult to treat. The well-informed physician will have a distinct advantage with regard to the treatment of the patient with AIDS. The information presented here, although transient, represents a solid knowledge base, a starting point on which the clinician can build effectively.


Nutrition for the patient with acquired immunodeficiency syndrome. Patients with ARC and AIDS develop a variety of symptoms that significantly affect their nutritional status. Podiatrists, although not directly involved with the intricacies of the nutritional management of people with AIDS, should be aware of the effect of the virus on the human body. Investigators are predicting that almost 100% of the estimated 12 million HIV-positive persons in the world will develop AIDS. By giving people with AIDS nutritional education, not only may there be a beneficial response in respect to treatment but it may enhance an individual's quality of life and positive self-image.


Physical therapy for the patient with acquired immunodeficiency syndrome. Treatment of HIV-infected patients has come a long way since the not-so-long-ago beginning of the AIDS epidemic. Implementation of new drug therapies has increased longevity of a patient's life after being diagnosed with the virus. Because HIV-related illnesses are consequently becoming more chronic in nature, patients commonly experience potentially debilitating CNS, PNS, or musculoskeletal problems during the course of the disease. As a result, these patients require delicate care from a number of different health care providers. A multidisciplinary team approach must be used within the podiatrist's treatment regimen. This team must include the physiatrist overseeing the physical therapist, to provide complete and optimal care to improve the patient's functional independence and quality of life. The conditions associated with HIV infection are insidious, slow, and crushing in nature. The medical community can help the patient with HIV infection and AIDS remain on his or her feet. By doing this, costs, both social and economic, can be lowered. The podiatrist must have a strong knowledge of the pathology of AIDS. He or she must use PT along with other disciplines: podiatric medicine, orthotic therapy, and general podiatric care. PT is effective in treating conditions of the lower extremities that affect the CNS, PNS, musculoskeletal system, and, lastly, rheumatologic effects of HIV infection.


Laboratory testing for human immunodeficiency virus. Laboratory testing for HIV infection presents a unique set of challenges for the podiatric physician. With increasing numbers of HIV-infected patients, the physician has the challenge of selecting, evaluating, and identifying the optimal testing methods for patients as well as for physicians. Because seroconversion can take weeks to occur, the need for specific tests such as antigen and culture becomes very important to both patients and physicians.


Preventing human immunodeficiency virus transmission in the podiatric practice. The role of the podiatric medical assistant. Rationales for the design and implementation of infectious disease control programs include protecting the health of patients and staff, reducing the risk of vulnerability in litigation, and complying with the regulatory environment that mandates such programs. The development and implementation of a comprehensive infectious disease control program is not a difficult project. The Universal Precautions Policy created by the CDC outlines basic recommendations for preventing the transmission of HIV. OSHA regulations also provide step-by-step guidelines that simplify adaptation of the CDC's policy to the podiatric medical practice. The execution of an effective infectious disease control program can be accomplished by the use of 10 basic protocols for the podiatric practice. These protocols provide the basis for policy, training, follow-up, and documentation. Design and implementation of this process within a podiatric medical practice can reduce dramatically the risk of inadvertent transmission of HIV and other blood-borne pathogens.


Hospital protocol for the patient with acquired immunodeficiency syndrome. This article discusses HIV transmission, prevention, and treatment in a hospital milieu. In a review of all the literature, minimal research has been done on correlating the potency of the virus in terms of transmission with the stage of the disease in an HIV-infected patient. It seems logical that the risk of transmission will increase when the HIV patient has the full blown disease. This might reflect the statistic that 5.3% of all the health care workers infected do not have a determinable cause. Yet it has been proven that seroconversion can occur after nonparenteral exposure. This is confirmed by a recent CDC update that reported seven cases of seroconversion from mucous membrane exposure. More extensive study is needed in developing more accurate statistics on the cumulative risk of health care workers in specific fields of medicine and specific patient communities. Because all the questions on AIDS apparently are not even close to being answered, the importance of using universal precautions cannot be overstressed. Unfortunately, research and experience have shown that compliance in adopting universal precautions is remarkably poor. Training and education must begin at the medical school level with reinforcement through yearly workshops. Prevention seems to be the only hope at this time. The physician's inability to test patients for this virus has only been a deterrent in learning about this dreadful epidemic.


Treatment of patients with acquired immunodeficiency syndrome in a podiatric emergency situation. All patients should be considered seropositive, and protective measures always should be taken. The mainstays of universal precautions are the use of barrier techniques and protection from inadvertent sharps exposure. Various studies show that emergency room or trauma patients have a higher HIV prevalence than the population as a whole. Several studies of health care workers with known parenteral and mucous membrane exposure to HIV positive patients indicate that the risk of seroconversion is less than 1%. This low percentage, however, should not be used to justify nonadherence to universal precautions.


Human immunodeficiency virus transmission in health care settings. Risks to health care workers. Taken together, studies of seroconversion, exposure incidents, and compliance with Universal Precautions Policy help researchers understand the risks to health care workers of occupationally acquired HIV infection. The seroconversion studies show that the risk of infection is low (1 in 250) even when the incident is a percutaneous exposure to blood from a known HIV-positive patient. When the exposure is to blood from a patient whose HIV-status is unknown, or if the exposure is not through the skin, or if the exposure is to a body substance other than blood, the risk is considerably lower. The studies of exposure incidents show that for most health care workers, percutaneous exposures to blood are infrequent. Studies of compliance with Universal Precautions Policy show that exposure incidents that do occur can be prevented nearly half the time. The risk of patient-to-provider transmission of HIV is small but not completely negligible. This small risk can be made even smaller by adhering to recommended infection control guidelines, but it cannot be eliminated completely. Although most health care workers enter the medical field accepting that their work may expose them to infectious agents, there is still a desire for risk-free practice. Achieving an entirely risk-free practice is probably impossible; it is certainly not within reach today. For the foreseeable future, the only reasonable course is to fully understand the risks, to enter into practice psychologically prepared to accept these risks, and to practice in a way that minimizes exposures without compromising patient care.


Public health considerations of human immunodeficiency virus. The full spectrum of HIV infection will touch the lives of millions of Americans. All people need to be aware of this health crisis and its implications on their own lives and society. Health care providers need to recognize the risks and take appropriate precautions. Millions need assessment of their personal behavior that may have permitted them to become infected or that may now be exposing them to significant risk of infection. Education and counseling are significant factors in prevention. It has been estimated that well over 1,200,000 people in the United States are presently infected with HIV. Given all of this, podiatrists must be a part of the public health team that offers education, prevention, and promotes early care to help prevent the spread of HIV infection and to permit those infected to have a chance for longer and healthier lives and, when all else fails, to be provided with appropriate and compassionate care. Individuals practicing in podiatric medicine can expect recommendations in the future that include, in addition to the CDC's Universal Precautions Policy, submitting to voluntary determination of serostatus for those who perform exposure-prone procedures. Practitioners who are HIV infected and perform exposure-prone procedures will have to disclose their status to local review panels who will determine their practice. Local panels will then monitor HIV-infected practitioners for compliance with practice limitations and report those who violate limitations or precautions to state licensing boards. Those who serve on review panels will be protected from legal challenges.(ABSTRACT TRUNCATED AT 250 WORDS)


Ethics and acquired immunodeficiency syndrome. The integration into daily practice of a fully realized sense of medical ethics is one of the greatest possible sources of personal and professional fulfillment. It is also, for the profession as a whole, one of the two ultimate claims to continuing legitimacy and respect, the other being technical competence. Of these two, the greater is excellence in moral commitments. For as the AIDS crisis is demonstrating so well, we often lack the requisite knowledge and skills. When knowledge and technology are deficient, it is only moral excellence that can protect the sacred values and commitments that make and keep our professions all that they have been, are, and can become.


The legal aspects of treating and being treated by an individual infected with human immunodeficiency virus. Since the first AIDS case was reported in 1981, the AIDS epidemic is spreading dramatically in the United States. In dealing with the prevention of HIV transmission, we need to carefully balance the protection of civil rights that may be devastated by the disclosure of HIV-infection and the protection of public health against HIV infection in the health care setting. Recognizing the need of guidances in this regard, the CDC has issued recommendations regarding the prevention of HIV transmission in the health care setting on the basis of scientific data. In order to assure the acceptance of CDC guidelines in the health care setting, Congress recently passed a law that requires every state to institute CDC guidelines or its equivalent within 1 year. It is hoped that this requirement will ensure that HIV infection control measures are uniform throughout the nations and help HCWs and patients know their legal rights and obligations. Most importantly, the law regulating HIV-infection control will from now on rely on scientific data rather than on the irrational fear of the general public.


Death, dying, and the patient with acquired immunodeficiency syndrome. This article has attempted to provide some insight into the subject of death, dying, and the patient with AIDS. Even though the thought of death and dying is common, it is a topic that at most times is left unspoken. This is especially true in relationship to an illness that, among many, is considered taboo. This article has presented the known psychological stages travelled by a terminally ill patient, with special emphasis on the unique problems suffered by the patient with AIDS, who is often alone and afraid. Only with the support and kindness of others will this lone individual be able to live out his life to its fullest, up to his dying day.


Pilot study for the Quebec Child Mental Health survey: Part I. Measurement of prevalence estimates among six to 14 year olds. A pilot study for a Quebec Child Mental Health Survey was completed in 1990 with 139 children aged six to 14 years from the general population. Six month prevalence estimates for seven disorders were established using DSM-III-R criteria alone and in combination with an impairment index related to the diagnoses. Prevalence estimates were studied separately for parents and children. Each age group (six to 11, 12 to 14) was also studied separately. The impairment index, working as a severity scale, lowered prevalence estimates and allowed identification of impairing and non impairing diagnoses. Little overlap was found between informants.


Pilot study for the Quebec Child Mental Health Survey: Part II. Correlates of DSM-III-R criteria among six to 14 year olds. A pilot study for a Quebec Child Mental Health Survey was completed in 1990 with 139 six to 14 year olds from the general population. The following variables, which were correlated with child psychopathology, were studied for each age group (six to 11 years, 12 to 14 years) and informant (parent, child): child's gender and stressful life events, respondent parent's psychiatric illness, family structure, parent-child relationships, parents' relationship, socioeconomic status, respondent parent's social desirability. Correlations obtained are consistent with those found in the literature. Correlations between the parent's mental health, parent-child relationships and the children's mental health are the most important results of the study.


Waiting list information strategies for child psychiatry: an intervention and measurement approach. This paper describes a number of steps we have initiated to study our chronic waiting list problems. We describe a program involving monthly data collection which has enabled us to document the effectiveness of some strategies and predictive variables. During 1989 the data were supplemented with information collected by a questionnaire mailed to every other referral. We found that an initial response to the questionnaire was a powerful predictor of successfully kept first appointments six to 12 months later. The significance of these differences, the impact of our tracking procedures and the issues and causes, along with some strategies, are discussed.


A comparison of the cost-effectiveness of day treatment and residential treatment for children with severe behaviour problems. This study compares the cost of treating 23 children admitted to a residential treatment unit in a psychiatric hospital and 23 children admitted to the same unit after it was converted to a day treatment program, through a retrospective chart review. The two groups were similar in age, gender, diagnosis, severity of pathology, family functioning and support, the number of subjects who dropped-out, and treatment outcome. The average length of stay on the unit dropped from 19.6 to 6.1 months, and the average cost of treatment per child decreased from $61,412 to $9,213 (Canadian dollars, adjusted for inflation). The sharp decrease in treatment time with day treatment may be the result of close links with community schools and maintaining the child in the family and community. The cost savings can be attributed to the shorter hospital stays and the lower operating costs of day treatment. Implications of these findings will be discussed with respect to health care policy including the need to raise awareness of day treatment as a cost-effective alternative to residential hospital treatment.


Causes of child abuse and neglect.

Causes of child abuse and neglect. This paper is a study of child abuse and neglect from the perspective of the child. Generally, the mistreatment of children was associated with "poor care" from parents, attributed mainly to immaturity, marital problems, alcohol abuse, unemployment, drug abuse and lack of money. Differences in attribution are noted between males and females, and some differences are noted by the age of the child. When factors other than the causes given by the children were taken into account, mistreatment was significantly related to family break-up, as well as long-term disinterest and lack of affection from the parents. When the children were asked for their "worst experience in life," the most common responses were "abuse" "family break-up," and for the juvenile offenders "getting charged with a crime."


[Mother-infant interaction and the origin of self awareness in the nursing infant]. The mother is the principal care-giving partner of the infant and an important source for the development of self-awareness and self-esteem. The importance of the early relational experiences of the nursing infant with its mother has been widely emphasized by the psychoanalytical approach. Through this special interaction with the parent, the infant gradually internalized images leading to the individuated self and to self-love. The purpose of this paper is to present succinctly some of the broad theoretical positions regarding the forming of the self in the nursing infant, first within the "classical" psychoanalytical current, then under the impact of more recent research in experimental psychology which have given rise to new syntheses. Empirically, the capacity for self-recognition may be observed during early childhood by means of a child's reactions in front of the mirror; therefore, the work dealing with this phenomenon will be discussed briefly.


Misdirected attachment behaviour--an unusual outcome of repeated hospitalization? This paper describes an infant with multiple congenital anomalies who developed an unusual reaction to recurrent hospitalization before age two. After spending much of her first year in hospital, she protested strongly whenever she left the hospital. We report the evolution and treatment of this patient's misdirected attachment behaviour.


Body image of children and adolescents and its measurement: an overview. The lack of a universally accepted definition of body image has impeded our understanding of body image disturbances in children and adolescents. This paper examines the evolution of body image as a multidimensional construct and the difficulties associated with the use of human figure drawing to measure body image. Directions for future research are considered.


The impact of a physically ill parent on adolescents: cross-sectional findings from a clinic population. The degree to which the physical illness of a parent affects adolescents is unknown. This study examines this issue through a cross-sectional survey of patients referred consecutively to an adolescent outpatient psychiatry clinic. Demographic and clinical data concerning symptoms, diagnosis of major depression, peer isolation, and family functioning were collected on all subjects from both the adolescent and a parent (usually the mother). No significant differences were found between the groups on measures of family functioning, peer isolation and major depression. According to both youth and parent report, adolescents with physically ill parents had more somatic symptoms than controls. These findings are discussed in the light of the existing literature and the methodological shortcomings of the study.


Substance abuse among adolescents with chronic mental illnesses: a pilot study of descriptive and differentiating features. Twenty-six adolescents with a chronic mental illness (schizophrenia or schizoaffective disorder of at least 1.5 years' duration) were assessed for the presence or absence of comorbid substance abuse. The two groups were compared on a number of variables believed to identify or predict substance abuse. The substance abusing subgroup were significantly different in levels of social functioning, school achievement, premorbid substance abuse, having parents or siblings who abused substances, dysfunctional families, cigarette smoking, number of hospital admissions, and emergency room visits. These findings are discussed in the context of clinical issues regarding the management of adolescents with chronic mental illnesses.


Anxiety disorders in children and adolescents: clinical and related issues in pharmacological treatment. Anxiety disorders in children and adolescents are receiving more attention from clinicians and researchers. Psychopharmacological approaches to controlling symptoms of anxiety are possible as part of a multi-model treatment approach. This paper provides an overview of some recent findings in child and adolescent anxiety disorders that may influence treatment decisions. It also reviews studies of the use of benzodiazepines and tricyclic antidepressants in treating children and adolescents who suffer from anxiety disorders, and suggests methods of integrating pharmacological treatment with other modalities in these disorders.


Child and adult psychiatry: comparison and contrast. Since its development from general psychiatry, child psychiatry has been influenced by its close involvements with the child guidance movement and pediatrics and by the age of its patient population. This has led it to evolve in ways quite distinct from adult psychiatry, so much so that at times the understanding and relationship between the two disciplines has been somewhat strained. This paper relates the development of child psychiatry to its history, its tasks and its patient population, highlighting some of the major differences between child and adult psychiatry. It then looks at why research in child psychiatry has lagged behind research in adult psychiatry. It concludes by discussing tensions between the two disciplines, and why it serves the interests of both professions as well as those of our patients, that a better understanding and collaboration between them be established.


A double-blind placebo-controlled comparison of moclobemide and amitriptyline in the treatment of depression. The objective of this study was to determine if moclobemide is an effective treatment for depression and if it is well tolerated by patients. A randomized, double-blind placebo-controlled trial was conducted in a tertiary ambulatory clinic which treats depression. Fifty-five patients participated. They fit the DSM-III-R criteria for major depressive episode, scored at least 18 on the 17 item Hamilton Rating Scale for Depression (HRSD), were between the ages of 18 and 65, and were not suffering from a major medical illness. After a one week washout period, patients were randomly selected to receive placebo, amitriptyline or moclobemide for up to six weeks. Moclobemide is a well-tolerated medication at therapeutic doses; it is globally as effective as amitriptyline in the treatment of major depression.


The efficacy of reversible monoamine oxidase inhibitors in depressive illness. The introduction of selective and reversible inhibitors of MAO-A (RIMA) has led to the re-examination of new MAO inhibitors in psychiatry. This paper reviews three controlled trials comparing moclobemide with imipramine and clomipramine. According to the data presented, moclobemide is as effective as imipramine and clomipramine in treating endogenous depression. Moreover, in a comparison with clomipramine, in patients with endogenous depression, moclobemide led to an earlier improvement in symptoms. A separate trial of moclobemide and clomipramine in outpatients with non endogenous depression found a comparable time of onset of clinical effect. Patients treated with moclobemide also showed greater tolerance after six and 12 weeks of treatment than patients treated with clomipramine. The three trials discussed found the RIMA compounds to be free of any serious adverse effects and generally better tolerated than the tricyclic compound with which they were compared.


Depression in the elderly.

Depression in the elderly. Depression is one of the most common behavioral disorders of later life. Although recognition of depression can be difficult and the management of depression in elderly patients is complex, effective treatment can dramatically improve their quality of life. This brief review presents some of the problems inherent in the diagnostic process, reviews the epidemiology of depression in later life, and outlines treatment approaches once the diagnosis of depression has been established.


RIMA: a safe concept in the treatment of depression with moclobemide. Moclobemide--a new, safer antidepressant drug--is described and clinical studies are reviewed. Moclobemide represents a new class of drug, the so-called RIMA compounds--reversible inhibitors of MAO-A. Unlike classical monoamine oxidase (MAO) inhibitors, moclobemide is devoid of hepatotoxicity and has only a slight potentiating effect on the hypertensive action of tyramine; treatment does not require a tyramine-restricted diet. Studies comparing moclobemide with tricyclic antidepressants (TCAs) indicate that moclobemide is significantly better tolerated than TCAs and slightly less well tolerated than placebo.


Lip cancer. Incidence trends in Connecticut, 1935-1985. Suspicions have recently arisen that cancer of the lip may exert an undue influence on overall oral cancer statistics and, therefore, possibly distort the true image of intraoral cancer. The authors investigated this question through epidemiologic analysis. A total of 2291 cases of lip cancer accessioned by the Connecticut Tumor Registry (CTR) from 1935 to 1985 (23.6% of all oral cancer) were analyzed. Occurrence trends for males and females had different patterns: for men, the age-adjusted incidence rates showed a fivefold decrease during the 51-year study; for women, the rates were relatively low and constant during the same period. Analysis for age-specific rates revealed that the older the age group, the higher the incidence rates for both sexes. Squamous cell carcinoma accounted for at least 87.4% of all lip cancers (96.2% if nonspecified epithelial neoplasms are assumed to be squamous cell carcinoma). The vermilion border of lower lip was the most common site. Moderately differentiated tumors were most common (48.5%), closely followed by well-differentiated tumors (44.2%). Analysis by county showed that the crude incidence rates for males in New London and Windham counties exceeded the average Connecticut statewide rates. The authors concluded that the epidemiology of Connecticut lip cancer differs significantly from that of intraoral squamous cell carcinoma in the same population studied within the same period of time. Epidemiologic studies involving "oral cancer" should direct attention to anatomic subsite to consider differences in disease trends according to specific location.


Flow cytometric DNA analysis of gastric smooth muscle tumors. To better understand the malignant grade of gastric smooth muscle tumors, the DNA content of these tumors was studied. In 43 patients with gastric smooth muscle tumors, the cellular DNA content was determined by flow cytometry and compared with the histologic classification and the prognosis. Flow cytometry indicated that all 21 leiomyomas and 9 of the 10 low-grade leiomyosarcomas were diploid; 10 of the 12 high-grade leiomyosarcomas were aneuploid. All patients with leiomyomas and 8 of the 11 patients with diploid leiomyosarcomas had neither local recurrence nor metastasis. By contrast, 8 of the 10 patients with aneuploid leiomyosarcomas died of their disease (mean survival, 41 months; range, 18-78 months). These results indicate that the DNA ploidy pattern shown by flow cytometry is related closely to the histologic classification and prognosis of gastric smooth muscle tumors.


Association of aneuploidy in index adenomas with metachronous colorectal adenoma development and a comparison. Features of index adenomas in the colorectum may be important for the prediction of metachronous adenoma development. Complete colonoscopic follow-up for a mean period of 10 years was achieved in 70 of 124 patients after endoscopic polypectomy of an adenoma from the colorectum. On the basis of the clinical outcome, the patients were divided into three groups: Group I, patients who had a colorectum free of adenomas and cancer; Group II, patients who had one or more metachronous adenomatous polyps; and Group III, patients who subsequently had a colorectal carcinoma. The clinical characteristics of the patients were collected, and the neoplastic specimens were re-examined with regard to pathologic parameters and flow cytometrically determined nuclear DNA content. Aneuploid stemlines were found in 35% of the index adenomas. Significantly more aneuploid adenomas were found in the index adenomas of Group I patients than in the adenomas of Group II patients (r = -0.20; P = 0.05). However, in the index adenomas of Group II patients, aneuploidy was associated with villous architecture (P < 0.05) and inversely related to cellular atypia (P < 0.05). Such relations were not found in the adenomas from Group I. In addition, in the Group II adenomas, aneuploidy was found frequently in the more proximally localized adenomas in the large intestine. Remarkably, all adenocarcinomas of the Group III patients were localized in the right colon. No significant differences were found in ploidy and mean DNA index between index adenomas and metachronous adenomas of the Group II patients. However, the ploidy class of the index adenomas was found not to be related to that of the metachronous adenomas in the individual patients. These results demonstrate that DNA cytometry in adenomas alone is not helpful in the prediction of the possibility of the development of a metachronous adenoma. However, aneuploidy in a villous adenoma located more proximally in the colon might indicate a higher risk for metachronous neoplasia development. Index and metachronous adenomas are similar in DNA content but show no relation with respect to ploidy class.


The care of patients with colorectal polyps that contain invasive adenocarcinoma. Endoscopic polypectomy or colectomy? The appropriateness of resection in patients from whom polyps with invasive adenocarcinoma were excised has been questioned. To determine the results of this policy, the authors reviewed the outcome of 42 patients from whom 44 such polyps were removed. Each polyp was categorized for the level of invasion according to the classification of Haggitt. Level 1 invasion was found in 27%; level 2, in 9%; level 3, in 11%; level 4, in 39%; and uncertain, in 14%. The histologic grade was well differentiated in 48% of patients and moderately differentiated in 52%. No polyps contained poorly differentiated adenocarcinoma; lymphatic and vascular invasion were not encountered. Excision was judged complete in 23 patients; 11 underwent resection, and in none was residual adenocarcinoma identified. In 14 patients, margins could not be evaluated; of 12 patients who underwent resection, residual adenocarcinoma was found in 1. Of the seven patients with positive margins who underwent resection, residual adenocarcinoma was found in only two. In the resected specimens in which residual carcinoma was encountered, all original lesions were designated level 4. None of the patients treated by polypectomy alone has experienced a recurrence at a mean follow-up time of 66 months (range, 12-152 months). The authors conclude that only patients with level 4 invasion require resection.


Serum-ascites albumin concentration gradient and ascites fibronectin in the diagnosis of malignant ascites. The differential diagnosis between malignant and nonmalignant ascites by using laboratory parameters has not been completely achieved so far. The authors studied serum-ascites albumin concentration gradients ([albumin]s - [albumin]a), ascites fibronectin and various parameters in 149 consecutive patients with ascites (including Group 1: 22 patients with intraabdominal malignant lesions; Group 2: 81 patients with chronic liver disease; and Group 3: 46 patients with hepatocellular carcinoma [HCC]). The concentrations of fibronectin, albumin, protein, lactate dehydrogenase, and carcinoembryonic antigen in ascites were significantly higher in Group 1 than in Group 2 (P < 0.001). By contrast, the [albumin]s - [albumin]a was significantly lower in Group 1 than in Group 2 (P < 0.001). None of these parameters was useful in differentiating the ascites of chronic liver disease from that of HCC. In this study, to differentiate malignant ascites from the ascites caused by liver diseases, [albumin]s - [albumin]a (< 1.5 g/dl) and the fibronectin level in the ascites (> 100 micrograms/ml) provided diagnostic accuracy (96.8% and 95.9%, respectively) as precise as those of the levels of albumin (> 1.6 g/dl), protein (> 2.5 g/dl), and lactate dehydrogenase (> 60 U/l; 97.9%, 96.7%, and 94.8%, respectively) in ascites. These results were better than that of carcinoembryonic antigen level (> 1.5 ng/ml, 80.9%). The authors concluded that [albumin]s - [albumin]a offered the best method to survey malignant ascites because of its sensitivity (100%).


Coagulation inhibition and activation in pancreatic cancer. Changes during progress of disease. To elucidate the disturbed hemostatic balance in patients with pancreatic cancer, the levels of plasma coagulation inhibition and coagulation activation were determined. Twenty-one patients with adenocarcinoma of the pancreas were followed from time of diagnosis until death, using plasma analyses of coagulation inhibitors and a molecular marker of coagulation activation (thrombin-antithrombin complex, TAT). TAT was increased significantly at the time of diagnosis of pancreatic cancer compared with age-adjusted healthy control subjects (mean, 6.2 +/- 4.6 micrograms/l [standard deviation] versus 2.0 +/- 0.7 micrograms/l). It increased with disease progression (mean in the terminal phase, 14.1 micrograms/l; P < 0.05). Plasma levels of tissue factor pathway inhibitor (TFPI) also were increased significantly at the time of diagnosis compared with the control group (mean, 176 +/- 80% versus 127 +/- 29%; P < 0.05). The TFPI decreased to normal levels (121 +/- 40%) after surgical removal of the pancreatic tumor (n = 4) or relief of the cholestasis using a bypass procedure (n = 6). The TFPI levels increased significantly as the malignant disease progressed (from 1-3 months postoperatively to the terminal phase of disease; mean, 114 +/- 52% versus 154 +/- 60%). There was a significant positive correlation between TFPI levels and bilirubin levels; the correlation coefficient at diagnosis was 0.70 (P < 0.001). The levels of the coagulation inhibitors antithrombin, heparin cofactor II, protein C, and free protein S decreased significantly with disease progression compared with the normal values found at diagnosis. The mechanism for TFPI increase in cancer is not known. It may be related to the preoperative cholestasis seen in this study, but the increased degree of coagulation activation also may contribute.


Phase II evaluation of fluorouracil and recombinant alpha-2a-interferon in previously untreated patients with pancreatic adenocarcinoma. Based on initial encouraging results of the combination of 5-fluorouracil (5-FU) with recombinant alpha-2a-interferon (r alpha-2a-IFN) in the treatment of advanced colorectal carcinomas, a clinical trial was conducted using 5-FU with r alpha-2a-IFN in 49 patients with advanced pancreatic adenocarcinoma. Forty-nine patients who had bidimensionally measurable disease and had not been treated previously with chemotherapy were entered in the trial. Starting on day 1, 5-FU was administered as a continuous infusion at a dose of 750 mg/m2/day for 5 consecutive days. Starting on day 12, it was administered as an intravenous bolus of 750 mg/m2 a week for 7 weeks. The r alpha-2a-IFN was administered subcutaneously at a dose of 9 x 10(6) units three times a week during weeks 1-8. Of the 46 patients evaluable for response, none had a complete response, and two had partial responses that lasted 14 and 28 weeks. The overall response rate was 4% (95% confidence interval, 1-15%). Fourteen patients had minor responses (median duration of response, 12 weeks). The median length of survival of all patients enrolled in this trial was 22 weeks. Grade 3-4 toxicities included oral mucositis in 19 patients, granulocytopenia in 16, fatigue in 8, and diarrhea in 3. One patient had severe ataxia and leg weakness. Another died of neutropenic sepsis. This regimen had significant toxicity and little evidence of therapeutic activity against advanced pancreatic carcinoma.


The distribution of epithelial membrane antigen in thymic epithelial neoplasms. Thymic carcinomas arising within a thymoma have been reported, but the relationship between thymoma and thymic carcinoma is poorly understood. Epithelial membrane antigen (EMA) is known to be an effective marker for establishing the epithelial nature of neoplastic cells, and it is reported that staining of tumors is clearly related to the degree of tumor differentiation. Eighty-one thymomas (59 noninvasive, 22 invasive) and 14 thymic carcinomas were studied immunohistologically using antiepithelial membrane antigen (anti-EMA) monoclonal antibody. Thymic carcinomas tended to express much larger quantities of EMA than thymomas, and instances of EMA-positive thymoma were seen significantly more often in invasive thymomas than in noninvasive ones (P < 0.05). However, EMA positivity was also associated with gland-like structures, which were not necessarily associated with malignant disease. Nevertheless, in view of the concept that thymoma and thymic carcinoma show a similar cellular differentiation, EMA-positive epithelial cells in thymoma with no relation to gland-like configurations might represent a pool of cells having a latent potential for malignant disease and might be transformed into thymic carcinoma cells under certain conditions. Immunolabeling for EMA appears to be a useful tool for determining the degree of malignant disease among thymic epithelial neoplasms.


Evidence for an association between hairy cell leukemia and renal cell and colorectal carcinoma. Hairy cell leukemia (HCL) has been associated with several disease states. In this study, a possible association is reported between HCL and renal cell carcinoma (RCC) and colorectal carcinoma (CRC). A retrospective study of the case records of 50 patients with HCL in a study of alpha-interferon (alpha-IFN) treatment of HCL. Three of 50 patients with HCL studied had RCC, and 2 of these also had CRC. In addition, two other patients had CRC. The other malignant lesions developed either before or after the diagnosis of HCL. In all patients, the HCL responded to alpha-interferon (alpha-IFN), but in four patients, the second lesion was diagnosed during IFN treatment. These findings could indicate that IFN does not correct a possible common basic etiologic defect and shows that even early CRC and RCC do not respond to the IFN doses administered. These findings should be considered in future trials of IFN treatment of these diseases. The authors also recommend a reevaluation of the frequency of second malignant lesions in HCL; this may be important particularly with the increased survival in patients with HCL who receive alpha-IFN treatment.


Increased secretion of interleukin-6 in malignant mesothelioma cells from a patient with marked thrombocytosis. A high prevalence of thrombocytosis in malignant mesothelioma has been reported, although its pathogenesis remains unknown. The case of a patient with marked thrombocytosis in peritoneal malignant mesothelioma is reported. To investigate the cytokines responsible for thrombocytosis in this patient, enzyme-linked immunosorbent assay and immunohistochemical analysis were used. Tumor cells produced large amounts of interleukin-6 (IL-6) and small amounts of granulocyte macrophage colony stimulating factor (GM-CSF) and monocyte colony stimulating factor (M-CSF). Immunocytochemical staining of tumor cells showed strong positivity for IL-6. These results indicated that persistent secretion of IL-6 promoted thrombogenesis in this patient.


Microinvasive carcinoma of the cervix.

Microinvasive carcinoma of the cervix. Microinvasive carcinoma of the cervix (MIC) has been poorly defined in the past and is still a focus of persistent controversy. In 1985, the International Federation of Gynecology and Obstetrics (FIGO) defined Stage IA as "preclinical invasive carcinoma, diagnosed by microscopy only," subdividing it into Stage IA1 or "minimal microscopic stromal invasion," and Stage IA2 or "tumor with invasive component 5 mm or less in depth taken from the base of the epithelium and 7 mm or less in horizontal spread." In 1974, the Society of Gynecologic Oncologists (SGO) defined MIC as any lesion with a depth of invasion of 3 mm or less from the base of the epithelium, without lymphatic or vascular space invasion. To assess the risk of lymph node metastasis and treatment failures, pathologic material and clinical data on 370 patients with Stage I carcinoma of the cervix, who were treated by radical hysterectomy and pelvic-aortic node dissection, were reviewed. Histopathologic analysis of tumors was based on a uniform format, including measurement of the maximum depth of invasion, the width and length of the horizontal tumor spread, invasive growth pattern, cell type, tumor grade, and lymphatic or vascular space involvement. Of the 370 patients, 110 had a depth of invasion of 5 mm or less. Of these, 54 patients fulfilled the SGO definition of MIC; 42, the new FIGO Stage IA2 definition; and 27, both definitions. None of the patients with MIC, as defined by either the SGO or the new FIGO Stage IA2, had lymph node metastases or tumor recurrence. These data support the conclusion that MIC, defined by either the SGO or FIGO definitions, have a low risk for lymph node metastasis or recurrent carcinoma. A review of the literature indicated a recurrence rate for Stage IA2 of 4.2%. In addition to depth of invasion, lymph vascular space invasion is a better predictor of lymph node metastasis and recurrence than the surface dimension. The authors recommend adoption of the SGO definition of MIC. Patients with a depth of invasion of 3 mm or less without lymph vascular space invasion safely can be treated conservatively.


Radical surgical procedure improves survival time in patients with recurrent ovarian cancer. There is plenty of evidence that survival time associated with advanced ovarian cancer is predominantly related to the amount of residual tumor after primary operation. However, there are only few and inconclusive reports concerning the effect of second debulking procedures on survival time after relapse. To evaluate the effect of radical second operation, 30 patients with clinically diagnosed relapses had second operations after a median recurrence-free interval of 16 months. Considerable efforts were made to resect all tumor tissue. Complete resection was achieved in 14 of 39 (47%) patients, and residual tumors smaller than 2 cm remained in 12 (40%) patients. In 19 (63%) patients, intestinal resections were necessary. Operation time, blood units needed, hospital stay, and complication rates were comparable to those associated with primary debulking procedures. Survival time after second operation was closely correlated with the residual tumor remaining after second surgical procedure and also with the length of the recurrence-free interval. Patients with complete resections had significantly longer survival times than those with residual tumors of less than 2 cm (median, 29 months versus 9 months; P = 0.004). Patients with a recurrence-free interval of more than 12 months had a longer survival time than those with a shorter disease-free time (median, 29 months versus 8 months; P = 0.002). Postoperative treatment also was shown to influence survival time, whereas grade of the tumor (P = 0.74), age of the patient (P = 0.87), and initial FIGO stage (P = 0.58) had no influence on survival time after second operation. Multivariate analysis (Cox regression) revealed that residual tumor after second surgical procedure (relative risk, 4.7) was the most important independent variable predicting survival time after second surgical procedure. Recurrence-free interval (relative risk, 2.7) and postoperative (second-line) treatment (relative risk, 3.0) were equally potent variables. Residual tumor after primary operation, was almost significant (P = 0.06) in the univariate analysis, but was canceled in the multivariate setting by the recurrence-free interval. Again, FIGO stage, grade of the tumor, and patient age had no predictive value. The authors conclude that radical surgical procedure can prolong survival times in patients with recurrent ovarian cancer. Patients who had a complete resection of cancer tissue in the primary operation or those who experienced a disease-free interval of more than 12 months after primary operation are most likely to benefit from second operation in recurrent ovarian cancer. Radical surgical procedure should be offered to these patients to enhance efficacy of second-line chemotherapy, which is of limited value in bulky recurrent disease.


Fibronectin is an immunosuppressive substance associated with epithelial ovarian cancer. Although the ascites of patients with ovarian cancer has been reported to contain immunosuppressive factors, the identity and source of this activity has not been determined. Previously, the authors showed that conditioned media from two of four epithelial ovarian cancer cell lines inhibits proliferation of mitogen-stimulated human lymphocytes. The physical characteristics of the inhibitory substance are unlike those of peptide growth factors but closely resemble those of fibronectin. In the current study, it was found that the two ovarian cancer cell lines that produce the inhibitory substance have more fibronectin on the cell surface and secrete significantly more immunoreactive fibronectin into their culture media than the other two ovarian cancer cell lines. In addition, the immunosuppressive activity was bound to a gelatin-Sepharose affinity column, known to bind fibronectin. Finally, in ascites from 20 patients with advanced epithelial ovarian cancer, fibronectin levels correlated with the ability to inhibit proliferation of lectin-stimulated lymphocytes (P < 0.001). Fibronectin is produced by some ovarian cancer cell lines and acts to inhibit proliferation of mitogen-stimulated lymphocytes. Additional studies are needed to clarify the role of fibronectin in ovarian cancer.


Adenocarcinoma of the prostate presenting initially as an intracerebral tumor. The authors report a patient who was admitted to the hospital with neurologic symptoms and signs that were thought to be caused by a primary intracranial tumor. Craniotomy resulted in successful resection of an occipital lobe tumor reported histologically as a papillary adenocarcinoma, probably metastatic from the kidney. However, a complete diagnostic study failed to demonstrate the primary focus. Thirteen months later, the patient was readmitted to the hospital and found to have metastatic prostatic carcinoma. Immunoperoxidase staining for prostatic acid phosphatase of the prostatic tissue and of the previously resected brain tumor tissue indicated that the brain lesion was metastatic from the prostate.


Black versus white racial differences in clinical stage at diagnosis and treatment of prostatic cancer in Connecticut. There are few published data on stage-specific prostate cancer incidence rates in United States black patients versus white patients, and there are no data comparing treatment received by black versus white patients with prostate cancer. Using data from a population-based cancer registry, the proportion of prostate cancers diagnosed in Connecticut from 1985-1988 at each clinical stage was examined for blacks and whites, along with stage-specific incidence rates. First course of treatment was also examined by clinical stage. The proportion of cases diagnosed at the metastatic stage was higher for black patients (35.4%) than for white patients (22.1%), and age-specific incidence rates for metastatic cancer were 1.5-3.3 times higher for black patients. Among localized-stage cases, the distribution of histologic grade (or degree of differentiation) did not differ in blacks versus whites, suggesting no difference in tumor aggressiveness or potential response to treatment. For localized (or A and B)-stage cancers, significantly lower use of prostatectomy in blacks versus whites younger than 70 years of age was the only important black-white difference, which requires confirmation in other studies. Frequency of use of hormonal therapy including endocrine surgery (orchiectomy) did not differ between black and white patients with pelvic metastases or disseminated disease. Comparisons were also made with data on treatment (all races combined) reported from the American College of Surgeons' national survey of prostate cancer cases diagnosed in 1983. Earlier detection of prostate cancer in blacks is needed to reduce black-white differences in stage at diagnosis and thereby reduce overall differences in survival rates. There was little evidence for inequities in treatment of prostate cancer for black patients versus white patients in Connecticut.


Pleomorphic granular cell astrocytoma of the pineal gland. Primary neoplasms of the pineal gland are uncommon. Two patients with unusual primary pineal tumors that had similar distinctive histologic features are reported. The surgically resected neoplastic pineal tissue from these patients were examined by light microscopy, immunohistochemistry, and electron microscopy and correlated with the patients' clinical course. These pineal tumors consisted of a mixture of spindle-shaped cells with fibrillated cell processes and many large lipidized and/or granular pleomorphic cells, some of which were multinucleated. These two tumors superficially resembled pleomorphic xanthoastrocytoma and granular cell tumors of the central nervous system. The pleomorphic tumor cells expressed glial fibrillary acidic protein and some also produced retinal S-antigen, a marker for retinal photoreceptor cells. Long-term follow-up (8 years) on one of these patients suggested a relatively "benign" clinical course. It is possible that this newly described tumor may be a distinct subset of pineal gland neoplasias with a favorable biologic behavior despite the histologic features that would suggest otherwise.


Postoperative wound infection. A poor prognostic sign for patients with head and neck cancer. The development of a wound infection has been identified as a favorable prognostic factor after oncologic surgical procedures. The authors retrospectively studied the relationship between postoperative wound infection, local/regional tumor recurrence, and survival rates in 134 patients undergoing therapeutic surgical resection for squamous cell carcinoma of the head and neck (SCCHN). The median age was 61 years (range, 25-87 years) with most (75%) patients having advanced disease (Stage III or IV). Patients without evidence of recurrent disease were followed up for a median time of 34 months (range, 24-68 months). Twenty-nine (22%) had local or regional bacterial infections develop postoperatively. Recurrence rates were increased (P = 0.008) in patients with postoperative wound infections compared with patients who had distant infections, e.g., pneumonia or urinary tract infection, or no infection. Disease-free survival also was adversely affected (P = 0.04) in this group. Both advanced tumor stage and postoperative wound infections were independently associated with decreased survival, with odds ratios of 2:3 and 2:4, respectively. These data contrast with other reports in the literature of a beneficial effect of postoperative wound infection on outcome. These findings suggest a possible relationship between local/regional immune function and postoperative infection in patients with SCCHN:


Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy. In addition to the desired antitumor effects, head and neck radiation therapy induces damage in normal tissues that may result in oral sequelae such as mucositis, hyposalivation, radiation caries, taste loss, trismus, soft-tissue necrosis, and osteoradionecrosis. These sequelae may be dose-limiting and have a tremendous effect on the patient's quality of life. Current policies to prevent these sequelae primarily are based on clinical experience and show great diversity. A protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy, based on fundamental research and data derived from the literature, is presented. The protocol is particularly applicable in centers with a dental team. This team should be involved at the time of initial diagnosis so that a successful preventive regimen is an integral part of the overall cancer treatment regimen.


Human cytotoxic T-lymphocytes specific for autologous follicular lymphoma recognize immunoglobulin in a major histocompatibility complex restricted fashion. Previously, autologous Burkitt lymphoma-specific cytotoxic T-lymphocytes (CTL) were found to express the gamma and delta T-cell receptor and recognize tumor idiotype in a major histocompatibility complex (MHC) unrestricted fashion. In this study, the authors established autologous CTL lines and clones specific for a B-cell follicular lymphoma. These CTL are tumor specific and inhibited by antiimmunoglobulin monoclonal antibodies, but unlike the Burkitt lymphoma-specific CTL, they are MHC restricted and express the alpha and beta T-cell receptor. These studies suggest that different B-cell lymphomas can induce CTL of different phenotypes and MHC restriction.


Image-directed percutaneous biopsy. A comparison of cytologic and histologic findings. Image-directed biopsies may be collected as histologic or cytologic specimens. In 34 patients, the results of aspiration cytologic examination were compared prospectively with core tissue biopsy findings obtained and diagnosed independently using the same image-guided procedure. Cytologic examination disclosed 22 patients with positive or suspicious findings of malignancy; there was one false-suspicious result. Seventeen patients with such results were discovered by examining the core biopsy specimens. Cytologic findings also were more definitive in diagnosing malignancy. Those in whom an immediate interpretation could be done were more likely to have adequate cytologic specimens (88%) than those without (62%). One to five passes were done, but all 21 patients with definitive findings of either benign or malignant by cytologic examination underwent three or fewer passes. The three patients with positive biopsy results, but less definitive cytologic findings, all underwent only one cytologic pass. Therefore, it was concluded that cytologic examination is more sensitive and definitive than biopsy in diagnosing lesions using image guidance. Immediate interpretation and/or multiple passes increase the diagnostic yield. However, more than three aspiration cytologic passes appear to yield diminishing returns.


Surgical stress impairs natural killer cell programming of tumor for lysis in patients with sarcomas and other solid tumors. Natural killer (NK) cells may provide a first line of defense against the metastatic implantation of circulating tumor emboli. Because tumor emboli are discharged systemically in patients undergoing solid tumor resection, it is important to determine the nature of surgical-stress impairment of perioperative NK cell cytotoxic function. The authors studied 85 patients undergoing surgical resection of solid tumors, most of whom had an abrupt and marked decrease in NK cell cytotoxicity that was detectable within 18 hours of surgical resection. This impairment was not caused by rapidly emerging suppressor cells (measured in autologous effector cell mixing studies) or decreased NK cell frequency in the peripheral blood (assessed phenotypically and morphologically). Instead, surgical stress exerted a direct "toxic" effect on NK cells that could be localized to a specific phase of the NK cell tumor lysis cycle. Tumor binding and the first round of tumor lysis were intact postoperatively (measured in single-cell assays). However, postbinding programming for lysis was decreased sharply after surgery (assessed by calcium pulse assays). In addition, the kinetics of lysis and the rate of lytic programming were slower after surgery (assayed in target saturation kinetic chromium-51 release tests). These latter defects probably were related to the programming for lysis deficiency because postprogramming NK cell maximal recycling capacity was not affected by surgical stress.


Cardiac malignant lymphoma in acquired immune deficiency syndrome. Extranodal malignant lymphomas (ML) are known to occur with increased frequency in patients with human immunodeficiency virus infection. The authors report a 30-year-old man with acquired immune deficiency syndrome (AIDS) with ML primarily involving the heart and compare the clinical and pathologic features to those of previously reported patients. The patient's hospital record was reviewed and pertinent clinical data were abstracted. Tissue obtained at autopsy was processed for routine light microscopic study and immunohistochemistry. A computer-assisted search of the medical literature for patients with malignant cardiac lymphoma was performed. The patient's initial signs and symptoms were nonspecific, and an abnormal gallium scan suggested pericarditis. Clinically, the course was characterized by progressive heart failure. Autopsy disclosed a diffuse large cell non-Hodgkin lymphoma of B-cell phenotype with massive involvement of the pericardium and extension into the myocardium. A literature search revealed 22 patients with cardiac lymphoma associated with AIDS. Clinical findings were nonspecific, but rapid progression of cardiac dysfunction was common after symptoms appeared. Pathologically, most lymphomas were of diffuse aggressive subtypes. ML of the heart is extremely rare but is being encountered with increasing frequency in patients with AIDS. The diagnosis should be considered in such patients in whom cardiovascular symptoms develop suddenly and progress rapidly.