Fractal dimensions of ductal patterns in the parotid glands of normal subjects and patients with Sjögren syndrome. The sialographic ductal patterns of the parotid glands in patients with Sjögren syndrome were compared with those of normal patients by measuring the fractal dimensions. Fractal dimensions were estimated using the modified pixel dilation method. The mean fractal dimension was 1.64 +/- 0.06 for the normal glands and 1.39 +/- 0.10 for the glands with Sjögren syndrome (P < .005). No correlation between the age or sex and fractal dimension was observed for both groups. In Sjögren syndrome, a significant difference in the fractal dimension was observed between the subgroup having punctuate fillings with a diameter less than 1 mm and the subgroup from 1 to 2 mm (P < .001). The fractal dimension is useful as a numeric grading of the complexity of the ductal pattern and the progression of parotid disease.


Extracorporeal liver ablation using sonography-guided high-intensity focused ultrasound. High-intensity focused ultrasound (HIFU) is the only radiation beam that can remotely destroy deep-seated tissue targets without causing damage to the intervening tissues. This study evaluates the ability of sonography-guided HIFU to extracorporeally induce liver ablation in a rabbit model. Under sonographic guidance, the HIFU beam was transcutaneously focused at the target tissue in the liver through a subcostal approach. A computer controlled the HIFU exposure and transducer movement to destroy a preselected tissue volume. Simultaneous sonography monitored the tissue response. Ten insonated rabbits were killed from days 0 to 10, and the liver and intervening tissues were examined histologically. A sharply demarcated sonolesion of coagulation necrosis was produced in the liver in 9 of 10 animals. No damage was found in the intervening tissues (n = 6) when adequate acoustic coupling and proper beam path was applied. Sonography-guided HIFU might be a potential new modality for extracorporeal inducement of liver cancer ablation without resorting to laparatomy.


Sonographic changes during hepatic interstitial laser photocoagulation. An investigation of three optical fiber tips. Interstitial laser photocoagulation (ILP) destroys tumors thermally, using laser energy delivered from implanted optical fibers. The objectives of the study are to identify a fiber tip/delivered energy combination which produces lesions of useful size, visible on ultrasound (US) during ILP, and to compare ILP lesions and their US images. Hepatic ILP was performed at laparotomy in six pigs, using three different fiber tips (cylindrical diffusing, spherical diffusing, plane-cut). US images were obtained during ILP, immediately after ("early" images), and before the animals were killed (2-2.5 hours, "late" images). Actual lesions were assessed histopathologically. Few US changes were seen around cylindrical diffusing and spherical diffusing tips until tip destruction. Plane-cut tips, at 1.5 to 2.0 W, produced prominent US images of the 1- to 2-cm thermal lesions. Early images tended to overestimate necrosis. Late images approximated necrosis. For US-controlled ILP, plane-cut tips are better than currently available cylindrical diffusing or spherical diffusing tips. Lesion image growth periods might enable control of lesion size. Further studies are needed to determine the consistency of the described relationship between lesion images and actual lesions.


Magnetic resonance imaging of the acute effects of interstitial neodymium:YAG laser irradiation on tissues. Laser irradiation therapy in deep tissues requires a monitoring method other than visual guidance. Magnetic resonance imaging (MRI) can be used for this purpose because it visualizes soft tissue structures and heat distribution. The authors performed interstitial laser irradiations in rat livers with various laser outputs and measured the sizes of laser-induced lesions. MRI of these lesions was done ex vivo and compared with the histologic findings. Laser-induced lesions also were studied in rabbit brain, liver, and skeletal muscle to show the influences of tissue optical and thermal properties. Imaging of interstitial laser irradiation also was performed in vivo in rabbit brains. MRI depicted the laser-induced lesions produced with different laser outputs and tissue types. MRIs of rabbit brain in vivo effectively demonstrated the signal decrease during heating and acute tissue changes. MRI has potential for monitoring interstitial laser surgery or hyperthermia.


Digital radiography with photostimulable storage phosphors. Control of detector latitude in chest imaging. A widely used digital radiography system based on a photostimulable storage phosphor (PSP) detector was analyzed with regard to radiographic contrast changes that result from the adjustment of detector latitude (x-ray sensitivity range) in the normal processing of chest images. Images of an acrylic step wedge were acquired using the digital system in a mode that permitted direct control of effective detector latitude. The images were post-processed in conditions duplicating those used for portable chest examinations, and contrast was measured. Increases in effective detector latitude provided only marginal radiographic contrast gains in the subdiaphragm-equivalent areas of the laser-printed digital film image, while causing large reductions in radiographic contrast in the lung-equivalent region. Detector latitude is an important variable that should be monitored or controlled in investigations that compare reader performance using conventional and digital systems.


Experimental pulmonary infarction in a pig model. The authors sought to develop a reliable animal model for experimental pulmonary infarction, to evaluate it with radiologic-pathologic correlation, and to determine the use of high-resolution computed tomography (HRCT) in monitoring parenchymal lung damage due to infarction. Selective left lower lobe pulmonary artery occlusion was performed in seven Yorkshire pigs with transcatheter silicone elastomer injection. After occlusion, 99m technetium (99mTc) macroaggregated albumin perfusion lung scans and sequential in vivo HRCT lung scans were obtained from days 0 to 46. The in vivo radiologic findings were correlated with specimen radiography, specimen HRCT, and histologic findings. A complete and permanent arterial occlusion was achieved, involving up to three orders of branching distal to the catheter. An anatomically defined perfusion defect was seen on 99mTc lung scans corresponding to the occluded area. HRCT changes consisted of confluent densities progressing to mixed alveolar and interstitial opacities within the first week after embolization. In the follow-up period, marked parenchymal clearing was observed. In all cases after pulmonary artery occlusion, the histologic findings were characteristic of pulmonary infarction and demonstrated alveolar edema, hemorrhage, limited alveolar wall damage, and septal thickening followed by residual fibrosis. Using this model, it is feasible to produce pulmonary infarction in the pig which may potentially be useful to study the pathophysiologic and radiologic changes of pulmonary infarction.


Alteration of human tumor cell adhesion by high-strength static magnetic fields. The authors investigated whether the ability of human malignant melanoma cells to increase in cell number or their ability to remain viable was compromised by high-field strength static magnetic fields. Normal human fibroblasts also were studied to determine if any magnetic field-related alterations were unique to tumor populations. Human cell lines were grown in monolayer culture in vitro and subjected to a static magnetic field using a 4.7-Tesla superconducting magnetic resonance imaging (MRI) magnet with the gradient coils removed. The number of cells within the total population was determined using an electronic particle counter. Cell viability was estimated by trypan blue exclusion, and the cellular morphology of the attached cells was documented using microscopy. Both the human malignant melanoma cells and the normal human cells were unaffected by the presence of a high-strength magnetic field in terms of increasing their cell numbers or their viability. However, the ability of the malignant melanoma cells to remain attached to the tissue culture surface was impaired. Normal fibroblasts were not affected in this regard. High-strength static magnetic fields alter the ability of human malignant melanoma cells to remain adherent to the tissue culture surface, but have no effect on normal human fibroblasts. This may affect the ability of tumor cells to successfully interact with their environment.


Phantom evaluation of imaging modalities for silicone breast implants. Recent concern regarding possible adverse effects from silicone breast implants has increased the role of radiologists in assessing augmented breasts. The authors compare the commonly available imaging modalities in evaluating the intact silicone implant as well as free silicone in the adjacent tissue. A contrast resolution phantom and breast of veal phantom were tested. Fat was used as a reference material. The phantoms were imaged with xeromammography, film-screen mammography, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Proton MRI spectroscopy also was performed on fat, silicone, water, and water/gelatin samples. The consensus of two radiologists determined whether free silicone was present. CT and MRI provided the best images of the implant and the free silicone. Several features of MRI were useful: spin-density scans and the fast low-angle shot (FLASH) and fast imaging with steady-state precision (FISP) techniques provided excellent resolution, a consistent chemical shift artifact appeared around the silicone, and frequency selective pre-saturation techniques resulted in marked suppression of the silicone. Additional testing in a more realistic setting, breast coil design, and improvement of various MRI techniques, particularly the frequency selective pre-saturation techniques, all appear promising in evaluating breast implants, the presence of free silicone, and the adjacent tissues.


Factor analysis of dynamic magnetic resonance imaging in predicting the response of osteosarcoma to chemotherapy. The response of osteosarcoma to preoperative chemotherapy was assessed using dynamic magnetic resonance imaging (MRI) processed by factor analysis of medical image sequences (FAMIS). Forty-nine dynamic image sequences, acquired after a bolus injection of gadolinium in 10 patients, were processed by FAMIS: FAMIS is a means whereby physiologic contrast enhancement kinetics, called factors, and their spatial distribution, termed factor images, are estimated. Tumor volumes were measured on static MRIs, and factor images were compared with histologic maps of the resected specimens. A substantial increase in tumor volume reflected a poor response to chemotherapy. Viable tumor was precisely depicted by the early vascular factor image, reflecting rapid uptake by tumor vessels. This early uptake disappeared in all five patients who responded to chemotherapy, whereas it persisted in four of five nonresponders. FAMIS of dynamic MRI is proposed as a possible means of predicting the response of osteosarcoma to chemotherapy.


Magnetic resonance image synthesis from analytic solutions of spin-echo and radio frequency-spoiled gradient-echo images. To synthesize magnetic resonance images (MRI) in real-time using a minimal data set obtained with routine clinical protocols and stored in a picture archiving and communication system (PACS) database. Analytic solutions for T1 and T2 were obtained from a double and a single spin-echo set, with routine parameters. Analytic solutions from radio frequency-spoiled gradient-echo images, with TRs as low as 33 mseconds, also were used to synthesize gradient-echo images. Phantom studies showed that the errors in the synthesized images were significantly smaller than the errors in the T1- and T2-calculated images and similar to the source images. The gradient-echo images resulted in significant scan time savings. MRI synthesis from analytic solutions of T1, T2, and rho saves computational time and yields accurate values for the intrinsic parameters while allowing the use of routine clinical protocols. The availability of clinical images in the PACS database and the ability to synthesize images in real-time has allowed the development of a practical interactive teaching module.


Proton (fat/water) chemical shift imaging in medical magnetic resonance imaging. Current status. Fat/water CSI has recently been transformed from an experimental method to a routine clinical MRI approach, particularly for evaluating paramagnetic contrast enhancement in fat-rich regions and as a piggyback method for decreasing MRI artifacts, such as in MR angiographic and echo-planar imaging. The full and appropriate use of CSI in medical MRI requires consideration of the factors and strategies outlined in this review. As the commercial implementation of fat/water CSI continues, we can expect further applications in clinical and experimental studies. For example, in imaging areas where MRI has been of limited efficacy, such as pancreas imaging, skin microimaging and vascular imaging, there are indications that these CSI methods may have practical importance. It seems reasonable to project that for high chemically specific detail, medical fat/water CSI will ultimately be supplanted by SI methods, and certainly by localized spectroscopy. The power of the fat/water CSI method remains its extremely high anatomic resolution, which cannot be achieved by current spectroscopy or SI methods. The fat/water CSI methods provide a means for clinically relevant MRI with more accurate and chemically specific information. Expansion of these methods into three-dimensional and fast imaging formats is already taking place at or near the commercial level. For example, the feasibility of combining echo-planar imaging and CSI methods has already been demonstrated. Methods based on the phase-contrast techniques, such as susceptibility mapping and interferometry, are additional implementations that can provide detailed and more specific information in a high anatomic detail format.


Student and faculty perceptions of interactive learning in the radiology clerkship. The objective of this research is to develop and evaluate medical students' perceptions of interactive learning techniques for teaching the role of radiology in medical diagnosis to senior medical students. Students in a 4-week radiology clerkship were given specific learning objectives and tasks that enabled them to be actively involved in radiology. Students rotated through six specialty areas in small groups. Some areas used the interactive format, whereas others used the traditional observation method. In the interactive format, clinical faculty involved student groups in examining patients, checking histories, making clinical/radiologic correlations, and discussing cases. Students consistently rated the interactive rotations higher (4.6 on a 5-point scale) than the observer format (3.3). The faculty and residents found the interactive format to be manageable and conducive to learning. Involving students in appropriate decision making and problem solving has proven to be a preferred way to teach radiology to medical students.


An aid to image interpretation and differential diagnosis. Proven case conference is a weekly 1-hour session designed to aid diagnostic radiology residents in their ability to interpret images and formulate differential diagnoses. This article provides a detailed description of the format of this conference and its use in evaluating resident performance. The scores of all residents on the written portion of this conference over a 2-year period were compiled. Results were divided according to each residency class, and each resident was compared with the mean of his or her class and with previous performance. There was overall improvement of the group over the course of residency. All individual scores showed improvement during the 2-year period studied. Proven case conference is a simply performed, well-accepted aid to image interpretation and differential diagnosis. It affords residents an ongoing opportunity for practical learning and provides the residency program director with an objective tool for resident evaluation.


An artificial neural network for lesion detection on single-photon emission computed tomographic images. An artificial neural network (ANN) has been developed to detect nonactive circular lesions on single-slice, single-photon emission computed tomographic (SPECT) images reconstructed using filtered back projection (FBP). The neural network is a single-layer perception which learns to identify features on the SPECT image using supervised training with a modified delta rule. The network was trained on a set of SPECT images containing clinically realistic levels of noise. The trained network was applied to a set of 120 images, and the detection performance was evaluated at several decision thresholds using receiver operating characteristic (ROC) analysis. The trained neural network performed better than human observers for the same detection task with the same images as reflected by a significantly larger ROC curve area. ANN can be trained successfully to perform lesion detection on reconstructed SPECT images.


T1 in subacute and chronic brain infarctions. Time-dependent development. Time-dependent behavior of T1 in brain infarcts and in brain tissue of the contralateral hemisphere was studied in the subacute and early chronic stages of stroke. T1 was measured from magnetic resonance images (MRIs) of 29 patients as a function of infarct location and age. Another group of 11 patients was studied with consecutive MRI studies during the first 5 weeks after the onset of infarct, and the distribution of T1 in the infarctions was analyzed from T1 maps using a histographic method. During the first 2 months after a stroke, T1 was longer in the infarcted gray matter than in the infarcted white matter (P = .002), and prolonged linearly in both. The histographic analysis showed a component arising from tissue breakdown products that could be identified for up to 5 weeks. A transient lengthening in T1 of the contralateral hemisphere, reaching a maximum at 3 weeks, also was observed. These characteristics of recent infarctions differentiate them from older, gliotic lesions. The lengthening of T1 in the contralateral hemisphere may reflect remote flow and metabolic effects of brain infarctions.


Magnetic resonance evaluation of regional left ventricular function. Effect of through-plane motion. Measurements of segmental contraction of the left ventricle by standard magnetic resonance imaging (MRI) and two-dimensional echocardiography involve the comparison of diastolic and systolic time frames acquired from the same imaging plane in space. As the cone-shaped left ventricle shortens along its long axis during systole, the observed contraction may differ from the true myocardial contraction. Spin-echo MRI examinations in 21 healthy subjects were performed to evaluate the error caused by failing to compensate for through-plane motion. The authors found that at the base and the mid-ventricle the observed contraction systematically underestimates true contraction by an average of 16% and 21%, respectively (P less than .001). At the apex, the segmental contraction may be overestimated or underestimated. Because of this error, standard MRI and echocardiography are less suited for basic research on cardiac contraction patterns. However, standard imaging techniques are valuable in clinical studies comparing groups of patients, because all measurements will suffer from the same systematic error.


The anticoagulant effects of ionic and nonionic low-osmolar contrast media in dogs. The anticoagulant effects of ionic and nonionic low-osmolar contrast media were evaluated in vivo. The amount of clot deposited on guide wires placed in the femoral vessels of dogs was weighed 30 minutes after the injection of 2 mL/kg of different contrast media. Six dogs were examined after injection of ioxaglate (ioxaglate group), six after injection of iopamidol (iopamidol group), and five after injection of saline (saline group). The mean weights of clot deposited on the guide wires in dogs in the ioxaglate group, the iopamidol group, and saline group were 30.5, 63.1, and 74.2 mg, respectively. The mean weight of clot deposition on the guide wires in the ioxaglate group was significantly less than in the iopamidol and saline groups, whereas there was no statistical difference in the mean weight of clot deposition on the guide wires in the iopamidol and saline groups. Ioxaglate, a low-osmolar, ionic contrast medium, has a greater anticoagulant effect than a low-osmolar, nonionic contrast agent, such as iopamidol.


Magnetic resonance imaging, microangiography, and histology in a rat model of primary liver cancer. N-nitrosodiethylamine is able to induce various benign and malignant liver lesions in rats with a high success rate and a low mortality rate. It provides a more appropriate model that better simulates the various lesions occurring in patients than the usual model of tumor implantations. Hepatic carcinogenesis was induced in 58 Wistar rats using oral N-nitrosodiethylamine. The rats subsequently were studied by liver magnetic resonance imaging (MRI), postmortem microangiography, and histologic examination. Hepatic tumors developed in 57 rats. A wide variety of the tumors in the degree of vascularization, the type of vessels, the areas of intratumoral secretion and necrosis, and the tumor cell differentiation resulted from the tumor model. The authors were able to assess the contribution of the vascular, extravascular, and cellular components in the final pattern of contrast enhancement in MRI. The N-nitrosoethylamine model for hepatic tumor induction is simple, and provides a more representative range of tumors for experimental evaluation.


Computed tomographic enhancement of the liver, liver abscesses, spleen, and major vessels with perfluorooctylbromide emulsion. Influence of dosage and injection velocity in an animal model. Computed tomographic (CT) enhancement of the liver, liver abscess, spleen, and major vessels was investigated between 2 and 48 hours after intravenous administration of perfluorooctylbromide (PFOB emulsion) in an animal model of 63 rabbits. Twenty-one animals received 3 g/kg PFOB as a fast bolus injection. Using a slow infusion rate, the same number of animals received either the same dose (3 g/kg) or half the dose (1.5 g/kg). Vascular enhancement was best after bolus injection of 3 g/kg emulsion. The density peak occurred after 2 hours. A continuous enhancement of approximately 100 Hounsfield units (HU) was observed up to 24 hours in the animals receiving 3 g/kg, independent of the injection velocity. A density peak of 70 HU was found 2 hours after the infusion of 1.5 g/kg. The density peak of the liver, the spleen, and the abscess wall was observed 48 hours after emulsion administration in all groups receiving 3 g/kg. The peak was approximately 150 HU for the liver, 400 HU for the spleen, and 150 HU for the abscess wall. In animals receiving only 1.5 g/kg perflubron, the peak density of the abscess wall was 132 HU after 12 hours, approximately 80 HU for the liver between 2 and 48 hours, and approximately 280 HU after 48 hours for the spleen. PFOB emulsion produces the highest vascular enhancement within the first 2 hours after the bolus injection of 3 g/kg. For spleen and abscess wall imaging, even the relatively low dose of 1.5 g/kg produced a satisfactory enhancement level for a significant length of time, whereas liver enhancement was best after administration of the higher dose.


Quantitative evaluation of sialograms.

Quantitative evaluation of sialograms. The authors developed and evaluated a quantitative analytic method for interpreting clinical sialograms. Images were obtained by digital subtraction sialography and transformed into binary form. The duct width of the image was calculated and represented as a normalized histogram. The effects of the volume of contrast medium injected and of the inclination angle of the objects on the histogram were examined. In model studies, the normalized histogram was affected insignificantly by these factors. Clinical sialograms of 18 patients with normal results, 12 patients with parotitis, and 5 patients with Sjögren syndrome were preliminarily analyzed by the histogram method and four representative parameters of the histogram. Discriminant analysis showed a relatively high correct-predictive rate in the distinction between patients with normal and abnormal results. This method reduces the effect of observer variation in diagnosing sialograms, and improves diagnostic accuracy for assessing the presence of inflammatory diseases of the parotid gland.


Vertebral body fractures in child abuse. Radiologic-histopathologic correlates. Vertebral injuries are rarely reported sequelae of child abuse, and little is known concerning the mechanisms of injury and healing. A preliminary investigation of these issues included correlating radiologic and histologic findings in children with vertebral injuries who died of complications relating to physical abuse. Ten vertebral body fractures from four abused infants and young children were studied radiologically and histopathologically. Infants ranged in age from 7 to 36 months (mean, 21 months). Three patients died of associated head injuries. One child died after abandonment. There were three pure vertebral body compression fractures, two superior end-plate fractures without compression deformity, and five anterosuperior end-plate fractures with associated compression deformity. Vertebral compression was generally mild (less than 25%). Typically, end-plate injuries were manifest histologically by extension of the fracture through the medullary trabeculae into the proliferative zone of the superior end plate. The resultant pattern was analogous to that described in a previous study, and could potentially result in a growth disturbance at the vertebral end plate. Observed radiologic patterns and histologic correlates may help explain previously described findings, such as vertebral notching, in abused infants.


Evaluation of a digital workstation for interpreting neonatal examinations. A receiver operating characteristic study. The purpose of this study is to compare the diagnostic accuracy of interpreting clinical neonatal radiographs using a commercially available digital workstation versus conventional radiographic images. The case sample consists of 100 chest or abdominal radiographs from the neonatal intensive care unit in which diagnosis was confirmed. Four radiologists served as observers. During two initial reading sessions, half of the studies were viewed on digital radiography monitors and the other half by plain film. Observers indicated whether each patient had normal or abnormal findings and their degree of confidence in this judgment. Six weeks later, observers viewed cases on the alternate presentation system. Two statistical analyses were performed: the data from each observer were treated as a separate experiment in the first analysis; the data from all observers were combined using a new method in the second analysis. No differences between areas under receiver operating characteristic (ROC) curves for viewing on the picture archiving and communication system (PACS) console and plain film were found for any observer (0.86 versus 0.86, 0.89 versus 0.86, 0.88 versus 0.85, 0.83 versus 0.82). The study suggests that for pediatric plain film images, video images offer diagnostic information comparable with that of conventional radiographs for neonatal examinations.


Medical coverage for the Iowa Games, 1987-1990. The author summarizes the experience of the medical staff of the Iowa Games competition from 1987-90. The rate of injuries decreased each year, perhaps because of the increased conditioning and experience of the athletes.


Victims of family violence are everywhere, say Iowa experts. Family violence has become such a pervasive problem that every physician must be educated on how to diagnose and assist its victims. Iowa experts discuss family violence, particularly child abuse and elderly abuse.


AMA fights back.

AMA fights back. The vice chairman of the AMA Board fo trustees discusses the AMA's renewed campaign against family violence, including release of protocols for primary care physicians and formation of the Physicians Coalition Against Family Violence.


The use of baseline investigations in patients admitted from an accident and emergency department. We studied the use of four investigations on patients admitted from our Accident and Emergency Department: full blood count, urea and electrolytes, chest x-ray and electrocardiogram. We found 1) that these investigations were performed on a high proportion of patients admitted 2) that a high percentage of these investigations yielded normal results. We suggest that a greater emphasis should be placed on clinical assessment, rather than the 'routine' use of investigations.


Phlebotomy practices/needles stick injuries/hepatitis B status/among interns in a Dublin hospital. Needlestick injury is the most important risk event for human immunodeficiency virus (HIV) and hepatitis B Virus (HBV) transmission to health-care workers. We examined phlebotomy practices, the frequency of needle stick injuries, the reporting of such injuries and hepatitis B status among interns in St James's Hospital during a six month period. This study took the form of a questionnaire. The response rate was 100%. 72% had at least one needlestick injury during this time period, 23% had injuries from known HIV sero-positive or hepatitis B surface antigen positive patients, less than 5% of all injuries were reported and only 41% of interns were definitely hepatitis B immune. The majority (77%) resheated needles by hand.


Communication skills training in undergraduate medicine: attitudes and attitude change. The importance of communication skills training in undergraduate medical education is now widely accepted. However little is known about student attitudes towards their own communication skills and whether their attitudes changes as a result of participating in communication skills courses. The aim of the present study was to identify these attitudes prior to commencing such a course and to further evaluate changes in these attitudes on completion of the course. Results demonstrated an improvement in perceived confidence regarding a number of specific communication skills. The study provides further evidence of the value of such courses in undergraduate medical training.


Continuous ambulatory peritoneal dialysis in children. Fifteen children with end-stage renal failure (ESRF) were treated with continuous ambulatory peritoneal dialysis (CAPD) in the Children's Hospital Temple Street Dublin between July 1984 and December 1988. These fifteen children had 150.5 treatment months, an average of 10.03 treatment months for each child. The children grew well during CAPD at an average of 0.59 cm per month. Blood pressure control was satisfactory with five out of 15 children requiring antihypertensive treatment during CAPD. The main complications of CAPD were peritonitis and catheter related problems. These 15 children experienced 47 episodes of peritonitis during 150.5 treatment months on CAPD with an average of one episode every 3.2 treatment months. Two of these children had a very high frequency of peritonitis (16 and 13 episodes each). If we exclude them from analysis, the remaining 13 children had frequency of one episode every 5.7 treatment months. During 150.5 treatment months, ten children required catheter replacement that is one catheter every 15 treatment months. One child died of candida peritonitis and to date twelve have proceeded to renal transplantation.


Home intravenous therapy using a silastic long line catheter in cystic fibrosis patients. Young patients with cystic fibrosis are now accustomed to having regular periods of intravenous therapy to help in the management of their recurring respiratory infections particularly due to pseudomonas organisms. Most patients will eventually experience difficulties in accepting recurring intravenous cannulations and the life span of the conventional intravenous cannula is frequently brief. We have compared percutaneous long line silastic catheters with conventional intravenous cannulas as intravenous access in children with cystic fibrosis being treated for pulmonary exacerbations. We conclude that silastic long lines are superior to conventional cannulas in terms of patient tolerance, reduction in the number of hospital admissions, reduction in the number of repeat venepunctures/cannulations and reduction in local complications. The high degree of patient acceptability has been impressive and has increased with the enthusiasm of children with cystic fibrosis for more frequent intravenous therapy.


Passive smoking and hearing loss in infants. A cohort of infants scheduled to attend the 10 month developmental assessment were studied to determine whether hearing deficits are more common in those exposed to cigarette smoke. Hearing was assessed by the standard distraction test and those with persistent abnormalities were referred to a medical audiologist. Overall 77% of infants were exposed to cigarette smoke and 40% failed the initial hearing tests. Exposure to cigarette smoke was associated with a 4.9 times increase in the prevalence of hearing deficits and 75% of the cases of hearing loss were statistically attributable to exposure to cigarette smoke. The results of this study lend further weight to the hypothesis that exposure to cigarette smoke is a cause of hearing deficits in children.


Consultation liaison psychiatry within the general hospital: referral pattern and management. The emergence of consultation psychiatry as an important psychiatric subspecialty is in part due to the siting of psychiatric units in general hospitals, the manifest advances in medical technology and the increasing elderly population needing specialist care. This paper describes an evaluation of all referrals to a liaison psychiatry unit in a 550 bed general hospital over a six month period. 205 requests for psychiatric consultation were received, which represented 2% of all admissions. There was considerable variation between departments with regard to the referral rate. Management most often consisted of advice, with over 50% of patients being subsequently referred for ongoing psychiatric care.


Herpes zoster oticus-diagnosis and treatment. Four cases of Herpes Zoster Oticus (HZO) with facial paralysis are presented. HZO is a Herpes Zoster viral infection of the Geniculate Ganglion of the facial nerve. It presents classically with severe otalgia, a vesicular rash in the Concha or on the Pinna of the affected ear in association with a lower motor neurone lesion of the homolateral facial nerve. There also may be labyrinthine symptoms, sensineural hearing loss and vesicular eruptions in the regions supplied by the vagus and glossopharyngeal nerves viz, hypopharynx and oropharynx as these nerves communicate with the facial nerve. Treatment consists of Acyclovir. One reference in the past refers to a clustering of the condition and its predisposition for females. Interestingly all cases presented were referred with incorrect diagnoses.


Committal procedures in Ireland.

Committal procedures in Ireland. The study aims to describe current committal practice in an Irish public psychiatric service and to establish the role of 'dangerousness' in determining practice. A six month retrospective review was undertaken using casenotes and original temporary forms of all patients committed to St Brendan's Hospital, Dublin within a six month period in 1990. A total of 136 cases were examined. In 65% of cases the application for detention was initiated by a spouse or relative. The recommending physician was identified as a General Practitioner in 80% of cases, although most were locum GP's. The number of male and female patients were almost equal. There was a wide age range with the largest group (42%) in the range 26-40 years. Previous contact with the psychiatric service was found in 89% of cases. There was a wide range of diagnoses with the largest category (56%) suffering from schizophrenia. Of those not admitted with alcohol or drug related illness 66% showed evidence of acute psychotic symptoms. Length of admission was relatively short with 84% of patients being discharged within three months. A total of 43% showed evidence of being a danger to themselves or others. Significant differences were found between these patients and the non-dangerous group, the latter being more likely to be older and to suffer from a major psychotic illness. These findings indicate that a committal law based purely on 'dangerousness' criteria would be likely to significantly affect committal practice in Ireland. These findings are discussed in relation to proposed changes in mental health legislation in Ireland.


Awareness of heart attack signals and cardiac risk markers amongst the general public in Dublin. Following myocardial infarction, early access to medical care is essential. In order to assess the ability to recognise and manage heart attack and its risk factors, 302 members of the public were surveyed. A surprisingly comprehensive knowledge base was revealed, together with apparently appropriate ideas about the management of myocardial infarction and its risk factors. The significance of this finding is discussed in the light of the well documented delays by members of the public in summoning help when they suspect heart attack.


Intrapartum asphyxia in term and post term infants. Many attempts have been made to identify infants at risk of suffering asphyxial brain damage. In a retrospective review of records at the Rotunda Hospital over a five year period all infants who died or suffered seizures, presumed secondary to asphyxia, were compared with the general hospital population. Out of 28,655 deliveries reviewed, there were 13 deaths in infants at or after term associated with perinatal asphyxia, and 32 surviving infants had asphyxial seizures. Seizures were regarded as asphyxial in origin if they occurred in the first forty eight hours of life and were associated with other clinical evidence of asphyxia. The incidence of abnormal presentations, assisted breech deliveries, instrumental deliveries and emergency caesarean sections was all increased in the asphyxial categories compared to the control population. Referral to the fetal assessment unit was associated with a seizure rate of 0.16/1000 live births compared with a rate of 1.4/1000 in the remaining non referred hospital population. Nineteen percent of the infants who seized subsequently developed cerebral palsy. It would appear from our data that referral to the fetal assessment unit and the consequent assignment to "high risk" status is associated with low risk in terms of asphyxial outcome.


Effect of nisoldipine on ambulatory blood pressure under 24-hour noninvasive monitoring. The antihypertensive effect of nisoldipine on ambulatory blood pressure was investigated using continuous noninvasive monitoring in 12 patients with moderate essential hypertension. Treatment with nisoldipine 5 mg twice a day for 2 weeks resulted in a decrease in the average of each patient's mean arterial pressure for the whole day from 110.3 +/- 6.8 to 103.2 +/- 8.8 mm Hg (P = 0.0007). This decrease in mean arterial pressure was due to a decrease in both systolic and diastolic pressures. The reduction in blood pressure was most marked at the time of the originally high blood pressure readings. Comparisons of consecutive means of 2-hourly mean arterial pressure readings showed a statistically significant effect from 6:00 AM to midnight. Blood pressures between midnight and 6:00 AM were similarly low, before and during nisoldipine therapy. There was no change in heart rate. Untoward symptoms were reported with similar frequency, and of similar severity, both before and during therapy. Nisoldipine 5 mg twice a day is an effective antihypertensive agent, reducing moderately elevated blood pressure in ambulatory, working patients with essential hypertension. At the dosage used, it had no demonstrable effect on heart rate and minimal, if any, side effects.


Vitamin A loading--an indicator of post-prandial lipoprotein clearance in healthy and hypertriglyceridemic subjects. To study post-prandial lipoprotein metabolism in normolipidemic and hypertriglyceridemic subjects, a vitamin A fat loading test was used. This method specifically labels dietary fat particles with retinyl palmitate (RP). Following RP concentrations, metabolic behavior of chylomicrons and chylomicron remnants were studied. In normal subjects, post-prandial lipoproteins were present for more than 10 h. Total RP increased rapidly between 1 and 4 h, peaked at 6 h and declined rapidly between 6 and 10 h. The chylomicron and chylomicron remnant fractions behaved differently, showing precursor product relationship. The hypertriglyceridemic patients demonstrated a very severe defect in chylomicron clearance. This fraction was 2.8-fold higher than in normal subjects, which was 7,260 vs. 2,600 micrograms/l, respectively. The large magnitude and long duration of post-prandial lipemia in normal and hypertriglyceridemic patients support the hypothesis that these atherogenic particles may play a role in the development of coronary heart disease.


Late presentation of Bochdalek hernia: our experience and review of the literature. During the last 18 years, 81 patients were diagnosed in the Department of Pediatric Surgery, Rambam Medical Center, as having congenital diaphragmatic hernia, 11 of whom (13.5%) presented after the first 24 h of life. In this retrospective study we describe our experience with late presentation (beyond 8 weeks after birth) of Bochdalek hernia in 5 of the 11 patients, and we review the literature.


The quality assurance committee in a general hospital: its use in improvement of the medical record. A twice-yearly audit of a sample of medical records from each department of a general hospital was initiated by a quality assurance committee and pursued for 8 years. Missing entries that were considered obligatory for good medical performance of each service were identified, and the results (expressed as percent of missing entries of the total) were communicated in graphic form to the specific departments and the senior staff of the hospital. This approach led to an improvement in the medical records (decrease of missing entries), which may reflect a higher quality of medical care. Thus, a sequential audit of medical records by a quality assurance committee may constitute a simple and effective method of monitoring and improving physicians' knowledge and performance.


Recent trends in drug utilization in Israel. There has been a considerable increase in the rate of medicine expenditure and consumption in Israel in the latter half of the 1980s in dollar terms compared to the previous decade both in total and per capita expenditure. At constant medicine prices there has been only a slight increase, reaching an average 9.4% annual growth in per capita consumption in the latter half of the 1980s. From the late 1970s to the late 1980s Israel had one of the highest rates of growth in total expenditure and per capita consumption at constant prices compared to OECD countries (Organization for Economic Cooperation and Development). The driving forces behind the real growth in overall expenditure continue to be the introduction of new drugs and changes in drug therapy. However, mainly as a result of substantial quantitative growth in per capita consumption in the private pharmacy sector, there was a greater growth in this sector than in Kupat Holim Klalit (Medical Insurance Scheme of the General Federation of Labor). An attempt to break down the aggregate into private pharmacy and Kupat Holim Klalit, according to expenditure, prices and consumption, indicate that although the latter has a much lower per capita expenditure, the price adjusted per capita consumption is similar in both sectors. Price adjusted per capita consumption is well below that of France and Italy, and close to that of the USA, the UK, West Germany and Switzerland. These findings are briefly discussed in terms of demographic differences.


Use of informed consent with therapeutic paradox. Debate persists in the literature and among clinicians about the ethical appropriateness of paradoxical interventions. It has been suggested that informed consent with therapeutic paradox would alleviate ethical concerns of deception, manipulation, harm to the client, and withholding of information from the client in therapy. The purpose of this study was to explore health care consumer reactions to the benefits and risks of therapeutic paradox as stated in a consent for treatment form. The study explored the responses of 32 medical patients to a hypothetical consent for treatment form for therapeutic paradox. Data were collected in a brief semistructured interview after subjects read the hypothetical consent form. Utilizing a case study, the investigator then offered an example of a successful paradoxical intervention and additional subject comments were solicited. Content analysis of the responses was made. Health care consumers had mixed responses to the consent form. While the consent form served as an obstacle for some consumers, many were willing to sign the consent form and accept treatment even though they had internal reservations and questions. Appropriateness of the consent form format is discussed.


Extra-articular synovial chondromatosis. Description of a rare localization in the arm. The author presents a rare instance of extra-articular chondromatosis located around the tendon of the long head of the biceps brachii. The tendon subsequently tore and retracted, resulting in the formation of numerous cartilaginous loose bodies which collected in a mid-brachial cavity communicating with the canal which had previously housed the tendon. The author comments on the peculiar mechanism of production of this rare case of synovial chondromatosis as well as possible interpretations.


The individual who is severely and persistently mentally ill: directions for research and practice. Psychiatric mental health nursing has not invested time and resources in the care of those with severe and persistent mental illness. In this article, current nursing research is reviewed and practice/research directions are delineated in the following areas: acute and chronic manifestations of symptoms, behavioral manifestations related to institutionalization, responses to psychiatric disorders over time, the long-term effects of psychotropic medication on behavior, and the impact of physical illnesses on psychiatric disorders. Knowledge is sorely needed in all of these areas to improve the nursing care of those persons with severe and persistent mental illness.


The role of magnetic resonance imaging in lumbar disc disease. The authors analyze 30 cases of herniated lumbar disc, comparing the clinical features with the magnetic resonance images and the intraoperative findings. In 10 cases it was possible to compare MRI with computerized tomography as well. This paper confirms, in agreement with the international literature, the great diagnostic value of this new imaging study. While MRI is non-invasive and does not expose the patient to ionizing radiation, it provides an amount of information that could previously be obtained only by combining CT with myelography and discography.


Noncompliance with medication regimens in severely and persistently mentally ill schizophrenic patients. Medication noncompliance contributes significantly to recurrence of symptoms and readmission to the hospital of schizophrenic patients. The purpose of this study was to determine factors identified by patients, family members, and nurses for patients' noncompliance. The Health Belief Model provided a theoretical framework. The sample consisted of 11 triads with a noncompliant schizophrenic patient, a family member, and a primary nurse in each triad. A structured interview was developed to assess stated reasons for noncompliance and factors relating to the patient's illness, medication practices, stressors, life-style, and support systems. Results showed that many patients stated they did not need medication or needed less than the amount prescribed. Family members and nurses agreed that the majority of patients did not believe that they needed medication. When asked if they thought they had a mental illness, most patients denied that they were ill. Other stated reasons for noncompliance were drug/alcohol use, and, for one patient, medication side effects. Additional findings were patients' low self-esteem; lack of knowledge about medications; inability to identify stressors in patients' lives; inability to identify early symptoms of relapse; patients' need for support from families; and families' stress from patients' abusive, unpredictable behavior. Use of the Health Belief Model is appropriate to study noncompliance in mentally ill patients if perception of illness threat is assessed. Conclusions were that patients and families could benefit from more knowledge of schizophrenia and its treatment, more awareness of stressors and signs of relapse, and improved mutual problem solving. Studies are needed to assess the effects of patients' denial of illness, denial of need for medication, and self-image/self-esteem on medication noncompliance.


Psychological adaptation of nurses post-disaster. Disasters have the potential to cause major disruptions in lifeline services and family support systems. As caregivers, nurses are required to make difficult choices during national emergencies and may be at risk for experiencing psychological distress following a disaster. This study describes the responses of a group of nurses following Hurricane Hugo, and makes recommendations to minimize the stress placed on nurses working in a time of disaster.


MR imaging in the diagnosis of carpal tunnel syndrome. Diagnosis of carpal tunnel syndrome (CTS) is usually made on the basis of clinical and electrophysiologic data. Other tests, however, such as ultrasound and CT, have enabled us to acquire additional information regarding the anatomical definition of the structures inside the carpal tunnel. The superior quality of MRIs soft-tissue definition led us to employ it in cases of median nerve compression at the wrist in order to determine its true diagnostic value. We compared the preoperative electrophysiologic and MRI findings in 23 cases of CTS which had undergone surgical decompression of the median nerve at the wrist. Exact correspondence with the intraoperative findings confirmed the reliability of the anatomical information provided by MRI, yet the same comparison revealed that correct "functional" information could be provided only by the electrophysiologic tests.


Ledderhose's disease: case study with histologic and ultrastructural analysis. Two cases of Ledderhose's disease (plantar fibromatosis) are described with emphasis on histologic features. This disorder has three histologic stages: in the first, or proliferative, stage, numerous fibroblasts associated with a small amount of collagen are observed; in the second, or active, stage, the cells are more mature and the collagen is more evident; in the third, or maturation, stage, the extracellular matrix is composed of dense bundles of collagen fibers with few fibroblasts. Ultrastructural analysis revealed filamentous aggregation of an unknown nature among the collagen fiber bundles. The authors discuss some clinical, physiological, and pathologic aspects of a disorder which is similar to Dupuytren's disease but does not involve retraction of the surrounding anatomical structures.


Group therapy for people with borderline personality disorder: interventions associated with positive outcomes. Group psychotherapy is becoming a more prevalent treatment option for people with borderline personality disorder. Various types of group approaches have been discussed; however, data about specific interventions and their relationship to outcomes for subgroups of people with borderline personality disorder are lacking. The purpose of this study was to explicate the interventions used in a successful group therapy program developed for community mental health center clients with borderline personality disorder. Two independent raters used the Hill Counselor Verbal Response Category System-Revised to describe and categorize the therapists' verbal responses. Coding of eight videotaped sessions indicated that the therapists' level and type of verbal activity did not change over time. The most frequently utilized interventions across sessions were providing information and seeking information. These responses are indicative of a moderate and high degree of structure. The results suggest that clinicians must consider the unique needs of serious and persistently ill people with borderline personality disorder and plan group interventions accordingly.


Living with dying: coping with HIV disease. People diagnosed with HIV disease experience multiple and severe stressors; however, little is known about these stressors and coping among this population. This phenomenological study was undertaken to (1) gain an understanding of the informants' lived experiences of coping with HIV disease and (2) develop a disease-specific instrument to measure stress and coping. The study involved interviews with 36 people with HIV disease. The interviews were analyzed and synthesized to (1) derive the structure of the experience through phenomenological analysis and (2) identify stress and coping themes through content analysis. Only the findings from the phenomenological analysis are reported here. The structure of the lived experience of coping with HIV disease unfolds from the initial diagnosis of being HIV-seropositive through the diagnosis of AIDS to impending death. The processes involved in this structure were labeled Living with Dying, Fighting the Sickness, and Getting Worn Out.


False aneurysm of the anterior tibial artery in lower leg fractures treated with the Ilizarov external fixator. Case report. A case of open segmental fracture of the right lower leg treated with an Ilizarov external fixator in emergency surgery is presented. Approximately two months after operation, swelling in the anterior compartment of the tibia and repeated episodes of bleeding from one of the Kirschner wire holes led the authors to perform an angiography, which revealed the presence of a false aneurysm of the anterior tibial artery. The intraoperative finding of a double lesion in the anterior tibial artery confirmed the iatrogenous nature of the injury.


Surgical treatment of arthritic varus knee by tibial corticotomy and angular distraction with an external fixator. The authors report their experience in surgical treatment of the arthritic varus knee. After a comparative study of the most commonly used osteotomy techniques, they describe the results of their first cases of metaphyseal tibial corticotomy and angular distraction using an external fixator (25 cases).


Relocation appraisal, functional independence, morale, and health of nursing home residents. Relocation to a nursing home can be stressful and may result in mental and physical illness. Appraisal, or the meaning assigned to relocation, can influence relocation outcome. This study examined the relationships between appraisal of relocation and 30 nursing home residents' psychological and physical health, morale, functional independence, and demographic and situational factors, including age, gender, income, education, prior residence, participation in the decision to relocate, and preparation for the move. Positive, benign, and challenge appraisals were related to higher morale and functional independence. Threat appraisal was related to poorer psychological health and lower morale. Harm-loss appraisal was associated with lower morale and lower functional independence. Preparation for the move was related to higher positive appraisal, higher morale, functional independence, and lower harm-loss scores. Implications include the need to assess people's appraisal of relocation so as to plan strategies that prevent relocation stress.


Recurrent dislocation of patella: three kinds of surgical treatment. The authors compare three surgical techniques for treatment of recurrent dislocation of patella. The best results, even in the correction of lateral patellar displacement, were achieved with proximal realignment, while the worst results occurred when lateral retinacular release was used alone. In distal realignment, the degree of correction necessary must be ascertained by thorough preoperative assessment of both patellar height and malalignment between femoral groove and tibial tubercle. If the medial retinacular structures are weakened, it may be necessary to perform proximal realignment. We believe that a single surgical option is insufficient, and that the best solution for each individual case should be chosen according to precise indications. The choices include proximal realignment, distal realignment, or a combination of both, while lateral release should always be used in combination with another technique.


Rotation of a skin flap from the side of the finger to the volar surface in the treatment of Dupuytren's disease. The authors illustrate the technique of rotation of a skin flap from the side of a finger in the treatment of severe Dupuytren's disease especially when localized in the fourth or fifth ray. The results in 20 cases with an average follow-up of 8 months are evaluated, and the indications and advantages over other surgical techniques are stated.


Surgical treatment of traumatic lesions of the middle and lower cervical spine with Roy-Camille plates. The authors report their experience in surgical treatment of traumatic lesions of the middle and lower cervical spine using the Roy-Camille method, discussing in detail the mechanism of injury according to the previously reported classification as well as the surgical technique. Special mention is given to the treatment of separation fracture of the articular mass and the results achieved with the "en-tuile" plate. The authors conclude that the Roy-Camille method yields satisfactory short and long-term results provided that the indications are closely followed.


Microdiscectomy in treatment of herniated lumbar disc. The authors studied 122 patients who had undergone microsurgery for herniated lumbar disc or isolated nerve root canal stenosis. The patients were reviewed one month and three months after surgery and then returned for a final evaluation after an average of 1.4 years. Intraoperative or postoperative complications occurred in 13 cases and consisted of misdiagnosis (discovered intraoperatively) of the level of the herniated disc (7 cases), dural laceration (3 cases), and discitis (3 cases). Limited discectomy was performed in 16 cases and complete discectomy in the others. Two patients who had undergone limited discectomy experienced recurrence; this did not occur when complete discectomy was performed. Discitis occurred in patients who had undergone complete discectomy. Most of the patients who underwent operation for disc herniation at one lumbar level with no complications began walking within 24 hours, and 72% were discharged within 36 hours. Eighty-five percent of the patients had a satisfactory result one month after surgery, and 91% had a satisfactory result at the final follow-up. There was no significant difference between patients with protruded herniation and patients with sequestered herniation. In the patients with nerve root canal stenosis the proportion of satisfactory results was 72% at one month and 88% at the final follow-up. The main advantage of microsurgery is the full illumination of the operative field, and this technique is strongly indicated in cases of single-level herniated disc. Over the short-term, microdiscectomy achieves a higher proportion of satisfactory results, requires a shorter hospitalization period, and allows an earlier return to work than traditional surgery. However, no significant difference was found between microsurgery and traditional surgery over the long-term.


Middle and long-term results of flexion osteotomy for avascular necrosis of the femoral head. The authors present the results of 19 flexion osteotomies performed in cases of avascular necrosis of the femoral head and followed up after an average of 8 1/2 years. Significant clinical improvement was achieved in 85% of the patients. The radiographic picture is not quite as positive, but only 26% of the patients developed severe degenerative arthritis. The authors therefore consider this technique to be a valid alternative to immediate prosthetic replacement in selected patients.


Intra-articular osteoid osteoma.

Intra-articular osteoid osteoma. The joint is a relatively rare localization for osteoid osteoma. The location of the tumor and the concomitant synovitis-explain the peculiarity of the clinical features, which makes differential diagnosis with inflammatory diseases of the joint difficult. The authors report the results of three cases of intra-articular osteoid osteoma in which it was possible to determine the levels of prostaglandin (PGE2) and prostacyclin (PGI2), which are synthesized by the tumoral tissue. The increased production of these substances, which can reach up to 70 times their production in normal tissue, explain both the character of the pain and the origin of the synovitis which is so commonly found in this kind of tumor. The results of this study confirm the ability of the neoplastic tissue to produce high quantities of mediators of inflammation and enable the authors to formulate a theory as to the pathogenesis of the concomitant reactive synovitis observed in cases of intra-articular osteoid osteoma.


Stress analysis of the growing femur: effects of frontal axial deviation. Both the pathogenesis and the evolution of lower limb deformity secondary to primitive axial deviation during the growth period are affected by biomechanical factors which direct the remaining skeletal growth along abnormal lines. This study, limited to the femur, aims to analyze these factors from a practical as well as abstract standpoint, with references to prevention and surgical treatment. For this biomechanical study the authors applied finite element analysis to 16 models of the femur with various deformities in the frontal plane--proximal, distal, valgus, and varus. Analysis of the results shows significant variations in the physiologic status of stress on the femur associated with axial deviation in the frontal plane. These variations have special characteristics according to the type and level of the deviation. Furthermore, the stress imbalances seem to be concentrated in the distal metaphyseal region, even in cases of proximal deformity.


The effects of lengthening on nerves.

The effects of lengthening on nerves. Use of external fixators in limb lengthening and skin expanders in plastic surgery are well-known operative techniques. In some cases neurologic complications arise due to distraction which is either excessive or too fast. What happens to the nerve in these cases has not yet been thoroughly investigated. We therefore conducted an experiment on the sciatic nerve of rats. In one group of animals the nerve was studied after lengthening the femur, and in the other group after lengthening the nerve itself with a skin expander. Electrophysiologic and histologic studies (optic microscopy and axon teasing) were used to examine the effects of tension on the sciatic nerve. The results suggest that if distraction is performed gradually, the nerve does not undergo any electrophysiologic functional changes. It does, however, undergo some morphologic changes, such as a decrease in both the areas of the axons and the myelin sheaths, an increase in the distances between the nodes, and proliferation of Schwann cells.


Relationship between femoral neck fractures and osteoporosis in the elderly: densitometric analysis. The authors report the findings of densitometric analysis performed on 25 patients from of 70 to 90 years of age with fractures of the proximal femur. Although bone density decreased progressively with age, there was not a close correlation between bone density and fracture, as the latter occurred even when the densitometric values were relatively high for the patient's sex and age.


Metabolic changes in bone in old age.

Metabolic changes in bone in old age. The authors conducted a study on the effect of aging upon the factors which regulate calcium metabolism. Hormonal and biochemical tests were performed on samples from patients selected on the basis of sex, age, and other characteristics in order to determine the trend of these regulatory factors in middle and old age, with particular attention to osteoporosis in women. The authors propose several theories regarding the pathogenetic mechanisms of osteoporosis on the basis of this study as well as the literature.


Acute rheumatic fever in Hawaii: 1966 to 1988. Seventy five children with acute rheumatic fever (ARF) were hospitalized on Oahu from 1984 to 1988. The annual incidence rate was 9.5 (all rates are per 100,000 children per year). The first attack and recurrent attack rates were 7.9 and 1.6. Polyarthritis occurred in 84%, chorea in 7%, and carditis in 32%. Mitral insufficiency was the most common valvular lesion (88%). Hawaiians/part Hawaiians and Samoans had the highest incidence rates (relative risk 3 and 56, respectively). Polynesian children were 84 times more likely to develop carditis. Five hundred thirty nine ARF cases were hospitalized on Oahu, 1966 to 1974 and from 1976 to 1988. The annual incidence rate of ARF on Oahu has remained fairly constant at about 12.4. The incidence rates in all ethnic groups have decreased except in Samoan children.


Cardiopulmonary exercise: a recently discovered secret of tai chi. Every piece of literature or book about tai chi claims it to be the supreme martial art (soft style) and a therapeutic exercise. Nevertheless, none of the authors can describe scientifically how and why it works. Many people did not gain any health benefit in practicing tai chi and only very few people were able to apply its legendary secret power. During the last 10 years, the author thought he had discovered the secret in Hong Kong and brought it to Los Angeles. The secret lies in the fundamental movements of the body, called tai chi basic exercise routines. The entry level of the exercise has many similarities with medical treatments for respiratory illness and with walking exercise--the most recommended aerobic exercise for coronary artery disease.


Tuberculosis: a personal commentary.

Tuberculosis: a personal commentary. Tuberculosis is another of those diseases from which our attention has been diverted in recent decades, and which may now come back to plague us. I refer to the timely warning in Dr Frankel's report and Dr Reppun's editorial comment in the Hawaii Medical Journal of December 1991.


Childhood onset cluster headaches.

Childhood onset cluster headaches. Cluster headaches are rare in childhood. We identified 35 patients with cluster headaches starting at or before 18 years of age, including 7 patients with onset prior to age 10. All patients met the criteria of the International Headache Society for episodic or chronic cluster headaches. Patients experienced cluster headaches for as long as 20 years before seeking medical attention and required many medical contacts to establish the correct diagnosis. The clinical features of cluster headaches during childhood were similar to those which typically occur in adult life. Cluster headache patterns changed over 18 years of follow up. The frequency and duration of cluster periods increased in 14 subjects. The frequency of single headache attacks during cluster periods also increased in a similar number of subjects. We conclude that cluster headaches starting in childhood or adolescence closely resemble the adult form of the disease. In many patients, the frequency and duration of cluster periods and the frequency of the individual headache episodes increased over time. Cluster headache represent a treatable under-recognized cause of severe headaches in childhood and adolescence.


Naproxen sodium versus ergotamine tartrate in the treatment of acute migraine attacks. A double-blind parallel study compared the efficacy and safety of naproxen sodium (NPX) and ergotamine tartrate (ERG) as abortive therapy for acute headache in 79 patients with classical or common migraine. The design study was of the double-blind design. Forty-two patients completed the study. Discontinuation of treatment was generally due to lack of efficacy or adverse reactions. NPX was significantly better than ERG in the overall efficacy of treatment rated by the patients (p less than 004). NPX was comparable to ERG in reducing the severity and duration of the headache and its associated symptoms. In classical migraine, NPX was better than ERG in alleviating the severity of headache. Patients in the NPX group tended to use less rescue medication. There was no significant difference in the frequency of side-effects reported by the patients under NPX or ERG. This study demonstrates that NPX is as safe as ERG, and somewhat more effective in acute migraine attacks (although the difference is not statistically significant) and that migrainous patients tend to prefer NPX to ERG in treating their acute migraine headaches.


Fear of pain in recurrent headache sufferers. We investigated the role of fear of pain in headache sufferers using the Fear of Pain Questionnaire (FPQ). Seventy-six headache sufferers and 58 controls completed the FPQ and measures of depression, anxiety, and anger. Headache sufferers also completed measures of stress-related physical symptoms and coping with pain. We found that the FPQ has excellent internal consistency as well as good concurrent and construct validity indicated by the high correlations between the FPQ subscales and both anxiety and depression but low correlations with anger. There were marked differences between headache sufferers and controls on the FPQ; headache sufferers showed much greater fear of severe and medical pain and lower fear of minor pain. Fear of pain was generally not related to headache characteristics such as frequency, severity, or duration. On the other hand, it was related to headache impact such as disruption of pleasurable activities. These results are consistent with models of chronic pain disorders which emphasize the role of fear of pain over the nociceptive intensity of the pain stimulus.


The prevalence of cerebral damage varies with migraine type: a MRI study. Studies on the prevalence of MRI signal abnormalities in the brains of migraineurs have yielded controversial results. In order to provide further data on this issue we reviewed the MRI scans of 38 migraine patients without current neurologic symptoms (mean age 35.8 +/- 11.9 years). In addition, we compared the findings in those 24 migraineurs under 50 years without major cerebrovascular risk factors (mean age 30.1 +/- 9.0 years) to that in 14 headache and risk factor free volunteers (mean age 37.8 +/- 5.3 years). Overall, focal areas of hyperintense signal were seen in 15 (39%) patients. They were present on both proton density and T2-weighted spin-echo sequences. Lesion prevalence varied according to the type of headache (18% in migraine without aura, 53% in migraine with typical aura, 38% in basilar migraine). The subset of migraine patients under 50 years exhibited MRI signal abnormalities more than twice as often as controls (33% vs. 14%). Punctate white matter hyperintensities were the predominant finding and were seen in 10 of 15 individuals with MRI lesions. More striking signal abnormalities consisted of symmetrical areas of hyperintensity lateral to the posterior horns in two 24 year old patients and of extensive white matter damage with lacunar infarcts in a 59 year old woman. Our findings confirm a higher prevalence of MRI lesions in a mixed group of migraineurs than in headache free individuals. Signal abnormalities are most often non-specific, however their occurrence relates to the type of migraine.


The relationship of ovarian steroids, headache activity and menstrual distress: a pilot study with female migraineurs. Fourteen female volunteers who met diagnostic criteria for migraine headache monitored their headache activity and menstrual distress symptoms for one menstrual cycle. Serum estradiol and progesterone levels, and menstrual distress measures were collected at four points of the menstrual cycle: menstrual, ovulatory, luteal and premenstrual. Results indicated that one patient (7.1%) had menstrual migraine, 10 patients (71.4%) had menstrually-related headache and 3 (21.4%) had migraine headache unrelated to their menstrual cycle: subsequent analyses were conducted with the first two groups. Headache activity for the sample was highest during the premenstrual phase. Headache activity during the luteal and premenstrual phases was related to luteal phase progesterone levels. Menstrual distress was highest during the menstrual and premenstrual phases of the cycle, and these symptoms were related to higher estradiol levels, higher estradiol/progesterone ratios, and increased headache activity. These results indicated that for women with menstrual migraine or menstrually-related migraine, luteal progesterone and estradiol and the estradiol/progesterone ratio may be significantly related to menstrual distress during the premenstrual phase of the cycle. The estradiol/progesterone ratio was not more related to headache or menstrual distress than either of these ovarian hormones alone. Suggestions for future research in this area are offered.


Flunarizine is effective in prophylaxis of headache associated with scleroderma. Migraine-like headaches may occasionally be seen in patients with scleroderma. The mechanism of these headaches is not well established but may be secondary to central "Raynaud's phenomenon". We report a patient with such headaches that responded dramatically to the centrally acting calcium channel blocker, flunarizine. We suggest that flunarizine should be considered in the management of patients with scleroderma and migraine-like headaches.


Migraine-associated dizziness.

Migraine-associated dizziness. We reviewed the clinical histories, examinations and results of quantitative vestibular testing in 91 patients with migraine-associated dizziness. Nausea and vomiting, hypersensitivity to motion and postural instability accompanied the dizziness. In the majority of patients, the temporal profile of the dizziness was more typical of the headache phase of migraine than of the aura phase. Nineteen patients (20.9%) had unilateral hypoexcitability to caloric stimulation, which represents a modestly increased risk of damage to the peripheral vestibular apparatus. We propose two separate pathophysiologic mechanisms for the production of dizziness with migraine: Short-duration vertiginous attacks lasting minutes to 2 hours and temporally associated with headache are due to the same mechanism as other aura phenomena (spreading wave of depression and/or transient vasospasm). Longer-duration attacks of vertigo and motion sickness lasting days, with or without headache, result from the release of neuroactive peptides into peripheral and central vestibular structures, causing an increased baseline firing of primary afferent neurons and increased sensitivity to motion.


Handling of 5-hydroxytryptamine by platelets in migraine. There is little dispute that a link exists between 5-hydroxytryptamine (5HT) and migraine but the exact mechanism of an attack has yet to be established. The handling of 5HT by the platelet is regarded as a simple model of the handling of 5HT by nerve terminals. If differences are seen in how the platelets from migraineurs handle 5HT compared to those from a control population, it is possible that a similar difference exists in the nerve terminal. The Haemostatometer allows the rapid and simultaneous in vitro assessment of platelet function (shear-induced haemostasis), coagulation and thrombolysis from non anticoagulated blood samples. In this study, a baseline comparison of haemostasis was made on 20 migraineurs between attacks and 20 controls. No differences were found in the results from each of the two groups. 5 microM of 5HT was then added to blood taken from 10 migraineurs and 10 controls and the recordings were repeated. Again, no differences were found between the results from the two groups. In blood taken from both migraineurs and controls, the effect of 5HT was to significantly enhance clotting time and clot lysis. No effect was seen on primary aggregation. The possible reasons for and significance of these findings is discussed.


Short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome): IV. Respiratory sinus arrhythmia during and outside paroxysms. SUNCT is a headache syndrome characterized by short-lasting (usually 15-120 sec), unilateral head pain paroxysms localized in the peri-ocular area, accompanied by conjunctival injection, lacrimation, nasal stuffiness, rhinorrhea, and subclinical forehead sweating, all on the symptomatic side. A relative bradycardia seems to be an integral part of the paroxysm; a parasympathetic stimulation could theoretically be the causative factor for the bradycardia. In 3 SUNCT patients, vagal nerve function (E:I ratio) has been monitored outside and during pain paroxysms, while 3 other patients could be studied in the attack-free period only. E:I ratio is obtainable in the course of a maximally deep breath and represents the ratio of the longest R-R interval during a 5 sec long expiration to the shortest R-R interval during a 5 sec long expiration. The mean E:I ratio of SUNCT patients outside paroxysms was significantly higher than the mean E:I ratio in an aged-matched control group. The E:I ratio was, however, significantly decreased during paroxysms in comparison with ratios obtained outside the pain paroxysms. After 0.6 mg atropine administration s.c. to one of the patients in the symptomatic phase, the heart rate increased, and the relative bradycardia during headache paroxysm was diminished (but not completely abolished). The E:I ratio was lowered but it was still slightly larger outside than during attacks. The reason for the abrupt and seemingly clear attack-related decrement in E:I ratio together with the previously described relative bradycardia remains enigmatic, however the possibility of increased parasympathetic tone cannot be excluded.


SUNCT may be another manifestation of orbital venous vasculitis. A patient with more than 20 years of SUNCT, i.e., long lasting periods with frequent attacks of intense orbital pain with a duration of about one minute, associated with ipsilateral conjunctival injection, lacrimation, rhinorrhea and facial sweating is described. Some attacks were possibly related to increased cerebral blood flow but could also be triggered from the oral area. Orbital phlebography showed pathologic changes on the side of the pain, changes which were normalized when these attacks ceased to appear. Due to these findings in conjunction with serum evidence of inflammation, associated systemic symptoms and susceptibility to steroids and azathioprine, venous vasculitis is suggested to be the cause of SUNCT in this patient. Carbamazepine and sumatriptan decreased the frequency, intensity and duration of attacks, although not completely.


Low dose flunarizine in the prophylaxis of migraine. In a period of one year (1990) we selected 40 patients suffering from migraine. For an open randomized study there were 2 groups of patients: the first were treated with 10mg of flunarizine per day and the second with 3 mg per day. The patients were treated for 4 months consecutively. There were 11 drop outs (27.5%): nine for poor compliance and 2 due to side effects. The efficacy of flunarizine in the prophylaxis of migraine was essentially identical in the two dosage groups while the incidence of side effects was considerably reduced in the patients treated with the lower dose.


Non-pharmacological treatment of headache: is less more? A twenty-six article review of the literature pertaining to non-pharmacological treatment of headache was undertaken. The data supports no significant difference in the efficacy of hypnosis, biofeedback and relaxation training. These studies demonstrated no relationship between hypnotizability or capacity for temperature elevation and headache improvement. The literature reviewed suggests the mechanism for improvement with non-pharmacological treatment may be physiologically nonspecific, with patient age, perceived locus of control and motivation likely to predict successful treatment. Home-based, minimal therapist contact, biofeedback and relaxation treatment appear to work as effectively as intensive clinic-based treatment.


Evaluation and emergency treatment of headache. Headache is a common complaint in patients presenting to the emergency department. Most such headaches are benign, but some have a more severe organic cause. Occasionally, patients present with a chronic headache disorder with which they can no longer cope. The new International Headache Society Classification of Headache is reviewed along with the differential diagnosis of benign headache disorders. Headache diagnosis by history is examined in detail followed by a discussion of the emergency presentation of headache patients. Causes for concern are presented, along with a detailed discussion of differential diagnosis, including subarachnoid hemorrhage, meningitis, sinusitis, glaucoma, internal carotid artery dissection, and cerebro-vascular disease. Also discussed are medications used for the symptomatic treatment of headache, including analgesics, NSAIDs, narcotics, and ergotamine preparations. Approaches to the treatment of the severe, persistent headache in the emergency department are outlined and treatment options suggested. Headache medication overuse is discussed and guidelines are presented to recognize the condition and prevent its recurrence.


Orbital phlebography: a comparison between cluster headache and other headaches. Orbital phlebography has previously been found to be pathologic in 8 of 13 patients with episodic cluster headache. To compare the frequency and pattern of the pathologic findings in cluster headache with those in other headache categories, orbital phlebographies were carried out in patients with cluster headache, cervicogenic headache, migraine and tension-type headache (tension headache). The investigations were evaluated independently by two radiologists, one of whom had no knowledge of the diagnoses. The frequencies of pathologic findings were at maximal 2/12 in the cluster headache group, 2/11 in the cervicogenic headache group, 5/12 in the migraine group and 5/15 in the tension-type headache group. The investigators agreed completely in the evaluation of 39/50 phlebograms, with lesser disagreements in 7. In conclusion, the frequency of pathologic findings at orbital phlebography in cluster headache was not higher than in the other diagnostic categories investigated, and the pattern of the pathology was generally the same.


Great auricular neuralgia.

Great auricular neuralgia. An unusual neuralgia of the great auricular nerve resulting from a skin incision to insert a cardiac pacemaker is described. The anatomy and presumed pathophysiology are discussed.


Association between malignancies of the upper aerodigestive tract and uterine cervix. Cancers of the cervix and buccal cavity share histologic, epidemiologic, and exposure characteristics. In particular, cigarette smoking and human papillomavirus (HPV) have been cited as etiologic cofactors of both malignancies. Using incidence data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute for the years 1973 through 1984, we evaluated the incidence of second cancers of the buccal cavity following an initial cervical cancer. Standardized incidence ratios (SIR) were uniformly elevated for both white (SIR = 2.0), and black (SIR = 3.5) women. There were also elevated risks for the development of cervical cancer following an initial buccal cavity cancer (SIRs = 3.3 and 2.5, respectively). A similar pattern was evident for laryngeal cancer among white women. HPV transmission could account in part for the paired occurrence of these two anatomically distinct cancer sites. Cigarette smoking could act as a synergistic cofactor in the malignant transformation of viral genome-harboring tissue.


Videofluoroscopy of the pharyngoesophageal segment during tracheoesophageal and esophageal speech. The purpose of this preliminary investigation was to identify the location and length of the pharyngoesophageal (PE) segment during esophageal and tracheoesophageal (TE) speech among laryngectomees who were proficient in both methods of vocalization. Four patients who had undergone total laryngectomy and tracheoesophageal puncture served as subjects. Voice recordings were obtained and played to listeners of varying experience with laryngectomees. Videofluoroscopy was performed while the patients sustained "ah" in both modes of speech. Results of these analyses revealed that TE speech was rated as more effective than esophageal speech in all 4 subjects. However, only minimal differences were found in the length and the location of the PE segment during TE and esophageal speech when within subject comparisons were made. This study is the first to compare the physical characteristics of the PE segment during esophageal speech and TE speech as produced by the same speaker.


Rapid superselective high-dose cisplatin infusion for advanced head and neck malignancies. Advances in vascular radiology techniques for superselective arterial infusions and methods to overcome systemic toxicity from high-dose cisplatin chemotherapy encouraged us to reevaluate the effects of rapid regional cisplatin infusion for patients with head and neck malignancies. Twenty patients (17 carcinomas, three sarcomas) received high-dose cisplatin (100-200 mg/m2) by this method. Fifteen of the 17 patients with upper aerodigestive tract carcinoma are part of an ongoing phase I dose escalation of cisplatin with sodium thiosulfate neutralization. Three additional patients with sarcomas were treated with intra-arterial (IA) cisplatin and systemic Adriamycin. Fifty-three IA infusions were performed without any complications. Only minimal toxicity related to the chemotherapy was observed. The overall response rate for previously untreated patients was nine of 10 (90%) [complete response (CR) 67%; partial response (PR) 33%]. The response rate for patients with recurrent disease was five of eight (63%) (CR 20%, PR 80%). The average length of follow-up is 9.5 months and the actuarial survival rate is 56%. Superselective rapid infusion of high-dose cisplatin for patients with advanced head and neck malignancies is feasible, relatively nontoxic, and may have important applications in multimodality therapy, particularly for patients with bulky primary disease.


Occult lymph node metastasis in small oral tongue cancers. The need to treat the neck in patients with a small primary cancer in the tongue remains controversial. Twenty-eight patients with stage I or II oral tongue squamous carcinomas were retrospectively reviewed. They had not received previous treatment. The tongue primary was excised via the transoral route and the neck was observed closely during follow-up. Thirteen patients developed ipsilateral nodal metastases during follow-up, three of whom also had simultaneous recurrence at the primary site. An additional patient had recurrence at the primary site alone. The incidence of occult neck metastasis was 42% (10 of 24). No tumor-related death occurred in the group without nodal metastasis. The salvage rate after appearance of nodal metastasis was 30%. In oral tongue cancers, elective neck treatment should be considered regardless of a small primary and negative neck examination because of the high incidence of occult nodal metastasis and the poor outcome after salvage treatment.


Embolization of a life-threatening mandibular vascular malformation by direct percutaneous transmandibular puncture. Vascular malformations of the mandible are uncommon, but often present with significant hemorrhage. Transarterial vessel occlusion has become a valuable primary or adjunctive treatment for such lesions, as well as for most other symptomatic congenital and acquired head and neck vascular anomalies. Permanent embolic obliteration of the malformation requires placement of occlusive material directly into the nidus (core) of the lesion. Prohibitively complex proximal vasculature may prevent successful catheter positioning and lead to failure of traditional embolotherapy. Even optimal placement of arterial embolic material may fail to fully obliterate the nidus, allowing eventual restoration of flow to the lesion due to arterial recanalization. Under such circumstances it may be possible to obliterate the malformation and control lesional hemorrhage by occlusion of the malformation or its venous drainage by direct percutaneous mandibular puncture. In our case, multiple transarterial embolizations failed to sufficiently manage a symptomatic vascular malformation. Successful embolotherapy was performed via direct puncture of the venous side of the malformation through the mandibular cortex. Venous thrombosis induced concomitant occlusion of abnormal arteriovenous shunts, resulting in long-term control of life-threatening oral hemorrhage.


Surgical anatomy of the external branch of the superior laryngeal nerve. Iatrogenic lesions of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomies are not infrequent due to the possibility of anatomic variations of the relationships of this nerve with the superior thyroid vessels. Therefore, based on an anatomic analysis of 30 superior thyroid poles from 15 fresh cadavers, a new classification of the EBSLN was proposed, considering the jeopardy during a thyroidectomy. Thirty-seven percent of the nerves were type 2, ie, crossing the superior thyroid pedicle less than 1 cm above the superior thyroid pole. It is notable that 20% were type 2b, ie, crossing the vessels below the upper border of the pole, having been considered "high risk." This incidence was comparable with other series, which found dangerous anatomic variations of the EBSLN in the range of 15% to 68%, confirming that a significant proportion of these nerves might be at risk during surgery on the superior thyroid pole.


Sarcoidosis masquerading as a parathyroid adenoma. Two patients presented with a presumptive diagnosis of hyperparathyroidism. Surgically excised "parathyroid glands" were found to be, in fact, large lymph nodes with sarcoid granulomata. In one patient, the preoperative localization of the "parathyroid adenoma" was based on scintigraphy (thallium-technetium subtraction imaging) and sonography procedures. The differential diagnosis of hypercalcemia, and positive scintigraphy-sonography studies, must include sarcoidosis in an isolated cervical lymph nodes.


Postgraduate education allowance: a regional analysis of the first year. A comparison of accredited education sessions attended by general practitioners in the West of Scotland during 1990-91, the first year of the postgraduate education allowance, and during the previous year is presented. During 1990-91 the mean number of half day sessions attended by each practitioner was 14.0. This is an increase of 36% over the number (10.3) attended during the previous year. The mean number of days attended during 1990-91 includes 5.5 devoted to disease management, 4.4 to service management, and 4.1 to health promotion. Eighty five per cent of practitioners attended a full day devoted to disease management, 78% a full day devoted to service management, and 72% to full day devoted to health promotion; 80% a day in two of these three categories, and 57% a day in all three. The average attendance exceeds the requirement of the new contract. The great majority of practitioners in the Region appear to be achieving the spread of attendance over the three categories required by the regulations.


Multifocal adult rhabdomyomas of the head and neck. Rhabdomyomas are usually found in the myocardium. Of the extracardiac sites, the head and neck is the most frequent region where this rare tumor arises. Multifocal head and neck lesions have only been described in 11 cases. We herein present two additional multifocal lesions.


Curative irradiation of the entire orbit in rhabdomyosarcoma: a case report. Rhabdomyosarcoma (RMS) is a relatively frequent tumor in children. Judicious combinations have markedly improved treatment results in recent years. Orbital localizations are treated with chemotherapy and radiotherapy. It has been advocated that radiotherapy be limited to the original tumor bed. This case report illustrates the danger of shielding part of the orbit: in a clinically tumor-free region before chemotherapy, which was shielded during radiotherapy, a local recurrence was seen while the original tumor bed remained controlled. Therefore, the whole content of the orbit should be irradiated in orbital RMS.


How do local doctors react to a hospice? Postal questionnaires were sent to general practitioner principals and hospital consultants in Ayrshire a year before and again 13 months after the opening of the Ayrshire Hospice. Seventy-three per cent of 342 doctors replied to the first survey and 62% replied to the second survey. There was initially a fairly strongly felt need for a hospice, with median Visual Analogue Score (VAS) of 16 ('definite need' = 0 and 'definitely no need' = 100). After the opening of the hospice doctors were much more enthusiastic (median VAS 5; p less than 0.0001). Doctors feeling no need for a hospice (VAS greater than 75) became fewer (9.6% before opening, 2% after). Doctors who would refer patients to a hospice, at first 82%, numbered 92% after opening. Seventy-one per cent of general practitioners and 60% of consultants had referred patients to the hospice within a year of opening. After opening, specialist advice with home care was considered the most useful aspect, in-patient beds useful, and day hospice least useful. Seventy-three per cent of referring doctors found the hospice a great help. In both surveys general practitioners and consultants felt the hospice should be run by a mixture of voluntary and NHS finance. Doctors appeared willing to learn about palliative care from hospice doctors, particularly after hospice opening. Doctors were initially rather dissatisfied with palliative care in existing hospitals, but became less so (particularly about pain control) after hospice opening. Surprisingly, in both surveys the attitudes of general practitioners and consultants were virtually identical.(ABSTRACT TRUNCATED AT 250 WORDS)


Audit of the quality of hospital discharge data. An audit of the quality of computerised hospital discharge data, in General Medicine and Paediatrics in Dundee, showed that the national data set was often inaccurate. Structured discharge summaries checked by senior medical staff are recommended.


Basaloid squamous carcinoma of the buccal cavity. Basaloid-squamous carcinoma was first recognized as a separate pathologic entity in 1986. It has been described in the hypopharynx, larynx, base of tongue, and nasal cavity. We report the first case of this rare tumor occurring in the buccal cavity and review the atypical squamous cell carcinomas that occurred in these sites.


Tumor suppressor genes.

Tumor suppressor genes. Tumor suppressor genes are negative regulators of cell growth. When their normal function is compromised, absence of their inhibitory effects can lead to unrestrained cell cycling and growth. Strong evidence now confirms that loss of proper function of these genes is a common occurrence leading to cancer. Their failure can be caused by alterations in the gene DNA or malfunction of their protein products. The recent extraordinary accumulation of knowledge about these genes reveals that normal carcinogenesis represents breakdown of normal regulatory processes.


Transferring at-risk babies in-utero or neonatally: a decade's experience from a peripheral consultant maternity unit. All maternity cases in which babies were transferred in-utero (n = 82) or neonatally (n = 273) from the William Smellie Memorial Maternity Hospital to a regional neonatal intensive care unit during 1980-89 were studied to detect changing trends and outcomes. The proportion of babies transferred in-utero has increased and most of these transfers appear to have been justified. Forty-seven per cent of babies transferred neonatally were mature infants (greater than 37 weeks) so that the need for intensive neonatal care would have been difficult to predict. Perinatal mortality has fallen in line with national rates, mainly due to the decline in mortality of premature babies transferred neonatally. The results do not sustain the argument for further increasing in-utero transfers.