Biomedical subjects
Publications and source records attributed to I Rosner.
Nuchal fibroma was diagnosed in a 54-year-old diabetic woman with a two year history of increased skin thickness of her low-posterior neck and interscapular region, causing discomfort and limitation of neck and arm motion. Physical and laboratory examinations excluded further disorders. The patient was released, free from symptoms, after complete excision of the soft tissue tumor.
UNLABELLED: Our goal was to describe the typical scintigraphic pattern of posterior tibial tendinitis. METHODS: Bone scintigraphs were reviewed to study the scintigraphic characteristics of posterior tibial tendinitis in nine patients with posterior tibial tendinitis related to generalized rheumatic disease and in eight patients with isolated posterior tibial tendinitis. RESULTS: The scintigraphic pattern of posterior tibial tendinitis is elongated increased uptake in the blood flow and blood-pool phase along the anatomical course of the tibialis posterior tendon at the medial aspect of the ankle (malleolus region). Static images demonstrate increased focal abnormal uptake at the medial malleolus and in the navicular bone. CONCLUSION: Bone scintigraphy depicts a characteristic pattern of posterior tibial tendinitis. It is useful for the early diagnosis of idiopathic- or rheumatic-related posterior tibial tendinitis.
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OBJECTIVE: To examine the pulmonary and cardiac function of children who survived an episode of acute hypoxemic respiratory failure. DESIGN: Descriptive cohort analysis. SETTING: Pediatric clinical research center of a university hospital. PATIENTS: Utilizing the criteria of PaO2 < 75 torr (< 10 kPa) with an FIO2 of > 0.5 while intubated, bilateral diffuse pulmonary infiltrates on chest radiograph, and exclusion of cardiogenic pulmonary edema, 147 patients were identified during the 6-yr period from July 1, 1986 to August 1, 1993. Fifty patients survived to discharge and 37 were alive at the time of follow-up. Fourteen patients were eventually entered into the study. INTERVENTIONS: The study patients were given a test battery consisting of a questionnaire specific for cardiopulmonary status, a physical examination, a chest radiograph, electrocardiography, echocardiography with detailed examination of the pulmonary circulation, pulse oximetry, complete blood count, and serum chemistries and pulmonary function testing with bronchoprovocation in selected patients. MEASUREMENTS AND MAIN RESULTS: The 14 follow-up patients were evaluated an average of 23 +/- 23 months (range 3 to 66) following intensive care unit discharge. No child reported a significant alteration in lifestyle or limitation of activities. Physical examinations were generally unremarkable. The room air oxyhemoglobin saturation was > or = 0.98 in all patients. Comparison of chest radiographs at the time of follow-up with those chest radiographs during the period of critical illness showed marked but not complete improvement in all. Electrocardiograms and echocardiograms showed new evidence of left ventricular hypertrophy in one child. The right ventricular preejection period to ejection time ratio was normal in all subjects. Eleven patients completed spirometry. Four patients were normal and the other patients had evidence of restrictive or obstructive disease either at baseline or after bronchoprovocation challenge. Ten children had lung volume measurements. Five children were normal, two showed increased volumes consistent with obstruction, and three showed decreased volumes indicative of restriction. Four of seven patients showed evidence of decreased diffusion capacity. Six of seven patients with evidence of abnormal pulmonary function had a positive response to bronchodilator administration. CONCLUSIONS: Although pediatric survivors of acute hypoxemic respiratory failure perceive neither a limitation in lifestyle nor chronic pulmonary morbidity, careful examination of the cardiopulmonary system demonstrates a significant number with abnormal chest radiographs and abnormalities in pulmonary function. These children require careful follow-up and may benefit from use of a bronchodilator.
The authors propose to encompass under the designation of "fasciitis-panniculitis syndromes" (FPS) a group of disorders characterized by induration of the skin due to chronic inflammation and fibrosis of the subcutaneous septa and muscular fascia. The prototype of the FPS is eosinophilic fasciitis. Thirty-two consecutive patients with FPS were cared for at the author's hospital during a 10-year period. The association of the FPS with other diseases, clinical presentations, histologic features, and response to treatment were analyzed. Idiopathic FPS, that is, eosinophilic fasciitis, was diagnosed in 14 patients. In the remaining 18 cases, the FPS were ascribed to vascular disorders (n = 6), infections (n = 6), and neoplastic disorders (n = 3), while trauma, insect bites, and Sweet syndrome antedated the FPS in 1 patient each. The lesions had a sleeve-like distribution in 20 patients, plaque-like distribution in 7, and a combined pattern in 5. Skin biopsies revealed lesions in the deep subcutaneous layers with the pathologic triad of septal and fascial fibrosis, chronic inflammatory infiltration, and small-vessel vasculopathy. Spontaneous improvement occurred in 4 cases. Following cimetidine monotherapy, complete remission was achieved in an additional 3 of 5 patients. The concept of the FPS serves to advance our understanding on several fronts: emphasizing the clinical and etiologic diversity; recognizing a stereotypic tissue reaction pattern; highlighting the panniculitis in addition to the fasciitic component; and describing a similar response to drug therapy in different clinical settings. Based on the results of the present series, cimetidine may be recommended as first-line treatment.
BACKGROUND: The frequency with which rheumatic disorders occur when malignant neoplasms first present is unknown, and the significance of rheumatic conditions as cancer markers is unappreciated. METHODS: Patients admitted to a medical ward of a general hospital (Bnai Zion Medical Center, Haifa, Israel) during a 10-year period were surveyed. The frequency of the diagnostic evaluation of rheumatic disorders resulting in uncovering occult neoplasia at the time of index hospitalization and during the 2-year follow-up period was assessed. RESULTS: The incidence of occult cancer among patients admitted to a general medical ward with previously unclarified rheumatic disorders was 23.1%. Seventy-two percent of the group of patients with rheumatic diseases and occult cancer were male; 69% with rheumatic disease without cancer (control group) were female. The median age in the group with occult cancer was an average of 10 years older than the group without cancer, 67 versus 57 years (P < 0.001). Weight loss or anemia occurred in 52% of the group with occult cancer and in 37.3% of the control cases (not significant). Typically, there were no distinguishing features of the rheumatic syndromes suggesting the coexistence of cancer. In 19 of 25 cases, the malignancy was uncovered by routine examinations. In four instances, neoplasia was not immediately apparent but was identified in a specific search. In two cases, no search for malignancy initially was undertaken, and Hodgkin's lymphoma was diagnosed 6 and 12 months later. In 9 of 25 cases, long term remission of neoplasia was achieved by cancer therapy with improvement of rheumatic manifestations coinciding with regression. CONCLUSIONS: A significant number of patients who are referred to a general medical ward for evaluation of previously unclassified rheumatic disorders may be found to have a previously undetected malignancy. For most patients, the symptoms of cancer are found by routine physical and laboratory examinations. The importance of the association of rheumatic disorders and malignancy requires greater awareness, appreciation, and clinical study.
Interest in the rheumatologic manifestations of cancer is related in part to practical considerations, ie, earlier cancer diagnosis is possible through enhanced awareness of cancer-associated rheumatic syndromes. The spectrum of rheumatic disorders associated with cancer includes over 30 conditions, including hypertrophic osteoarthropathy, polymyalgia rheumatica, palmar fasciitis with polyarthritis, most autoimmune connective tissue diseases, and the more recently described antiphospholipid syndrome. It is generally held that extensive search for occult malignancy in most rheumatologic disorders is not cost efficient and not recommended unless accompanied by specific findings suggestive of malignancy. The present article discusses the supplementary findings that may justify malignancy evaluation.
The clinical presentation of acute appendicitis and the idiopathic granulomatous variety are, as a rule, indistinguishable. Five patients with idiopathic granulomatous appendicitis, treated during past decade, had histological acute and chronic appendicitis abounding with granulomas. Investigations not disclosing a systemic or enteric granulomatous disease and the patients' long-term complete postoperative recovery support the diagnosis of idiopathic granulomatous appendicitis.
Atrial myxoma was diagnosed in a young woman who had cutaneous and constitutional manifestations clinically suggestive of cutaneous vasculitis without cardiac signs or symptoms. Scrupulous physical and laboratory examinations excluded additional medical disorders. The patient was totally cured by surgical removal of the tumor. Various aspects of the association of cardiac myxoma with dermatological findings are discussed, emphasizing the importance of echocardiography in the diagnostic workup of various skin abnormalities, including unexplained vasculitis, even in the absence of cardiac findings.
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The term fasciitis-panniculitis syndrome (FPS) is proposed as a novel compilation encompassing several disorders, common to which is subcutaneous induration caused by cicatrizing fasciitis as well as septal and lobular panniculitis and perimysial fibrosis. Included herein are Shulman's eosinophilic fasciitis, morphea profunda, lupus profundus, venous lipodermatosclerosis, toxic oil syndrome, altered tryptophane-related eosinophilic myositis, graft-versus-host reaction, and fasciitis reactive to subjacent basal cell carcinoma. FPS should be differentiated from scleroderma, which primarily affects the dermal structures and in which arterioles are injured. In contrast, vasculopathy of the subcutaneous medium-sized veins accompanies the hypodermal lesions of FPS. The importance of recognizing and grouping these disorders lies in their different histopathology, characterization as reactive phenomena, enhanced responsiveness to treatment, and better prognosis than scleroderma. In view of the excellent prognosis of FPS, steroid treatment is not warranted. Long-term therapy with cimetidine appears to benefit the majority of patients.
We present the results of the second year of follow-up of 100 patients wearing disposable contact lenses on an extended wear basis. Thirty-seven males and 63 females participated in the study (mean age: 41.1 years +/- 13.88 (mean +/- 1 standard deviation); and the mean patient follow-up time was 26 months +/- 4.9). A total of 13 patients were lost to follow-up. Seventeen patients discontinued extended wear yet continued to wear soft lenses on a daily wear basis--the reasons for this finding are discussed. A significant decrease in the number of events defined as complications (32 events) was noted when compared to the first year of follow-up (136 events). Seven corneal infiltrates occurred during the second year, compared to 6 such events during the first year of the study. Additional complications included: giant papillary conjunctivitis (6 cases), corneal staining (5 cases), and corneal abrasions (4 cases). Disposable extended wear soft contact lenses offer a reasonable means of vision correction in the properly selected patient. At the same time, caution should be exercised in the fitting and wear of these lenses.
The risk of infection after application of vapour heated prothrombin complex concentrate PROTHROMPLEX S-TIM 4 (PCC) was investigated in patients undergoing cardiovascular surgery. The study was conducted according to the recommendations of the International Committee on Thrombosis and Hemostasis (ICTH) with the exception that most patients required other blood products in addition to PCC. Twenty-One patients were eligible to test for the risk of acquiring hepatitis NANB (ALT-levels) and samples from 12 patients were available that could be screened for anti-HCV. Twenty patients qualified for evaluation of the risk of developing hepatitis B, and 67 patients qualified to test for HIV-1-Infection. None of these patients showed any signs of infection. Vapour heating of prothrombin complex concentrate seems to lower the risk of transmitting viral diseases considerably.
A retrospective evaluation of 100 patients who wore disposable extended-wear contact lenses is presented. The patients were selected at random and were fitted with one of three lens brands approved for extended wear. There were 37 males and 63 females in the study. The mean age was 40.1 years (range, 14 to 76 years). Sixty-seven of the patients wore nondisposable extended-wear soft contact lenses before being fitted with disposable lenses. Complications were noted and included two instances of infectious ulcerative keratitis and six cases of peripheral corneal infiltrates. It is believed that the rate of complications is due to the ongoing hypoxic effect of prolonged use of extended-wear or other contact lenses and may be improved by providing a greater variety of lens fitting parameters. Disposable extended-wear lenses may be a reasonable means of vision correction in the appropriately selected patient and with proper follow-up. At the same time, caution should be exercised in the fitting and wear of disposable extended-wear lenses.
Adrenal response to iv administration of 1-24 ACTH (250 micrograms) was examined in normal volunteers under various conditions. The effect of basal cortisol levels was examined by performing the tests at 0800 h with and without pretreatment with dexamethasone. The effect of time of day was evaluated by performing the tests at 0800 h and at 1600 h, eliminating possible basal cortisol influence by pretreatment with dexamethasone. In the first set of tests, despite significantly different baseline levels, 30-min cortisol levels were not different (618 +/- 50 vs. 590 +/- 52 nmol/L). Afternoon cortisol levels in response to ACTH were found to be significantly higher than morning levels at 5 min (254 +/- 50 vs. 144 +/- 36 nmol/L, p less than 0.01) and at 15 min (541 +/- 61 vs. 433 +/- 52 nmol/L, p less than 0.02). This difference in response was no longer notable at 30 min (629 +/- 52 and 591 +/- 52 nmol/L). We tried also to determine the lowest ACTH dose which will elicit a maximal cortisol response. No difference was found in cortisol levels at 30 and 60 min in response to 250 and 5 micrograms 1-24 ACTH. Using 1 micrograms ACTH, the 30-min response did not differ from that to 250 micrograms (704 +/- 72 vs. 718 +/- 55 nmol/L, respectively). However, the 60-min response to 1 microgram was significantly lower (549 +/- 61 vs. 842 +/- 110 nmol/L, p less than 0.01). Using this low dose ACTH test (1 microgram, measuring 30-min cortisol level), we were able to develop a much more sensitive ACTH test, which enabled us to differentiate a subgroup of patients on long-term steroid treatment who responded normally to the regular 250 micrograms test, but had a reduced response to 1 microgram. The stability of 1-24 ACTH in saline solution, kept at 4 C, was checked. ACTH was found to be fully stable after 2 hs in a concentration of 5 micrograms/ml in glass tube and 0.5 micrograms/ml in plastic tube. It was also found to be fully stable, both immunologically and biologically, for 4 months, under these conditions. We conclude that the 30-min cortisol response to ACTH is constant, unrelated to basal cortisol level or time of day. It is therefore the best criterion for measuring adrenal response in the short ACTH test. The higher afternoon responses at 5 and 15 min suggest greater adrenal sensitivity in the afternoon, but further studies are needed to clarify this issue.(ABSTRACT TRUNCATED AT 400 WORDS)
Three patients presented with septal fasciitis and panniculitis, associated with clinical and laboratory features which precluded straight-forward classification into eosinophilic fasciitis, localised scleroderma, or lupus erythematosus profundus. Treatment with cimetidine caused the remission of cutaneous manifestations and the extracutaneous abnormalities, such as nailfold capillary disturbances and the presence of antithyroid antibodies, improved. It is concluded that features of eosinophilic fasciitis or localised scleroderma and certain additional atypical elements should be categorised as atypical fasciitis-panniculitis syndrome.
We describe 13 patients who developed erosive gastritis with overt gastrointestinal bleeding while receiving 75-250 mg nonbuffered aspirin per day for the secondary prevention of cardiac or cerebrovascular events. The bleeding occurred despite good initial tolerance to aspirin for several months or years. All patients were elderly and had severe atherosclerotic cardiovascular disease. Our data suggest that, contrary to common belief, very low doses of nonbuffered aspirin are attendant with clinically apparent gastrointestinal complications.