A teacher's guide to the future of dental education.
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Comprehensive Dental Care↗
Biomedical subjects
J Hoffman
Publications and source records attributed to J Hoffman.
Is CT portography (CTAP) really useful in patients with liver tumors who undergo intraoperative ultrasonography (IOUS)?
The objectives were to compare the role of CT during arterial portography (CTAP) and intraoperative ultrasound (IOUS) in the management of patients with primary or metastatic liver tumors; to study the ability of CTAP to define resectability before laparotomy in these patients; and to study whether the omission of CTAP in the imaging algorithm resulted in a diminished resectability rate. Eighty-eight consecutive patients with primary or metastatic liver cancer who underwent CTAP and/or IOUS between January 1990 and December 1993 were reviewed. Thirty patients had both CTAP and IOUS and underwent 31 laparotomies (Group I). The sensitivity of these two tests to detect liver tumors was compared. Twenty-eight explorations were performed for hepatic metastases and three for hepatocellular carcinoma. Fifty-three patients, including those in group I, underwent CTAP before laparotomy and were studied to assess the sensitivity of CTAP in determining unresectability (Group II). Thirty-five patients (Group III) had IOUS only and were studied to determine whether the omission of CTAP decreased the resectability rate. In Group I, 52 hepatic lesions were found by a combination of imaging studies, operative exploration, and pathologic examination. The sensitivity of CT, CTAP, IOUS, and exploration were 67 per cent, 65 per cent, 100 per cent, and 75 per cent, respectively. IOUS was more sensitive than any other modality in detecting liver tumors (P < 0.001). It added new information in 7/31 cases (23%). The false positive rate of CTAP was 4/31 (13%). In one case (3%), a false positive result would have precluded a curative resection. CTAP changed management of 4/53 patients (7.5%) by showing unresectable disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenocarcinoma↗
Inaccuracies in using the lumpectomy scar for planning electron boosts in primary breast carcinoma.
PURPOSE: To determine the accuracy of using the lumpectomy scar, specifically the midpoint or center of the scar, to define the tumor bed in the electron beam boost for the treatment of early stage breast carcinoma. METHODS AND MATERIALS: Electron boost simulation films from 316 cases of early breast carcinoma treated with lumpectomy and radiotherapy were reviewed. For each case which had surgically placed lumpectomy bed clips (N = 316), four clinical set-up methods ("hypothetical fields") of several field sizes were compared to the actual location of the tumor bed (as defined by the surgical clips). Each method was based on using the center of the scar as the center of the field and is described as follows: Method 1 uses a standard circular cone of a given diameter, method 2 also uses circular cones, but the diameter is based on the scar length; method 3 uses an oval field in which a constant margin is kept around the scar; method 4 results in an oblong field in which a 2 cm margin is placed on the lateral edge of the scar, but a larger margin around the center of the scar. The adequacy of each of these popular clinical set-up techniques was then analyzed for the population as a whole. "Inadequate" coverage was defined as any portion of the field edge coming within 1 cm of at least one surgical clip. RESULTS: (1) Method 1: Inadequate coverage was found in 43%, 26%, and 17% of cases, using 7, 8, and 9 cm cones, respectively. (2) Method 2: Inadequate coverage was found in 88%, 61%, 36% and 20% of cases, with field size = scar length + 0, 2, 3, and 4 cm, respectively. (3) Method 3: Inadequate coverage was found in 34%, 17%, and 10% of cases, using 3, 3.5, and 4 cm margins, respectively. (4) Method 4: Inadequate coverage was found in 36% and 24% of cases using 3.5 and 4 cm margins around the scar center, respectively. Inadequate coverage was found in 51% and 42% of cases using margins equal to one-half the scar length or one-half the scar length + 1 cm, respectively. CONCLUSION: We conclude that the lumpectomy scar is often a poor indicator of the location of the underlying tumor bed as defined by surgical clips. We recommend the use of clip placement and simulation of the electron boost to maximize target definition.
Breast Neoplasms↗
Preoperative chemoradiation for adenocarcinoma of the pancreas and duodenum.
PURPOSE: This study was designed to evaluate the effects of preoperative chemoradiation on resectability, response, local control, and survival in patients with local or local-regional involvement from carcinoma of the pancreas or cancer of the duodenum and to assess the associated toxicity of such treatment. METHODS AND MATERIALS: This prospective pilot study of preoperative chemoradiation was initiated in 1986 for patients with clinical evidence of adenocarcinoma of the pancreas or duodenum without evidence of distant metastases. Radiation was given at 1.8 Gy per day to a total dose of 50.4 Gy. Two cycles of chemotherapy were given concurrent with radiation. On days 2-5 and 29-32, 5-fluorouracil (1 gm/m2/24 h x 4 days) was given, while mitomycin-C (10 mg/m2) was given on day 2 only. Surgical resection was 4-6 weeks following completion of chemoradiation. Thirty-one patients (17 male and 14 female) were entered on the protocol with a median potential follow-up of 4.5 years (range 6 months to 7.5 years). The median age was 64 years (range 32-73 years). Twenty-seven patients had pancreatic cancer (25 head, two body), while four patients had carcinoma arising from the duodenum. Twenty-one patients were initially judged to be unresectable and ten potentially resectable prior to chemoradiation. RESULTS: Twenty-nine of 31 patients completed the entire course of radiation and both cycles of chemotherapy. Acute toxicity from chemoradiation consisted of nausea, vomiting, diarrhea, stomatitis, or hematologic suppression which was moderate to severe (Grade 3 or 4) in seven patients (23%). One patient died of sepsis following the first week of therapy. Seventeen patients (55%) underwent curative resection with subtotal or total pancreatectomy or Whipple resection (four duodenum, 13 pancreas) and two (2/17) had pathologic nodal involvement, while (0/17) none had involved margins. A complete pathologic response was seen in all four (4/4) patients with duodenal cancer and in none (0/13) with pancreatic cancer who underwent resection. The median postoperative hospitalization stay was 22 days (range 4-144 days). Of 17 patients who underwent curative resection, there were two postoperative mortalities (12%). Late complications have included abscess, one; and nonmalignant ascites, five. Ten of the 31 patients are alive. For patients with pancreatic cancer the median survival is 9 months, while survival at 1 year and 3 years are 36% and 19% overall and 60% and 43% at 1 and 3 years for those undergoing resection. Six of the 27 patients (22%) with pancreatic cancer are alive without recurrence. All four patients with duodenal cancer are alive without recurrence (12 months, 23 months, 35 months, 90 months). CONCLUSION: Preoperative chemoradiation for cancer of the pancreas and duodenal region was relatively well-tolerated and enhanced resectability and downstaging of nodal metastases were suggested. The 3-year survival, particularly in patients who underwent resection, was high. For these reasons the applicability of this treatment regimen for pancreatic cancer is presently being studied in a group-wide multi-institutional Phase II trial. Chemoradiation for duodenal cancer has produced a complete pathologic response in all patients and survival has been excellent, suggesting efficacy of this regimen for duodenal cancer.
Adenocarcinoma↗
Positive sacroiliac screening tests in asymptomatic adults.
STUDY DESIGN: In a prospective, single-blinded study, the incidence of false-positive screening tests for sacroiliac joint dysfunction was investigated using the standing flexion, seated flexion, and Gillet tests in 101 asymptomatic subjects. OBJECTIVES: This study determined if these commonly used sacroiliac screening tests can be abnormal in an asymptomatic population. SUMMARY OF BACKGROUND DATA: The sacroiliac joint is a potential source of back and leg pain. One condition affecting this joint is termed sacroiliac joint dysfunction. Diagnosis of this is made primarily by physical examination using screening tests as preliminary diagnostic tools. These screening tests evaluate for asymmetry in sacroiliac motion due to a relative, unilateral hypomobility in one the sacroiliac joints. The specificity of these tests, however, has not been thoroughly evaluated in a well-selected asymptomatic population. METHODS: A single-blinded examiner performed the standing flexion, seated flexion, and Gillet tests on all subjects. An asymptomatic and a symptomatic group were studied. RESULTS: Overall, 20% of asymptomatic individuals had positive findings in one or more of these tests. The specific percentage of false positives are reported by test, age, sex, and side. CONCLUSION: This study suggests that asymmetry in sacroiliac motion due to relative hypomobility as determined by these tests can occur in asymptomatic joints. Obviously, one should not rely solely on these tests to diagnose symptomatic sacroiliac dysfunction.
Adult↗
Flumazenil for reversal of respiratory depression.
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Anti-Anxiety Agents↗
Estimating creatinine clearance in elderly patients with low serum creatinine concentrations.
The accuracy of creatinine clearance (CLcr) estimates generated for elderly patients with a low serum creatinine (SCr) concentration when the SCr concentration was rounded to 1.0 mg/dL was evaluated, and daily aminoglycoside dosages calculated with CLcr estimates based on the actual and the rounded SCr concentrations were compared with the actual dosage required as determined by aminoglycoside concentration measurements. Twenty-four-hour urine collections were obtained from elderly hospitalized patients with stable renal function, and CLcr was measured. SCr concentrations were measured at baseline, during urine collection, and after urine collection. CLcr was calculated twice with each of seven methods, once by using the actual SCr concentration and once by rounding the SCr concentration to 1.0 mg/dL. Rounding the SCr concentration to 1.0 mg/dL resulted in significant underestimation of CLcr by all seven methods. The Cockcroft-Gault equation used with ideal body weight and the rounded SCr concentration resulted in the largest bias. For six of the seven methods, bias was greater and precision less when SCr concentrations of < 0.7 mg/dL were rounded than when SCr concentrations of > or = 0.7 mg/dL were rounded. The Bjornsson method used with the actual SCr concentration appeared to offer the best combination of low bias and high precision. The required aminoglycoside dosage was significantly underestimated when the rounded SCr concentration was used. In elderly patients with low SCr concentrations, rounding the SCr concentration to 1.0 mg/dL led to underestimates of both CLcr and the correct aminoglycoside dosage.
Aged↗
Validation of the Multi-Attitude Suicide Tendency scale in adolescent samples.
The present study extended research on the factor structure and psychometric properties of the Multi-Attitude Suicide Tendency scale (MAST). A mixed sample of 215 adolescents, aged 15 to 18 years, participated in the study. Exploratory principal-components analysis of the 30 MAST items provided support for the four-factor structure of the scale: attraction toward and repulsion by life and death. The MAST subscales showed satisfactory levels of internal consistency. Specific and subset of the MAST subscales were identified for differentiating among adolescents who differed in degrees of psychopathology and suicidal behavior. Correlational and regression analyses examined the relations among the MAST subscales and self-report measures of suicidal behavior, social desirability, and general psychopathology. Limitations and suggestions for future research are discussed.
Adolescent↗
Management of non-palpable breast lesions detected mammographically.
A total of 212 consecutive fine-wire localization breast biopsies in 202 patients were performed on impalpable mammographically suspicious lesions. Preoperative fine-needle aspiration cytology was performed on 159 lesions and was valuable in planning the extent of the fine-wire localization biopsy. All 212 target lesions were accurately biopsied during the initial surgery. Overall, 134 lesions were malignant and 78 benign (benign:malignant ratio 1:1.72), with fewer biopsies for benign lesions performed in screened patients (benign:malignant ratio 1:2.43) than in those with symptoms (ratio 1:1). Breast conservation was achieved in 72 patients (80 per cent) with screen-detected in situ or invasive carcinoma and in 19 of 37 presenting via a symptomatic clinic. In 160 of 202 patients (79 per cent) the initial fine-wire localization biopsy was diagnostic and therapeutic.
Biopsy, Needle↗
Serosal imprint cytology in colonic cancer: a simple staging technique.
Accurate staging of colonic cancer is essential in defining the rational use of adjuvant treatments. Recent studies have shown that prognostic accuracy can be significantly improved by recognition of primary tumour extension to the free serosal surface. This study compares the technical results of serosal imprint cytology with the results of histology in assessing serosal involvement. When analysed in terms of the modified Dukes' staging the results of cytology imprints taken from the peritoneum overlying the colonic primary were positive for tumour cells in 4/13 Dukes' B, 7/14 Dukes' C, and 5/9 metastatic cancers. Imprint cytology was positive in 6/7 Dukes' B and C cases with histological serosal invasion and was suspicious in the remaining case. However, a further 5/20 cases without identified invasion on routine histology also had positive cytology. Imprint cytology is an adjunct to routine histology which is easily performed and allows more precise staging of serosal involvement in Dukes' B and C colonic cancers. Final evaluation of this technique requires long-term follow-up of patients.
Colon↗
Evaluation and treatment of patients receiving radiation for cancer of the rectum or sigmoid colon in the United States: results of the 1988-1989 Patterns of Care Study process survey.
PURPOSE: For the first time, a Patterns of Care Study (PCS) was conducted in 1989 to determine the national practice standards of radiation oncologists in evaluating and treating adenocarcinoma of the rectum and sigmoid colon. MATERIALS AND METHODS: A national survey of 73 institutions using two-stage cluster sampling was conducted, and specific information on 408 patients from 69 facilities with adenocarcinoma of the rectum and sigmoid colon who received radiation as part of definitive or adjuvant management was collected. RESULTS: Using the modified Astler-Coller (MAC) pathologic staging system, the stage distribution was as follows: A, 0.5%; B1, 4.4%; B2, 23.5%; B3, 5.1%; C1, 8.9%; C2, 30.2%; and C3, 6.6%. Preoperative radiation was used in 29% of patients, but the total dose was greater than 40 Gy in only 20%. Seventy-three percent of patients received postoperative radiation, with approximately 4% receiving combined preoperative and postoperative radiation. Chemotherapy was administered to 44% of patients overall, representing 55% of patients with disease through the bowel wall and/or involving lymph nodes. Only 37% of all patients received chemotherapy concurrent with radiation. An abdominoperineal resection was used in 43%; a low anterior resection was used in 43% as well, while 5% underwent other types of bowel resection. Approximately 8% of patients were treated with a local curative procedure less than bowel resection (eg, local excision, endoscopic resection, fulguration, or contact radiation). At least one third of patients had interruption in their pelvic irradiation of greater than 3 days. There was no statistically significant difference in the frequency of treatment interruptions by dose per fraction or whether chemotherapy was given concurrent with radiation. There was no significant difference in total dose delivered to patients staged B2 and higher treated without chemotherapy compared with concurrent chemotherapy and radiation. Also, there was no significant difference in total dose delivered to patients with B1 and B2, or C1 and C2 versus B3 or C3 cancer. CONCLUSION: This study was conducted on patients treated just before the 1990 National Institutes of Health consensus guidelines issued on the management of colon and rectal cancer. This study indicates that the minority of patients treated with radiation in 1988 and 1989 received concurrent chemoradiation, as currently recommended. Additionally, insofar as present studies are investigating important issues such as the use of sphincter-sparing procedures, preoperative radiation and chemotherapy, and the importance of radiation dose and scheduling with chemotherapy, the information provided by this study will serve as a useful baseline to track future changes in rectal cancer evaluation and management.
Adenocarcinoma↗
Charles Eriksen. Past, present, and future.
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History, 20th Century↗
The role of mastectomy in patients with stage I-II breast cancer presenting with gross multifocal or multicentric disease or diffuse microcalcifications.
PURPOSE: Women with Stage I-II invasive breast cancer who present with gross multicentric disease or diffuse microcalcifications have a significant risk of breast recurrence when treated with conservative surgery and radiation. The purpose of this report is to present the results of mastectomy in this group of patients. METHODS AND MATERIALS: Between 1982 and 1989, 88 patients with clinical Stage I-II breast cancer who presented with clinical and mammographic evidence of gross multicentric disease or diffuse microcalcifications underwent modified radical mastectomy. Median followup was 4 years for the 57 patients with gross multicentric disease and 5.6 years for 31 patients with diffuse microcalcifications. At the time of mastectomy, 42% of patients were found to have positive axillary nodes. Following mastectomy, 15 patients received post mastectomy radiation and 35 patients received adjuvant systemic chemotherapy. RESULTS: When compared to a group of 1295 patients with unifocal, Stage I-II breast cancer, treated with conservative surgery and radiation during the same time period, patients with gross multicentric disease and diffuse microcalcifications had a significantly higher incidence of > or = 4 positive nodes, patients with gross multicentric disease had a lower incidence of positive resection margins following mastectomy and patients with diffuse microcalcifications were younger. The 5-year actuarial risk of an isolated local-regional recurrence was 8% for patients with gross multicentric disease or diffuse microcalcifications and 7% for patients with unifocal disease. Patients with gross multicentric disease or diffuse microcalcifications and > or = 4 positive axillary nodes who did not receive post mastectomy radiation had an increased risk for local regional recurrence. There were no significant differences in the 5-year actuarial overall or relapse-free survival (88% and 73% gross multicentric disease, 97% and 86% diffuse microcalcifications and 90% and 79% unifocal disease), freedom from distant metastasis (76% gross multicentric disease, 90% diffuse microcalcifications, 86% unifocal disease) or incidence of contralateral breast cancer (10% gross multicentric disease, 13% diffuse microcalcifications, 8% unifocal disease) among the three groups. CONCLUSION: The present study demonstrates no increased risk of local-regional recurrence in patients with gross multicentric disease or diffuse microcalcifications undergoing mastectomy in contrast to the increased risk of breast recurrence in patients with gross multicentric disease undergoing conservative surgery and radiation. Indications for post mastectomy radiation include > or = 4 positive nodes or close or positive surgical margins. Despite a significantly higher incidence of > or = 4 positive nodes, patients with gross multicentric disease and diffuse microcalcifications have a 5-year actuarial overall and relapse-free survival comparable to a group of patients with unifocal disease treated with conservative surgery and radiation.
Actuarial Analysis↗
Comparison of the Farnsworth-Munsell 100-Hue, the Farnsworth D-15, and the L'Anthony D-15 desaturated color tests.
OBJECTIVE: The Farnsworth-Munsell 100-Hue, the Farnsworth D-15, and the L'Anthony D-15 desaturated color tests were administered to patients with glaucoma to determine whether the D-15 or D-15 desaturated color tests could be used to predict performance on the 100-Hue test in clinical populations. METHODS: The three color tests were administered to 35 patients with glaucoma. The results were analyzed using the method of Vingrys and King-Smith that calculates an angle (type of color loss) score, S-index (measure of the randomness of cap arrangement), and a C-index (a measure of the severity of color loss) based on the cap arrangement. RESULTS: The 100-Hue error score was significantly related to the D-15 and D-15 desaturated C-indexes. Furthermore, the 100-Hue S-index could be predicted from the D-15 or D-15 desaturated S-indexes. The 100-Hue angle could not be predicted from the D-15 or D-15 desaturated color tests. CONCLUSIONS: The D-15 desaturated color test (which requires significantly less time to administer) may be used to assess the severity of color vision deficit in some patient populations.
Color Perception Tests↗
Effect of sympathetic block demonstrated by triple-phase bone scan.
The triple-phase bone scan is frequently used in the diagnosis of reflex sympathetic dystrophy although the etiology of the abnormal findings is not well established. This study evaluated the effect of increased blood flow secondary to sympathetic block on the triple-phase bone scan. In 15 reflex sympathetic dystrophy patients, all of whom had significant relief with sympathetic block, baseline and postsympathetic block bone scans were analyzed. There was a significant linear relationship between change in counts from baseline to postsympathetic block on the blood pool image and bone uptake image. As the blood pool and bone uptake counts increased, the likelihood of typical reflex sympathetic dystrophy findings on visual inspection also increased. These results strongly support the concept of increased vascular flow as the cause of increased periarticular uptake.
Autonomic Nerve Block↗
Electron paramagnetic resonance spectroscopy of stable free radicals in the liver compared with ultrastructural and functional damage in a rat model of alcohol- and iron-overload.
1. Electron paramagnetic resonance spectroscopy was used to study free-radical signals in freeze-clamped frozen liver tissue from rats after a 1 year period of dietary supplementation with alcohol, iron, or alcohol and iron. In alcohol-fed, iron-fed and alcohol- and iron-fed animals, mild histological damage was seen on light microscopy and evidence of mitochondrial and nuclear injury was identified by electron microscopy. 2. Subcellular fractionation studies showed an increase in the activity of the peroxisomal marker catalase (P < 0.01) in alcohol-fed rats compared with controls, but a fall of 82% (P < 0.001) in alcohol- and iron-fed animals. The activity of the mitochondrial marker succinate dehydrogenase rose by 7% (not significant) in alcohol-fed animals and by 17% (not significant) in iron-fed animals, but fell by 94% (P < 0.001) in alcohol- and iron-fed animals, suggesting serious impairment of mitochondrial function. 3. Iron overload was substantial in the iron-fed animals and there was an excellent correlation between liver iron concentration and iron-derived signals by electron paramagnetic resonance spectroscopy (P < 0.001). A clear free-radical signal of g = 2.003-2.005 was detected in all liver samples, but there was no significant difference in the magnitude of this signal in any study group. 4. The absence of any increase in the stable free-radical signal, even in the presence of considerable hepatic damage, does not support the hypothesis that free radicals mediate alcoholic liver disease in this animal model, although the results cannot be taken as proof against this hypothesis.
Animals↗
Saccadic eye movements and dual-task interference.
Four dual-task experiments required a speeded manual choice response to a tone in a close temporal proximity to a saccadic eye movement task. In Experiment 1, subjects made a saccade towards a single transient; in Experiment 2, a red and a green colour patch were presented to left and right, and the saccade was to which ever patch was the pre-specified target colour. There was some slowing of the eye movement, but neither task combination showed typical dual-task interference (the "psychological refractory effect"). However, more interference was observed when the direction of the saccade depended on whether a central colour patch was red or green, or when the saccade was directed towards the numerically higher of two large digits presented to the left and the right. Experiment 5 examined a vocal second task, for comparison. The findings might reflect the fact that eye movements can be directed by two separate brain systems--the superior colliculus and the frontal eye fields; commands from the latter but not the former may be delayed by simultaneous unrelated sensorimotor tasks.
Attention↗
Granulation tissue polyposis associated with carcinoid tumours of the small intestine.
We report two patients with ileal carcinoid tumours which were associated with polyps due to mucosal granulation tissue proliferation. In both cases the tumours had extensively infiltrated the small bowel wall and mesentery, and one had hepatic metastases. The mucosal surface of each specimen showed numerous, pale brown, sessile polyps which were restricted to the intestinal segment involved by carcinoid tumour, although not always closely related to neoplastic cells. The polyps were formed by the proliferation of capillaries, smooth muscle cells and myofibroblasts as demonstrated by immunohistochemistry and electronmicroscopy.
Aged↗