Biomedical subjects
Publications and source records attributed to M Cohen.
Women's health is determined not only by biology but also by social context. While the health of both men and women is adversely affected by poverty, a higher proportion of women suffer from its effects because of increasing "feminization of poverty." The extent of this phenomenon, its multiple roots, and the role physicians could play in addressing it are discussed.
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OBJECTIVES: This study was designed to compare the response of unstable angina and non-Q wave myocardial infarction during treatment with antithrombotic therapy. BACKGROUND: Antithrombotic therapy is beneficial in patients with these two coronary syndromes. METHODS: In a multicenter trial of antithrombotic therapy in unstable angina or non-Q wave myocardial infarction, 358 patients admitted within 48 h of chest pain were randomized to antithrombotic therapy with either 1) aspirin alone, or 2) aspirin plus heparin followed by aspirin plus warfarin, and were prospectively followed up for 12 weeks. Admission cardiac enzyme analyses revealed unstable angina in 268 patients and non-Q wave myocardial infarction in 62. Given an event rate of about 25%, this study has a power of 80% to detect a 50% difference between the two groups. RESULTS: Patients with unstable angina and non-Q wave myocardial infarction were similar with regard to age, gender, coronary risk factors and prior antianginal medication. Primary end points at 12 weeks were recurrent ischemia, infarction and death. [table: see text] In the non-Q wave group, all infarctions and death occurred within the 1st week. CONCLUSIONS: Patients with unstable angina or non-Q wave myocardial infarction on antithrombotic therapy have a similar total number of ischemic events by 12 weeks. However, despite maximal medical therapy with antianginal and antithrombotic medication, patients with non-Q wave infarction have a significantly higher rate of reinfarction and death.
BACKGROUND: Cystosarcoma phyllodes (CP) is an uncommon fibroepithelial breast neoplasm that rarely involves the central nervous system (CNS). METHODS: The authors encountered two patients with CNS metastases and reviewed the literature to identify reports of CP affecting the nervous system. Patients must have been reported in sufficient detail to characterize clinical course, extent of tumor burden, and histologic type of the primary tumor and metastasis to be included in the study. RESULTS: Eleven cases were identified from the literature, but only six were presented in sufficient detail for analysis. Including the current patients, the mean age of patients with CP metastases was 52 years. The time between initial diagnosis and CNS involvement was 5 years. Parenchymal brain metastases respond poorly to treatment, with a mean survival of 29 days, whereas survival is significantly longer with CNS involvement secondary to epidural extension of tumor from adjacent bony structures. Local recurrence or widespread metastases nearly always were present at the time of CNS involvement. CONCLUSIONS: Brain metastases from CP are refractory to therapy and carry a dismal prognosis. Patients with CP and brain metastases should undergo brain biopsy to exclude metastases from associated epithelial breast tumors, which have significantly better prognoses. Patients with compressive lesions arising from bone have a better prognosis and may benefit from aggressive management.
We report 3 patients with autopsy-proven Creutzfeldt-Jakob disease who, early in their course, developed abnormal eye movements that included periodic alternating nystagmus and slow vertical saccades. These findings suggested involvement of the cerebellar nodulus and uvula, and the brainstem reticular formation, respectively. Cerebellar ataxia was also an early manifestation and, in 1 patient, a frontal lobe brain biopsy was normal at a time when ocular motor and cerebellar signs were conspicuous. As the disease progressed, all saccades and quick phases of nystagmus were lost, but periodic alternating gaze deviation persisted. At autopsy, 2 of the 3 patients had pronounced involvement of the cerebellum, especially of the midline structures. Creutzfeldt-Jakob disease should be considered in patients with subacute progressive neurological disease when cognitive changes are overshadowed by ocular motor findings or ataxia.
Charts from 86 patients treated for carcinoma of the tongue were reviewed to identify strategies that might improve patient outcome. Seventy-one patients (83%) were black and 69 patients (80%) were male. Overall 2- and 5-year survival rates were 20% and 12%, with stage-specific 2-year survivals of 71% (I and II, n = 7), 33% (III, n = 15), and 11% (IV, n = 64) (P < 0.01). Patients with well-differentiated tumors (n = 27) had a higher 2-year survival than that of the others (n = 53, 30% vs. 11%, P = 0.05). Six were unclassified. Twenty-three (27%) patients underwent primary surgical resection and lymphadenectomy with or without adjuvant therapy. Two-year overall and disease-free survivals were 43% and 26%, respectively. Fifty (58%) patients received radiotherapy with or without chemotherapy, achieving 2-year overall and disease-free survivals of 12% and 6% (P < 0.01). The remaining 13 patients received chemotherapy alone or no treatment and survived an average of 6 months. Distant metastasis were diagnosed in 14 patients (16%). Tongue carcinoma in this socioeconomic setting was characterized by late diagnosis and poor prognosis. Degree of tumor differentiation, disease stage, and treatment modality seemed to correlate with prognosis. Surgery, when possible, achieved superior results for disease control and survival. While cancer prevention efforts are critical, steps to identify high-risk groups to implement early detection programs may help improve outcome for these patients.
We report a patient who had six episodes of acute Guillain-Barre syndrome during his life. He is the fifth such case with postmortem analysis.
An intraoperative patient stabilization device is described for use in aesthetic breast surgery. This simple device maintains the patient in the vertical position throughout the many positional changes during aesthetic breast surgery.
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Gastrointestinal (GI) tract involvement in Langerhans cell histiocytosis is probably not uncommon [1,2], but reports of radiologic findings have been limited to the small intestine and mesenteric lymph nodes [3-5]. We report a 16-month-old child with known Langerhans cell histiocytosis, who was found to have mucosal irregularities of the colon as seen on air contrast barium enema, and was subsequently found to have diffuse involvement of the colon histologically confirmed by multiple biopsies.
Plasma and brain concentrations of the dopamine D1 receptor antagonist, SCH 39166, were measured and compared to behavioral activity in the conditioned avoidance response paradigm (CAR). SCH 39166 was administered at two behaviorally active doses (1 mg/kg, SC and 10 mg/kg, PO) and the time course for CAR activity was compared with the plasma and brain concentrations of unconjugated SCH 39166. Conjugation and N-demethylation of SCH 39166 after oral administration were also determined and first pass metabolism examined. Results from these studies demonstrated a similar time-dependent disappearance of unconjugated SCH 39166 from both the plasma and brain, independent of route of administration. Brain concentrations of SCH 39166 were approximately 5-fold higher than corresponding plasma concentrations, regardless of route. However, plasma and brain concentrations of unconjugated SCH 39166 were higher after SC administration of 1.0 mg/kg, than after PO administration of 10 mg/kg, suggesting a substantial first pass metabolism of SCH 39166. In addition, total (conjugated and unconjugated) plasma concentrations of SCH 39166 were at least 10-fold higher than unconjugated concentrations of SCH 39166 after PO administration of 10 mg/kg, demonstrating that a high proportion of drug was conjugated. Metabolism to the N-desmethyl analog, SCH 40853, was observed after PO administration of 10 mg/kg SCH 39166 and a high proportion of conjugation of the desmethyl analog was also seen. Finally, plasma concentrations of unconjugated SCH 39166 exhibited a high positive correlation (r = 0.934, P < 0.001) with brain concentrations of unconjugated SCH 39166.(ABSTRACT TRUNCATED AT 250 WORDS)
The role of coronary collateral circulation in limiting ischemia and infarction has been studied prospectively. Transient occlusion of a coronary artery angioplasty has provided evidence that collateral circulation decreases wall motion abnormalities, ST segment changes, and lactate production. Patients who have collateral flow also have a better outcome after coronary artery dissection and acute closure than patients without collateral flow. Collateral circulation also limits infarct size during acute myocardial infarction with and without thrombolysis. Although collateral flow may decrease coronary artery bypass graft patency in certain subgroups of patients, the perioperative infarct rate and mortality is decreased. Growth factors have been identified that increase the development collateral circulation and may improve ventricular function in the setting of myocardial infarction.
Forty-two patients with an ejection fraction of 0.20 or less underwent coronary artery bypass grafting from 1986 to 1990 using a method of myocardial protection we term "centigrade cardioplegia," combining single-dose, cold, crystalloid cardioplegia, systemic hypothermia, and local hypothermia. Thirty-day mortality was 4.8% (2/42). Perioperative morbidity included two myocardial infarctions (4.8%) and one stroke (2.4%), which fully resolved. Postoperative left ventricular function improved (left ventricular ejection fraction, 0.157 +/- 0.028 to 0.226 +/- 0.085; p < 0.0002), as did New York Heart Association class (3.4 +/- 0.73 to 1.8 +/- 0.63; p < 0.0001) and Canadian class (3.3 +/- 0.81 to 0.61 +/- 0.92). Survival, 88% at 1 year, declined to 68% at 3 years and 34% at 6 years. This high-risk group had very acceptable short-term results, indicating adequate intraoperative myocardial protection. Four clinical variables were associated with long-term survival: (1) chief complaint of pain only (p = 0.05), (2) history of unstable angina (p = 0.04), (3) Canadian class less than IV (p = 0.05), and (4) New York Heart Association class less than IV (p = 0.05). Reduced survival, although not statistically significant (p = 0.07), was noted for right ventricular ejection fraction of 0.30 or less. These factors may help predict which patients with severe left ventricular dysfunction will benefit from revascularization.
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Pericranial flaps based on the musuloaponeurotic or myofacial layers of the scalp have great utility in the management of acquired and congenital craniofacial deformities. Their use in traumatic deformities is indicated in the presence of craniopharyngeal communications and significant anterior cranial fossa dead space created from frontal sinus obliteration. The indications and operative techniques and the results of the use of these flaps in 10 consecutive patient with extensive cranial base trauma are presented.
Candida tropicalis is a well-documented pathogen affecting humans. There is limited clinical and experimental evidence that C. tropicalis causes hematogenous endophthalmitis. We report two cases of C. tropicalis endophthalmitis and review 12 cases reported in the literature. Clinical presentation was similar to that described for Candida albicans endophthalmitis. Therapy with amphotericin B, with or without flucytosine, resulted in resolution of the lesions except in one patient, for whom enucleation of the eye was necessary to control the infection. None of the patients were leukopenic.
The transcoronal surgical approach for the treatment of orbital disease has become increasingly popular since it affords excellent surgical exposure through a cosmetically acceptable incision. Exposure of the inferior orbit, however, can be difficult due to limited flap mobility in the frontal plane. Increased inferior exposure may be obtained by extending the incision inferiorly in preauricular skin. In children and young adults without excess preauricular skin folds or wrinkling, however, the wound may be quite apparent, compromising cosmesis. To overcome this drawback, we demonstrate a modified transcoronal incision that redirects the inferior limbs into the postauricular sulcus. This incision not only results in superior cosmesis, but avoids important preauricular neurovascular structures and enhances orbital exposure.
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