Fractures of the proximal tibia.
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Arthroscopy↗
Biomedical subjects
R E Hunter
Publications and source records attributed to R E Hunter.
Knee dislocations.
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Anterior Cruciate Ligament Injuries↗
Primary traumatic anterior shoulder dislocation in patients 40 years of age and older.
During three consecutive ski seasons (1991 to 1994), 125 patients 40 years of age and older without previous shoulder injuries or surgery sustained a traumatic first-time anterior shoulder dislocation. At a minimum of 2 years' follow-up, patients were contacted to determine long-term outcome and to identify factors leading to prolonged morbidity or the need for surgical intervention. Fifty-two patients were available for interview. A modified Rowe shoulder score showed 32 excellent, nine good, eight fair, and three poor results. Eighteen (35%) rotator cuff tears were subsequently identified, with only 11 (61%) of these patients obtaining an excellent or good outcome (P = .011). Of the 11 patients with a fair or poor result, seven (64%) had a rotator cuff tear. Of the 12 patients with isolated cuff tears, 84% had an excellent or good result when treated surgically, compared with 50% when treated nonsurgically. Our findings indicate that recurrence is not a frequent complication of traumatic anterior shoulder dislocation in this age-group (4%). However, prolonged morbidity secondary to rotator cuff tear is more prevalent than in a younger population. We believe early diagnosis of rotator cuff pathology by either magnetic resonance imaging (MRI) or arthrogram with subsequent surgical repair can lead to faster restoration of function and a better outcome in these select individuals.
Adult↗
Delta Dental Plan of Massachusetts' perspective on financing.
The continually increasing costs of dental treatment have stimulated searches for alternative means of financing care. Cost has also raised questions about the definition of quality in oral health. Payers are beginning to evaluate alternatives based on prevention and health outcomes rather than volume of treatment delivered. Not-for-profit organizations, such as the Deltas, have a proactive role to play in this search for alternatives. In the end, it is the combination of market forces which will shape both how dentistry is financed and how it is defined.
Costs and Cost Analysis↗
Managed care in dentistry.
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Managed Care Programs↗
The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction.
A prospective study was designed to determine the impact of surgical timing on postoperative motion and stability following anterior cruciate ligament (ACL) reconstructive surgery. The study population was limited to acute ACL ruptures from downhill skiing undergoing arthroscopic ACL surgery without arthrotomy or surgical intervention for other ligamentous structures; 185 patients were entered into four separate groups based on the time interval from injury to surgery. Motion and stability were tested at multiple time points from the index surgery and adverse events were recorded. We found no statistical difference in restoration of extension or flexion in any group at any time point. KT-1000 data at 12 months showed a side-to-side difference of < or = 3 mm in 94%, with 6% showing a side-to-side difference of > 3 and < or = 5 mm. We conclude that, in this population, by using modern arthroscopic surgical techniques and an aggressive postoperative physical therapy protocol, motion and stability can be restored in a high percentage of patients and that surgical success is independent of the timing of surgery.
Adolescent↗
Cervical spinal fractures in Alpine skiers.
A 5-year review of skiing injuries in the Aspen/Snowmass area revealed 18 cervical fractures. This represents a yearly average of 3.6 fractures (range: 2 to 5). There were 16 men and 2 women identified, with an average age of 40.8 years (range: 20 to 73). Using estimates of skier days and total injuries, cervical fractures represented approximately 0.1% of all skiing injuries. Six of 18 injuries (33%) were avulsion injuries of the spinous processes and were treated symptomatically with a soft collar. However, five patients had neurologic involvement secondary to fracture displacement, two with lasting quadriparesis. In addition, there was one death attributed to cervical fracture. Forty-four percent of the patients had associated injuries, most commonly facial and head (33%). The three oldest patients (average age: 67 years, range: 57 to 73) had three of the more serious injuries. Two of these patients were the quadriplegics, and a third required halo stabilization of bilateral C2 facet fractures. Typically, those patients who were involved in collisions with immovable objects (trees or fences) had more severe injuries and a greater chance of neurologic involvement.
Adult↗
Accuracy of frozen-section (intraoperative consultation) diagnosis of ovarian tumors.
OBJECTIVE: Frozen-section evaluation of ovarian tumors can be used to establish a histopathologic diagnosis and guide the surgeon to perform the appropriate surgical procedure. A retrospective study was conducted to determine the accuracy of frozen-section diagnosis of ovarian tumors. STUDY DESIGN: Frozen- and permanent-section diagnoses were divided into three categories (benign, borderline, and malignant). The sensitivity, specificity and predictive values, and 95% percent confidence intervals of each frozen-section diagnosis were determined. RESULTS: Three hundred eighty-three ovarian tumors that underwent frozen-section evaluation between June 1983 and June 1993 were studied. The final histopathologic diagnosis was 61.1% benign, 7.6% borderline, and 31.3% malignant. Frozen section was accurate in 92.7% of all cases and inaccurate in 7.3%. The sensitivity for malignant tumors was 92.5% tumors (95% confidence intervals 87.7% to 97.2%), the sensitivity for borderline tumors was 44.8% (95% confidence interval 26.4% to 63.2%). The specificity for benign tumors was 92.0% (95% confidence interval 88.6% to 95.4%) but increased to 97.9% (95% confidence interval 96.1% to 99.7%) if borderline tumors were excluded. The positive predictive value and 95% confidence intervals were 92.0% (88.6% to 95.4%) for benign tumors, 65% (43.6% to 86.5%) for borderline tumors, and 99.1% (97.3% to 100.0%) for malignant tumors. Thirteen of 16 (81%) ovarian lymphomas and tumors metastatic to the ovary were correctly identified by intraoperative frozen section. The sensitivity for borderline serous tumors was 64.3% and for borderline mucinous tumors 30.8% (p = 0.48). CONCLUSION: With the exception of borderline tumors, the sensitivity and specificity of frozen-section diagnosis of ovarian tumors are high. Borderline tumors remain difficult to accurately diagnose at frozen section because of the extensive sampling required. Frozen-section diagnoses have important implications regarding the type and extent of surgery performed at the initial operation.
Adolescent↗
Cochlear polyamines: markers of otitis media-induced cochlear damage.
High-performance liquid chromatography (HPLC) set to the femtomole [corrected] sensitivity level was used to identify and quantify the polyamines spermidine and spermine as well as the diamine putrescine in the different tissues of the inner ears of guinea pigs with experimentally induced otitis media. The tissues examined were the lateral wall (stria vascularis and the spiral ligament), the organ of Corti, and the cochlear nerve. The difference in polyamine profile in the different tissues of the control noninfected guinea pigs suggests a relation to the particular function of each of these tissues [see erratum notice re: preceding sentence]. The difference in polyamine profile in infected different inner ear tissues compared to controls encourages the assumption that the polyamines may be involved in a repair process of the inner ear after injury and that they may be considered as biochemical markers for inner ear damage secondary to acute otitis media.
Animals↗
Advanced ovarian cancer in a woman with a family history of ovarian cancer, discovered at referral for prophylactic oophorectomy. A case report.
Despite an initial complete response to therapy, she died of the disease 60 months after the diagnosis. Although only a small percentage of ovarian cancer patients report a family history positive for ovarian cancer, such a history remains the most recognizable risk factor in this elusive disease. Accurate prediction of the risk of ovarian cancer in subjects with multiple affected family members and the efficacy of prophylactic oophorectomy need to be determined.
Carcinoma↗
Serial serum CA 125 measurements for evaluation of recurrence in patients with endometrial carcinoma.
OBJECTIVE: To evaluate the usefulness of serum assays for CA 125 to detect recurrent endometrial carcinoma. METHODS: Two hundred sixty-six patients were studied with 1101 post-treatment assays. Patients were categorized as low, medium, or high risk based on surgical-pathologic findings. CA 125 values were analyzed with respect to each patient's disease status. RESULTS: Serial CA 125 levels were elevated (greater than 35 U/mL) in 19 of 33 patients (58%) with recurrent disease. Among 236 surgically treated patients, 97 (41.1%), 42 (17.8%), and 97 (41.1%) were considered low, medium, and high risk, respectively. None of the low-risk and only two (4.7%) of the medium-risk patients developed recurrent disease. One of the latter patients was detected based on an elevated CA 125 level alone. Twenty-seven (27.8%) of the high-risk patients developed recurrent disease, 23 of whom had elevated pre-treatment CA 125. Fifteen of 16 (94%) with recurrent disease had an elevated CA 125 level. Nine of 12 patients with papillary serous carcinoma experienced recurrence; eight of these nine had elevated CA 125 levels at diagnosis and recurrence, in contrast to only one patient with a normal pre-treatment level (P = .018). False elevations were noted in 13 patients, 12 of whom had received radiation therapy. CONCLUSIONS: CA 125, if elevated at diagnosis of endometrial carcinoma, is an important marker for recurrent disease. The use of serial CA 125 assays is most beneficial in diagnosing recurrence in a high-risk population, including patients with papillary serous carcinomas. False elevations may occur following radiation therapy.
Adenocarcinoma, Clear Cell↗
Primary radiation therapy for endometrial carcinoma: a case controlled study.
PURPOSE: Primary radiation therapy is generally considered inferior to a surgical approach for patients with endometrial carcinoma and is reserved for patients with a high operative risk. These patients are usually elderly, have multiple medical problems and frequently die of intercurrent disease. To evaluate the efficacy of primary radiation therapy a case controlled analysis comparing corrected survival of patients treated with primary radiation to patients treated with surgical therapy with or without radiation therapy was performed. METHODS AND MATERIALS: Sixty-four patients treated with primary radiation therapy were retrospectively studied. A Kaplan-Meier product limit survival analysis was used to estimate survival among patients treated with primary radiation therapy. A case control study matched by clinical stage, tumor grade, and time of diagnosis was performed. The Mantel-Cox statistic was used to evaluated the equality of the survival curves. RESULTS: Primary radiation therapy was used to treat 9.0% of the patients with endometrial carcinoma during the study period. Cardiovascular disease, diabetes, age greater than 80 and morbid obesity were the most common indications. Ninety percent of patients had either Stage I or II disease. Forty-eight of the 64 patients (75%) completed treatment which included both teletherapy and brachytherapy. Ten patients received brachytherapy only. Twelve complications, both acute and chronic, occurred in eleven patients (17%). Intercurrent disease accounted for 13 of the 36 (36%) of the deaths. Clinical stage of disease and histologic grade of the tumor were significant predictors of survival, p = 0.0001 and p = 0.013, respectively. The case controlled study of Stage I and II patients treated by primary radiation therapy matched to surgically treated controls showed no statistical difference in survival. Dilatation and curettage after the completion of radiation therapy was predictive of local control, p = 0.003. CONCLUSION: Although surgery followed by tailored radiation therapy has become widely accepted therapy for Stage I and II endometrial carcinoma, even in patients who are a poor operative risk, the survival with primary radiation therapy is not statistically different.
Adult↗
Serum squamous cell carcinoma antigen levels in invasive cervical cancer: prediction of response and recurrence.
OBJECTIVE: The rate of normalization of human chorionic gonadotropin or CA 125 in other gynecologic malignancies is highly predictive of response to therapy and recurrence. Serum squamous cell carcinoma antigen (SCC antigen) levels were studied in patients with invasive cervical carcinoma to determine if the rate of normalization was associated with outcome. STUDY DESIGN: One hundred eighty-four patients were studied. A logistic regression of elevated SCC antigen levels was performed. RESULTS: In primary squamous cell carcinoma the SCC antigen level was elevated in stages I, II, III, and IV disease and all stages combined in 24%, 57%, 67%, 71%, and 43% of cases, respectively. Only 27% of patients with nonsquamous carcinoma of the cervix had elevated SCC antigen levels. SCC antigen levels were elevated in 50% of patients with recurrent disease. In both primary and recurrent disease elevated SCC antigen levels decreased with effective therapy. Normalization of elevated SCC levels was associated with a complete response; however, logistic regression of SCC antigen values was not. CONCLUSION: When initially elevated, SCC antigen assays aided in determination of response and detection of recurrences.
Adenocarcinoma↗
Serum squamous cell carcinoma antigen levels in invasive squamous vulvar cancer.
Squamous cell carcinoma (SCC) antigen levels were studied in 34 patients with primary (N = 27) or recurrent (N = 7) SCC of the vulva. In primary disease, the SCC antigen level was greater than 2.5 ng/ml in only four patients (15%). Elevated antigen levels ranged from 2.7-18.0 ng/ml. All of these patients had advanced disease by either clinical or surgical staging systems. Four of twelve patients with inguinal metastasis had elevated SCC antigen levels. In two of these patients the inguinal nodes were abnormal to palpation. No association of the SCC level and the degree of tumor differentiation was observed. SCC antigen levels were increased slightly (2.7-4.5 ng/ml) in three of six patients with locally recurrent disease. In one patient with distant recurrence the SCC antigen was 15.3 ng/ml. In both primary and recurrent disease all elevated SCC antigen levels decreased with effective therapy. Vulvar cancer is primarily a local disease that is easily assessed by physical examination. An effective tumor marker in vulvar cancer would benefit only the rare patient with distant but not local disease.
Antigens, Neoplasm↗
Accuracy of frozen-section diagnosis at surgery in clinical stage I and II endometrial carcinoma.
OBJECTIVES: The purpose of our study was to determine if frozen section accurately identifies certain poor prognostic pathologic factors in endometrial carcinoma that are known to be associated with pelvic and paraaortic nodal metastasis, including deep myometrial invasion, poorly differentiated tumor, cervical invasion, adnexal involvement, and poor histologic type. STUDY DESIGN: The frozen-section pathologic results of 199 patients with clinical stage I and II endometrial cancer were retrospectively compared with permanent-section pathologic findings. RESULTS: The depth of myometrial invasion (superficial third vs deep two thirds) was accurately determined by frozen-section diagnosis at surgery in 181 of 199 cases (91.0%). The sensitivity of frozen-section diagnosis for deep myometrial invasion was 82.7%, and the specificity was 89.1%. The following tumor characteristics were accurately determined on frozen section at surgery: poorly differentiated tumor (95.0%), cervical invasion (94.0%), adnexal involvement (98.5%), and histologic type (94.0%). Frozen section underestimated deep myometrial invasion in 17.3% of patients with this characteristic and poorly differentiated tumor in 26.3% when compared with permanent-section diagnosis. In patients with unfavorable histologic types, papillary serous and adenosquamous carcinomas were the most commonly misdiagnosed histologic types by frozen section at surgery (70.6%). However, when the preoperative curettage pathologic findings were included, these inaccuracies in tumor grade and histologic type dropped to 15.8% and 35.3%, respectively. Only 13 of 199 patients (6.5%) were not correctly identified by frozen section at surgery as having poor prognostic pathologic features. CONCLUSION: Frozen section diagnosis at surgery is an important procedure that enables the surgeon to identify patients at high risk for pelvic and paraaortic nodal metastasis.
Adenocarcinoma↗
Radiation therapy for surgically proven para-aortic node metastasis in endometrial carcinoma.
The impact of para-aortic field radiation therapy upon survival was studied among 26 patients with para-aortic nodal metastases from carcinoma of the endometrium. Seventeen of these 26 patients received postoperative radiation therapy to the para-aortic field as a part of their primary therapy. Sixteen of the 17 also received adjuvant hormonal therapy. Nine of 17 patients (53%) are alive without evidence of disease (18-55 months) with a median survival time of 27 months. Of the remaining eight patients, six (35%) died of endometrial cancer at 6-38 months, with a median survival time of 14.5 months. Five of these patients had distant disease. Two of the 17 patients (12%) died of intestinal obstruction felt to be secondary to radiation enteritis, one of whom was disease free. No difference in survival was detected in patients treated with radiation therapy with microscopic versus macroscopic nodal involvement. Of the nine patients who did not receive para-aortic radiation, eight were treated with hormonal therapy (n = 6) or chemotherapy (n = 2). Seven patients died of disease from 5-28 months, with a median survival time of 13 months. One patient is alive at 12 months. Survival in the 17 patients treated with para-aortic radiation was better than the eight patients not treated with para-aortic radiation (p = 0.004). This survival difference remained significant for patients with microscopic but not macroscopic nodal disease. Para-aortic field radiation appears to improve survival, but has a significant complication rate, and should be reserved for patients with histologic evidence of para-aortic metastases.
Adenocarcinoma↗
Human antibody response to the intravenous and intraperitoneal administration of the F(ab')2 fragment of the OC125 murine monoclonal antibody.
We have characterized the human immune response against murine monoclonal antibodies (HAMA) in 18 patients following administration of the F(ab')2 fragment of the murine monoclonal antibody OC125. OC125 is directed against the CA125 antigen, present on the surface of many human ovarian cancers. An affinity matrix was used to separate serum into immunoglobulin-containing and immunoglobulin-free fractions. HAMA titer was determined on the immunoglobulin fraction with an OC125 sandwich enzyme-linked immunosorbent assay (ELISA). All patients developed an HAMA response, despite the use of F(ab')2 fragments and small amounts (1-4 mg) of antibody. It may be that the intraperitoneal (i.p.) route provides a more marked HAMA response. Enzyme-linked sandwich immunoassays were also used to determine anti-isotype and anti-idiotype titers. Anti-isotype titers were analyzed with antigen irrelevant, isotype-matched murine antibodies and OC125-HRPO. Anti-idiotypes titers were assessed in a sandwich assay that utilized F(ab')2 and F(ab') fragments of OC125. The anti-isotype response tended to be of low titer and short duration, while the anti-idiotype response was of high titer and remarkably persistent. HAMA interfered in an unpredictable manner with the correct measurement of serum levels of CA125 in an enzyme immunoassay using OC125. Corrected values of CA125 could be obtained by measurement of antigen in the immunoglobulin-free fraction of serum. The response of one patient, who developed a markedly elevated anti-idiotype titer after serial i.v./i.p. injections, was further characterized and found to contain an antibody consistent with an anti-anti-idiotype to the CA125 antigen.
Adenocarcinoma↗
Implementing service guarantees--the Delta Dental Plan story.
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Consumer Behavior↗