Biomedical subjects
Publications and source records attributed to W J Mann.
Newly developed technology and specially trained operators offer physicians and deaf or hard-of-hearing patients several options for communicating by telephone. This article discusses communication equipment, implications and benefits of direct physician/patient communication, removal of communication barriers, and confidentiality.
BACKGROUND: This study reviewed all patients managed by the Gynecologic Oncology service of a tertiary care facility (n = 468) whose deaths occurred between 1980 and 1990 to ascertain the site of death and potential factors affecting whether patients died at home or in a hospital. METHODS: Gynecologic Oncology Tumor Registry data were analyzed for patient diagnosis, age at diagnosis, age at death, marital status, insurance coverage, and year of death in relation to location of death. RESULTS: This study found that 78% of patients died in the hospital, and 22% died at home. The mean terminal hospital stay was 15 days. The variables examined in this study could only accurately predict location of death in 59% of the cases. Examination of the variable year of death, however, demonstrated that the likelihood of death in the hospital generally increased from 1980 to 1990, despite introduction of diagnosis related groups and aggressive efforts by caregivers to facilitate and encourage death at home. CONCLUSIONS: Philosophical and economic considerations to the contrary, a significant majority of terminal patients with gynecologic cancers will die in a hospital, thus extensively utilizing our limited health resources.
The ability of 111In-CYT-103 immunoscintigraphy to aid in the diagnosis of patients with primary or recurrent/residual ovarian cancer was evaluated in a multicenter trial. The 111In-labeled immunoconjugate of the monoclonal antibody B72.3 was prepared using a site-specific conjugation method. A total of 103 patients received a 1 mg infusion of 111In-CYT-103 and subsequently underwent surgery or biopsy. The infusion of 111In-CYT-103 was well tolerated; only 1 patient experienced a modest elevation in blood pressure that was likely related to the infusion. 111In-CYT-103 immunoscintigraphy correctly identified surgically confirmed tumor in 68% of patients with ovarian adenocarcinoma. The sensitivity of 111In-CYT-103 immunoscintigraphy was positively influenced both by the size of the tumor lesion and the tumor TAG-72 antigen expression. The overall sensitivity of 111In-CYT-103 immunoscintigraphy was greater than that of CT imaging (44%). Antibody imaging detected occult disease in 20 of 71 patients with surgically documented ovarian adenocarcinoma; 6 patients being evaluated after initial surgery and chemotherapy had an otherwise negative presurgical workup and a normal CA 125 serum level. The results of this trial also indicate that 111In-CYT-103 immunoscintigraphy can contribute to the medical and surgical management of some patients with ovarian cancer. The results of this trial indicate that 111In-CYT-103 immunoscintigraphy should be a valuable addition to the presurgical evaluation of patients with suspected persistent or recurrent ovarian cancer.
Transcranial Doppler ultrasound (TDU) recording is presented as a diagnostic method for the evaluation of the cerebral cross-flow in patients in whom, for therapeutic reasons, ligature or resection of the common or internal carotid artery is planned. Examinations were performed under normal conditions and while using manual compression of the ipsilateral carotid artery. Patients with various skull base and neck tumors were examined and in all patients an immediate decrease of the flow velocity in the middle cerebral artery (MCA) of 25 to 90% was registered. In 39% of these patients the flow velocity of the MCA reached 90% or more of its value under normal conditions within a short interval. In 29% of the patients the flow velocity of this vessel under manual compression of the carotid artery remained under 50% of its original value. In 68% of the cases TDU recording with manual compression of the carotid artery showed reliable results for the function of cerebral collateralization as a prognostic factor of ischemic risk due to hemodynamic changes after carotid ligature. In these cases no further examination of the cerebral cross-flow conditions was carried out. This method is convenient, harmless to the patient, inexpensive, does not require sophisticated equipment, and yields reproducible results when compared with cerebral angiography.
We retrospectively reviewed the cases of 51 patients with borderline ovarian tumors seen over a 9-year period. Half of these tumors were manifested by abdominal distention and pain; the remainder were found incidentally at the time of surgery planned for other reasons. Overall survival is excellent, but proper surgical staging reveals that approximately 15% of patients have metastasis beyond the ovaries, most commonly to the omentum, peritoneum, and retroperitoneal lymph nodes.
The range of procedures now routinely done through the laparoscope has continued to expand due to improved equipment for insufflation, hemostasis, and tissue manipulation, and to imaginative approaches to otherwise "routine" gynecologic problems traditionally treated by laparotomy. As with all new technologies, advocates predict that the methodology will prove to have an almost unlimited potential, while established skeptics predict that it will have a narrow applicability. With time and further clinical application, a consensus somewhere between the two positions will be reached. But while this technology develops and experience begins to accumulate, it is necessary to train residents in the technique. We discuss our experience with introducing laparoscopic management of ectopic pregnancy into a residency training program. Our results indicate a rapid learning curve, with minimal patient morbidity, brief hospitalization, and rapid convalescence.
Cytologic smears of squamous cell carcinomas (UICC T2 through T4) from the mucosa of the upper aerodigestive tract without cervical lymph node metastases (n = 10) and with metastases (n = 20) were examined. Subsequently, the cytologic smears of the metastases (n = 20) obtained by fine-needle aspiration or following neck dissection were evaluated morphologically. Each specimen was then stained with Papanicolaou and Feulgen techniques, and quantitative DNA measurements were performed with an image analysis system. Morphologically, the primary tumors with metastases revealed an increased mean nuclear perimeter and mean nuclear area compared with tumors unassociated with metastases. On quantitative DNA measurements, the tumors with metastases had an increased DNA content, a higher 2c deviation index, and a higher DNA malignancy grade and increased number of aneuploid cells. The specimens obtained from the metastatic nodes yielded the highest values for mean DNA content, 2c deviation index, aneuploidy, and malignancy grade. The stem lines of metastasis were always nondiploid. These data indicate a positive correlation between aneuploid tumor cell clones in primary cancer and the manifestation of lymph node metastases.
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Leakage of cerebrospinal fluid may complicate surgical procedures of the temporal bone and skull base. This presentation details experience utilizing 7 days lumbar drainage in an attempt to prevent the occurrence of a postoperative CSF fistula. Thirty-nine patients underwent surgery for various intracranial pathologies and were felt to be at high risk for the development of postoperative CSF fistulae. None of the patients was given prophylactic antibiotics. Ten patients developed clinical and laboratory findings consistent with early meningitis and were treated with appropriate antibiotics. Three patients eventually developed a CSF fistula, with two resolving spontaneously and the third requiring a second surgical procedure to repair the dura (again using lumbar drainage postoperatively). Our conclusions suggest that prophylactic placement of a lumbar catheter in high risk patients increases the likelihood of successful dural closure with an acceptable morbidity. Is these patients routine antibiotic coverage is not indicated.
Since up to 45% of patients with atypical Papanicolaou smears have been shown to have significant pathology, women with persistent atypia are usually referred for colposcopy. This study evaluated the use of a new adjunctive screening test, speculoscopy, in selecting women with atypical Papanicolaou smears who would most benefit from referral for colposcopy. Both screening and referral patients were evaluated with the Papanicolaou smear, speculoscopy and colposcopy at 10 study centers. Biopsies were obtained from most women with positive colposcopy. The results in patients with atypical smears were used to perform a cost-benefit analysis of each of three management protocols. Using the results of speculoscopy to select women with atypical Papanicolaou smears for colposcopy provided a cost-effective alternative to performing colposcopy either on all women or on those with persistent atypia following treatment. Even when all women undergo speculoscopy at the time of screening, this protocol provides a cost savings of up to 24% and no significant loss of diagnostic accuracy. These data suggest that speculoscopy performed at the time of initial screening can accurately select women with atypical Papanicolaou smears who require colposcopy for diagnostic biopsy in a cost-effective manner.
OBJECTIVES: We attempted to determine the clinical usefulness of a preoperative platelet count for predicting malignancy in patients presenting with a pelvic mass. Additionally, in patients in whom a preoperative serum CA 125 level was also determined, the clinical usefulness was compared. STUDY DESIGN: A retrospective review of charts of 241 patients presenting with a pelvic mass was carried out. The patients were then divided by pathologic diagnosis into group 1, benign disease (n = 102), and group 2, invasive (n = 121) or borderline (n = 18) malignancies. Thrombocytosis (platelet count greater than 400,000/microliters) was present in 16% (n = 16) of patients in group 1 and in 56% (n = 78) of patients in group 2 (p less than 0.0001). Of the 241 patients, 130 also had preoperative serum CA 125 levels measured. Elevated values of serum CA 125 (greater than 35 U/ml) occurred in 14% (n = 8) of group 1 and in 81% (n = 60) of group 2 (p less than 0.0001). The chi 2 test was used to analyze results of data. RESULTS: Statistically significant differences in preoperative platelet count and serum CA 125 values were found between group 1 and group 2 patients. The specificity and positive predictive value for thrombocytosis (84% and 83%) compared well with those for serum CA 125 (86% and 88%). The combined use of the tests resulted in specificity of 96% and positive predictive value of 95%. CONCLUSIONS: Preoperative platelet count is a test that is rapidly available and easily obtained. The test results may be of value in planning the original management of women presenting with a pelvic mass.
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Concerning malignant tumours of the oral cavity, pharynx and larynx, bone metastases are in general rarely seen. For the specification to which patients the whole body bone scintigraphy as detection method should be applied, the findings of 370 patients were analysed retrospectively. In respect of primary staging, bone metastases could be found by scintigraphy in only 1.4% of the patients. On the other hand, there was a detection rate of 12% during the further course of the disease, especially in case of clinical symptoms pointing at spreading metastases or in tumour recurrences. Nevertheless, positive scan findings which were not due to metastases could be found in both groups with equal frequency (12 and 13%, respectively). Therefore the routine performance of whole body bone scintigraphy as a screening method does not seem to be useful in the primary staging of cancer of the mouth, pharynx and larynx. Contrary to this, in the follow-up of these tumours bone scanning proves to be a valuable and sensitive method for detecting skeletal metastases.
Tumors of the infratemporal fossa may extend superiorly into the middle cranial fossa and inferiorly into the retromaxillary space. Surgical removal commonly requires an interdisciplinary skull base team, which may have to approach the tumor from above and below in order to resect it. In an attempt to resect infratemporal fossa tumors of this magnitude with a single surgical approach, a pterional trephination (with or without removal of the zygomatic arch) was utilized in 13 cases to define its usefulness and limitations. In nine cases the histologic examination revealed a diagnosis of meningioma, in three, adenoid cystic carcinoma, and in one, undifferentiated carcinoma was found. Postoperative computed tomography was performed in all cases to assess the completeness of tumor resection. This article will detail the successful use of this single-stage approach to intra- or extradural lesions that originate in the infratemporal fossa.
Seven cases of endometrial stromal sarcoma (five low grade and two high grade) were analyzed immunohistochemically for the presence of estrogen and progesterone receptors. In four cases (three low grade and one high grade), these results were compared to biochemical findings. All low-grade endometrial stromal sarcomas were positive for progesterone receptors using immunohistochemical techniques. These results correlated well with biochemical evaluation of progesterone receptors. The high-grade endometrial stromal sarcomas were negative for progesterone and estrogen receptors by both methods. The advantages of immunohistochemical evaluation of steroid receptors have been well established in breast and endometrial carcinomas. This study demonstrates the usefulness of this technique in endometrial stromal sarcomas.
Ultrasound as a diagnostic aid in the evaluation of the sinuses has been a controversial issue. Sensitivities have been reported from 29% to 100% and specificities from 55% to 99%. These wide variations in results from previous studies may have resulted from technical differences. However, the "gold standard" most often used for comparison has been a Water's view radiograph, which has been shown to correlate poorly with intraoperative and CT scan findings. To our knowledge, no one in the English language literature has evaluated sonography of the sinuses with computed tomography as the gold standard. In addition, evaluation of the ethmoid sinus has been neglected by previous studies that have primarily assessed the maxillary sinus. We report the results of a blinded, prospective trial comprised of 41 patients examined by B-mode ultrasound with comparison to computed tomography. Frontal and maxillary sinuses were examined with traditional sonographic techniques and the ethmoid sinuses were scanned with a transglobe technique not previously evaluated in the English language literature. Excluding isolated mucous retention cysts and focal minimal mucosal thickening (defined as < 4 mm), sensitivities for ultrasound of the maxillary, frontal, and ethmoid sinuses were 100% each. Specificities were 98% for the maxillary sinus, 100% for the frontal sinus, and 94% for the ethmoid sinus. Technical aspects and implications of this and previous reports will be discussed.
Tracheomalacia resulting from tracheostomy or compressive thyroid disease often represents a difficult problem in airway management. In an attempt to improve this condition, biocompatible ceramic rings were surgically implanted in 16 patients to restore normal patency of the airway by first expanding the tracheal lumen lateral, and then in an anterior dimension. Preoperatively, patients displayed moderate to severe obstruction with marked restrictions in lifestyle, as confirmed by history, physical examination, and airway resistance studies. Additionally, three of these patients were trach-dependent at the time of implantation. Postoperatively all 16 patients have normal airway resistance parameters with a dramatic improvement in lifestyle, whereas the three with tracheostomy were successfully decannulated. The routine use of these rings has alleviated the need for rib/cartilage grafts, primary resections with anastomosis, prolonged periods of cannulation, and multiple surgeries. Our experience in the use of ceramic rings for tracheomalacia repair will be presented, highlighting selection criteria for their use, intraoperative placement, perioperative complications, and post-operative followup for a minimum of 6 months.
Ultrasonography of the parotid gland was introduced in 1989 as part of the diagnostic protocol of every patient treated in our clinics with acute facial paralysis. Ten of 50 patients so tested were found to have unilateral nonpalpable enlarged lymph nodes in the caudal portion of the parotid gland around the stylomastoid foramen. All 10 patients were eventually diagnosed as having Lyme disease. It is suggested that in patients with acute facial paralysis, ultrasonography is an inexpensive tool to improve diagnosis of Lyme disease and may have a more useful purpose in monitoring therapy.