Biomedical subjects
Publications and source records attributed to W King.
A case of clinically and mammographically occult invasive ductal carcinoma presenting as a focally dilated duct on ultrasound is reported. The features of ductal dilatation in benign and malignant conditions on ultrasound are highlighted.
BACKGROUND: Breast-conserving surgery combined with radiotherapy has emerged as an alternative to mastectomy for women with early breast cancer, and cosmetic outcome has correlated closely with the psychosocial and physical well-being of the patient. Cosmetic outcome assessment after breast-conserving therapy in Chinese patients has so far not been conducted among the clinicians, the patients or their spouses. METHODS: The cosmetic results from breast-conserving therapy were evaluated in a group of 33 patients who had been selected as suitable for undergoing local excision, axillary dissection and postoperative radiation therapy for early stage breast cancer. The success of the procedures was assessed by the patients, the clinicians and the patient's spouse, and their ratings were compared with each other. RESULTS: Eighty per cent of the patients and their spouse were satisfied with the cosmetic outcome. Using McNemar's test, when the groups were evaluated on a case-by-case basis, there was a good level of concordance between the patients and their spouses, and that of the patients and the clinicians. CONCLUSIONS: Evaluation of the cosmetic and psychosocial sequelae of breast cancer patients is essential when new approaches to treatment are introduced; our data suggest that cosmetically successful breast conservation is feasible in a selected group of Chinese women with early breast cancer.
The value of ultrasound in the diagnosis of a large rapidly growing thyroid mass was assessed in a study of 42 patients with a large (> 3 cm) rapidly growing (< two months) solitary mass. Haemorrhage into a thyroid nodule was present in 31 patients and thyroid malignancy in 11. Ultrasound of haemorrhage into a thyroid nodule revealed a large cystic mass in all 31 patients containing internal debris (22), septations (three), or a combination of both (six). The malignant causes of a large rapidly growing mass were lymphoma (two), anaplastic carcinoma (four) and metastasis (five). Ultrasound of these thyroid malignancies revealed a mass with a smooth, well-defined margin and strikingly low homogeneous echogenicity in all cases. Patients with thyroid metastases had evidence of widespread metastatic disease elsewhere. Lymphoma was differentiated from anaplastic carcinoma on fine-needle aspiration cytology or surgical biopsy. Ultrasound was of value in differentiating between a benign haemorrhagic nodule and a malignant tumour. The various malignant tumours had similar appearances, however, and could not be distinguished on ultrasound.
Facioscapulohumeral muscular dystrophy (FSHD) is an autosomal dominant, 4q35-linked, slowly progressive muscular dystrophy with no known effective treatment. Since prednisone improves strength in Duchenne dystrophy, we performed a pilot, open-label trial of prednisone in eight subjects fulfilling strict diagnostic criteria for FSHD. Prednisone (1.5 mg/kg/day; maximum 80 mg/day) was administered for 12 weeks. Manual muscle testing, maximum voluntary isometric contraction testing, and muscle mass estimations by dual energy x-ray absorptiometry and urinary creatinine excretion were performed at baseline and at 12 weeks. There were no significant changes in strength or muscle mass. We conclude that prednisone given for 12 weeks does not produce major improvement in strength or increase muscle mass in FSHD. The study did not have sufficient power or length of follow-up to address the possibility that prednisone might arrest or slow disease progression.
OBJECTIVE: Peripheral nerve tumors (PNTs) of the neck are uncommon and are frequently mistaken for lymph nodes. The purpose of this study is to describe the sonographic appearance of PNTs in the neck and determine features useful in differentiating PNTs from lymph nodes. CONCLUSION: PNTs of the neck have features that should alert the sonographer to the correct diagnosis. Features of value in differentiating PNTs from lymph nodes include a solitary, oval, hypoechoic mass with posterior enhancement and absence of an echogenic hilum. These features should lead to a careful search for the associated nerve to confirm the diagnosis. In addition, schwannomas have a vascular pattern indicating marked hypervascularity that can be obliterated with light pressure from the probe.
Triage guidelines are needed to help in the decision process of intensive care unit (ICU) versus non-ICU admission for patients with diabetic ketoacidosis (DKA). Pediatric risk of mortality (PRISM) scores have long been used to assess mortality risk. This study assess the usefulness of the traditional PRISM score and adaptation of that score (PRISM-ED, which uses presentation data only) in predicting hospital stay in pediatric patients with DKA. PRISM and PRISM-ED were tested for correlation with length of stay and length of ICU stay. A medical record review was conducted for patients admitted to The Children's Hospital of Alabama with DKA during an 18-month period (n = 79). Two scores were calculated for each study entrant: PRISM using the worst recorded values over the first 24 hours and PRISM-ED using arrival values. Median scores, median test, and Spearman rank correlations were determined for both tests. Median PRISM scores were PRISM = 11 and PRISM-ED = 12; Median PRISM and PRISM-ED scores for patients admitted to the ICU were less than median scores among floor-admitted patients: [table: see text] Spearman rank correlations were significant for both scores versus total stay: PRISM, rs = 0.29; P = 0.009; PRISM-ED, rs = 0.60, P < 0.001. Also, correlations were significant for both scores versus ICU stay: PRISM rs = 0.22, P = 0.05; PRISM-ED, rs = 0.41, P < 0.001. Triage guidelines for ICU versus floor admission for DKA patients could have significant economic impact (mean ICU charge = $11,417; mean charge for floor admission = $4,447). PRISM scores may be an important variable to include in a multiple regression model used to predict the need for ICU monitoring.
Facioscapulohumeral muscular dystrophy (FSHD) is characterized by marked inter- and intrafamilial heterogeneity in its clinical expression. The contribution of genetic factors to this variability is not well characterized. We examined the relationship of phenotype to genotype in a clinically and genetically well-defined FSHD population. Quantitative isometric myometry (QMT) scores, normalized for age, gender, and height, were used to quantify disease severity. We found a significant (r = 0.92, p < 0.004) correlation between disease severity and the size of the 4q35-associated deletion. In addition, when relative disease severity of parent-offspring pairs was compared, the offspring were found to be significantly more severely affected (p = 0.011). This generational effect suggests the presence of anticipation in FSHD and raises the possibility of an underlying dynamic mutation.
Axillary lymph node status is important in the staging of breast carcinoma. To evaluate the accuracy of technetium-99m sestamibi breast scintigraphy in detecting metastatic axillary lymph nodes as compared with other accepted imaging modalities, we performed 99mTc-sestamibi breast scintigraphy, conventional mammography and ultrasound in 36 patients with primary untreated breast carcinoma. With histopathology as the gold standard, 99mTc-sestamibi breast scintigraphy was found to yield true-positive results in 7 of 11 cases (64%) of axillary lymph node metastases and true-negative results in 18 of 20 cases (90%); it has an accuracy of 81%, a positive predictive value of 77.8% and a negative predictive value of 81.8%.
Lymphoma and metastases are common causes of cervical lymphadenopathy. Clinical examination alone is unable to differentiate the two. Ultrasound (US) with its high sensitivity and specificity when combined with a find needle aspiration cytology (FNAC) is therefore the ideal initial investigation. We present the spectrum of findings in 19 patients with non Hodgkins lymphoma (NHL), 15 patients with pharyngeal, laryngeal and oesophageal (PLO) carcinomas, 22 patients with oral cavity tumours and 12 patients with infraclavicular carcinomas. The US features found consistently useful in differentiating NHL from other metastases were the distribution of the nodes, distal enhancement and lack of intranodal necrosis. Other US features of abnormal nodes helped identify abnormality but did not help in differentiation.
The sensitivity and specificity of MIBI breast scintigraphy, conventional mammography and ultrasound in differentiating malignant and benign palpable breast lesions was compared in 48 women. MIBI breast scintigraphy had a sensitivity of 97% a specificity of 69%, a positive predictive value of 87.5% and a negative predictive value of 91.7%. Ultrasound and mammography had comparable results with accuracy rates of approximately 93%. We conclude that MIBI breast scintigraphy may have a complementary role in the evaluation of palpable breast lesions, but is not specific enough to replace current imaging modalities.
Axillary lymph node status is crucial in the evaluation of prognosis and in treatment planning of breast cancer. High-resolution real-time sonographic scans of the breast and both axillae were performed on 114 patients with breast carcinoma, all of whom had axillary lymph node dissection and histologic assessment. The sensitivity of high-resolution ultrasonography in the detection of axillary nodal metastases was 84.1%, with a specificity of 97.1%, accuracy of 92.1%, positive predictive value of 94.9%, and negative predictive value 90.7%. Ultrasonography of the axilla provides good information on anatomy and pathology and may have a potential role in the prognostic work-up of patients who are not surgical candidates.
We prospectively assessed the accuracy of high resolution breast ultrasonography in the diagnosis of palpable breast masses in comparison to clinical palpation and x-ray mammography. Four hundred and eight Chinese women with palpable breast lumps had clinical assessment followed by ultrasonography of the breast, mammography (for women over 35 years), and fine needle aspiration cytology. Excisional biopsy or surgery was performed for suggestive lesions. The clinical, mammographic and ultrasound diagnoses were compared with the final pathologic diagnosis. In the determination of whether a lesion was malignant, the sensitivity, specificity, and positive predictive values were 97%, 97%, and 85%, respectively, for ultrasonography; 92%, 94%, and 84%, respectively, for mammography; and 88%, 92%, and 67%, respectively, for clinical evaluation. The specificity for combined clinical palpation and ultrasonography was higher (99%) than that for combined clinical palpation and mammography (96%). Addition of ultrasonography to combined clinical palpation and mammography increased specificity. Mammography in addition to combined clinical palpation and ultrasonography did not significantly improve the sensitivity, specificity, or positive predictive value. This limited usefulness raises the question as to whether it should be eliminated in the workup of a palpable mass in the average Chinese patient. Its main advantage is the detection of extended foci of carcinoma in situ related to a palpable mass, which often is undetected by ultrasonography.
BACKGROUND: Myoblast transfer has been proposed as a technique to replace dystrophin, the skeletal-muscle protein that is deficient in Duchenne's muscular dystrophy. Donor myoblasts injected into muscles of affected patients can fuse with host muscle fibers, thus contributing their nuclei, which are potentially capable of replacing deficient gene products. Previous controlled trials involving a single transfer of myoblasts have been unsuccessful. METHODS: We injected donor muscle cells once a month for six months to the biceps brachii muscles of one arm of each of 12 boys with Duchenne's muscular dystrophy. The opposite arms served as sham-injected controls. In each procedure 110 million cells donated by fathers or brothers were transferred. The patients were randomly assigned to receive either cyclosporine or placebo. Strength was measured by quantitative isometric muscle testing. Six months after the final myoblast transfer, the presence of dystrophin was assessed with the use of peptide antibodies specific to the deleted exons of the dystrophin gene. RESULTS: There was no significant difference in muscle strength between arms injected with myoblasts and sham-injected arms. In one patient, 10.3 percent of muscle fibers expressed donor-derived dystrophin after myoblast transfer. Three other patients also had a low level of donor dystrophin (< 1 percent); eight had none. CONCLUSIONS: Myoblasts transferred once a month for six months failed to improve strength in patients with Duchenne's muscular dystrophy. The value of exon-specific peptide antibodies in the interpretation of myoblast-transfer results was demonstrated in a patient with Duchenne's muscular dystrophy who had a high percentage of donor-derived dystrophin. Specific variables affecting the efficiency of myoblast transfer need to be identified in order to improve upon this technique.
OBJECTIVE: To determine the outcome and cost for children resuscitated following out-of-hospital cardiopulmonary arrest. DESIGN: Retrospective case series. SETTING: An organized prehospital emergency medical system within Birmingham, Ala, in a county with 150,493 children under the age of 15 years. PATIENTS: Sixty-three pediatric victims of out-of-hospital cardiopulmonary arrest of any cause presenting to the emergency department of a children's hospital. INTERVENTION: Standard resuscitative techniques were performed for all patients until resuscitative efforts were discontinued in the hospital emergency department or successful resuscitation was achieved. MAIN OUTCOME MEASURES: Successful resuscitation, survival to hospital discharge, neurological outcome, final disposition, and cost of hospital care. RESULTS: Of 63 children with out-of-hospital cardiopulmonary arrest treated in the emergency department of a children's hospital, 60 were pulseless and apneic on arrival, 18 (28.6%) were successfully resuscitated and admitted to the intensive care unit, and six (9.5%) were discharged from the hospital. Five of the survivors had severe neurological deficits and one appeared normal. On follow-up, two patients had died (1 month and 7 months after discharge), three were in a vegetative state, and one was normal. The normal patient had successful defibrillation prior to arrival at the emergency department. The average inpatient charge was $10,667 per patient for those who died and $100,000 for those discharged. CONCLUSIONS: Aggressive treatment does not lead to intact survival for victims of out-of-hospital cardiopulmonary arrest who present to the pediatric emergency department with a preterminal rhythm and absence of spontaneous circulation. Resuscitation efforts in the emergency department are commonly successful but lead to death or severe neurological sequelae at discharge with extremely high cost of care.
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Tuberculous adenitis and metastatic nodes from Nasopharyngeal carcinoma may have a similar clinical presentation. Clinical examination and laboratory tests alone are unable to differentiate the two. However, ultrasound is a useful initial investigation in differentiating these two conditions. We present ultrasound appearances in 33 patients with proven tuberculous cervical adenitis and 32 patients with proven metastatic nasopharyngeal carcinoma. The ultrasound features we found useful were the distribution of the nodes, cystic change, matting and surrounding soft tissue oedema. The size, shape and internal architecture of the nodes, previously described criteria in differentiating benign from malignant nodes, did not help.
The ultrasound appearances and histological correlation of metastatic cervical lymph nodes in 20 patients with papillary carcinoma of the thyroid are presented. The majority of the malignant nodes were homogeneous (81.2%), hyperechoic (87.5%) compared to adjacent sternomastoid muscle and 68.7% showed peripheral punctate calcification on US and histology. Histology revealed that the peripheral echogenic foci seen within the nodes on US correlated with psammoma bodies which are characteristic for papillary carcinomas, highlighting the importance of recognizing peripheral punctate calcification in the cervical nodes as a useful sign for the diagnosis of metastatic papillary carcinoma of the thyroid.