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PubMed2006

Coagulation abnormalities in critically ill patients.

Many critically ill patients develop hemostatic abnormalities, ranging from isolated thrombocytopenia or prolonged global clotting tests to complex defects, such as disseminated intravascular coagulation. There are many causes for a deranged coagulation in critically ill patients and each of these underlying disorders may require specific therapeutic or supportive management. In recent years, new insights into the pathogenesis and clinical management of many coagulation defects in critically ill patients have been accumulated and this knowledge is helpful in determining the optimal diagnostic and therapeutic strategy.

Blood Coagulation↗
PubMed2005

Sustained attention in patients with mild traumatic brain injury.

OBJECTIVE: To demonstrate that two tests of sustained attention were sensitive to attention deficits in patients with mild traumatic brain injury (TBI). DESIGN: A cross-sectional study recruiting 51 patients with TBI and 51 matched controls. OUTCOME MEASURES: The Sustained Attention to Response Task (SART) and Monotone Counting Test. RESULTS: The patient groups performed significantly worse than the normal controls in both sustained attention tests. The SART performance was also correlated with pathology severity in the patient group in terms of loss of consciousness (r = 0.247, p = 0.05). A cut-off of less than 1 standard deviation (SD) gives optimal diagnostic information in terms of sensitivity in the present sample (0.61 for Monotone Counting Test; 0.75 for SART). CONCLUSION: These findings suggest that the SART and Monotone Counting Test are sensitive to patients with mild TBI. The SART-assessed sustained attention is also sensitive enough to detect attention impairment in this clinical group regardless of diagnosis and may provide clinicians with an alternative method of assessing sustained attention in these clinical groups.

Attention↗
PubMed2006

Cutaneous community-associated methicillin-resistant staphylococcus aureus among all skin and soft-tissue infections in two geographically distant pediatric emergency departments.

OBJECTIVES: To describe the culture results of cutaneous infections affecting otherwise healthy children presenting to two pediatric emergency departments (EDs) in the southeastern United States and southern California. METHODS: Medical records of 920 children who presented to the pediatric EDs with skin infections and abscesses (International Classification of Diseases, Ninth Revision codes 680.0-686.9) during 2003 were reviewed. Chronically ill children with previously described risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) were excluded. Data abstracted included the type of infection; the site of infection; and, if a culture was obtained, the organism grown, along with their corresponding sensitivities. RESULTS: Of the 270 children who had bacterial cultures obtained, 60 (22%) were CA-MRSA-positive cultures, most cultured from abscesses (80%). Of all abscesses cultured, CA-MRSA grew in more than half (53%). All CA-MRSA isolates tested were sensitive to vancomycin, trimethoprim-sulfamethoxazole, rifampin, and gentamicin. One isolate at each center was resistant to clindamycin. The sensitivities at both institutions were similar. CONCLUSIONS: The authors conclude that CA-MRSA is responsible for most abscesses and that the pattern of CA-MRSA infections in these geographically distant pediatric EDs is similar. These data suggest that optimal diagnostic and management strategies for CA-MRSA will likely be widely applicable if results from a larger, more collaborative study yield similar findings.

Abscess↗
PubMed1985

A characteristic pattern of leukemic cell differentiation without cytoreduction during remission induction in acute promyelocytic leukemia.

While differentiation of leukemic cells in vitro is well established, the role of differentiation in vivo is not defined and is generally attributed to differentiation inducers. In five patients with acute promyelocytic leukemia (APL) an unusual pattern of a slow and progressive decrease of immature blasts with a concomitant increase in mature cellular elements was observed following intensive combination chemotherapy. All patients eventually achieved complete remission, four of them without an intermediate phase of marrow hypoplasia. This morphologic pattern of response suggests that leukemic cellular differentiation rather than cytotoxicity was one mechanism involved in remission induction. Cytogenetic studies of remission revealed disappearance of the cytogenetic marker, the balanced translocation between the long arms of chromosomes 15 and 17. This remission induction process appears to be due to the cellular biologic characteristic rather than the therapy used as it occurs in a substantial proportion of patients with APL. It should be considered for optimal diagnostic and therapeutic decisions.

Acute Disease↗
PubMed1992

Expression of myeloid-associated and lymphoid-associated cell-surface antigens in acute myeloid leukemia of childhood: a Pediatric Oncology Group study.

PURPOSE: Although the expression of both myeloid- and lymphoid-associated cell-surface antigens in acute myeloid leukemia (AML) has been described, the clinical significance of such antigen expression remains unknown in the pediatric population. We sought to define an antibody panel for optimal diagnostic antigenic analysis and to test associations among antigen expression and a number of clinical features at presentation and prognosis in pediatric AML. PATIENTS AND METHODS: We reviewed the extensive immunophenotypic analysis performed at the time of diagnosis on 132 assessable patients registered on a single Pediatric Oncology Group AML protocol between 1984 and 1988. RESULTS: Eighty-eight percent of patients were identified by testing for expression of CD33 and CD13. Overall, 61% of patients expressed at least one lymphoid-associated antigen, most commonly CD4, CD7, or CD19. Expression of CD5, CD10, CD20, or CD22, commonly detected in T- or B-lineage pediatric acute lymphoid leukemia (ALL), was uncommon; coexpression of multiple lymphoid-associated antigens was also uncommon. Expression of the monocyte-associated antigen CD14 correlated with French-American-British (FAB) M4 or M5 morphology. Otherwise, no correlation between antigen expression and FAB classification was noted. None of the myeloid, lymphoid, natural-killer (NK), or progenitor-associated antigens were associated with significant differences in the likelihood of remission induction or event-free survival when expressor versus nonexpressor groups were compared. CONCLUSIONS: The distribution of cell-surface antigen expression in pediatric acute leukemia usually permitted the discrimination of AML from ALL by using a limited panel of antibodies. Although the expression of lymphoid-associated antigens was common, such expression did not seem to be associated with an adverse prognosis in pediatric AML.

Acute Disease↗
PubMed2005

Cushing's syndrome during pregnancy: personal experience and review of the literature.

Cushing's syndrome (CS) occurs rarely during pregnancy. We investigated and treated four patients with pituitary-dependent Cushing's syndrome during pregnancy over a 15-yr period at the National Institutes of Health. Except for preservation of menses before conception, our patients presented with typical clinical features, increased urinary free cortisol, and loss of diurnal variation of cortisol. The diagnosis was facilitated, without complications, by the use of CRH testing and inferior petrosal sinus sampling in three women. Transsphenoidal pituitary surgery achieved remission in three women, but there were two fetal/neonatal deaths. This experience and review of 136 previous reports suggest that: 1) urinary free cortisol in CS patients overlaps the normal pregnant range; 2) ACTH levels are not suppressed in adrenal causes of CS, which may be identified by the 8-mg dexamethasone test; 3) inferior petrosal sinus sampling and transsphenoidal pituitary surgery, the optimal diagnostic test and treatment for nonpregnant patients with pituitary-dependent Cushing's syndrome, can safely facilitate the management of pregnant patients; and 4) surgery may achieve remission during pregnancy, but the prognosis for the fetus remains guarded. It is likely that earlier recognition and treatment would improve outcome. There is a need for development of criteria for interpretation of diagnostic tests and increased consideration of CS in pregnancy.

Adrenocorticotropic Hormone↗
PubMed1996

The etiology of pleural effusions in an area with high incidence of tuberculosis.

To investigate the etiology of pleural effusions in our region, we undertook a prospective study of patients with this condition in our centers. During a 5-year period, we studied 642 pleural effusion patients aged 57.1 +/- 21.1 years, of whom 401 were men aged 56.5 +/- 21 years and 241 were women aged 57.8 +/- 21.4 years; the male/female ratio was 1.6:1. The most frequent cause of pleural effusion was tuberculosis (25%), followed by neoplasia (22.9%) and congestive heart failure (17.9%). The etiology of 48 cases (7.5%) remained uncertain. In the neoplastic effusion group, the most frequent locations of the primary tumor were lung (32.6%), breast (11.5%), lymphoma (10.8%), and ovary (7.5%); in 21 cases (14.3% of the neoplastic group), it was not possible to identify the primary tumor. The 111 patients aged younger than 40 years with tuberculous effusions made up 69.4% of tuberculous effusion cases and the same percentage of patients younger than 40 years; the proportion of effusions that were tuberculous peaked in the 11- to 30-year-old age group and declined steadily thereafter. Of the patients with neoplastic effusions, 83% were older than 50 years; the proportion of effusions that were neoplastic rose steadily from zero in the 0- to 30-year-old age group to a peak among 60- to 70-year-olds. The age-wise distribution of effusions secondary to congestive heart failure was similar to that of neoplastic effusions. Of the effusions secondary to congestive heart failure, 86% (99/115) affected the right pleura or both, and 83% of effusions secondary to pulmonary thromboembolism (15/18) affected the right side. Neoplastic, tuberculous, parapneumonic, empyematous, and other exudative effusions showed no preference for either side. Of the 97 bilateral effusions, 77 (79.4%) were secondary to heart failure (59, 60.8%) or neoplasia (18, 18.6%). We conclude that in our region, the most frequent cause of pleural effusion is tuberculosis, followed by neoplasia and congestive heart failure. We suggest that all those interested in pleural disease should determine the etiologic pattern of pleural effusion in their region with a view to the adoption of regionally optimized diagnostic and therapeutic attitudes.

Adolescent↗
PubMed1983

Bronchogenic carcinoma presenting as an endobronchial mass.

The purpose of this study was to determine the optimal number of biopsy specimens which should be taken of an endobronchial mass lesion to assure the diagnosis of bronchogenic carcinoma. Five biopsies were performed on each of 18 consecutive mass lesions. Before biopsy, the tumor was well visualized, cleared of blood if possible, and the forceps carefully placed on the mass. Each biopsy specimen was placed in a separate coded container so that the pathologic interpretation was blind to the order in which the samples were taken. Ten out of a total of 90 biopsy specimens were negative for tumor and all of the tumors were diagnosed within the first three biopsy samples. The totals of negative diagnoses for each of the five biopsy specimens were not significantly different by the approximate Cochran Q test (p = 0.441) or by the exact test (p = 0.360), and no evidence was found for dependence of successive biopsies (p = 0.106) or for a patient effect (p = 0.325). The estimated probability of obtaining a diagnosis of malignancy after one biopsy was .889; after two biopsies, .9877; and after three, .9986. The yield is not meaningfully increased with more biopsies being done. We suggest performing three biopsies of endobronchial mass lesions to achieve an optimal diagnostic yield with minimal risk of bleeding.

Adenocarcinoma↗
PubMed1991

Utility of bronchoscopic sampling techniques for cryptococcal disease in AIDS.

Although cryptococcal pneumonia is a well recognized complication of the acquired immunodeficiency syndrome, optimal diagnostic approaches remain to be defined. During a 32-month period (October 1984 to June 1987), 11 patients were diagnosed with CP at our institution. The diagnosis was established in all 11 patients from specimens obtained via fiberoptic bronchoscopy (ten) and/or double-lumen catheter lavage (one). Direct stains of sedimented bronchoalveolar lavage were positive for organisms characteristic of Cryptococcus neoformans in nine of 11 patients. Transbronchial biopsies were positive (special histologic stains) in six of eight patients; bronchial washings were positive (direct smear) in seven of ten patients, the bronchial brushings were positive on stain in six of nine patients, and in one patient, a Wang transbronchial needle aspirate was positive on stain. Fungal cultures were positive on the BAL in seven of 11 patients, and on the bronchial washings in four of ten patients; the TBBx culture samples were all negative (zero of three). The serum cryptococcal antigen titer was elevated (median = 1:1024) in all eight patients in which it was assayed. Our data suggest that BAL and bronchial washings have a combined sensitivity on smear equal to that of TBBx and superior to that of TBBx fungal culture. The TBBx does not appear to be necessary in this setting. In addition, an elevated serum cryptococcal antigen titer appears to be an important adjunct in the evaluation of pulmonary infiltrates in AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Recent advances in diagnosis and therapy of human papillomaviruses.

Infection with human papillomavirus is extremely common throughout the world. Almost 50% of sexually active young women are infected with human papillomavirus and although most infections are transient, a subset has the potential to progress to invasive cancer. During the last 20 years, our understanding of the human papillomavirus life cycle and the role of human papillomavirus in human cancer has dramatically increased. Recent technological advances in human papillomavirus detection have provided the means to detect the presence of human papillomavirus with great sensitivity. In the context of patient care, there is still substantial debate regarding the optimal diagnostic and prognostic use of information derived from hybrid capture or polymerase chain reaction-based detection. The inventory of available treatment options is growing somewhat slowly. The most promising advances are being made in the clinical evaluation of candidates for prophylactic vaccination. This review is focused on the current status and future directions of prevention, diagnosis and therapy.

Animals↗
PubMed2004

Usefulness of simultaneous evaluations of contractile reserve, perfusion, and metabolism during dobutamine stress for predicting wall motion reversibility (myocardial stunning) after successful PTCA.

The optimal diagnostic approaches using contractile reserve, perfusion, and free fatty acid metabolism together for identifying myocardial stunning after reperfusion have not been clarified in the clinical setting. We investigated the usefulness of simultaneous evaluation of these parameters during myocardial stunning to predict the functional recovery in infarct-related myocardium after reperfusion. In 43 patients (60.7 +/- 10.4 years) with successful coronary angioplasty early after a first myocardial infarction, low-dose (5 to 10 microg/kg/min) dobutamine stress thallium-201/iodine-123 beta-methyl-iodophenyl pentadecanoic acid (BMIPP) dual-isotope single photon emission computed tomography was performed with echocardiography in the acute phase within 1 week after reperfusion. Regional wall motion and the uptake of each tracer were obtained simultaneously in the infarct-related segments. In 93 segments with dyssynergy in the acute phase after reperfusion, the sensitivity, specificity, and accuracy using contractile reserve for predicting the final functional recovery in the chronic phase more than 3 months after PTCA were 81.3%, 67.2%, and 72%, respectively. More accurate predictions were obtained by simultaneous measurements of thallium-201 and BMIPP uptakes (93.8%, 66.7%, and 79.4%, respectively). The final functional recovery in the stunned myocardium after early reperfusion following acute myocardial infarction was predicted more accurately by simultaneous evaluation of these parameters at dobutamine stress testing.

Aged↗
PubMed1976

Optimal visualization of esophageal varices.

Twelve patients with known esophageal varices and willingness to cooperate were included in the study. Medications administered were placebo, 2 mg of glucagon, and 30 mg of propantheline bromide. All medications were given double-blind and crossover. On the basis of this study the authors believe that for optimal visualization of esophageal varices the following is the procedure of choice: (1) the patient should remain horizontal (this is best done in the left lateral position for comfort and ease of expectoration) for ten minutes after swallowing high density barium; (2) the patient should "clear his throat" frequently and expectorate all saliva (barium sticks to the pharynx and makes the patient want to swallow and "clearing his throat" by forced expiration helps the patient to expectorate this coating and prevents swallowing); (3) filming should be done in expiration in the supine (left posterior oblique to table top) position; and (4) in equivocal cases the examination can be repeated with an anticholinergic drug if the patient has no contraindications to its use. The patient should empty his bladder just before administration of the drug. The intelligent use of these factors should result in a saving of both fluoroscopic time and film, and give the radiologist a safe optimal diagnostic yield.

Adult↗
PubMed1978

Scanning techniques in computed body tomography.

Clinical examinations with the whole body CT scanner require considerable individualization of examination technique in relation to specific organs, anatomic areas, and clinical problems. Careful selection of radiographic factors, patient position, contrast agents, and pharmacologic adjuncts will optimize diagnostic results and patient throughput.

Contrast Media↗
PubMed2002

Development of a perigraft seroma around modified Blalock-Taussig shunts: imaging evaluation.

OBJECTIVE: The modified Blalock-Taussig shunt is a synthetic shunt between the subclavian and pulmonary artery, frequently used in the treatment of children with pulmonary hypoperfusion caused by congenital heart disease. The development of a perigraft seroma is a known complication of this procedure. We sought to describe the imaging features of a perigraft seroma and to define an optimal diagnostic strategy in patients with a suspected perigraft seroma. MATERIALS AND METHODS: Between January 1993 and December 1998, 96 children underwent 105 modified Blalock-Taussig shunt procedures. In eight children, 11 cases of perigraft seromas were identified. The mean age of these children at the time of operation was 3 years (range, 6 days to 5 years 8 months). Pre- and postoperative chest radiographs were routinely performed in the children in whom seromas had been found. Additional postoperative radiologic investigations consisted of thoracic sonography (in 11 cases), CT (in eight cases), and MR imaging (in two cases). In all cases of perigraft seroma, the modified Blalock-Taussig shunts were constructed through a posterolateral thoracotomy at the fourth intercostal space. RESULTS: On average, the chest radiographs showed the first signs of the seroma on day 10 after the surgery (range, day 1-day 30). Using thoracic sonography, it was possible to visualize the perigraft seroma and the modified Blalock-Taussig shunt in eight (73%) of 11 cases. CT and MR imaging performed equally well in revealing perigraft seromas. CONCLUSION: As was found in these critically ill children, sonography has an advantage over CT and MR imaging because of its portability and, therefore, capability for bedside use. We recommend the use of sonography as the initial imaging modality in suspected cases of perigraft seroma development.

Blood Vessel Prosthesis Implantation↗
PubMed2004

[Congenital hiatus hernia associated with reflux esophageal stenosis].

A small group of three patients presented in our study represents extraordinary and very complicated problem of congenital hiatus hernia in infant period from 6th to 9th month of life, associated with gastroesophageal reflux and consecutive esophageal stenosis. There are two very rare and delicate entities within differential diagnosis, in the domain of the same pathology: congenitally short esophagus and congenital esophageal stenosis; with completely different surgical options for their treatment. That is why an optimal diagnostics and an adequate operative technique are extremely important for the treatment of hiatus hernia. The uppergastrointestinal barium radiography is definitely the method of diagnosing hiatus hernia, which provides typical, almost pathognomonic image of hiatus hernia accompanied by the esophageal stenosis. Nissen fundoplication is the technique of choice for its surgical treatment, with gastrostomy for probable postoperative esophageal dilatation. The results are more than satisfying: early peroral feeding, with spontaneous resolving of esophageal stenosis, which significantly diminishes the need for esophageal bougienage.

Esophageal Stenosis↗
PubMed1998

Scapulothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation.

Clinical examinations and biomechanical analysis of the shoulder often include an assessment of the scapulohumeral rhythm. It is important to understand factors which may affect the scapulohumeral rhythm so that optimal diagnostic and therapeutic strategies can be devised. The purpose of this study was to determine if the scapulohumeral rhythm, when assessed under dynamic conditions, is altered as a result of a fatigue-inducing exercise. Twenty-five subjects were required to elevate their arm against maximum resistance until they were no longer able to completely elevate their arm. Three-dimensional kinematics were measured using an electromagnetic tracking system. Electromyographic activity was recorded from the upper trapezius, lower trapezius, serratus anterior, and the middle deltoid muscles. Power frequency spectrum using the Fast Fourier Transform and the root mean square signal amplitudes were determined for each muscle. The scapulohumeral rhythm was determined using least squares regressions of humeral elevation to scapular upward rotation for 20% intervals (phases) of elevation for each subject. The results showed that during the midrange of elevation to maximum elevation [phases 3-5 (60-150 degrees)], the scapulohumeral rhythm decreased with fatigue, and that the decrease in the scapulohumeral rhythm was associated with myoelectric indicators of fatigue (median power frequency). The study suggests that shoulder fatigue affects the way in which the scapula moves concomitantly with the humerus. Fatigue tends to result in increased motion of the scapula, which alters the scapulohumeral rhythm.

Adolescent↗
PubMedDate not supplied

Pheochromocytoma and paraganglioma in children: a report of 24 cases of the French Society of Pediatric Oncology.

Pheochromocytoma and paraganglioma of childhood are rare neuroendocrine tumors. Urinary catecholamine measurements, metaiobenzylguanidine (MIBG) scanning, computed tomographic scanning, and magnetic resonance imaging have greatly facilitated diagnosis. Prognosis after surgical resection is excellent. In this retrospective series collected from French oncology centers, the risk of tumor progression was studied in order to assess prognostic factors and the optimal diagnostic and therapeutic management. Medical records of 24 children with paraganglioma were reviewed. This tumor occurred at a median age of 12.5 years and in most cases was revealed by arterial hypertension. The diagnosis was made by the demonstration of urinary excretion of catecholamines and their metabolites. Six patients had bilateral adrenal pheochromocytomas; two patients had extra-adrenal paragangliomas. In eight patients, the paraganglioma occurred as a familial disease. Surgical excision was the only therapeutic procedure. With a follow-up of 5.2 years, 14 of the patients are still in first complete remission and 6 have developed metastases or shown tumor progression. Despite a high long-term survival rate, the risk of malignancy and of multifocal involvement is of concern and is associated with a significant rate of late events. The outcome depends on adequacy of tumor resection and must be serially assessed.

Adolescent↗
PubMed2006

Drug-resistant temporal lobe epilepsy due to cavernous malformations.

OBJECT: Supratentorial cavernous angiomas may be associated with drug-resistant focal epilepsy. Surgical removal of the malformation may result in seizure control in a number of patients, although in most studies a long history and high frequency of attacks have been recognized as indicators of unfavorable seizure outcome. In the literature, there are no clear indications regarding the optimal diagnostic presurgical workup and the surgical strategy for this particular subgroup of patients with symptomatic epilepsy. In this paper the authors focus on the preoperative workup and the surgical management of the disease in eight consecutive patients undergoing surgery for drug-resistant temporal lobe epilepsy (TLE) due to cavernous malformations (CMs), and the relevant literature on this issue is also reviewed. METHODS: Preoperatively, all patients were assessed using a noninvasive protocol aimed at localizing the epileptogenic zone on the basis of anatomical, electrical, and clinical criteria. The presurgical assessment yielded an indication for lesionectomy in two cases, lesionectomy plus anteromesial temporal lobectomy in four cases, and lesionectomy plus extended temporal lobectomy in two cases. At follow-up examinations, seizure, neuropsychological, and psychiatric outcomes were all evaluated. Seven patients were categorized in Engel Class IA (seizure free), and one was categorized in Engel Class IB (occasional auras only). No adverse effects on neuropsychological or psychosocial functioning were observed. CONCLUSIONS: Epilepsy surgery can be performed with excellent results in patients with intractable TLE caused by CMs. Noninvasive presurgical evaluation of these patients may enable a tailored approach, providing complete seizure relief in most cases.

Adult↗