[Knowledge of Andalusian pediatricians and parents about early-onset tooth decay]. / Conocimiento de pediatras y padres andaluces sobre caries de aparición temprana.

OBJECTIVES: To determine the level of knowledge of pediatricians and parents from Andalucía (southern Spain) about early-onset tooth decay, and to assess if pediatricians provide information to parents about pediatric oral care and visits to the pediatric dentist. MATERIAL AND METHOD: A random sample of 113 pediatricians and 112 parents with children under 3 years of age received an anonymous questionnaire comprising 14 items for pediatricians and 16 items for parents, grouped into five blocks: visits to the dentist, oral hygiene, caries, nutritional habits, and treatment of caries. The chi-squared test was used to assess differences between groups. RESULTS: Pediatricians showed deficiencies in their knowledge about visits to the dentist and treatment of caries, however their level of knowledge on oral hygiene, tooth decay and nutritional habits were adequate. Parents showed a low level of knowledge in all aspects of the study, mainly about the treatment of tooth decay. There were no significant differences between pediatricians and parents in the knowledge about visits to the dentist, however pediatricians had more knowledge than the parents about hygiene, tooth decay, nutritional habits and treatment (P<0.001). Most of the parents indicated that pediatricians did not provide them detailed information on oral care, and about the possibility of visiting a pediatric dentist. CONCLUSIONS: Andalusian pediatricians should improve their knowledge about early-onset tooth decay, and provide more information to parents about the oral care and the possibility of visiting a pediatric dentist. Parents have a very low level of knowledge about early-onset tooth decay, and particularly about treatment.

Influence of the antioxidant content of saliva on dental caries in an at-risk community.

OBJECTIVE: This study aims to evaluate the relationship between the total antioxidant capacity of saliva and the presence of dental caries in deciduous and permanent teeth, in a group of Saharan children. METHODS: The dental examination was carried out in accordance with the recommendations of the World Health Organization (WHO). The total antioxidant capacity of the saliva was determined by colorimetry. RESULTS: The total antioxidant capacity (TAC) of the saliva of patients with caries in deciduous teeth was 2.89 1/IC50 greater than among those without. We observed a statistically significant linear regression between the number of deciduous teeth affected by caries and the total antioxidant capacity of the saliva: y = 0.24 + 0.53 x TAC saliva (t = 2.93; p = 0.004) (95% CI of b: 0.018-0.088). CONCLUSIONS: Our results show that the amount of caries in deciduous teeth is in direct proportion to the observed TAC of saliva, and that the presence of caries in deciduous teeth is associated with caries in permanent teeth.

An update on vulvar cancer.

Vulvar cancer is a rare gynecologic malignancy whose primary treatment is surgical. It is not uncommon for patients to delay seeking medical attention or for physicians to delay diagnosing the condition. The most prevalent vulvar cancer is squamous cell carcinoma, with vulvar melanoma being the second most common. The basic understanding of the anatomy and the mechanisms of lymphatic spread have made modifications in surgical technique possible, allowing less radical excisions with significantly less morbidity. New approaches using lymphatic mapping with sentinel node dissection appear promising for the future treatment of early vulvar cancers.

The impact of intraoperative autologous blood transfusion during type III radical hysterectomy for early-stage cervical cancer.

OBJECTIVE: The aim of this study was to determine the effects on transfusion rates, perioperative complications, and survival of using intraoperative autologous blood transfusions for patients undergoing type III radical hysterectomy and lymphadenectomy. STUDY DESIGN: A retrospective analysis was conducted on 156 patients treated with type III radical hysterectomy and lymphadenectomy at the University of Miami School of Medicine from 1990 to 1997. One group of patients (n = 50) had intraoperative autologous blood transfusions and the other (n = 106) did not. RESULTS: The group that received intraoperative autologous blood transfusion had a significant reduction in homologous blood transfusions (12% vs 30%; P =.02). Patient demographic data, histologic parameters, and operative factors were similar between the 2 groups. There was a higher percentage of patients with positive pelvic lymph nodes in the group that did not receive intraoperative autologous blood transfusion (10% vs 30%; P =.02). Seven patients in the intraoperative autologous blood transfusion group (14%) died with disease present and all the recurrences in this group were local. CONCLUSION: The use of intraoperative autologous blood transfusions during type III radical hysterectomy and lymphadenectomy appears to be safe and effective without compromising rates and patterns of recurrence.

Generation of tumor-specific cytotoxic T lymphocytes by stimulation with HPV type 16 E7 peptide-pulsed dendritic cells: an approach to immunotherapy of cervical cancer.

OBJECTIVE: The aim of this study was to generate HPV-16 E7 peptide-specific cytotoxic T lymphocytes (CTLs) in vitro for future adoptive immunotherapy of cervical cancer. METHODS: Peripheral blood mononuclear cells (PBMC) were isolated from HLA-A2+ healthy donors. The PBMCs were incubated with HPV-16 E7(11-20) peptide and varying cytokines in the primary culture. Restimulation was performed weekly with peptide-pulsed, irradiated autologous PBMCs. Alternatively, the PBMCs were depleted of abundant CD4+ cells and stimulated with HPV-16 E7(11-20) peptide-pulsed dendritic cells. Cytolytic activity was determined by a standard 4-h (51)Cr-release assay. RESULTS: After 6 weeks in culture, we were able to establish peptide-specific CTL lines in one of seven donors by incubating PBMCs with HPV-16 E7(11-20) peptide. When we employed autologous peptide-pulsed dendritic cells to stimulate CD8+ cell-enriched PBMCs, we obtained CTL lines in four of seven donors. The primed CTLs were able to lyse the HLA-A2+ and HPV-16+ cervical cancer cell line Caski. SiHa, an HLA-A2-, but HPV 16+, cervical cancer cell line could be lysed only after transfection with HLA-A2. In addition, a high cytotoxicity (>80%) was obtained against peptide-pulsed, but not unpulsed, targets such as autologous Ebstein-Barr virus-immortalized B cells or allogeneic lipopolysaccaride-stimulated PBMCs. DCs were clearly the most potent of all tested antigen presenting cells to stimulate a CTL response in a proliferation assay. CONCLUSION: HPV-16 E7 peptide-specific CTLs could be generated in vitro. A practical protocol to expand the CTLs to a sufficient number for an application in a clinical trial is in progress.

Management of early and late complications of ileocolonic continent urinary reservoir (Miami pouch).

PURPOSE: The object of this study is to review our experience and formulate a plan for early recognition and effective management of early and late complications seen in patients who have undergone construction of the ileocolonic continent urinary reservoir. METHOD: Charts of patients who underwent continent urinary diversion at the Division of Gynecologic Oncology, University of Miami School of Medicine, from 1988 to 1996 were reviewed. We analyzed our data in terms of early and late (beyond 6 weeks) complications resulting directly from the operation or from this form of urinary diversion. RESULTS: Urinary diversion via the continent ileocolonic reservoir has been performed at our institution since February 1988. Sixty-six women have undergone construction of the Miami pouch over the past 81 years. Sixty-three of 66 patients needed a reservoir as a part of total pelvic exenteration for persistent or recurrent gynecologic malignancy. Three patients underwent reservoir construction for repair of vesicovaginal fistula. Sixty-two of 66 patients (95%) have a history of prior pelvic radiation. A total of 35 patients (53%) suffered early complications resulting in an operative mortality rate of 9% (6 of 66 patients). Early complications related to the construction of the reservoir included ureteral stricture/obstruction [10], anastomotic leak [4], reservoir-cutaneous fistula [4], difficulty in catheterization [5], pyelonephritis [10], sepsis [6], DIC [2], and ARDS [1]. Nonsurgical management strategies used for reservoir-related complications in these cases included percutaneous nephrostomy, peripheral hyperalimentation, intravenous antibiotics, and ultrasound-guided catheter placement. Eighty-four percent (16/19) of functional complications of the reservoir resolved with conservative management, whereas 3/19 patients needed surgical revision. One or more late complications (beyond 6 weeks) occurred in 25 patients (37%). Late complications seen included ureteral stricture/obstructions [6], incontinence [8], difficulty in catheterization [7], and urinary stones [4]. Nonsurgical management strategies used included percutaneous nephrostomy, balloon dilation, scheduled catheterization, ultrasound-guided catheter placement, and endoscopic/percutaneous lithotripsy. Four of 25 patients needed reoperation, whereas in 84% (21/25) of patients problems resolved with initial conservative management. CONCLUSION: Successful conservative therapy constitutes establishment of drainage, adequate nutrition, avoidance of sepsis, close observation, and patience. This article reviews the complications of the continent ileocolonic form of urinary diversion and formulates a treatment outline emphasizing an initial conservative approach that offers optimal management of early and late complications seen in this patient group.

Comparison of bimanual examination with ultrasound examination before hysterectomy for uterine leiomyoma.

OBJECTIVE: To correlate the preoperative bimanual examination with ultrasound examination with regard to estimating the size of enlarged nongravid leiomyomatous uteri. METHODS: We performed a retrospective review of 161 patients who underwent hysterectomy for uterine leiomyoma between January 1994 and December 1994 and between July 1995 and April 1996. Uterine size was estimated clinically by bimanual examination. Ultrasound reports were reviewed. Uterine weights and dimensions in pathology reports were compared with findings on bimanual examination and ultrasonography. Body mass index (BMI) was calculated and patients were divided into two groups, one with BMIs of more than 30 and another with BMIs of less than or equal to 30. RESULTS: Ultrasound examination was ordered in 111 patients (68.9%) preoperatively. There was a strong correlation between the bimanual examination findings and the ultrasound dimensions. The equation for this relationship is ultrasound length (cm)=3.68 + 0.68 x number of weeks (r=.78, P < .001). Ultrasound length also was related strongly to size given in the pathologic reports; the equation for this relationship is ultrasound length (cm)=2.94 + 0.75 x pathology length (cm) (r=.73, P < .001). The correlation between bimanual examination and ultrasound findings was similar in obese and in nonobese patients, when uterine size could be estimated. CONCLUSION: There is a strong correlation between bimanual and ultrasound examinations with regard to determining the size of leiomyomatous uteri. Routine ultrasound is not indicated when an experienced examiner can assess uterine size. Ultrasonography may be appropriate when physical assessment is difficult, as in the case of obesity.

The role of radioimmunoscintigraphy and computed tomography scan prior to reassessment laparotomy of patients with ovarian carcinoma. A preliminary report.

BACKGROUND: Accurate evaluation of patients with ovarian carcinoma who have completed primary therapy often requires surgical exploration. Radioimmunoscintigraphy (RIS) represents an evolving technique that may allow noninvasive detection and localization of persistent or recurrent disease in these patients. METHODS: Our prospective, blinded study enrolled patients with normal CA 125 levels and no clinical evidence of disease after primary cytoreductive surgery and cytotoxic chemotherapy for ovarian carcinoma. Each patient underwent RIS using Indium-satumomab pendetide (labeled antibody B72.3 to the tumor-associated antigen TAG-72) and abdominal/pelvic computed tomography (CT) prior to reassessment laparotomy. RESULTS: Twenty patients were enrolled from January 1994 to January 1995. Two patients with negative RIS scans refused reassessment laparotomy and were without evidence of disease > 15 months from the study. Twelve of the remaining 18 patients (66.7%) had histologically proven disease at reassessment laparotomy. RIS images indicated the presence of disease in all 12 patients, whereas CT scans detected disease in only 2 patients. In three of five patients, biopsy-proven microscopic disease (no gross disease at the time of laparotomy) was found only in specimens obtained by RIS-directed biopsies. RIS was superior to CT in sensitivity (100% vs. 16.7%), accuracy (72% vs. 33%), and negative predictive value (100% vs. 28.6%) (P < 0.005). CONCLUSIONS: Routine use of CT is of limited value in the assessment of ovarian carcinoma patients with negative physical examinations and normal CA 125 levels. With its high level of sensitivity and negative predictive value, RIS may play a role in the detection of persistent disease in this population and aid in the classification of patients into three distinct groups: those with gross residual disease, small volume or microscopic disease, and no disease. Separation of this heterogenous group without surgery may help guide subsequent consolidation therapy. However, attaining a high level accuracy with RIS, depends on optimizing the method of image acquisition, the timing of scans, and the reconstruction of data.

Ovarian remnant syndrome: experience at Jackson Memorial Hospital, University of Miami, 1985 through 1993.

OBJECTIVE: Ovarian remnant syndrome has become increasingly recognized as a cause of pelvic pain after extirpative surgery. The purpose of this review was to compare our patient population with those reported in the literature, as well as to address the usefulness of careful retroperitoneal discussion in the surgical management of these patients. STUDY DESIGN: This article discusses the presentation and surgical management of eight cases of ovarian remnant. RESULTS: Data were obtained through a retrospective chart review of pathologically confirmed cases of ovarian remnant. Discussion focuses on the surgical management of these cases. CONCLUSION: In summary, extensive and careful retroperitoneal dissection is typically required to facilitate identification and removal of the ovarian remnant tissue.

Surgery for the treatment of locally recurrent disease.

BACKGROUND AND METHODS: Total pelvic exenteration is a salvage procedure done in the effort to eliminate completely pelvic cancer. Low colorectal anastomosis and continent urinary diversion are two new procedures that allow complete pelvic evisceration without the need for external appliances. From 1984 through 1994, 67 patients have undergone rectosigmoid colectomy and low-colorectal anastomosis. Sixteen patients underwent surgery as part of a total pelvic exenteration for recurrent cervical cancer, and 51 patients underwent surgery for either primary or recurrent ovarian carcinoma as part of an optimal debulking procedure. Between 1988 and 1995, 55 patients have received continent urinary diversion with the Miami Pouch. Fifty-two patients underwent surgery for recurrent cervical cancer, two patients for advanced vulvar cancer, and one patient for a vesico-vaginal fistula. All of the patients with recurrent cervical cancer had previously received radiation therapy for gynecologic cancer. RESULTS: Of the 16 patients with recurrent cervical cancer who had a low colorectal anastomosis, 14 had a temporary colostomy. Of these 14 patients, eight had a colostomy takedown and have maintained fecal continence. Of the 51 patients with ovarian cancer who had a low colorectal anastomosis, all achieved fecal continence. With the Miami Pouch, a urinary continence rate of 86% was obtained. Twenty-four (44%) patients had early complications, including ureteral obstruction, ureterocolonic anastomotic leak, reservoir cutaneous fistula, small bowel obstruction, and pyelonephritis. Nineteen (35%) patients had late complications, including ureteral reflux, urinary incontinence, difficult catheterizations, and reservoir stones. There was a perioperative mortality rate of 5%. CONCLUSIONS: Low-colorectal anastomosis is an attractive alternative to permanent colostomy, allowing all patients who had the protective colostomies taken down to achieve fecal continence. Continent urinary diversion with the Miami Pouch is also a worthwhile procedure because of its high continence rate. Although survival advantage for either procedure has not been proven, the quality of life of patients undergoing such procedures has been substantially improved because of the avoidance of external appliances. This has been achieved with acceptable morbidity and mortality rates.

Molecular characterization of a new family with alpha-thalassemia-1 (--MA mutation).

A Spanish family with alpha-thalassemia-1 (alpha-Thal-1), deletion (--MA), is described. In addition to the loss of 22 kb of DNA with a deletion of the alpha 1, alpha 2, psi alpha 2, and psi zeta 1 genes, a triplication of the zeta gene cluster in "cis" is produced. The structure of this triplication is formed by the psi zeta 1 gene, the interzeta region, and, possibly, the insertion of the psi alpha 2 fragment.

National survey of ovarian carcinoma XII. Epithelial ovarian malignancies in women less than or equal to 25 years of age.

BACKGROUND: Epithelial ovarian carcinoma in women less than or equal to 25 years of age is a rare entity. This study used the database of the National Survey of Ovarian Carcinoma to analyze the disease and survival in women less than or equal to 25 years of age. METHODS: Tumor registries of 1230 hospitals were asked to enter the first 25 patients with histologically confirmed ovarian carcinoma from January 1 to December 31, 1983 and from January 1 to December 31, 1988. Data for a total of 12,136 patients were collected. Survival analysis and long-term evaluations were available on patients diagnosed with cancer in 1983. Chi-square analysis was used to compare the frequencies of operations performed in 1983 and 1988. RESULTS: Of 12,136 patients with epithelial ovarian carcinoma, 135 (1.1%) were less than or equal to 25 years of age. The majority of patients had early disease with the following distributions: stage I, 58.5%; stage II, 8.9%; stages III and IV, 28.9%. More patients had early-grade lesions with the following distributions: borderline, 21.5%; Grade 1, 27.4%; Grade 2, 11.1%; Grade 3, 6.7%; and unknown grade, 33.3%. Optimal cytoreduction was achieved in 77% of patients. During the 5-year study period, there was a significant change in the patterns of care toward more conservative surgery. In particular, unilateral salpingooophorectomy increased significantly from 38.2 to 59.7% (P = 0.0237), whereas hysterectomy decreased proportionally from 54.4 to 29.9% (P = 0.0039). The overall 5-year survival rate was 87.3% with the following divisions: stage I, 96.7%; stage II, 90.0%; stage III, 78.5%; and stage IV, 76.4%. Regarding histologic grade, 5-year survival rates were: borderline, 91.6%; Grade 1, 93.7%; Grade 2, 85.7%; Grade 3, 33.3%. CONCLUSION: Young patients with epithelial ovarian carcinoma appeared to have favorable stage and histologic grade. These factors combined with good performance status and optimal cytoreduction resulted in improved survival from cancer.

Radical hysterectomy for stage IB adenocarcinoma of the cervix: the University of Miami experience.

The treatment of adenocarcinoma of the cervix has traditionally followed that of squamous cancer. A 25-year review of 88 radical hysterectomies for Stage IB adenocarcinoma of the cervix at the University of Miami/Jackson Medical Center (UM) is compared to over 1600 cases reported in the literature. Adenocarcinoma represented 10.4% of 978 radical hysterectomies performed at UM from July 1965 to December 1990. In a survey of the literature, patients with Stage IB cervical adenocarcinoma treated by radical surgery alone had a statistically better 5-year survival than those treated by radiation alone (79% vs 67%, respectively; P < or = 0.05). Furthermore, no additional benefit was achieved by combining the two therapeutic modalities. The corrected 5-year survival at UM is 81% for Stage IB adenocarcinoma of the cervix treated with radical hysterectomy, a number consistent with the cumulative data base. Radical surgery is an acceptable primary therapy in Stage IB adenocarcinoma of the cervix.

Radical hysterectomy for invasive cervical cancer. A 25-year prospective experience with the Miami technique.

BACKGROUND: The Miami modification of the traditional Wertheim-Meigs radical hysterectomy was used to treat Stage IB-IIA cervical cancer in a 25-year prospective study involving 978 patients. METHODS: The modifications included: vaginal reconstruction and closure using bladder and rectosigmoid serosa, retroperitoneal drainage through abdominal suction catheters, and suspension of the denuded ureters with the ipsilateral obliterated hypogastric artery. RESULTS: The overall corrected 5-year survival rate was 90.1%, with a surgical mortality rate of 1.4% and an overall urinary fistula rate of 1.4%. This fistula rate was significantly better than a 4.4% incidence rate in a literature survey. Although not measured, the Miami modification appeared to lengthen the vagina. CONCLUSIONS: Therefore, it was concluded that radical hysterectomy with the Miami modifications can be done safely in most patients with Stage IB-IIA cervical cancer.

Complications of the Miami pouch.

The Miami pouch, a continent colonic urinary reservoir, was constructed in 75 patients after cystectomy for invasive bladder tumor (44), gynecological tumor (25), neurogenic bladder (4) and conversion of an ileal conduit (2). Continence was achieved by tapering the distal ileum over a 14F catheter and reinforcing the ileocecal valve with 3 circumferential silk sutures in a pursestring fashion. Ureterocolonic anastomosis was performed in a nontunneled fashion. There were 5 perioperative deaths. One or more early (perioperative) complications occurred in 19 patients (26%). Late complications (beyond 6 weeks) were found in 16 patients (23%). Total continence rate was 98.6% and the success rate of the ureterocolonic anastomosis was 90%. Followup was 7 to 69 months. We present a review of the technical aspects of the construction of the Miami pouch, and the early and late complications associated with this procedure.

[Focal hepato-splenic mycosis caused by Trichosporon beigelii in a patient with acute leukemia]. / Micosis hepatoesplénica focal por Trichosporon beigelii en un paciente con leucemia aguda.

We report a case of infection produced by Trichosporon beigelii in a patient with acute leukaemia. In spite of treatment with amphotericin B the patient died and the necropsy studies showed only involvement of liver and spleen without disseminated infection. Focal hepatosplenic fungal infection has been recognized with increasing frequency in recent years as a serious complication in immunosuppressed patients. Usually it is produced by Candida spp and this is the first case described in the literature due to the newly recognized fungus T. beigelii.

[Clinical experience of tapered distal ileum for construction of a continent colonic urinary reservoir].

Construction of continent colonic urinary reservoir was performed in 44 patients after exenteration for invasive bladder carcinoma or various gynecologic tumors. The distal ileum was tapered over a 14 French red rubber catheter. The ileocecal valve was reinforced with three circumferential silk sutures in a purse-string fashion. Full continence was obtained in all patients (100%). A non-tunneled, non-refluxing ureterocolonic anastomosis was performed in all 88 ureters. No obstruction or reflux was observed in 84 ureters (95%). There were 7 early postoperative complications and 3 of them required reoperation (pelvic abscess 1, urinary leak from ureterocolonic anastomosis 1, pouch-vaginal fistula 1). Moreover, there were 7 late complications and 3 of them required reoperation (stomal stenosis 1, parastomal hernia 2). These results suggest that this method is a safe, simple and useful one for permanent urinary diversion.

Continent urinary diversion in gynecologic oncology.

Pelvic exenteration is a salvage procedure used primarily for recurrent gynecologic carcinoma. Up to the present time, an ileal or colon conduit has been used for urinary diversion and the patient remains incontinent of urine. This is a preliminary report of nine patients with gynecologic carcinoma in whom a continent urinary diversion procedure was performed. A segment of distal ileum, the ascending colon, and part of the transverse colon are used to create the colonic reservoir. The segment of colon is opened along the tenia and folded onto itself. The walls of the ascending and transverse colon are anastomosed to detubularize this segment of bowel and eliminate the transient high pressure of the colon. Surgical staples are used for the anastomosis. The segment of ileum is tapered and three purse-string sutures (2-O silk) are placed at the level of the ileocecal valve to achieve continence. The short segment of ileum is then exteriorized as a stoma through which the patient catheterizes. Antirefluxing, non-tunneled ureterocolonic anastomoses are performed. The anterior wall of the reservoir is closed with absorbable staples. Postoperative urodynamic studies have shown maximum capacity of 750 ml and the area of continence to be at the ileocecal valve where the purse-string sutures are placed. All patients are continent and postoperative radiographs were negative for reflux. Follow-up was 6 to 12 months. The colonic reservoir is a capacious low-pressure system and warrants further clinical trials in patients with gynecologic cancer.

Carcinoma of the fallopian tube: clinical management.

From 1970 to 1986, 36 women were diagnosed to have primary fallopian tube cancer. Fifty-three percent of the patients were Stage III with a median adjusted survival of 27 months. Although varied adjunctive therapies were employed, none provided a clear survival benefit. Five "second-look" procedures were performed. Only one was negative, occurring in a Stage IIIC patient treated with combination chemotherapy. She has continued without evidence of disease 26 months following diagnosis. Recurrent disease was uniformly fatal, despite efforts at salvage therapy. Disease biology and response to therapy parallels that of similar stage epithelial carcinoma of the ovary.