The percutaneous trampoline platysmaplasty: technique and experience with 105 consecutive patients.

BACKGROUND: Controversy persists regarding the optimal procedure to rejuvenate the aging neck. More invasive procedures carry increased risks of complications, whereas less invasive approaches may deliver marginal results. The challenge is selecting the appropriate procedure for delivering consistent, durable results meeting both the patient's and surgeon's expectations. OBJECTIVES: The authors describe their trampoline platysmaplasty (TPP) approach, a percutaneous suture suspension necklift that constitutes a less invasive approach for neck rejuvenation. METHODS: A retrospective study was conducted of 105 consecutive patients who underwent TPP. Age, sex, procedure(s) performed, complications, and patient satisfaction were recorded. Cadaver studies were conducted to compare the tensile strength of the ligaments that anchor the TPP to the tensile strength of the sutures placed to approximate the medial platysma borders. In addition, the accuracy of light transillumination to determine depth of travel of the light-emitting diode (LED) lighted rod was evaluated. RESULTS: Patients underwent either TPP alone (18 women, 24 men) or TPP with a facelift (35 women, 28 men) between October 2007 and June 2009. The average age of the patients was 52 years, and average length of follow-up was 33 months. Patient satisfaction was high. Three early patients underwent immediate revision to improve results secondary to the suture matrix being too loose. Six additional patients had recurrent banding around one year postoperatively, but correction was achieved in all six by replacing the matrix with the help of the lighted rod. The results of the cadaver study revealed that the tensile strength of the retaining ligaments was statistically identical to the medial platysma borders, and the light transillumination feedback was accurate with regard to the depth of travel of the illuminated rod tip. CONCLUSIONS: The TPP approach for neck rejuvenation is effective and durable in properly-selected patients. It works well as a stand-alone procedure and in conjunction with facelift procedures. It also offers younger patients a less-invasive option to improve neck contours inherited through genetics. After nearly three years of follow-up of the patients in this report, the results appear to be long-lasting.

Efficacy of 2'-deoxycoformycin in hairy-cell leukemia: a study of the National Cancer Institute of Canada Clinical Trials Group.

Thirty-one patients with hairy-cell leukemia were treated with 2'-deoxycoformycin (DCF) in a National Cancer Institute of Canada multicenter trial. The DCF was administered in a cycle (4 mg/m2 iv weekly X 3), which was repeated every 8 weeks. Following a complete remission, consolidation was done with two further cycles of DCF. Of 28 patients evaluable for response, 25 obtained a complete remission; 3 had a partial response. To date there has been only one relapse; the median time with no therapy was 429.5 days (range 99-743 days). Toxicity was moderate and included nausea and vomiting, lethargy, and skin rash; with the first cycle of treatment, neutropenia and an increased incidence of fever or infection were also observed. We conclude that low-dose DCF is highly effective in treating hairy-cell leukemia.

Variance of surgeons versus pathologists in staging of colorectal cancer.

AIM: Accurate staging of colorectal cancer depends on adequate retrieval and reporting of lymph nodes in the specimen. The presence of positive lymph nodes is an indication for adjuvant therapy. Both surgeons and pathologists influence the number of lymph nodes that are retrieved and reported in specimens. Although several recommendations exist in the literature regarding the minimum number of lymph nodes required for reliable staging, the relationship of examined to infiltrated lymph nodes has not been clarified. The aims of this study were to examine variance among surgeons and pathologists in the retrieval and reporting of lymph nodes in colorectal cancer specimens; to examine the relationship between retrieved/examined lymph nodes and infiltrated lymph nodes; to identify in our own series the minimum number of retrieved lymph nodes required to secure accurate staging. METHODS: Cross-sectional study of 284 patients with colorectal cancer followed in our hospital and retrospective analysis of histopathology reports. Correlation analysis, ANOVA, and survival analysis were performed on the data. RESULTS: There were 127 patients with cancer of the rectum and 157 patients with cancer of the colon under follow-up. The median number of lymph nodes per specimen was 8 (range 0-29). There was no difference in the number of retrieved lymph nodes among 9 surgeons. There were 2 outliers among pathologists, with one reporting a mean of 11.4 (9.8-12.9) 95% CI nodes per specimen and another reporting a mean 4.9 (3.6-6.2) 95% CI nodes per specimen. Dukes and T stage did not affect the number of nodes. Correlation analysis revealed a linear correlation between the total number of reported lymph nodes and the existence of positive lymph nodes. From the correlation equation we calculated that, in order to have one positive node, a minimum of 8.4 nodes was required in the specimen. Therefore, in our group of patients, a minimum of 8.4 nodes was required for accurate Dukes staging. However, survival analysis did not show any difference between patients with more and patients with less than 9 reported lymph nodes. CONCLUSIONS: Variance among pathologists exists and may be at least as important as variance among surgeons. Specialisation of pathologists similar to that of surgeons as well as employment of new techniques may be required . There is a linear correlation between the number of examined lymph nodes and the presence of positive nodes in a colorectal cancer specimen. This linear correlation makes the calculation of the minimum number of lymph nodes possible. In our series a minimum of nine nodes must be examined. However, we have not demonstrated an effect of inadequate nodes numbers on survival, possibly because survival in colorectal cancer is multifactorial.

Randomized comparison of pentostatin versus interferon alfa-2a in previously untreated patients with hairy cell leukemia: an intergroup study.

PURPOSE: Therapy of hairy cell leukemia has markedly improved. Interferon alfa-2a and pentostatin are active agents. The National Cancer Institute organized an intergroup trial to compare these agents prospectively in untreated patients. METHODS: Patients were randomized to receive either interferon alfa-2a (3 x 10(6) U subcutaneously three times per week) or pentostatin (4 mg/m2 intravenously every 2 weeks). Patients who did not respond to initial treatment were crossed over. RESULTS: Of 356 patients on study, 313 were eligible. Among interferon patients, 17 of 159 (11%) achieved a confirmed complete remission and 60 of 159 (38%) had a confirmed complete or partial remission. Among pentostatin patients, 117 of 154 (76%) achieved a confirmed complete remission and 121 of 154 (79%) had a confirmed complete or partial remission. Additional patients achieved criteria for complete remission, but lacked confirmatory follow-up evaluation. Response rates were significantly higher (P < .0001) and relapse-free survival was significantly longer with pentostatin than interferon (P < .0001). The median follow-up duration is 57 months (range, 19 to 82). Myelosuppression was more frequent with pentostatin (P = .013). A multivariate logistic regression analysis of the confirmed complete remissions on pentostatin showed the following factors to be important for achieving a complete remission: high hemoglobin level (two-tailed P = .024), young age (P = .0085), and no or little splenomegaly (P = .0029). CONCLUSION: Both agents were well tolerated. Pentostatin produced higher response rates, and the responses were durable. Patient age and clinical status had an impact on outcome with pentostatin. Pentostatin is effective therapy for hairy cell leukemia.

Diabetic glucose control: matching plasma insulin concentration to dietary and stress hyperglycemia.

Optimal management of the diabetic patient includes normalization of plasma glucose concentration. Attainment of this goal is difficult because both food and stress result in acute elevations of blood glucose that cannot be matched with a single subcutaneous injection of NPH insulin. This paper examines the currently available methods for delivery of insulin to the diabetic subject and the degree of metabolic control attained. It suggests that optimal diabetic control will be achieved only when newer methods of insulin delivery are available to the clinician that match plasma insulin requirements to the simultaneous plasma glucose concentration.

Breast cancer in hospitalized psychiatric patients.

Elevated serum prolactin levels caused by antipsychotic agents have been suspected of increasing the risk of breast cancer. The authors reviewed all the cases of breast cancer in 1969-1978 among the female population of a large psychiatric hospital and compared the incidence and prevalence rates of this group to expected rates. The rates of breast cancer among these psychiatric patients were not higher despite their use of antipsychotic drugs.

Utilization of swine to study the risk factor of an elevated salt diet on blood pressure.

Two homogeneous groups of castrated swine were fed identical diets except that one contained an increased sodium chloride content. The diets were initiated at weaning age and the blood pressure of the pig was followed for 8 months. Blood pressures were measured with an automatic blood pressure recorder for a 1-week period every 4th week. At the end of 8 months, the group on the high salt diet had blood pressure elevated above that of the group on the low salt diet.

Long-term outcome following treatment of hairy cell leukemia with pentostatin (Nipent): a National Cancer Institute of Canada study.

We have previously demonstrated that pentostatin (Nipent; SuperGen, San Ramon, CA) is highly effective in the treatment of hairy cell leukemia and report here the long-term outcome of this study. Pentostatin was administered intravenously in cycles of 4 mg/m2 weekly x 3 repeated every 8 weeks. Patients who achieved a complete remission (CR) received two further cycles for consolidation. Of 28 evaluable patients, 25 achieved a CR and three a partial remission. Twenty-three patients are alive at a median follow-up duration of 118 months (range, 55 to 133 months). Of the 25 patients who achieved a CR, 14 (56%) remain in CR at a median of 119 months (range, 109 to 133 months) from the time of CR. Nine additional patients relapsed at a median time of 49 months (range, 15 to 122 months). Only three of the relapsed patients have required treatment: two patients who received cladribine achieved CRs; the third received interferon-alpha and died from hairy cell leukemia. The three patients in partial remission continue to have normal blood counts at 58, 105, and 120 months. Five patients have developed a second malignancy: one mycosis fungoides and four solid tumors. Three patients died from the second malignancies. There were no treatment-related deaths due to toxicity or opportunistic infection. Pentostatin is a highly effective agent for hairy cell leukemia and produces prolonged remissions in the majority of patients.

Myeloproliferative disorders: a paradox of in-vivo and in-vitro platelet function.

A patient with features of a myeloproliferative disorder developed an acute multisystems illness and died. In-vitro platelet aggregation was imparied, but necropsy revealed widespread platelet-rich thromboemboli and multiple organ infarctions. It is suggested that platelets are damaged during disseminated intravascular platelet aggregation (DIPA) and that disaggregation of platelet thrombi and recirculation of platelets give rise to their subsequent hypofunction when tested in vitro.

Sensitivity of PCR in detecting monoclonal B cell proliferations.

AIMS: To evaluate the rapid detection of various forms of monoclonal B cell proliferations by using the polymerase chain reaction (PCR) to identify clonal immunoglobulin heavy chain genomic rearrangements. METHODS: Thirty four B cell lymphomas defined by morphology, immunophenotyping, and positive immunoglobulin heavy chain gene rearrangements detected by Southern blot analysis were examined. An additional 22 cases representing miscellaneous lymphoproliferative and non-lymphoproliferative disorders were also studied. RESULTS: Monoclonal rearrangements were identified in 19 (56%) cases of B cell lymphoma. The method was less sensitive in the detection of follicular centre cell lymphomas (15 of 28, or 54%) than non-follicular centre cell lesions (four of six, or 67%). Monoclonal rearrangement was not identified in 19 control cases, including T cell lymphomas, Hodgkin's disease, reactive lymphadenopathy and metastatic carcinoma. Three cases showed positive immunoglobulin gene rearrangement by PCR but were negative on Southern blotting. Two of these cases had definite clinical, morphological, and immunophenotypic evidence of monoclonal B cell proliferation suggesting that PCR could, on occasion, pick up cases missed by Southern blotting and that the two methods are complementary in clonal lymphoproliferative disease diagnosis. The third case represented a "false positive" PCR reaction involving a colonic adenocarcinoma. CONCLUSIONS: PCR analysis, using the primer sequences outlined in this study, will detect about 55% of clonal lymphoproliferative proliferations with increased sensitivity for non-follicular centre cell lesions. With these levels of detection in mind, this testing strategy can still be especially useful in cases which prove diagnostically problematic with standard morphological and immunophenotypic analysis, and in instances where the quantity and type of diagnostic material is limiting (needle aspirates and cellular fluids).

Measurement of lung water in inhalation injury.

Pulmonary inhalation injury is a major cause of morbidity and mortality rates in burn victims. But the pathophysiology of parenchymal inhalation injury has not been fully elucidated. In this study, extravascular lung water volume (EVLW) was measured in burn patients with and without inhalation injury. Patients with parenchymal inhalation injury (group II) had elevated admission extravascular lung water volumes (10.12 +/- 3.43 ml/kg), whereas patients without parenchymal injury (group I) had significantly lower lung water values (3.91 +/- 1.49 ml/kg). Both accumulation of EVLW and ventilation-perfusion abnormalities in the group II patients occurred within hours of smoke inhalation. But the severity of inhalation injury did not consistently correlate with the elevation of EVLW. This indicated that both interstitial edema and ventilation-perfusion imbalance contributed, in varying degrees, to the pathophysiology of inhalation injury. In this study, the general clinical criteria for inhalation injury--presence of facial or oropharyngeal burns, carboxyhemoglobin levels, carbonaceous sputum, or closed space injury--did not differentiate patients with airway injury only from those with parenchymal injury. Patients in both groups who died of sepsis had significant (P less than 0.01) increases in EVLW 24 to 48 hours after the clinical onset of sepsis. The normal hydrostatic pressures in these septic patients suggested that the increase in EVLW observed with sepsis was due to an increase in pulmonary capillary membrane permeability.

The effect of increasing end-expiratory pressure on extravascular lung water.

The objective of this study was to define the response of extravascular lung water (EVLW) to different levels of positive end-expiratory pressure (PEEP) following a standardized oleic acid injury to the lung. All animals responded to the injection of intravenous oleic acid by the rapid development of hypoxemia. There was a twofold increase in EVLW during the first 3 hours after oleic acid injection which remained stable during the remainder of the experiment, including periods on PEEP. Intrapulmonary shunt (Qs/Qt) increased significantly (P less than 0.001) during the first hour following oleic acid injection. PEEP therapy resulted in an immediate decrease in Qs/Qt and amelioration of the hypoxemia. Return to zero PEEP resulted in a rapid decrease in PaO2 with concomitant increase in Qs/Qt by the end of the experiment. The oxygen transport in the animals did not improve significantly with the addition of PEEP. This was due to the decrease in cardiac output that more than offset the effects of a diminished Qs/Qt with PEEP. This study indicates that the mechanism by which PEEP improves oxygenation does not appear to be mediated by effect on lung water. The study also emphasizes the importance of determining oxygen transport when managing patients on PEEP.

The peritoneal absorption of insulin in diabetic man: a potential site for a mechanical insulin delivery system.

The potential of the peritoneum as a site for an "artificial beta cell" was studied. Three 14-hr studies were performed in an insulin-dependent diabetic male maintained on chronic peritoneal dialysis. All studies were performed between dialyses and throughout three standard American Diabetes Association (ADA) 600 calorie meals. The degree of insulin absorption from the peritoneal space was assessed by measuring the changes in plasma-free insulin concentration during these studies. The results of this study demonstrate that normalization of plasma insulin profiles may be observed with the administration of insulin into the peritoneal space. This absorbed insulin exerts hypoglycemic activity that suppresses the meal-induced rise in plasma glucose concentration. Thus, the peritoneal space may be a feasible route into which insulin may be delivered by an artificial beta cell.

Acute respiratory acidosis: large-dose furosemide and cerebrospinal fluid ions.

NaCl cotransport carrier is known to be involved in transepithelial fluid absorption and secretion in various tissues. Recent studies indicate that Na-K-2Cl cotransport carrier also exists in the choroid plexus cells and that inhibition of the carrier decreases cerebrospinal fluid (CSF) production. In this study, we used large-dose intravenous furosemide, an inhibitor of Na-K-2Cl carrier, to determine the effects on cisternal CSF ionic composition in acute respiratory acidosis. In pentobarbital-anesthetized mechanically ventilated dogs, renal pedicles were ligated to prevent furosemide-induced diuresis. The experimental group (group II, n = 7) received 400 mg/kg of furosemide intravenously, and group I (control group, n = 7) received the vehicle. In group II, serial serum and CSF furosemide concentrations were approximately 10(-3) and 10(-5) mol/l, respectively. During 5 h of acute respiratory acidosis in both groups, the mean arterial PCO2 increased approximately 25 Torr, with comparable changes in CSF PCO2. In both groups, CSF [HCO3-] and [H+] rose approximately 3 meq/l and 20 neq/l, respectively. Changes in CSF [Na+], [K+], [Cl-], and [Na(+)-Cl-] were also similar and were not significantly different from each other when the two groups were compared. These data show that furosemide at the dose that inhibits NaCl cotransport carrier does not significantly alter ionic composition of cisternal CSF.

Ethanol is a potent inhibitor of canine cerebrospinal fluid production: an acute and reversible effect.

Neuropathological studies have shown increased cerebral spaces in alcoholics, yet, the effect of ethanol on cerebrospinal fluid (CSF) production is not known. We investigated the effects of ethanol on CSF production measured by ventriculocisternal perfusion (VCP) technique, in two groups (n=10 in each) of anesthetized, paralyzed and mechanically ventilated dogs. In group I, which served as control, VCP was performed with normal mock CSF. Ethanol (150 mg/dl of mock CSF, approximately 33 mM) was added to VCP in group II. Beginning 60 min after the start of VCP, CSF production was measured every 15 min for the next 4 h. In group I, mean (+/-S.D.) value for CSF production was 51+/-10 microliter/min initially and decreased significantly but slightly with time, to the lowest value of 44+/-11 microliter/min at the end of the experiment. In group II, values for CSF production were 41+/-8, 41+/-8, 41+/-8, 43+/-6, 43+/-8, 42+/-6, 42+/-8, 38+/-6, 37+/-6, 36+/-5, 36+/-5, microliter/min, respectively, from 15 to 165 min. These values were invariably significantly lower than their respective mean values in the control group. Furthermore, when ethanol was withdrawn at the trough of CSF production (at 165 min), production significantly increased by about 40%. We conclude that ethanol at a concentration of 150 mg/dl (far below lethal levels) is one of the most potent inhibitory drugs for decreasing CSF production. This effect is short-onset and is fully reversible within 15 min of ethanol withdrawal.

Different effects of omeprazole and Sch 28080 on canine cerebrospinal fluid production.

We investigated the effects of omeprazole and Sch 28080, a more specific and a more potent inhibitor of K+,H+-ATPase than omeprazole, in canine cerebrospinal fluid (CSF) production. CSF production was measured by ventriculocisternal perfusion (VCP) technique in three groups (n = 10 in each group) of anesthetized, paralyzed and mechanically ventilated dogs. Group I served as control, Sch 28080 (10(-4) mol/l of synthetic CSF) was added to VCP in group II, and omeprazole (10(-5) mol/l of synthetic CSF) was added to VCP in group III, after baseline control CSF production had been determined at 15, 30, 45, and 60 min. Comparing the three groups, the mean baseline values for CSF production did not differ significantly. However, the percent decreases in CSF production in the omeprazole treated group were 26 +/- 17 and 24 +/- 13 at 210 and 225 min, which were significantly more than the respective values in the control group. Percent decrease in CSF production in Sch 28080 was not significantly different from that in the control group. We conclude that in the canine model, physiological doses of omeprazole decrease CSF production by about 26%. However, the effect is independent of the K+,H+-ATPase activity, since Sch 28080 which is more potent than omeprazole did not significantly affect CSF production.

What happens to patients following open access gastroscopy? An outcome study from general practice.

BACKGROUND: Open access gastroscopy allows general practitioners to request a gastroscopy without prior referral to a specialist. The effect of open access gastroscopy upon patient management is poorly explored. Most studies have been hospital based and have focused on diagnostic yields and on means of tightening requests to reduce inefficient use. A user evaluation can only be made by measuring outcomes in primary care. AIM: A study was undertaken to determine the impact of open access gastroscopy in general practice and in particular, the value of a normal result. METHOD: All general practices in South Tees District Health Authority were asked to participate. Any of their patients who had had open access gastroscopy in the year prior to July 1990 were identified from the hospital computer and their general practitioner notes examined. Patient management during the year prior to the open access gastroscopy was compared with the year after. The main outcome measures were: detection rate and grade of lesion, change in graded score of prescribed drugs, consultation rate for dyspepsia and non-dyspepsia problems, and further hospital referral and investigations. Outcomes among those with normal and abnormal gastroscopy results were compared. RESULTS: The study sample comprised 715 patients, 36% of whom had a normal gastroscopy result, 34% a major abnormality and 26% a minor abnormality (4% of patients had miscellaneous diagnoses). It was found that 39% of all patients, and 60% of those with normal findings on open access gastroscopy had their drug treatment stopped or reduced in grade after the investigation. Of those with a major endoscopic abnormality 58% increased their treatment score. Consultations for dyspepsia in the year before and after gastroscopy fell by 57% overall among those with a normal gastroscopy result, by 37% among those with a minor finding and by 33% in those with a major finding. There was a 21% fall in consultations for all reasons among those with a normal gastroscopy result but those with a minor abnormality had a 23% increase in non-dyspepsia consultations. Of all patients 19% were referred to hospital subsequently. CONCLUSION: Open access gastroscopy has a major effect upon patient management in general practice, and a normal endoscopy result has an important an impact as an abnormal one. Open access gastroscopy is associated with a rationalization of drug therapy, reduced consultations and a low hospital referral rate.

Erythroblast multinuclearity in bone marrow and spleen. Congenital dyserythropoietic anemia-like abnormalities without functional evidence of dyserythropoiesis.

A dyserythropoietic syndrome with coincidental immune thrombocytopenia seen during pregnancy is discussed. The morphological and serological results in this case most resemble type II congenital dyserythropoietic anemia. However, functional evidence of dyserythropoiesis was absent and the patient was not anemic. Splenectomy was performed for the resistant thrombocytopenia and microscopic examination of the spleen showed evidence of extramedullary dyserythropoiesis. The significance of these findings is discussed with regard to the spectrum of recognized dyserythropoietic disorders and the unusual discrepancy between the abnormal morphology and the absence of functional dyserythropoiesis.

Experimental cryptosporidiosis and infectious bursal disease virus infection of specific-pathogen-free chickens.

Specific-pathogen-free chickens orally inoculated at 4 days of age with a moderately pathogenic vaccine strain of infectious bursal disease virus (IBDV) and/or at 5 days of age with Cryptosporidium baileyi oocysts remained free of overt clinical signs throughout a 16-day period postinoculation (PI). The prepatency period for C. baileyi oocyst shedding was shorter in chickens receiving higher numbers of oocysts, but once shedding was detected, there were no obvious differences in shedding patterns among groups receiving 10(3) through 10(6) oocysts. On days 8 and 16 PI, cryptosporidia were located primarily in the bursae of Fabricius. IBDV exposure was associated with bursal follicle atrophy, whereas C. baileyi infection resulted in bursal epithelial hypertrophy and hyperplasia, mild follicle atrophy, and heterophil infiltration of the bursal mucosa. Examination of experimental groups of 30 birds each indicated that concurrent infection with both agents resulted in more severe bursal lesions, more infected birds, and greater numbers of cryptosporidia in infected tissues. At the termination of the trial, 16 days PI, Cryptosporidium infection was associated with a 6% decrease in mean body weight compared with controls.

Cryptosporidia-positive rates of avian necropsy accessions determined by examination of auramine O-stained fecal smears.

Fecal smears from 112 avian necropsy accessions representing 431 birds were stained with auramine O and examined for Cryptosporidium oocysts by fluorescence microscopy. Stained Cryptosporidium oocysts fluoresced bright yellow-green and were easily differentiated from extraneous material by their uniform small size (approx. 5 micron) and morphology. The rates of cryptosporidia-positive accessions were 27.3% (9/33) of broilers, 10% (3/30) of broiler breeders, and 5.9% (1/17) of layers. Further analyses of available data for various risk factors that may have influenced rates of cryptosporidia-positive samples in broilers, broiler breeders, and layers failed to show significant relationships. However, it was apparent that positive samples were clustered within accessions and not scattered throughout the population sampled. This survey also resulted in the first reported identification of Cryptosporidium oocysts from a budgerigar, macaw, and tundra swan.