High-dose cytosine arabinoside as the initial treatment of poor-risk patients with acute nonlymphocytic leukemia: a Leukemia Intergroup Study.

Sixty-seven patients with newly diagnosed acute nonlymphocytic leukemia (ANLL) who were considered to be poor candidates for treatment with cytosine arabinoside (ara-C)/anthracycline antibiotic therapy were treated with high-dose ara-C (HDara-C) remission induction therapy. Thirty-four of the 67 patients had a hematologic disorder before developing acute leukemia or had a history of exposure to marrow toxins, 23 patients were greater than 70 years old, and 10 patients had medical problems that were felt to be a contraindication to therapy with an anthracycline antibiotic. Forty-two percent of patients entered complete remission (CR), whereas 22% failed to enter remission because of persistent leukemia. Treatment was associated with substantial toxicity varying from nausea and vomiting to irreversible cerebellar toxicity. Thirty-four percent of patients died during therapy. Poor performance status, a low serum albumin, and a low platelet count were associated with death during remission induction therapy, whereas a high pretherapy leukemic cell mass and a large number of residual leukemic cells in the marrow after six days of therapy were associated with treatment failure due to persistent leukemia.

Pancreatic pseudocyst that compressed the inferior vena cava and resulted in edema of the lower extremities.

To our knowledge, edema of the lower extremities has not previously been reported as a sign of a pancreatic pseudocyst. In this case report, we describe a 66-year-old man in whom such a lesion compressed the inferior vena cava and caused pronounced leg swelling. After drainage of the pseudocyst, the edema did not recur. Although the most well-known complications of pancreatic pseudocyst are pain, hemorrhage, rupture, infection, and obstruction of adjacent viscera, bilateral edema of the lower extremities can be the initial manifestation of this lesion.

Histamine-induced constriction of canine peripheral lung: an airway or tissue response?

We compared the histamine responsiveness of peripheral airways (less than 6.0 mm diam) and parenchymal tissues in eight anesthetized paralyzed open-chest mongrel dogs. We measured pressure in a peripheral bronchus by using an antegrade wedged catheter and pressure in the alveolar region subtended by the wedged bronchus by using an alveolar capsule. Sinusoidal volume oscillations at a frequency of 0.5 Hz were delivered by a linear motor pump into the segment through the wedged catheter. We calculated the resistance of the segment (Rseg) and partitioned Rseg into tissue viscance (i.e., proportional to the resistive pressure drop between the alveolus and the pleura) and peripheral airway resistance. Measurements were taken under baseline conditions and after delivery of increasing concentrations of aerosolized histamine (0.1 micrograms/ml to 100.0 mg/ml) into the segment. We found that the histamine responsiveness of the peripheral airways and lung tissues varied markedly within a given dog. In four of eight dogs the airways were more responsive to histamine, in three of eight the tissues were more responsive, and in one of eight the response was equivalent at the two sites. We conclude that in a given animal, there is marked heterogeneity in the histamine responsiveness of the peripheral airways and parenchymal tissues and that either may dominate responsiveness in the peripheral lung.

Spinal epidural abscess: unusual CT and microbiologic findings.

The incidence of spinal epidural abscess is increasing. Its expeditious diagnosis is essential if treatment is to be effective. The authors present a case in which both the computed tomography appearance and the microbiologic observations were unusual.

Duplex ultrasonography criteria for internal carotid stenosis of more than 70% diameter: angiographic correlation and receiver operating characteristic curve analysis.

OBJECTIVE: To determine duplex ultrasonography criteria for detecting stenosis of 70% or more in the internal carotid artery, to be used as a means of selecting candidates suitable for endarterectomy (a procedure suggested by the North American Symptomatic Carotid Endarterectomy Trial as appropriate for symptomatic patients with 70% to 99% stenosis). PATIENTS AND METHODS: Between Jan. 1, 1991, and Apr. 30, 1993, 120 patients underwent internal carotid angiography at a tertiary care hospital for transient ischemic attacks, asymptomatic bruits or preoperative assessment. Of these, 83 also underwent duplex ultrasonography within 31 days of angiography. The angiographic and sonographic studies for 145 vessels in 75 of the patients (50 men and 25 women) were suitable for further study. The sonographic criteria were selected on the basis of a receiver operating characteristic curve relating peak systolic velocity of the internal carotid artery to the degree of stenosis determined angiographically. RESULTS: Angiography indicated that 33 of the vessels had stenosis of 70% or more and that 12 additional vessels were completely occluded. The combined sonographic criteria of peak systolic velocity of less than 40 cm/s or 175 cm/s or more yielded 91% sensitivity and 60% specificity for angiographically determined stenosis of 70% or more. CONCLUSION: In this patient population the combined criteria of peak systolic velocity of less than 40 cm/s or 175 cm/s or more were highly sensitive and reasonably specific for internal carotid artery stenosis of 70% or more.