Immunohistochemistry of affected tissue may guide cGVHD treatment decisions.

Chronic graft-vs-host disease (cGVHD) myositis is a rare complication of hematopoietic SCT, for which the pathogenesis and optimal therapy are unclear. We performed immunohistochemistry on muscle biopsies from pediatric cGVHD myositis and typical cases of autoimmune dermatomyositis and polymyositis. The immunostaining pattern of cGVHD myositis was distinct from that of typical cases of autoimmunity. There was a high proportion of CD20+ and CD68+ cells, and the best therapeutic response was achieved with rituximab (anti-CD20). These results suggest that cGVHD myositis may be mediated by different leukocytes than similar autoimmune diseases and that treatment may be optimized by targeting the specific cellular infiltrates identified in affected tissue.

PML-IRIS in patients with HIV infection: clinical manifestations and treatment with steroids.

BACKGROUND: Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection that develops in immunosuppressed patients with HIV infection. Paradoxically, some of these patients may develop PML during combined antiretroviral therapy in the setting of immune reconstitution. We describe the types of PML in relation to immune reconstitution inflammatory syndrome (IRIS) and the effects of steroid use in these patients. METHODS: We performed a retrospective review of the literature (1998 to 2007) and of all HIV-infected patients diagnosed with PML-IRIS at Johns Hopkins Hospital (2004 to 2007). We recorded information on clinical features, microbiologic and virological analysis, neuroimaging, pathology, treatment, and outcome. RESULTS: Of 54 patients with PML-IRIS, 36 developed PML and IRIS simultaneously (PML-s-IRIS) and 18 had worsening of preexisting PML (PML-d-IRIS) after the initiation of combined antiretroviral therapy. PML-IRIS developed between 1 week and 26 months after initiation of antiretroviral therapy. PML-d-IRIS patients developed IRIS earlier, had higher lesion loads on MRI of the brain, had shorter durations of survival, and had higher mortality rate compared to PML-s-IRIS patients. Twelve patients received treatment with steroids, of which five died and seven showed good neurologic recovery. Patients who survived had received steroids early after IRIS diagnosis for longer durations and had contrast enhancement on IRIS neuroimaging. CONCLUSIONS: Immune reconstitution following initiation of combined antiretroviral therapy may lead to activation of an inflammatory response to detectable or latent JC virus infection. Early and prolonged treatment with steroids may be useful in these patients but requires further investigation.

Subjectively perceived quality of life after coronary artery bypass surgery.

BACKGROUND: Judgment of quality of life after coronary artery bypass surgery is usually based on objective measures of cardiovascular status. Quality of life cannot be determined solely objectively because such indicators do not explain how persons perceive and experience their lives. OBJECTIVES: To assess the quality of life and mood state over time in patients undergoing coronary artery bypass grafting and to improve understanding of subjective perceptions of well-being and how these perceptions change over time. METHODS: Three questionnaires, the Quality of Life Index, the Medical Outcomes Study 36-Item Short-Form Health Survey, and the Profile of Mood States, were administered at 3 different times (before surgery, 6 weeks after surgery, and 3 months after surgery) to a convenience sample of hospitalized adults undergoing coronary artery bypass surgery for treatment of coronary artery disease. RESULTS: For all 3 questionnaires, responses differed significantly over time. Mean scores were significantly different over time for total mood disturbance (P = .03), the socioeconomic domain of the Quality of Life Index (P = .02), and the physical functioning (P = .004), vitality (P = .007), and social functioning (P = .002) dimensions of the 36-item short-form survey. CONCLUSIONS: Subjective perceptions of physical and psychological well-being changed significantly from before surgery to 3 months after surgery. Measures of mood state, physical functioning, vitality, and social functioning improved significantly over time. However, satisfaction with the socioeconomic domain decreased significantly from before surgery to 3 months after surgery.

Needle-localized biopsy of occult breast lesions: an update.

We have performed 207 needle-localized breast biopsies for nonpalpable, mammographically suspicious lesions over the past 6 years. A mass lesion and grouped microcalcifications were associated with malignancy, while a mass with microcalcifications was never associated with malignancy. Biopsy revealed malignancy in 26 cases (12.6%), with 19 of 22 (86.4%) having no histologic evidence of axillary spread. Advanced age and a past history of a breast cancer were again the risk factors present in a significant number of the patients with a positive biopsy result. There were 11 complications (5.3%): three hematomas (1.4%), one infection (0.5%), and seven (3.4%) required a repeat biopsy to remove the suspicious lesion missed on the original biopsy. We conclude that needle-localized breast biopsy continues to be a reliable method of detecting early breast carcinoma. Given the minimal morbidity, this procedure should be done in all patients with mammographically suspicious nonpalpable breast lesions.

The solitary pulmonary nodule: a recent military experience.

During a 5-year period from 1983 to 1987, a total of 226 thoracotomies were performed at David Grant USAF Medical Center. Within this group, 62 patients (27%) had resection of a solitary pulmonary nodule. Fifty percent of the resected nodules were subsequently proven malignant, with 27 of 62 (43%) having a primary lung carcinoma. From 1958 to 1963, the Veterans Administration Armed Forces Cooperative Study evaluated a total of 1,134 patients with asymptomatic solitary pulmonary nodules. The data generated from that report has become the standard within the literature. We compared our recent 5-year experience to that data. The primary difference found in our series was an increase in solitary pulmonary nodules in our female population.

Wound complications following modified radical mastectomy: an analysis of perioperative factors.

To assess the effect of perioperative factors on the incidence of postoperative wound complications, the authors retrospectively analyzed 101 patients who had undergone modified radical mastectomy. These factors included age, body weight, operative techniques, estimated blood loss, wound-catheter drainage, extent of axillary dissection, nodal involvement, and length of hospital stay. Complications included seroma (10.9%), wound infection (8.9%), wound necrosis (5%), hematoma (3%), lymphedema (2%), and pneumothorax (1%). The logistic regression method was used to analyze the data. When electrocautery was used to create the skin flaps, the probability of a wound complication was .462, a 44% increase over that calculated for the cold-knife technique (P = .05). A prolonged hospitalization accompanied the occurrence of a wound complication. No other factors reached statistical significance.

Atypical carcinoid tumor of the lung: a case report and discussion of the literature.

Carcinoid tumors comprise 1% to 2% of all tumors of the lung. Although carcinoid tumors are generally felt to be of low grade malignancy, an atypical variant exists that exhibits more virulent behavior and a less favorable prognosis. The treatment of carcinoid tumors is complete surgical removal and a more aggressive approach is required in the treatment of atypical carcinoids. A case is presented with a review of the literature.

Needle-localized biopsy of occult breast lesions.

Over a 3 1/2-year period, we did 121 needle-localized breast biopsies for nonpalpable, mammographically suggestive lesions. The presence of a mass lesion on mammography with or without microcalcifications was associated with malignancy more frequently than microcalcifications alone. In 15 cases (12.4%), biopsy showed malignancy; 13 patients had modified radical mastectomy, with 11 (85%) having no histologic evidence of axillary metastases. Evaluation of risk factors associated with breast cancer in those patients with positive biopsy results showed that advanced age and a past history of a breast cancer were present in a significant number of patients. Four patients (3.5%) had complications; a hematoma developed in one (0.8%), and three (2.7%) required a second biopsy to remove the suggestive mammographic lesion. We conclude that needle-localized breast biopsy is a reliable tool in detecting early breast carcinoma. The procedure causes only minimal morbidity and we believe it should be done in all patients with mammographically suggestive, nonpalpable breast lesions.

Burns in the elderly.

The records of 327 burn patients over age 65 show that flame burns were the most common causative agent and that more than 70 percent of all burns occurred in the home. Despite improved treatment, mortality from burns remains unacceptably high among the elderly. Future efforts must be directed toward the prevention of these injuries, especially those sustained in the home.

Staging of non-small cell bronchogenic carcinoma. Relationship of the clinical evaluation to organ scans.

Organ scans are generally performed on patients with bronchogenic carcinoma only when clinical evaluation is suspicious for metastases. However, it is not clear whether the clinical abnormalities will direct attention to the single organ which should be scanned, or if all three organs (bone, brain, liver) should be evaluated if any clinical abnormality is present. We investigated the use of triple organ radionuclide scanning and computerized tomography (CT) of the brain in the initial staging of patients with non-small cell bronchogenic carcinoma with no obvious metastases. Of 122 patients with newly diagnosed lung cancer, 53 met our criteria for further study. Thirty-three (62 percent) of these had at least one clinical abnormality suggestive of metastasis. Bone scanning detected metastases in seven (21 percent) and head CT in two additional patients (6 percent). Brain and liver scanning had no yield. In only five of these nine patients did the clinical abnormality direct attention to the organ with detectable metastases. Twenty of the 53 (38 percent) patients had a negative routine clinical evaluation, yet bone scanning showed metastases in three (15 percent). We concluded that clinical abnormalities are not specific for the organ in which metastases may be detected, so three scans (bone, liver, CT of the brain) should be obtained if there is any suspicion of metastasis based on history, physical examination, and laboratory tests. The value of bone scanning in clinically normal patients deserves further study.