Endosonographic features predictive of lymph node metastasis.

Endosonographic features that are thought to characterize lymph node metastasis were evaluated in 100 patients with esophageal carcinoma. Subjects underwent preoperative endoscopic ultrasonography to assess depth of tumor invasion (T stage) and lymph node metastasis (N stage). Endosonographically imaged lymph nodes were evaluated according to the following parameters: size, shape, border demarcation, and central echo pattern. Sensitivity and specificity of endosonography in detecting lymph node metastasis were 89.1% and 91.7%, respectively, when stringent criteria were used. When lymph nodes were imaged endosonographically, regardless of the specific features, the likelihood of N1 disease, was 86%, whereas when no lymph nodes were imaged, the chance of N0 disease was 79%. Endosonographic features predictive of malignancy in increasing order of importance were echo-poor (hypoechoic) structure, sharply demarcated borders, rounded contour, and size greater than 10 mm. Collectively, the EUS features produced an additive effect with respect to accuracy in the prediction of malignant lymph node involvement; malignancy could be predicted with 100% accuracy when all four features were present. These results demonstrate that a careful and systematic approach to the endosonographic assessment of lymph node metastasis can improve staging accuracy.

Diagnostic accuracy of different ultrasonographic growth parameters in predicting discordancy in twin gestation: a different approach.

The purpose of this study was to examine the predictability of intrapair percentage differences of ultrasonic fetal biometric parameters in detecting twin discordancy. Fetal biometric parameters obtained in 90 twin gestations within 7 days of delivery were analyzed. Intrapair differences of 5% and 10% were used for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length, and HC/AC to assess their predictive value. Statistical analysis was performed using chi 2 test and Fisher's exact test. Receiver operator characteristic (ROC) analysis was done to determine if there was a difference between absolute and intrapair differences. Intrapair AC and HC differences of 5% were found to have significantly higher true positive rates in detecting discordancy. At an intrapair difference of 10%, AC and BPD were found to have high sensitivity rates in detecting discordancy. ROC analysis did not show any difference between use of absolute and intrapair difference in predicting discordancy (P = 0.0001). We conclude that fetal AC is the most significant sonographic parameter in detecting discordancy in twins.

Does quality of life differ among headache diagnoses? Analysis using the medical outcomes study instrument.

BACKGROUND: To analyze the differences in quality of life associated with headache diagnoses using the Medical Outcomes Study Short Form Health Survey (SF-20). METHODS: A patient interview survey using the SF-20 Short Form Health Survey was conducted in a headache clinic within a multi-specialty group practice. All six health components of the SF-20 were included in the study. Headache diagnoses were made using IHS criteria. RESULTS: 208 consecutive headache patients were studied. Patients with cluster headache had a significantly higher (worse) pain score (P < 0.018) and higher percentage of patients with poor health due to pain (P < 0.005) than patients with migraine headache. There were fewer cluster patients with poor health associated with physical functioning than tension-type (P < 0.020) or mixed headache (P < 0.022) patients. Poor health associated with social functioning was greater for cluster (P < 0.011) and tension-type headache (P < 0.015) than for migraine. There was a significantly higher percentage of tension-type headache patients with poor health associated with mental health (P < 0.002) than patients with migraine. CONCLUSIONS: The SF-20 is a reliable and valid measure of quality of life for patients with different headache diagnoses. Distinct headache diagnoses are marked by unique patterns of impairment and quality of life.

Reduction of blood loss from diagnostic sampling in critically ill patients using a blood-conserving arterial line system.

STUDY OBJECTIVE: To demonstrate the utility of a new blood-conserving arterial line system in reducing blood loss associated with blood drawing in the critical care setting. DESIGN: Prospective, randomized, crossover comparison between two arterial line systems. SETTING: Medical intensive care unit (ICU); tertiary care teaching institution. PATIENTS: Thirty-one patients who required invasive arterial blood pressure monitoring throughout their ICU course. INTERVENTIONS: For ICU days 1 to 2, patients were randomized to receive either a conventional arterial line system or a new blood-conserving arterial line system. On ICU days 3 to 7, patients with a conventional arterial line were crossed over to the blood-conserving arterial line, and vice versa. Laboratory blood volumes, mixed discard volumes, and blood discard volumes were then recorded to document how much blood loss is associated with each aspect of the blood sampling process. RESULTS: The mean total volume of blood sent to the laboratory for testing was 257.4 ml. As a result of "clearing the line" over the 7-day period, patients with the conventional arterial line system lost a mean volume of 340.2 ml of blood mixed with heparinized saline solution more than patients with the blood-conserving arterial line. In terms of the blood component of the blood-heparinized saline solution mixture, use of the conventional arterial line was associated with an average of 156.8 ml more blood discarded than with the blood-conserving arterial line. CONCLUSION: The new blood-conserving arterial line system provides a simple and effective method for reducing blood loss related to diagnostic sampling in the critical care setting.

Lateralizing signs in intractable partial epilepsy: blinded multiple-observer analysis.

We evaluated the accuracy and interobserver variability of selected ictal and postictal behavioral changes. Three observers, blinded to clinical history, EEG, and side of surgical resection, analyzed videotapes of 166 seizures in 38 patients, looking for lateralizing signs. Twenty-seven patients with temporal lobe resections were seizure-free for > or = 1 year postoperatively, and 11 with extratemporal resections had at least 90% reduction in seizures > or = 1 year postsurgery. The epileptogenic region (ER) was lateralized by analyzing lateralizing signs in 78% of patients; positive predictive value (PPV) was 94% (90% CI = 87% to 100%). Overall kappa was 0.68. Signs were considered present if seen by two or more observers. Forty-five percent had version, ie, forced and sustained head deviation (kappa = 0.76, PPV = 94%); 37% had dystonic posturing of the upper extremity (kappa = 0.47, PPV = 93%); and 34% had unilateral mouth deviation (kappa = 0.83, PPV = 92%). These signs indicated a contralateral ER. Twenty-one percent had unilateral upper extremity automatisms, all ipsilateral to the ER (kappa = 0.65, PPV = 100%); 21% had postictal dysnomia, indicating a dominant-hemisphere ER (kappa = 0.89, PPV = 100%); and 16% had ictal speech, usually indicating a nondominant-hemisphere ER (kappa = 0.75, PPV = 83%). Dystonic posturing, postictal dysnomia, ictal speech, and unilateral upper extremity automatisms may indicate a higher probability of temporal lobe epilepsy. Analysis of lateralizing signs shows good interobserver agreement and provides useful clinical information.

Benign angiopathy: a distinct subset of angiographically defined primary angiitis of the central nervous system.

OBJECTIVE: Primary angiitis of the central nervous system (PACNS) has been considered a rare and highly fatal disorder when untreated. In recent years the disease has been increasingly diagnosed by cerebral angiography, often without histologic confirmation. We have questioned whether cases of PACNS diagnosed on the basis of angiography alone are equivalent to histologically confirmed cases. METHODS: All cases of PACNS reported from 2 sources, including all cases reported in the English medical literature through January of 1990 as well as from the case records of the Cleveland Clinic Foundation were reviewed. Sixty-five variables were analyzed including demographic data, clinical signs and symptoms, treatment, outcome, diagnostic modalities and associated conditions. The cases were divided into 3 groups based on method of diagnosis. Group A referred to those diagnosed by angiography alone, but unconfirmed by histology, Group A & P for those who had positive histologic evidence angiitis confined to the central nervous system and a positive angiogram and Group P containing those diagnosed on the basis of histology who either never underwent angiography or who had angiographic findings other than arteritis. RESULTS: Cases of PACNS defined by angiography alone (Group A) appear often to be clinically distinctive, occurring more frequently in young women, often presenting with the sudden onset of focal neurologic deficit and associated with a relatively benign cerebral spinal fluid analysis. Patients defined in such manner frequently have a self-limited clinical course and may not require combination therapy with corticosteroids and cytotoxic drugs. CONCLUSION: We believe that PACNS is more clinically heterogeneous than is recognized and that a distinct and possibly more benign subset of disease that can be diagnosed on clinical and angiographic grounds has been identified.

Quality of life and well-being of headache patients: measurement by the medical outcomes study instrument.

OBJECTIVE: To assess the reliability and validity of the Medical Outcomes Study (MOS) Short Form Health Survey as an indicator for quality of life in patients with chronic headaches. DESIGN: Patient interview survey. SETTING: A headache clinic within a multi-specialty group practice. PATIENTS: 208 consecutive patients seeking evaluation of headache at the above site. MEASUREMENTS: All six health components of the MOS Short Form Health Survey were included in the study. MAIN RESULTS: The MOS Short Form Health Survey was both reliable and valid in the group of patients with headache. Patients with headache had significantly worse physical, social, and role functioning, and worse mental health than did patients with chronic diseases (P < 0.0001). The functioning associated with chronic headaches was worse than that associated with major chronic medical conditions such as arthritis and diabetes, and was comparable to the level of functioning associated with recent myocardial infarction or congestive heart failure. CONCLUSIONS: The MOS survey is a reliable measure of quality of life for patients with chronic headaches. Chronic headache disorders cause significantly more morbidity and impairment of function than has previously been appreciated.

Hypoplastic trachea in Down's syndrome.

Our study sought to determine whether tracheal dimensions were reduced in patients with Down's syndrome and whether such a narrowing, if present, was related to the presence of congenital heart disease or to body habitus (height or weight). The inner diameter of the tracheal air column was measured at 2 cm above the aortic arch in 14 adult patients with Down's syndrome, and the results compared with previously established norms. Two-way analysis of variance showed no significant difference in z-scores between sexes or between those with or without congenital heart disease. Z-scores were significantly different from zero for both coronal diameters (p = 0.0010) and sagittal diameters (p = 0.0003). The negative limits on the 95% confidence interval for coronal z-scores (-2.5 to -0.8) and sagittal z-scores (-2.6 to -1.0) indicate that our patients have tracheal diameters significantly smaller than normal. Linear regression analysis showed no significant correlation between tracheal diameters and patients' height or weight. We conclude that tracheal diameters in adult patients with Down's syndrome are reduced and that the narrowing cannot be ascribed to associated congenital heart disease or to body habitus.

Quality of life in multiple sclerosis. Comparison with inflammatory bowel disease and rheumatoid arthritis.

Multiple sclerosis (MS) and other chronic illnesses can drastically decrease quality of life (QOL), but there has been little systematic study of QOL in patients with chronic medical diseases. We analyzed QOL in 68 patients with MS, 164 patients with inflammatory bowel disease, and 75 patients with rheumatoid arthritis. The previously validated test instrument was a standardized interview consisting of 41 questions clustered in four subscales: functional and economic scale, social and recreational scale, affect and life in general scale, and medical problems scale. Patients were included in the study if they had a definite medical diagnosis and disease duration of 10 years or longer. In the patients with MS, Kurtzke's Expanded Disability Status Scale correlated strongly only with the medical problems score. Of Kurtzke's Functional System Scales, only the visual Functional System Scores was correlated with total QOL and subscale scores, suggesting that vision is strongly related to QOL. Duration of MS was unrelated to QOL scores. There were significant differences between patients with MS, inflammatory bowel disease, and rheumatoid arthritis on the subscale and total QOL scores. Results suggested that QOL was best in the inflammatory bowel disease group and worst in the MS group. Numerous statistically significant differences on individual questions were evident, suggesting that unique clinical profiles differentially characterize these diseases. Assessments of QOL are a meaningful addition to impairment scales, such as Kurtzke's Expanded Disability Status Scale. Furthermore, QOL scores may meaningfully measure the impact of a chronic medical disease, such as MS, compare the impacts of different diseases, and assess the effects of therapeutic intervention.

Nitrogen mustard as induction therapy for rheumatoid arthritis: clinical and immunologic effects.

We treated 5 patients diagnosed with rheumatoid arthritis (RA) with nitrogen mustard (HN2) and monitored clinical and immunologic variables. HN2, 0.3 mg/kg ideal body weight was given over 7 days. Disease activity and immune function were monitored during and after treatment. Duration of morning stiffness (p = 0.0044), joint count (p = 0.0140), and assessment of pain (p = 0.0264) and function (p = 0.0057) improved by Day 6. T lymphocytes (p = 0.0060), especially T memory cells (CD4CD29; p = 0.0017) fell dramatically. HN2 is effective for rapidly gaining control of active RA. This effect is T cell specific.

Doppler velocimetry in concordant and discordant twin gestations.

Doppler blood flow studies in 63 pairs of concordant and 17 pairs of discordant twins were compared with those of 277 appropriate for gestational age singleton fetuses. Discordancy was defined as a more than 20% intra-pair actual birth weight difference. The data were divided into five groups: singletons and large and small concordant and discordant twins. Statistical comparisons of the regression lines for the large concordant and discordant twins and the singletons showed no significant differences among the three lines, either in slopes (P = .1) or intercepts (P = .08). Comparisons of the regression lines for small concordant and discordant twins and the singletons indicated a significant interaction among the three lines (P = .01). Additional analysis leads us to conclude that the systolic-diastolic ratio (S/D) decreases with advancing gestational age for all groups except small discordant twins. The S/D of small discordant twins differed significantly from that of singletons and tended to differ from that of small concordant twins.

Primary angiitis of the central nervous system: diagnostic criteria and clinical approach.

Primary angiitis of the central nervous system has until recently been considered rare, usually progressive, and untreatable. In 1987, preliminary diagnostic criteria for the disorder were proposed in the hope of gaining a more accurate description of the disease. We used these criteria in reviewing all cases reported in the English language (99 cases) and those seen at The Cleveland Clinic Foundation (9 cases). We believe that the disorder is heterogeneous, and has a better prognosis than previously thought. Furthermore, a relatively benign subset of this disorder, termed "benign angiopathy of the central nervous system," can be defined on clinical grounds. We propose a revised set of diagnostic criteria and a practical approach to treatment.

Diagnostic efficacy of digitized images vs plain films: a study of the joints of the fingers.

Four hundred fifteen finger joints from 30 patients were evaluated for the presence of joint-space erosion, narrowing, and degenerative spurring on plain films, low-resolution digitized images (1024 x 840 bytes x 12 bit matrix), and high-resolution digitized images (2048 x 1680 bytes x 12 bit matrix). Three hundred four joints were abnormal. Low- and high-resolution digital images were displayed on a 1K x 1K monitor with the ability to change level, window, orientation, and brightness. Five radiologists interpreted images. The presence or absence of each abnormality was determined by consensus of two skeletal radiologists who did not otherwise participate in the study. Receiver-operating-characteristic analysis was used to obtain an area and a true-positive rate at a 0.10 false-positive rate for each interpreter. Randomized block analysis of variance with interpreters as blocks was used to compare areas and true-positive rates among imaging techniques for each type of abnormality; no statistically significant differences were found. In conclusion, the efficacy of display of digitized images on high- and low-resolution modes is not significantly different from that of plain films in the detection of erosions, joint-space narrowing, or degenerative spurring in small joints of the hands.