Anterior sonography of glenohumeral joint in patients with inflammatory joint disease.

Ultrasonography (US) was shown as an effective imaging modality in evaluating the shoulder. The shoulder joint is probably the most accessible joint for sonography in adults. However, inflammatory changes of the shoulder have received too little attention in US studies. Anterior access for US assessment of glenohumeral joint (GHJ) has not been investigated. Another problem of patients with acute synovitis of glenohumeral joint is the difficulty to perform a 90 degrees abduction for the axillary US because of severe pain and active and passive limitation. We offer the anterior access for assessment of glenohumeral joint synovitis (GHS). Sonographic evaluation (Sonosite-Titan) was carried out in 25 patients with acute GHS and 15 healthy controls. The diagnosis of GHS was made after the patients underwent physical examination and the laboratory evidence was obtained. We used the anterior position of transducer applied laterally to coracoid processus along the anterior joint cavity. The problem of anterior joint cavity investigation in neutral position is a poor presentation of the joint and the application of the biceps tendon. The problem is simply resolved after supination of the hand and external rotation of the shoulder. We measured and compared upper, middle, and lower width of the anterior GHJ cavity. Echogenicity of joint cavity was assessed by comparison with adjacent tissues. Homogeneity and regularity of GHJ cavity was designated in both groups as well. We measured labrum-infraspinatus distance on posterior view for assessment of GHJ synovitis. All cases of GHJ synovitis were confirmed by a US Doppler study. US investigation of healthy controls enabled to find normal values of the width of the anterior GHJ cavity that was less than 7.4 mm. The synovitis group showed GHJ cavity expansion: 8.3+/-2.4 (p=0.001) and 10.5+/-3.1 (p<0.001) for the middle and the lower anterior part of the GHJ respectively. The upper part width was not different in synovitis and control groups. Anterior joint cavity extension to 7.4 mm and upper in its lower part was high sensitive (96%) and specific (86%) US sign of synovitis with the test power above 0.9. The posterior labrum-infraspinatus extension had high specificity for synovitis (100%), but only seven of 25 patients (28%) had increased (>2 mm) the value of the labrum-infraspinatus dimension, which was previously proposed as the US sign of synovitis. Echogenicity of the anterior joint cavity in healthy controls was moderately high (far more echogenic than deltoid muscle). Echogenicity of synovitis declined, and mild effusions were found to be common. Those were not to be seen on US of GHJ in neutral position and were revealed only in supination and external rotation of the shoulder. Intra-articular tissue of healthy controls was relatively echo-homogenic compared with nonhomogenic one of the synovitis group. Bone irregularity was found in patients with long-standing GHJ synovitis reflecting erosive process. A certain position of the shoulder and good knowledge of the normal anterior joint cavity parameters enabled us to diagnose synovitis by anterior shoulder sonography, with the patients experiencing minimal pain during movements.

American Society of Clinical Oncology 1998 update of recommended breast cancer surveillance guidelines.

OBJECTIVE: To determine an effective, evidence-based, postoperative surveillance strategy for the detection and treatment of recurrent breast cancer. Tests are recommended only if they have an impact on the outcomes specified by American Society of Clinical Oncology (ASCO) for clinical practice guidelines. POTENTIAL INTERVENTION: All tests described in the literature for postoperative monitoring were considered. In addition, the data were critically evaluated to determine the optimal frequency of monitoring. OUTCOME: Outcomes of interest include overall and disease-free survival, quality of life, toxicity reduction, and secondarily cost-effectiveness. EVIDENCE: A search was performed to determine all relevant articles published over the past 20 years on the efficacy of surveillance testing for breast cancer recurrence. These publications comprised both retrospective and prospective studies. VALUES: Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design. BENEFITS, HARMS, AND COSTS: The possible consequences of false-positive and -negative tests were considered in evaluating a preference for one of two tests providing similar information. Cost alone was not a determining factor. RECOMMENDATIONS: The attached guidelines and text summarize the updated recommendations of the ASCO breast cancer expert panel. Data are sufficient to recommend monthly breast self-examination, annual mammography of the preserved and contralateral breast, and a careful history and physical examination every 3 to 6 months for 3 years, then every 6 to 12 months for 2 years, then annually. Data are not sufficient to recommend routine bone scans, chest radiographs, hematologic blood counts, tumor markers (carcinoembryonic antigen, cancer antigen [CA] 15-5, and CA 27.29), liver ultrasonograms, or computed tomography scans. VALIDATION: The recommendations of the breast cancer expert panel were evaluated and supported by the ASCO Health Services Research Committee reviewers and the ASCO Board of Directors.

The need to consider survival, outcome, and expense when evaluating and treating patients with unknown primary carcinoma.

BACKGROUND: Patients who present with unknown primary carcinomas represent 10% to 15% of the patients with cancer who present to medical centers. Despite data in the literature indicating minimal success in determining the location of primary carcinomas, these patients continue to be evaluated exhaustively. Additionally, identification of the location of primary carcinomas does not often affect treatment. Clinical treatment and prognosis are only affected if a reevaluation of the pathologic findings yields a potentially curative diagnosis of an undifferentiated lymphoma, germ cell tumor, or a hormonally sensitive carcinoma. METHODS: Tumor registry files from January 1, 1990, through December 31, 1992, were retrospectively retrieved to identify adult patients who presented with metastasis of an unknown primary site at the H. Lee Moffitt Cancer Center and Research Institute, a 162-bed tertiary care cancer center specialty hospital affiliated with the University of South Florida College of Medicine, Tampa. Medical records were reviewed for age, sex, histologic findings of previous malignant growth, types and duration of symptoms, and mode of presentation. Fifty-six of the 199 patients were included in the study; 31 were men (55.4%) and 25 were women (44.6%), with ages ranging from 33 to 83 years. Diagnostic evaluations were reviewed and included data from procedures conducted at both the H. Lee Moffitt Cancer Center and at outside facilities. Diagnostic studies performed included barium swallow; intravenous pyelogram; mammogram; abdominal ultrasound; chest x-ray film; bone scan; magnetic resonance imaging; computed tomography of the head, chest, abdomen, and pelvis; laparotomy; bronchoscopy; gastroscopy; and colonoscopy. Information for the diagnostic test procedures was taken from the point of initial patient contact until the determination of metastatic disease. RESULTS: The primary cancer site was found in four (7.1%) of the 56 cases in the study and could not be classified as curable by systemic means. The average cost of diagnosis was $17,973, with 19.6% of the patients surviving for more than 1 year. The mean survival period was 8.1 months. A total of 410 tests were performed with only four tests correctly identifying the location of the primary tumor. CONCLUSIONS: Once a potentially curable malignancy has been excluded, there is little justification to support extensive diagnostic evaluation of the patient. Substantial costs are incurred and survival is often not significantly affected. It was estimated that 1.2 million new cancer cases would have occurred during 1994, with approximately 10% of these patients presenting with cancer of unknown primary origin. Based on cost assessments, investigation of these patients would exceed $1.5 billion. This clinical scenario is one where attention to outcome, clinical management, and expense should be carefully considered.

Calcium and vitamin D enriched diets increase and preserve vertebral mineral content in aging laboratory rats.

To assess the long-term effect of vitamin D or calcium supplementation on the skeletal metabolism of aging laboratory rodents, 1.5-month-old female Wistar rats were fed with diets containing twice the concentration of vitamin D (group 2) and of calcium (group 3) as in the usual rat chow. Follow-up to 24 months of age did not show significant differences between the enriched-diet groups and the controls (group 1) in terms of the vertebral body weight and protein content. Significantly higher bone mineral contents were found in groups 2 and 3 than were found in controls, as revealed by an increased bone mineral density (BMD: +62%, group 2; +48%, group 3) and vertebral calcium content (+73%, group 2; +84%, group 3). The vertebral alkaline phosphatase enzymatic activity was significantly lower in the enriched diet groups than in controls (-47%, group 2; -45%, group 3). The ratio alkaline phosphatase/acid phosphatase activity was markedly reduced in groups 2 and 3 (-57% and -59%, respectively), which might indicate a diminished rate of bone turnover. The trabecular bone volume (BV/TV) decreased in all groups during senescence, being significantly elevated in group 3 as compared to controls. Vitamin D and calcium dietary supplementations increase the axial mineral bone content in laboratory rats and might reduce the bone turnover. Their influence on the trabecular bone volume has yet to be examined.

Portrait of the scientist as a frustrated writer.

The purpose of this report is to show that a number of scientists feel dissatisfied with the rigid structure of the scientific article as a pattern of communication. Through examples taken from specialized medical journals, we follow their way from sporadic literary quotations supporting their own texts to attempted literary creations on scientific and moral issues.

Transient osteoporosis of the hip.

Transient osteoporosis of the hip (TOH) is an uncommon but possibly underdiagnosed condition. This pattern of regional osteoporosis affects previously healthy middle-aged men, and women in the third trimester of pregnancy. Its etiology is still unclear, yet in view of similarities to regional migratory osteoporosis and reflex sympathetic dystrophy, vascular and neurologic disturbances have been proposed as the possible pathogenetic mechanisms. Pain in the hip area and functional disability of the affected limb are the main clinical signs. Diagnosis is supported by local radiological osteopenia whose gradual disappearance parallels the spontaneous recovery. Bone scintigraphy, magnetic resonance imaging, computed tomography, and other imaging methods are supplementary diagnostic tools. Exclusion of more common entities is required. The purpose of this report is to elucidate the diagnostic and therapeutic aspects of TOH and to stimulate the physician's awareness of this condition, recognition of which may prevent unnecessary invasive procedures and inadequate treatment.

Arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis.

OBJECTIVE: To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC). METHODS: The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch-pouchitis-is discussed. RESULTS: The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. Steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true. CONCLUSIONS: Arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies.

Insufficiency fractures of the pubic ramus.

Seven elderly women with insufficiency fractures of the pubic ramus are described. The predisposing factors for this condition were osteoporosis, rheumatoid arthritis, renal failure, prolonged corticosteroid treatment, pelvic irradiation, and mechanical changes after hip surgery. The clinical presentation included progressive inguinal pain, limping, and inability to walk. Because initial radiographs were diagnostic only in four cases, bone scintigraphy and computed tomography were necessary to confirm the diagnosis and detect additional fractures. In most patients, bed rest, non-weight-bearing ambulation, symptomatic treatment, and therapy for osteoporosis resulted in rapid improvement, and long-term follow-up showed complete or partial recovery. In one case, no recovery was achieved because of noncompliance with treatment. Insufficiency fracture of the pubic ramus should be suspected in cases of unexplained inguinal or hip-area pain and inability to walk in the elderly. The clinical suspicion should be supplemented by radiological investigation. Bone scintigraphy and computed tomography are useful means for early and accurate diagnosis. The risk factors for this condition should be identified and treated. If therapy is initiated early and pursued, this type of fracture has a benign outcome.

Cotrimoxazole treatment for rheumatoid arthritis.

OBJECTIVES: To review the literature on the immunomodulatory and anti-inflammatory properties of cotrimoxazole (CTX)-a combination of sulfamethoxazole and trimethoprim, to summarize the use of this medication in the treatment of autoimmune diseases, to stimulate and renew the interest of both physicians and researchers in this possible therapy for rheumatoid arthritis (RA), and to inspire further investigation in this field. METHODS: A MEDLINE search of the literature from 1966 until 2000 was performed, and information about the pharmacology of CTX and its use in the therapy of rheumatic diseases was critically reviewed. RESULTS: RA treatment is associated with numerous problems such as lack of efficacy, frequent side effects, and high cost. Analysis of the relevant literature revealed that experience with CTX in the treatment of RA is limited. However, the results of several nonrandomized and evidently forgotten clinical trials and laboratory investigations suggested that CTX might serve as an effective and inexpensive therapy for RA. Several lines of evidence suggested that CTX has nonspecific anti-inflammatory and immunomodulatory properties. Although nausea and vomiting were common reasons for CTX withdrawal, they were noted in only some studies, and no major organ toxicity was observed. CONCLUSIONS: Because of its therapeutic qualities, low cost, and relative nontoxicity, CTX seems to warrant a role in the treatment of RA.

Chronic tophaceous gouty arthritis mimicking rheumatoid arthritis.

OBJECTIVES: To analyze the factors which differentiate chronic tophaceous arthritis from rheumatoid arthritis. METHODS: We describe two cases of chronic gouty arthritis masquerading as rheumatoid arthritis. The characteristic features of each of these two conditions and the diagnostic approach are discussed in light of relevant literature. RESULTS: The correct diagnosis was reached by the combination of accurate history taking (family history of gout, alcoholism, previous diuretic therapy and renal stones), guiding clinical features (subcutaneous tophaceous deposits) and specific radiological (assymetrical erosions with sclerotic margins and overlying edges) and laboratory findings (hyperuricemia and hyperuricosuria). It was confirmed by the identification of monosodium urate (MSU) crystals in the synovial and subcutaneous tissues. CONCLUSIONS: Gout and rheumatoid arthritis rarely coexist. Chronic gouty arthritis may mimic rheumatoid arthritis, and vice-versa. Clinical suspicion supplemented by characteristic laboratory, radiological and histologic findings help at reaching an accurate diagnosis.

Tumor-induced osteomalacia.

Tumor-induced (oncogenic) osteomalacia is a rare clinicopathologic entity in which the clinical signs and symptoms of osteomalacia and the specific laboratory abnormalities of hypophosphatemia, hyperphosphaturia, and low serum levels of 1,25(OH)2 vitamin D are associated with the finding of a neoplastic process in the patient. To date, less than 100 cases of oncogenic osteomalacia have been described. We report a new case of adult-onset hypophosphatemic osteomalacia leading to the discovery of an asymptomatic phosphaturic mesenchymal lung tumor. Complete resection of the pulmonary neoplasia was followed by rapid normalization of the laboratory findings and clinical remission. The clinical, laboratory, and histopathologic spectrum of tumor-induced osteomalacia is presented, and the postulated mechanism of this condition is discussed in light of the relevant literature. The presence of occult neoplasms should be considered in cases of unexplained adult osteomalacia, with the physician's efforts being rewarded by the dramatic cure that follows excision of the tumor.

Prostate-cancer surveillance - a cost-effective strategy.

The intention of a surveillance program to monitor prostate cancer patients is to detect recurrence of disease as soon as possible and institute therapy at the time of recurrence in order to improve the chance of cure or extend survival. We analyzed the cost of four surveillance programs for prostate cancer. As PSA levels are more sensitive than the bone scan, prostatic acid phosphatase and alkaline phosphatase, a surveillance program which utilizes these latter tests provides no additional clinically useful information beyond a PSA level and is costly. Adopting a strategy of eliminating these tests from a surveillance program would reduce national annual expense by approximately $1.5 billion in the year 2000.

Evaluation of a frozen section protocol in endometrial carcinoma.

Between May 1987 and December 1991 sixty four patients with Stage I Endometrial carcinoma were treated primarily with surgery at the University of Colorado Health Sciences Center, Denver and at hospitals in the Tampa Bay Metropolitan region. A frozen section protocol on the hysterectomy specimen was utilized in a uniform manner at all institutes. The aim of the study was to determine the speed and accuracy of this protocol in determining the dominant grade of the tumor and depth of invasion of the myometrium. The accuracy rate for reporting dominant tumor grade when compared to permanent histology was 100% for 33 specimens and 93.6% for the remaining 31 specimens. The overall accuracy for depth of myometrial invasion was expressed as a comparison of the average ratio of myometrial invasion to adjacent uninvolved myometrial thickness between frozen and permanent histology specimens. The correlation was 97.7% in this study. The average time taken was 12.6 minutes for 16 specimens, 18.8 minutes for 33, and 32.4 minutes for 17. A case is made in this paper for the value of such intraoperative information being made available to the surgeon on a routine basis.

Heroic measures when treating patients with hematologic malignancies - the economic cost of survival.

The survival of patients with hematologic malignancies who require admission to the intensive care unit (I.C.U.) is poor. The potential for cure in this group of patients necessitates aggressive treatment that can result in life-threatening complications. A medical, ethical and financial dilemma arises when aggressive therapy and intensive support is balanced with actual survival, meaningful survival and the financial burden to society and the patient's family. We collected complete financial information on 64 leukemia and lymphoma patients admitted for the first time to the intensive care unit (I.C.U.) at the H. Lee Moffitt Cancer Center and Research Institute between 7/1/88 and 6/30/90. The charges were calculated from actual itemized statements and included all inpatient and out-patient charges. Survival was addressed by individually evaluating candidate variables with parametric and non-parametric analysis. Survival after I.C.U. admission and hospital discharge were studied as dependent variables in a stepwise multiple regression analysis. The nadir of the platelet count and albumin level prior to and during the I.C.U. admission significantly affected survival. During the I.C.U. admission, the BUN, serum creatinine and the need for mechanical ventilation significantly affected survival. Seventy-eight percent of patients survived less than five months and spent less than two and one half months at home. Fifty percent of patients expired during the I.C.U. admission. Only 3.2% of patients who had received two or more chemotherapeutic regimens had survived more than one year. The cost per year of life gained for the entire group of patients was $189,339. The results of this study show that the majority of leukemia and lymphoma patients who are admitted to the I.C.U. expire prior to discharge or spend a minimal amount of time at home prior to expiring. This study suggests that the cost of meaningful survival must be borne in mind by physicians and should encourage them to discuss treatment options, potential outcomes, risks and benefits so that a reasonable strategy can be planned by the physician, patient and family prior to treatment.

The effect of duration of intervention and locus of control on dietary change.

Scientific evidence supports a relationship between diet and the incidence of cancer. This finding has resulted in dietary recommendations that have been disseminated to the public. To reduce actual cancer incidence, these recommendations must lead to dietary changes among the population. We compared two brief dietary interventions with a longer term intervention and found that all three interventions produced significant reductions of calories, fat, fiber intake, and weight. The duration of the intervention did not significantly affect the magnitude of these reductions. We also found that health locus of control did not affect dietary change. Participants who initially were found to have an internal locus of control, or who subsequently internalized their locus of control during the period of observation, did not demonstrate a significant change in their intake of any of the nutrients measured when compared to participants with an external locus of control. Thus, we suggest a brief dietary intervention as a feasible and effective mechanism to produce progressive incremental dietary changes in a large population.

Breast cancer screening and compliance and evaluation of lesions.

It appears that screening mammography certainly is of value in women over age 50, and although controversy exists regarding screening of women under 50 years of age for breast cancer, the authors believe that this strategy is the most reasonable one for women 40 to 64 years of age at this time. Additionally, it is important for physicians to remember to encourage their patients to undergo cancer screening evaluation. Encouragement by physicians is an important factor in increasing cancer screening rates.

DES-ja vu.

Prior to the use of antiestrogens, high dose estrogen therapy was widely used as effective therapy for breast cancer. The introduction of antiestrogens with their reduced toxicity profile greatly minimized subsequent use of estrogen to treat metastatic breast cancer. We administered diethylstilbestrol (DES), a nonsteroidal synthetic estrogen, to eight postmenopausal women with advanced breast cancer who had been heavily pretreated with hormones and cytotoxic chemotherapy. We report on response rates and toxicities related to this form of hormonal therapy. Eight postmenopausal women aged 53 to 79 years with progressive metastatic breast cancer were treated. All had been pretreated with 3 to 6 hormonal agents including an antiestrogen, a progestin and an aromatase inhibitor; 6 of the 8 patients had received treatment with 2 or 3 combinations of cytotoxic agents. All patients received diethylstilbestrol 5 mg orally three times daily until evidence of disease progression or significant toxicity. Four women (50%) showed objective responses, two (25%) had stable disease and two (25%) had progressive disease. Measurable responses included a complete and partial response and two minor responses. The duration of the responses were 12, 11, 6, and 3 months. The hormone was well-tolerated. High-dose estrogen is effective and safe therapy for breast cancer patients even when they are heavily pretreated with prior chemotherapy and hormonal therapy. High dose estrogen could be re-introduced into this clinical setting as effective therapy with an acceptable toxicity profile.

The impact of current use of hormone replacement therapy on prognostic factors and surgical treatment of new breast cancers.

When postmenopausal women were diagnosed with breast cancer while taking hormone replacement, no adverse effects were noted in either clinical or prognostic factors when compared to a similar group not on hormones. Younger age at diagnosis and an increased chance of carcinoma in situ were noted in those on hormones. A surveillance or observational bias is one explanation for these findings. A promotional effect of hormone replacement therapy could not be eliminated based on this study.

The effects of NSAIDs on breast cancer prognostic factors.

There are several risk factors involved in the pathogenesis of breast cancer. The role of non-steroidal anti-inflammatory drugs (NSAIDs) in the development of breast cancer has not been fully clarified. In order to investigate the impact of NSAIDs ingestion on prognostic factors of breast cancer we studied a total of 341 women with invasive carcinoma of the breast who presented between March and September 1993 to the Breast Cancer Clinic of the H. Lee Moffitt Cancer Center in Tampa, Florida. We noted that ingestion of NSAIDs was inversely associated with the size of the primary tumor, the lymph node status, and the number of involved axillary nodes. ingestion of NSAIDs may impact favorably on factors that determine the prognosis and clinical outcome of women with breast cancer.

Cancer-patients - the survival and expense of traditional care and hospice care.

Hospice care is a reasonable treatment strategy for those cancer patients whose disease process is no longer responsive to standard treatment regimens or who are unable to tolerate the adverse side effects of continued aggressive therapy. A 1:1 matched case-control study design that designated those patients selecting the hospice model of care as controls and those receiving acute care as cases was utilized. Data was abstracted from medical records and financial billing statements. The difference between total hospital charges plus hospice charges during the last 6 months of life for the hospice patients ($35,625) compared to the non-hospice patients ($50,152) was statistically significant. The hospice model of care may be a less costly option for those cancer patients where palliation is the objective.