Meningovascular syphilis after 'appropriate' treatment of primary syphilis.

Meningovascular syphilis developed in a patient two years after the treatment of primary syphilis with a single intramuscular injection of 2.4 million units of penicillin G benzathine as recommended by the Centers for Disease Control. Although it could not be established with certainty whether this infection represented a reinfection or a treatment failure, the case emphasizes the necessity for serologic follow-up examination in all patients treated for primary syphilis.

Validity of utilization management criteria for psychiatry.

OBJECTIVE: This study examined the validity of four psychiatric utilization management criteria sets: the 1992 and 1993 InterQual Intensity, Severity, and Discharge (ISD) criteria, the Managed Care Appropriateness Protocol, and an instrument developed by the Department of Veterans Affairs (VA). METHOD: The appropriateness of acute care admission and continued stay for 70 randomly selected VA psychiatric inpatients was retrospectively assessed with each criteria set. The sensitivity and specificity of each instrument were evaluated by comparing its assessments to the consensus of judgments of a panel of expert psychiatrists who reviewed the same cases. Sensitivity was defined as the proportion of admissions or continued-stay days the panel found appropriate for acute care that the criteria judged to be appropriate for acute care; specificity was the proportion the panel found inappropriate for acute care that the criteria judged to be inappropriate for acute care. RESULTS: For admissions, there were only minor differences in the validity of the four criteria sets as assessed by agreement with the panel's judgments. For each of 4 continued-stay days studied, either the sensitivity or specificity of the 1993 InterQual ISD criteria was below 0.30. The specificity of the 1992 InterQual ISD criteria was below 0.60 for 2 days. In contrast, for the Managed Care Appropriateness Protocol, sensitivity was 0.73-0.93 and specificity was 0.78-0.88 over the 4 days. CONCLUSIONS: The findings raise major concerns about the validity of the widely used InterQual ISD psychiatry criteria, suggest that the Managed Care Appropriateness Protocol may be a useful tool for psychiatric utilization management, strongly underline the need to validate all criteria used to assess medical care, and support the appropriateness of the procedures used to perform these assessments.

Liver cancer and oral contraceptives.

PIP: The author read with interest the article "Combined epithelial and sarcomatous elements in a liver cancer associated with oral contraceptive use" (American Journal of Surgical Pathology 3: 185, 190, 1979). The authors attributed the bimorphism to imply a collision tumor. Some years ago the author reported a rhabdomyosarcohepatoma in an adult and felt that the neoplasm, based on hepatic embryology, represented variable differentiation in a growth derived from a common progenitor cell type. Of more importance is the association of a malignant hepatic tumor with oral contraceptive use. This association was also recorded, and a recent review of this subject appears quite germane.^ieng

Pure squamous cell carcinoma of the larynx with cervical nodal metastasis showing rhabdomyosarcomatous differentiation. Clinical, pathologic, and immunohistochemical study of a unique example of divergent differentiation.

We describe a unique case of pure squamous carcinoma of the larynx that developed a cervical lymph node metastasis showing rhabdomyosarcoma admixed with squamous carcinoma (that is, carcinosarcoma). The rhabdomyosarcoma showed foci immunoreactive to multiple cytokeratin monoclonal antibodies, as well as to markers for striated muscle, thus indicating true divergent epithelial and rhabdomyosarcomatous differentiation. Although the morphogenesis of carcinosarcomas remains controversial, the sequence of events for the current case favors sarcomatous transformation of the original carcinoma (that is, sarcomatous neometaplasia of the primary carcinoma clone). The possible contributory role of radiation therapy in this case in inducing such a change is noted.

Necrobiotic granulomas of the uterine cervix. A probable postoperative reaction.

Three cases of necrobiotic granulomas of the uterine cervix occurring in patients with a history of previous cervical surgery are described. This distinctive lesion histologically resembles a rheumatoid nodule but is not associated with infection or connective tissue disease. The clinicopathologic features of these cases are virtually identical to analogous postoperative lesions that have been described in the prostate. Such necrobiotic granulomas seem to be a result of prior surgery and should not be confused with other more portentous granulomatous diseases.

Mucocele-like changes in Bartholin's glands.

Two cases are described in which changes identical to those of oral mucocele occurred in Bartholin's glands. The histopathology, histochemistry, and pathogenesis are discussed.

Mucinous transformation of synovium.

A unique case of mucinous transformation of knee joint synovium associated with recurrent mucinous joint effusions and severe osteoarthritis is presented. The lesion probably represented an extreme pathologic expression of physiologic synoviocytic synthesis of hyaluronic acid. It did not appear to be related to other myxoid lesions that may occur in this area.

Proliferative sialometaplasia arising in an intraparotid lymph node.

A case of florid proliferative sialometaplasia arising in salivary ductal inclusions in an intraparotid lymph node is described. This lesion probably represents an exuberant response to sialadenitis. Other entities that enter into its differential diagnosis in this particular location are discussed. Except for Warthin tumors, lesions of clinical import originating from such inclusions are rare.

Fall risk assessment measures: an analytic review.

BACKGROUND: Clinicians are often unaware of the many existing scales for identifying fall risk and are uncertain about how to select an appropriate one. Our purpose was to summarize existing fall risk assessment scales to enable more informed choices regarding their use. METHODS: After a systematic literature search, 21 articles published from 1984 through 2000 describing 20 fall risk assessments were reviewed independently for content and validation by a panel of five reviewers using a standardized review form. Fourteen were institution-focused nursing assessment scales, and six were functional assessment scales. RESULTS: The majority of the scales were developed for elderly populations, mainly in hospital or nursing home settings. The patient characteristics assessed were quite similar across the nursing assessment forms. The time to complete the form varied from less than 1 minute to 80 minutes. For those scales with reported diagnostic accuracy, sensitivity varied from 43% to 100% (median = 80%), and specificity varied from 38% to 96% (median = 75%). Several scales with superior diagnostic characteristics were identified. CONCLUSIONS: A substantial number of fall risk assessment tools are readily available and assess similar patient characteristics. Although their diagnostic accuracy and overall usefulness showed wide variability, there are several scales that can be used with confidence as part of an effective falls prevention program. Consequently, there should be little need for facilities to develop their own scales. To continue to develop fall risk assessments unique to individual facilities may be counterproductive because scores will not be comparable across facilities.

Primary carcinoid of prostate.

The first case of pure primary prostatic carcinoid is presented. Previous demonstration of the presence of enterochromaffin cells in the non-neoplastic prostate and in otherwise ordinary adenocarcinomas of the prostate furnishes a basis for the origin of this unique neoplasm.

Angiomyolipoma of penis.

We report a case of angiomyolipoma of the penis in a fifty-three-year-old patient. This lesion is rare outside of its usual intrarenal location, and, to our knowledge, has never before been reported to occur in the penis.

Dermal analogue tumor arising in a lymphoepithelial cyst of the parotid gland.

We report a case of monomorphic adenoma, dermal analogue type, arising in a typical lymphoepithelial cyst of the parotid gland. This case supports the hypothesis that lymphoepithelial cysts of the major salivary glands arise from inclusions of salivary gland tissue in lymph nodes.

Evaluation of double aortic arch and aortic coarctation by intravenous digital subtraction angiography (IV DSA).

Eleven pediatric patients with congenital aortic anomalies were evaluated using intravenous digital subtraction angiography (IV DSA). Excellent correlation was found between IV DSA, other imaging studies, and operative findings. Ten of 11 patients studied (90.9%) were correctly diagnosed using this technique. Intravenous DSA may be the procedure of choice in assessing aortic arch anomalies in selected patients.

Focal arteries of the breast.

The fourth case of focal (isolated) arteritis of the breast is reported. The lesions, which may be unilateral or bilateral, presents as a painful or tender mass and has been confused clinically with carcinoma. Arteritis, either necrotizing or granulomatous, may occur as an isolated phenomenon restricted to a solitary organ; it does not necessarily imply concurrent or subsequent systemic vasculitis.

Bacterial endocarditis on calcification on the mitral anulus fibrosus: report of an unusual case.

Endocarditis restricted to the base of the mitral valve and an adjacent calcified anulus is rare. This report describes a hitherto unrecorded complication: massive intramural hemorrhage of the left atrium.

Fine needle aspiration of intramuscular myxoma of the tongue. A case report.

Intramuscular myxoma of the tongue is a rare, benign, mesenchymal neoplasm that has sometimes been found in conjunction with systemic syndromes. We report a case of intramuscular myxoma of the tongue diagnosed by fine needle aspiration cytology and briefly discuss the significance of this lesion.

Symptomatic leiomyoma of the adrenal.

Although small leiomyomas of the adrenal are a common incidental finding at autopsy, larger examples are extremely rare and have been asymptomatic, discovered as an incidental finding during computed abdominal scanning. We report the first, to our knowledge, instance of a large, symptomatic adrenal leiomyoma, and discuss the pathological and radiological features of the lesion.

The reliability of peer assessments. A meta-analysis.

A meta-analysis of studies examining the interrater reliability of the standard practice of peer assessments of quality of care was conducted. Using the Medline, Health Planning and Administration, and SCISEARCH databases, the English-language literature from 1966 through 1991 was searched for studies of chance corrected agreement among peer reviewers. The weighted mean kappa of 21 independent findings from 13 studies was .31. Comparison of this result with widely used standards suggests that the interrater reliability of peer assessment is quite limited and needs improvement. Research needs to be directed at modifying the peer review process to improve its reliability or at identifying indexes of quality with sufficient validity and reliability that they can be employed without subsequent peer review.

Symptomatic leiomyoma of the adrenal.

Small leiomyomas of the adrenal gland are pathologic curiosities, usually discovered incidentally at autopsy, and thought to arise from smooth muscle of the adrenal vasculature. We report the clinical, radiologic and pathologic features of a symptomatic adrenal leiomyoma, which, to our knowledge, represents the first recorded example.

Practical applications of healthcare marketing ethics.

All businesses--healthcare businesses in particular--have an absolute duty to treat their customers ethically; anything less is unacceptable. Author Goldman discusses four ethical principles that can be applied to help ensure that marketing decisions conform to the highest ethical standards.