Risk factors for the rising rates of primary liver cancer in the United States.

BACKGROUND: A recent increase in the incidence of hepatocellular carcinoma was reported in the United States. The cause of this witnessed rise remains unknown. METHODS: We examined the temporal changes in both age-specific and age-standardized hospitalization rates of primary liver cancer associated with hepatitis C, hepatitis B, and alcoholic cirrhosis in the Department of Veterans Affairs Medical Center's Patient Treatment File. RESULTS: A total of 1605 patients were diagnosed with primary liver cancer between 1993 and 1998. The overall age-adjusted proportional hospitalization rate for primary liver cancer increased from 36.4 per 100,000 (95% confidence interval [CI], 34.0-38.9) between 1993 and 1995 to 47.5 per 100,000 (95% CI, 44.6-50.1) between 1996 and 1998. There was a 3-fold increase in the age-adjusted rates for primary liver cancer associated with hepatitis C virus, from 2.3 per 100,000 (95% CI, 1. 8-3.0) between 1993 and 1995 to 7.0 per 100,000 (95% CI, 5.9-8.1) between 1996 and 1998. Concomitant with this rise, the age-specific rates for primary liver cancer associated with hepatitis C also shifted toward younger patients. During the same periods, the age-adjusted rates for primary liver cancer associated with either hepatitis B virus (2.2 vs 3.1 per 100,000) or alcoholic cirrhosis (8. 4 vs 9.1 per 100,000) remained stable. The rates for primary liver cancer without risk factors also remained without a statistically significant change, from 17.5 (95% CI, 15.8-19.1) between 1993 and 1995 to 19.0 per 100,000 (95% CI, 17.3-20.7) between 1996 and 1998. CONCLUSIONS: Hepatitis C virus infection accounts for most of the increase in the number of cases of primary liver cancer among US veterans. The rates of primary liver cancer associated with alcoholic cirrhosis and hepatitis B virus infection have remained stable. Arch Intern Med. 2000;160:3227-3230.

Nutrition Societies Presidents' Forum: future challenges and opportunities for nutrition societies in the 21st century.

The Chair introduced "Pasteur's Quadrant" as a potentially useful paradigm for modern science. Developed by Princeton's Donald E Stokes, the quadrant is two-by-two matrix that classifies knowledge as fundamental and/or applied. The Chair also noted the effect of competitive pressures, and the necessity for cooperation among nutrition societies. The Presidents of The American Society for Nutritional Sciences (ASNS), The American Society for Clinical Nutrition (ASCN), The American Society for Parenteral and Enteral Nutrition (ASPEN), and the Chair of the Institute of Food Technologist's (IFT) Nutrition Division presented their views on how societies can prepare to meet their members' upcoming needs. The Director of the Center for Food and Nutrition Policy discussed the future role of nutrition societies and how they might interact with various interest groups. The Forum, which included an opportunity for audience participation, took place soon after the February 1996 release of "Meeting the Challenge: A Research Agenda for America's Health, Safety, and Food." Published by the Executive Office of the President's Office of Science and Technology Policy, the report highlights the importance of nutrition to our nation's health.

The role of radiologic imaging in diagnosing complications of video-assisted thoracoscopic surgery.

STUDY OBJECTIVE: To examine the role of radiologic imaging in evaluating complications of video-assisted thoracoscopic surgery. DESIGN: Retrospective review of radiographic and clinical data. SETTING: Tertiary referral hospital. PATIENTS: All patients who underwent thoracoscopy at the University of Maryland Hospital between July 1990 and June 1994. A total of 260 procedures were performed on 239 patients. MEASUREMENTS AND RESULTS: Imaging studies performed before, during, and after surgery in cases in which complications occurred were reviewed by two thoracic radiologists. A randomly selected group of 22 CT scans from uncomplicated cases were used as control subjects. Complications occurred in 24 (9.2%) of the 260 thoracoscopic procedures. Intraoperative complications developed in 14 (5.4%) patients. Ten of the 14 patients had an obliterated pleural space that prevented access of the trocars and videoscope. Preoperative imaging showed significant pleural thickening or calcifications in seven of these ten patients. Other intraoperative complications were malposition of the double-lumen endotracheal tube (n=2) and dislodgement of a localizing needle-wire (n=2). In 8 (3.1%) patients, radiographically evident postoperative complications developed; these complications included prolonged air leak, empyema, recurrent pneumothorax, pulmonary edema, and pneumonia. CONCLUSION: Pleural calcification or thickening that is found on preoperative studies may help predict difficulty in inserting the thoracoscopic instruments but also can be seen on preoperative CT scans in uncomplicated cases. Thoracic CT scans may fail to predict complete pleural symphysis.

Accuracy of CT for the detection of pleural adhesions: correlation with video-assisted thoracoscopic surgery.

STUDY OBJECTIVE: The presence of pleural adhesions may render video-assisted thoracoscopic surgery (VATS) difficult or impossible. The aim of this study was to assess the value of chest CT in the detection of pleural adhesions prior to VATS. DESIGN: Prospective study of the accuracy of chest CT in detecting pleural adhesions prior to VATS. SETTING: Tertiary-referra; teaching hospital and Veterans Administration hospital. PATIENTS: Between July 1994 and March 1995, 63 consecutive patients undergoing 64 VATS procedures were evaluated with chest CT prior to surgery. MEASUREMENTS AND RESULTS: Preoperative scans were interpreted by consensus of two pulmonary radiologists prior to surgery. Suspected pleural adhesions and other findings related to the pleura were recorded on a form given to the surgeon prior to VATS. The surgeon confirmed or excluded each suspected adhesion during VATS, and documented any other lesions not identified preoperatively. Patient-by-patient and lesion-by-lesion analyses were performed. Pleural adhesions were correctly identified by CT in 28 of 39 cases (sensitivity, 71%) and excluded in 18 of 25 cases (specificity, 72%). On a lesion-by-lesion basis, 73 adhesions were identified during VATS, of which only 28 were identified prospectively at CT. There were 45 missed adhesions and 20 adhesions that were suggested falsely (sensitivity, 38%; specificity, 46%). Eighteen pleural spaces were correctly identified as being free of pleural adhesions. CONCLUSIONS: CT is moderately sensitive and specific for preoperative identification of pleural adhesions in patients undergoing VATS but its accuracy is poorer for individual lesions.

MR imaging of slipped stacked breast implants: a potential pitfall in the diagnosis of intracapsular rupture.

The integrity of silicone-gel breast implants can be evaluated by MR imaging. The findings of intra- and extracapsular rupture have been described. Increasingly sophisticated breast reconstruction techniques such as stacking of prostheses have lead to a wider range of implant appearances. We report a case where intracapsular rupture was simulated by slippage of two retropectoral stacked implants in relation to each other. The MR and CT findings are described.

A comparison of learning activity packages and classroom instruction for diet management of patients with non-insulin-dependent diabetes mellitus.

Forty patients were randomly assigned to receive either the individualized learning activity packages or classroom instruction. Effectiveness was evaluated on the basis of fasting plasma glucose, glycosylated hemoglobin, percent of ideal body weight, and knowledge and behavior scores. No significant differences were found between the groups at entry or at the 2-month follow-up. At the 5-month follow-up, the group that received the learning activity packages scored significantly higher on knowledge assessment, significantly increased their behavior score, and decreased their percent of ideal body weight. Patients who received classroom instruction increased their behavior score and exhibited significantly decreased glycosylated hemoglobin levels. Behavior and blood glucose levels were significantly correlated. Although the learning activity packages proved effective in increasing knowledge, no significant improvement was observed in blood glucose levels.

Protein digestibility-corrected amino acid scores for bean and bean-rice infant weaning food products.

Vegetable proteins are an integral part of infant weaning diets in Latin America. Protein quality in plant-based products, however, is constrained by amino acid composition and intrinsically present antinutritional factors. The goal of this study was to improve bean protein quality by utilizing fermentation and germination processing. The objectives were to determine if protein quality, as measured by Food and Agricultural Organization (FAO) approved True Protein Digestibility (TPD) and Protein Digestibility-Corrected Amino Acid Scores (PDCAAS), of formulated bean-based weaning products could be improved upon fermentation and germination and if protein quality could be further improved when processed beans were combined with cooked rice. Results showed that the highest TPD and PDCAAS values were obtained for cooked germinated beans combined with rice. The TPD values for products ranged from 80 to 91%, and the PDCAAS values were 0.38-0.51. There was no significant increase (P < 0.05) of either TPD or PDCAAS values upon fermentation. Germination increased TPD of cooked bean products; this increase was not, however, accompanied by an increase in PDCAAS. When combined with rice, the PDCAAS values for all bean products improved significantly, thus supporting the concept of cereal-legume complementation. In conclusion, this study showed the range of PDCAAS in processed black bean and bean-rice infant weaning food products. The potential for incorporation of these products into the diets of weaning age Latin American children would, however, be confirmed only after validation with growth or metabolic balance studies in human infants.

Iron and zinc bioavailability in rats fed intrinsically labeled bean and bean-rice infant weaning food products.

Beans are the core of the Latin American diet and contain iron and zinc. However, the bioavailability of these trace minerals from beans is low. The objective of this study was to determine if the bioavailability of iron and zinc could be improved with the use of fermentation and germination processing technologies. Black beans native to Costa Rica were grown hydroponically with either radioactive iron or zinc. The influence of fermentation and germination on iron and zinc bioavailability from intrinsically labeled infant weaning food products based on black beans and beans-rice was determined in rats. Mineral bioavailability was determined using whole-body (59)Fe retention for iron, and whole-body (65)Zn retention and incorporation of radiolabel into bone for zinc. Percent absorption of (59)Fe from fermented products ranged between 48.0 and 58.0. Percent absorption of (65)Zn ranged from 57.0 to 64.0. Fermentation did not increase iron bioavailability in rats fed fermented beans without rice. Fermentation of cooked beans significantly increased zinc retention. Germination significantly enhanced iron retention from cooked beans from 46 to 55% and from cooked beans-cooked rice from 34 to 48%. Germination significantly improved zinc absorption and retention from cooked beans without added rice.

An infected mediastinal cyst.

The authors describe a 43-year-old patient who had a mediastinal mass that became infected after a transbronchial needle aspirate biopsy. A paraspinal, extrapleural window with a saline-lidocaine mixture was created that allowed the placement of a percutaneous drainage catheter into the infected lesion. This procedure resulted in an excellent clinical outcome, and obviated the need for a thoracotomy and more invasive surgical management.

Bronchial artery aneurysms in association with Mycobacterium avium intracellulare complex.

An immunosuppressed patient with scleroderma presented with hemoptysis due to bronchial artery aneurysms associated with Mycobacterium avium-intracellulare complex (MAC).

The role of computed tomography in the diagnosis and management of human immunodeficiency virus (HIV)-related pulmonary diseases.

This review summarizes the current role of CT in the diagnosis and management of respiratory disease in human immunodeficiency virus (HIV)-positive patients. Recommendations are made concerning optimum technique for diagnostic CT as well as practical considerations concerning the use of CT in biopsy and thoracic interventional procedures in acquired immune deficiency syndrome (AIDS)-related thoracic disease. Clinical scenarios discussed include the use of CT when the chest radiograph is normal in a patient with a high clinical suspicion of pulmonary disease, utility of CT in the differential diagnosis of parenchymal abnormalities and in the assessment of patients with airways disease, hemoptysis, progressive lung disease, and intrathoracic complications. Finally, the use of thoracic CT in the staging of AIDS-related neoplastic conditions involving the chest is discussed.

Comparison of radiology residency programs in ten countries.

The purpose of our study was to compare various aspects of radiology training schemes in ten countries. A questionnaire was sent to senior residents in the UK, USA, Canada, Australia, New Zealand, Italy, Egypt, India, Malaysia and Greece. The questions concerned length of training, required pre-training experience, the organization of the training scheme, teaching, resources, stages at which residents can independently perform and report examinations, fellowships, and progression to jobs. A wide variety of training, ranging from highly scheduled programs with detailed aims and objectives, to self-learning occurs across the world. Examinations and assessments are also variable. There are lessons to be learned from varying practices; more exchanges of ideas should be encouraged. In view of the "internationalization" of radiology services and the variation in training styles an international qualification for quality assurance purposes may be desirable.

CT appearance of endobronchial non-Hodgkin lymphoma.

OBJECTIVE: Endobronchial involvement by non-Hodgkin lymphoma (NHL) is a very rare manifestation of the disease. We describe this unusual entity and emphasize the role of chest CT scan. MATERIALS AND METHODS: Two radiologists reviewed the chest radiographs and CT scans of two patients with endobronchial NHL. The studies were reviewed for the presence and extent of endobronchial involvement. Bronchoscopic confirmation was obtained. RESULTS: In each case CT showed endobronchial lesions that correlated well with the extent of tumor found at bronchoscopy. CONCLUSION: Computed tomography is useful to suggest endobronchial NHL in the proper clinical context and to assist the bronchoscopist in selecting the appropriate site for biopsy.

Metabolism in rats of selenium from intrinsically and extrinsically labeled isolated soy protein.

Absorption, retention and tissue accumulation by rats of 75Se from intrinsically labeled isolated soy protein were compared with utilization of 75Se from the extrinsic sources of [75Se]selenite, [75Se]selenate or [75Se]selenomethionine. Extrinsic sources of selenium were given by gavage or mixed with isolated soy protein. There were no differences in absorption and retention of 75Se from intrinsically labeled soy diet compared to the three extrinsically labeled soy diets. Of the three extrinsic sources tested, 75Se from selenate was better absorbed than from selenite or selenomethionine when incorporated into a soy diet. Absorption of 75Se was significantly lower when given to animals in gavage solution than when mixed with soy diets. After a 14-d test period, retention of 75Se was the same for all four soy diet groups. In gavaged groups, 75Se from selenomethionine was retained to a greater extent than 75Se from selenite. The liver, testes and kidney accumulated more 75Se from the test meal than did the blood and lungs. In the testes more 75Se from selenite and selenate was accumulated than from selenomethionine-labeled diets. Selenium absorption from the soy isolate source was very high (86-96%), indicating that, although soy does not normally contain high levels of selenium, the selenium present is well absorbed from this plant source.

Newly diagnosed cystic fibrosis in adults: pattern and distribution of bronchiectasis in 12 cases.

OBJECTIVE: The aim of this study was to analyse the type and distribution of bronchiectasis at computed tomography (CT) in adults with recently diagnosed cystic fibrosis. METHODS: The CT examinations of 12 consecutive patients diagnosed with cystic fibrosis in adulthood (six male, six female; age range at diagnosis 25-63 years) were analysed retrospectively using a modified Bhalla scoring system. Bronchiectasis was catergorized by Reid type and by location within the affected lobe (peripheral, central or mixed). RESULTS: Bronchiectasis was identified in 70 of 71 lobes. Two or more bronchopulmonary segments were involved in 67 of 71 lobes. The majority of lobes demonstrated cylindrical bronchiectasis as the predominant type (n = 51), with varicose (n = 11) and cystic (n = 8) less commonly seen. Bronchiectasis was mainly central in 16 lobes, and both central and peripheral in 54 lobes. The severity of bronchial dilatation was greatest for the upper lobes (mean score, 1.75 right, 1.58 left) compared with the middle lobe/lingula (mean score, 1.42 right, 1.17 left) and lower lobes (mean score, 1.09 right, 1.17 left). CONCLUSION: Bronchiectasis in patients with cystic fibrosis diagnosed in adulthood is usually widespread, predominantly cylindrical, and is more severe in the upper lobes. The diagnosis of cystic fibrosis should be considered in adults with 'idiopathic' bronchiectasis showing these features on CT.

Peripheral frequency mis-match in the primitive ensiferan Cyphoderris monstrosa (Orthoptera: Haglidae).

Peripheral auditory frequency tuning in the ensiferan insect Cyphoderris monstrosa (Orthoptera: Haglidae) was examined by comparing tympanal vibrations and primary auditory receptor responses. In this species there is a mis-match between the frequency of maximal auditory sensitivity and the frequency content of the species' acoustic signals. The mis-match is not a function of the mechanical properties of the tympanum, but is evident at the level of primary receptors. There are two classes of primary receptors: low-tuned and broadly tuned. Differences in the absolute sensitivity of the two receptor types at the male song frequency would allow the auditory system to discriminate intraspecific signals from sounds containing lower frequencies. Comparisons of tympanal and receptor tuning indicated that the sensitivity of the broadly tuned receptors did not differ from that of the tympanum, while low-tuned receptors had significantly narrower frequency tuning. The results suggest that the limited specialization for the encoding of intraspecific signals in the auditory system of C. monstrosa is a primitive rather than a degenerate condition. The limited specialization of C. monstrosa may reflect the evolutionary origin of communication-related hearing from a generalized precursor through the addition of peripheral adaptations (tympana, additional receptors) to enhance frequency sensitivity and discrimination.

Hyperacute directional hearing in a microscale auditory system.

The physics of sound propagation imposes fundamental constraints on sound localization: for a given frequency, the smaller the receiver, the smaller the available cues. Thus, the creation of nanoscale acoustic microphones with directional sensitivity is very difficult. The fly Ormia ochracea possesses an unusual 'ear' that largely overcomes these physical constraints; attempts to exploit principles derived from O. ochracea for improved hearing aids are now in progress. Here we report that O. ochracea can behaviourally localize a salient sound source with a precision equal to that of humans. Despite its small size and minuscule interaural cues, the fly localizes sound sources to within 2 degrees azimuth. As the fly's eardrums are less than 0.5 mm apart, localization cues are around 50 ns. Directional information is represented in the auditory system by the relative timing of receptor responses in the two ears. Low-jitter, phasic receptor responses are pooled to achieve hyperacute timecoding. These results demonstrate that nanoscale/microscale directional microphones patterned after O. ochracea have the potential for highly accurate directional sensitivity, independent of their size. Notably, in the fly itself this performance is dependent on a newly discovered set of specific coding strategies employed by the nervous system.

Occult craniocerebral injuries from dog bites in young children.

Although dog bite injuries to the head and scalp of children occur frequently, penetrating dog bite wounds to the cranial vault occur only occasionally and may go unnoticed on initial examination. Substantial morbidity and mortality can ensue if these penetrating injuries are not detected and treated. The authors detail the evaluation of dog bites of the scalp in young children. They highlight the ease with which puncture wounds of the calvarium may be missed during physical examination as a result of scalp displacement at the time of puncture. The cranial puncture may not be large and may later be covered by scalp that returns to its native position. Well-scrutinized skull films and a careful, methodical physical examination are advocated. Recognized craniocerebral injuries should be explored. Depressed cranial fractures should be irrigated, debrided, and elevated. Dural tears should be repaired. Expedient management is necessary to prevent meningitis and its associated sequelae.

Trends in survival of patients with hepatocellular carcinoma between 1977 and 1996 in the United States.

The recent increase in the incidence of hepatocellular cancer in the United States is thought to underlie the rising mortality of this malignancy. However, it remains unknown whether survival of patients with hepatocellular carcinoma (HCC) has changed during the same time period. Using the SEER database (Surveillance, Epidemiology, and End Results) of the National Cancer Institute, we examined the temporal changes and determinants of survival among patients with histologically proven HCC over a 20-year period. Between 1977 and 1996, 7,389 patients diagnosed with HCC were followed in the survival database of SEER. The overall 1-year relative survival rate increased from 14% (95% confidence intervals (CI): 12-16) during 1977-1981 to 23% (95% CI: 21-24) during 1992 to 1996. Between the same two time periods, less improvement was seen in the 5-year survival rates, which increased from 2% (95% CI: 1-3) to only 5% (95% CI: 4-7). The median survival increased slightly from 0.57 years during 1977 to 1981 to 0.64 years during 1992 to 1996. In general, there were no significant differences in survival between men and women or between ethnic groups. During 1987 to 1991, a small fraction (0.8%) of patients underwent radical surgery; these patients had 1-year survival of 59% (95% CI: 35-83%), and 5-year survival of 35% (95% CI: 12-58%). Similar rates were seen during 1992-1996. In conclusion, a small improvement in survival of patients with HCC was seen between 1977 and 1996. Most of this apparent benefit is restricted to the first year following cancer diagnosis, raising the possibility of lead-time bias. There were no significant differences related to gender or ethnicity.