Accuracy of computerized tomography in determining hepatic tumor size in patients receiving liver transplantation or resection.

Computerized tomography (CT) of liver is used in oncologic practice for staging tumors, evaluating response to treatment, and screening patients for hepatic resection. Because of the impact of CT liver scan on major treatment decisions, it is important to assess its accuracy. Patients undergoing liver transplantation or resection provide a unique opportunity to test the accuracy of hepatic-imaging techniques by comparison of findings of preoperative CT scan with those at gross pathologic examination of resected specimens. Forty-one patients who had partial hepatic resection (34 patients) or liver transplantation (eight patients) for malignant (30 patients) or benign (11 patients) tumors were evaluable. Eight (47%) of 17 patients with primary malignant liver tumors, four (31%) of 13 patients with metastatic liver tumors, and two (20%) of 10 patients with benign liver tumors had tumor nodules in resected specimens that were not apparent on preoperative CT studies. These nodules varied in size from 0.1 to 1.6 cm. While 11 of 14 of these nodules were less than 1.0 cm, three of 14 were greater than 1.0 cm. These results suggest that conventional CT alone may be insufficient to accurately determine the presence or absence of liver metastases, extent of liver involvement, or response of hepatic metastases to treatment.

Effect of observer instruction on ROC study of chest images.

Receiver-operating characteristic (ROC) analysis has been used in many medical imaging applications during the past decade. In order to ensure that reader-confidence ratings are analyzable (well distributed to meet convergence requirements of curve-fitting algorithms) and meaningful (limit extrapolation of the data), many investigators train readers specifically for this purpose. No experimental data are available concerning the possible effects of such training on the results of ROC studies. We performed a multi-observer, multi-disease study in which 300 chest images were rated by four radiologists before and after they were trained to provide well-distributed confidence ratings. The results indicate that for our data set, reader and disease-specific accuracy was not significantly affected by the training process for interstitial disease and pneumothoraces. However, the accuracy of two readers was significantly affected for the detection of nodules (P less than 0.05), and the overall accuracy of one reader was significantly affected for the classification of normal versus abnormal images (P less than 0.01). Thus, in spite of the difficulties associated with the performance of ROC studies in a free-reading environment, one should carefully consider the possible effects of any intervention on the results prior to conducting ROC studies.

Enhanced fibrin formation in high-altitude pulmonary edema.

Blood coagulation, fibrinolysis, and arterial blood gases were examined in 66 nonacclimatized mountaineers at 4,557 m. Subjects were classified according to a clinical score as healthy (n = 25), having mild acute mountain sickness (AMS) (n = 24), showing severe AMS (n = 13), and suffering from high-altitude pulmonary edema (HAPE) (n = 4). Coagulation times, euglobulin lysis time, and fibrin(ogen) fragment E were normal in all groups without significant changes. Fibrinopeptide A (FPA), a molecular marker of in vivo fibrin formation, was elevated in HAPE to 4.2 +/- 2.7 ng/ml (P less than 0.0001) compared with the other groups showing mean values between 1.6 +/- 0.4 and 1.8 +/- 0.7 ng/ml. FPA was normal in one patient with HAPE, however. Severe AMS was accompanied by a significant decrease in arterial PO2 due to an increase in alveolar-arterial O2 difference, whereas arterial PCO2 did not change significantly. We conclude that activation of blood coagulation is not involved in the pathogenesis of AMS and the impairment of gas exchange in this disease. Fibrin generation occurring in HAPE is probably an epiphenomenon of edema formation.

Effects of voluntary hyperventilation on glucose, free fatty acids and several glucostatic hormones.

BACKGROUND: The aim of the present study was to measure the influence of a defined period of standardised voluntary hyperventilation on the levels of glucose, free fatty acids and several glucose regulating hormones in healthy volunteers. STUDY DESIGN: Eight healthy male subjects were submitted to 20 minutes of controlled hyperventilation and blood levels of glucose, free fatty acids, insulin, glucagon, cortisol, catecholamines and pCO2 were measured before, immediately after and 20 minutes after the end of the hyperventilation period. RESULTS: The hyperventilation led to a significant increase in all above mentioned parameters, except for glucose, where the effect was negligible. CONCLUSIONS: In view of the frequency of accompanying hyperventilation in a great variety of diseases and notably in some intensive care patients we postulate that pitfalls in the interpretation of plasma values of substances involved in glucose metabolism may be avoided by simultaneous determination of arterial pCO2.

Radiation and risk for thyroid cancer: atypical findings of a community thyroid recall program.

Screening of 553 persons for thyroid disease by scan and physical exam was performed. Group I (245) had documented irradiation, with most (85%) receiving 300 R for lymphoid hyperplasia. Group II (308) had only a history of prior irradiation. Abnormal glands were found in 17 of 245 (7%) of Group I with 7 of 245 (3%) having nodular disease. No cancers were found in six of eight (75%) persons with nodular disease having surgery. Abnormal glands were found in 45/308 (14.6%) of Group II with 16/308 (5.2%) having nodular disease. Twelve of 16 (75%) with nodular disease from Group II had surgery and three thyroid cancers were found; in addition, one person from this group had a history of prior surgery for thyroid cancer. The incidence of thyroid cancer in Group I was 0%, Group II was 1.3%, and the combined incidence was 0.7%. The relatively low incidence of thyroid cancer observed is attributed to the relatively late average age at time of irradiation; 22 years for Group 1, 13 years for Group II.

Cholescintigraphic detection of intraperitoneal bile leakage from a perforated duodenal ulcer.

A 66-year-old woman with known gallstones and peptic ulcer disease presented with acute epigastric pain. Cholescintigraphy revealed nonvisualization of the gallbladder with subhepatic and perihepatic accumulation of tracer. An upper gastrointestinal examination with water-soluble contrast revealed a perforated duodenal ulcer, with leakage confirmed at laparotomy. The gallbladder was intact.

The C-terminus of p63 contains multiple regulatory elements with different functions.

The transcription factor p63 is expressed as at least six different isoforms, of which two have been assigned critical biological roles within ectodermal development and skin stem cell biology on the one hand and supervision of the genetic stability of oocytes on the other hand. These two isoforms contain a C-terminal inhibitory domain that negatively regulates their transcriptional activity. This inhibitory domain contains two individual components: one that uses an internal binding mechanism to interact with and mask the transactivation domain and one that is based on sumoylation. We have carried out an extensive alanine scanning study to identify critical regions within the inhibitory domain. These experiments show that a stretch of ∼13 amino acids is crucial for the binding function. Further, investigation of transcriptional activity and the intracellular level of mutants that cannot be sumoylated suggests that sumoylation reduces the concentration of p63. We therefore propose that the inhibitory function of the C-terminal domain is in part due to direct inhibition of the transcriptional activity of the protein and in part due to indirect inhibition by controlling the concentration of p63.

The first German textbook of ophthalmology "Augendienst" by G. Bartisch, 1583.

This book contains various illustrations, portraits and an exact index, testimonials proving the author's professional successes as well as an accurate list of the qualities that should be demanded from any ophthalmologist. The anatomy of the head and eye is described according to Galen's ideas and Vesalius' book. Many remedies, prescriptions and medical treatments are discussed, partly showing the mystic influences of the Middle Ages. Bartisch reports several diseases for the first time: Allergic reactions, sympathetic ophthalmia, hemeralopia, photoelectric keratoconjunctivitis, amaurosis due to toxemia of pregnancy. But most important is the part on surgery. A careful pre- and postoperative treatment is demanded in cases of cataract operations. Bartisch describes the removal of eyelashes to cure trichiasis, the operations of ptosis, blepharochalasis and the exenteration of the orbit. This book was appreciated for a long time so that in 1686 a nearly identical reprint was published.

[Conjunctival grafting. Experiences with lyophylized donor-tissue (author's transl)]. / Ersatz der Konjunktiva (Bisherige Erfahrungen mit lyophilisierter Spenderbindehaut)

Firstly the different methods of surgical replacement of the conjunctiva are discussed. Despite certain disadvantages buccal mucosa is often transplanted. More useful and easier is the use of lyophilized human donor conjunctiva. In 10 years we have operated on 110 eyes in 76 patients according to this method. In some eyes conjunctiva of different donors was used, often the whole conjunctival sack had to be reestablished. A brief description is given of winning the donor material, or surgical grafting technique and results, and one of the case histories of the patients is given. No transplant rejection occured, probably because there are no specific proteins or enzyme activities in the lyophilized tissue. Sometimes in pemphigus and similar diseases the tissue will again be included into areas of contracture. After chemical injuries and burns the end of inflammatory signs should be awaited before grafting.

The ophthalmology of Fabricius Hildanus in the 17th century.

Wilhelm Fabricius, born in Hilden, near Düsseldorf, (Fabricius Hildanus) lived from 1560 until 1634. He had been working as physician and surgeon in Switzerland. He left a voluminous literature posthumously edited as 'Opera observationum et curationum medicochirurgicarum'. It is a compendium of 600 extremely interesting pathological cases, some of them in form of letters to close colleagues. Ophthalmology is represented by quite a big chapter, one of them reports a successfully performed exenteratio orbitae because of a tumor. Further parts, for example, describe special ophthalmic twizzers with certain fixing mechanisms and some kind of an operation table equipped by an adjustable prop for the operator's arm. Fabricius points out that after perforation of the eye the loss of aqueous humour is not consequently noxious. He, too, demonstrates the treatment of a symblepharon and describes amongst other therapies the first successful magnetic extraction of an iron foreign body out of the eye in ophthalmic history.

[Complications after photocoagulation and cryotherapy (author's transl)]. / Schäden bei Licht- und Kryokoagulation.

A report of 3 cases is given. Following a photocoagulation because of a retinal tear a rapidly maturing cataract developed. The same occured in a patient after treatment with equatorial transconjunctival cryotherapy (according to Haut) because of dense vitreous turbidities. Though the vitreous cleared, 6 weeks after surgery a mature cataract had developed which had to be removed. In the third case a peripheral retinal hole was surrounded by dryo applications. 6 weeks later a severe proliferative macular detachment developed. Brief case reports and a discussion follow.

Leveling the playing field.

This article describes the application of a relative value scale to management of a large, academic department.

[The influence of artefacts on visual evoked respnses (author's transl)]. / Uber den Einfluss von Artefakten auf visuell evozierte Potentiale.

In 38 healthy persons ranging in age from 23 to 30 years the visual evoked potential over both hemispheres were taken and the latencies and amplitudes of waves I-V registered, first undisturbed, then following defined eye and arm movements, and acustic irritation. The results of 30 persons could be evaluated. It is shown that under these experimental conditions the form of visual evoked potentials is practically undisturbed.

[Steroid withdrawal syndrome. A current problem of outpatient medicine]. / Das Steroidentzug-Syndrom. Ein aktuelles Problem der ambulanten Medizin.

In contrast to a widespread belief, the authors consider a single measurement of serum cortisol concentration in the early morning to be a reliable and simple outpatient screening method for detecting spontaneous or iatrogenic adrenal insufficiency. In patients on steroids the method allows detection of iatrogenic damage to the adrenals while steroid therapy is still continuing. Important guidelines for the conduct of a planned attempt to withdraw steroids can thus be obtained. Routine use of early morning cortisol measurements has greatly improved clinical knowledge about the multifaceted steroid-withdrawal syndromes (SWS). The symptoms of classical adrenal insufficiency in the form of SWS are described, as are the often atypical signs and symptoms occurring when the disease initially calling for steroid treatment is still active during attempts to lower the therapeutic dose. In addition, attention is drawn to SWS due to psychological causes.