Admission criteria for inpatient substance abuse/dependence rehabilitation: implications for managed care.

In view of recent trends toward the replacement of traditional inpatient rehabilitation programs with nonresidential services, we examined the extent to which patients currently admitted to inpatient rehabilitation for alcohol or drug abuse/dependence met published criteria suggesting a preferential need for inpatient or residential care. Over 90% of almost 300 veterans with a primary DSM-III R diagnosis of alcohol or substance abuse/dependence, admitted to six New York Metropolitan Area Veterans Administration Medical Centers for inpatient rehabilitation, met at least one criterion dimension considered indicative of a need for such services, with over two-thirds meeting two or more dimensions. These findings suggest a continuing need for initial primary inpatient or residential rehabilitation for such patients.

Combined modality treatment of symptomatic pancreatic ductal lithiasis.

OBJECTIVE: To assess the efficacy and safety of the removal of pancreatic duct stones by a combined modality approach in patients with pancreatic ductal lithiasis and recurrent abdominal pain. DESIGN: Retrospective review with a mean follow-up of 19 months (range, 1 to 56 months). SETTING: A tertiary care, private community hospital with a university affiliation. PATIENTS: The records of patients who presented to the hospital or who were referred with recurrent abdominal pain and who were demonstrated to have pancreatic ductal lithiasis between 1989 and 1994 were reviewed. Patients were assessed by their clinical response to pancreatic duct stone extraction by a variety of therapeutic interventions. RESULTS: Fifteen patients were included in the study. One patient was excluded from analysis because of a concurrent choledochocele. Two patients required operative decompression and stone extraction for endoscopically inaccessible stones. Six patients were treated with endoscopic management alone, and six were treated with a combination of extracorporeal shock wave lithotripsy and endoscopic stone retrieval. Twelve patients had complete clearance of the pancreatic duct. One patient had a stone that was not removed, but adequate pancreatic ductal decompression was achieved. The remaining patient had incomplete clearance of pancreatic stone fragments following extracorporeal shock wave lithotripsy but had adequate ductal drainage. No patient has required further therapy or hospitalization for abdominal pain. No complications occurred as a result of any intervention in this study. CONCLUSIONS: A multidisciplinary combined modality approach is a safe and effective method for extracting pancreatic duct stones in symptomatic patients. Stone extraction and reestablishment of adequate ductal drainage appear to relieve symptoms in some patients.

Familial nonmultiple endocrine neoplasia medullary thyroid carcinoma: an evolving clinical entity.

BACKGROUND: A rare kindred of familial nonmultiple endocrine neoplasia medullary thyroid carcinoma arising from a 73-year-old proband case is reported to further define this distinct entity. METHODS: Twenty-four family members across four generations, four with medullary thyroid carcinoma (MTC) and two with C-cell hyperplasia (CCH), were studied. RESULTS: Basal calcitonin levels were elevated in three patients with MTC and were normal in one patient with microscopic MTC and two patients with CCH who had persistent subtle elevation in calcium and/or pentagastrin-stimulated calcitonin levels. One patient had unilateral MTC without CCH. Associated abnormalities included papillary carcinoma (2), thyroiditis (4), adenoma (2), and colloid nodule (1). Minimum treatment was total thyroidectomy. Two patients with MTC and marked hypercalcitonemia have recurrent disease at 2.5-year and 11-year follow-up. Two patients with MTC and normal or minor elevations in basal calcitonin and two with CCH had normal provocative calcitonin testing at 6 to 18 months follow-up. CONCLUSIONS: Unilateral MTC without CCH and MTC in the elderly do not preclude a familial cause. Microscopic MTC or CCH may be seen with subtle elevations in stimulated calcitonin levels, and recognition allows for curative thyroidectomy. Other apparent dominant thyroid pathologic conditions may occur concomitantly with familial medullary thyroid carcinoma and thus routine calcitonin, and immunohistochemical testing should be performed in patients with an appropriate family history.

Percutaneous tetracycline instillation for sclerosis of recurrent thyroid cysts.

Of 770 hypofunctioning thyroid nodules subjected to needle biopsy since 1977, the fluid of 172 cysts (22%) was aspirated. The fluid, cytologically examined, showed no evidence of carcinoma except in three instances: papillary carcinomas that were subsequently treated surgically. Of the cystic lesions, 19 (11%) recurred and were treated by reaspiration and the instillation of tetracycline hydrochloride into the cyst cavity. In all but one instance this resulted in obliteration of the cysts (95%). This is a considerably higher rate of success than that reported from aspiration alone (40% to 85%). The follow-up period ranged from 1 to 42 months, with no recurrence or subsequent development of a thyroid nodule in these patients. The one recurrent cyst was reaspirated and reinstilled a second time, which resulted in great reduction in size. Not considered for this procedure were patients in whom the cytologic condition of the fluid was abnormal or indicative of a malignancy. Also excluded were those in whom there was incomplete decompression of the cyst, manifested by a persistent nodule. No patients had a history of head or neck irradiation or cervical lymphadenopathy, both contraindications for this procedure. No patients had grossly bloody aspirates. Recurrence of thyroid cysts after aspiration was not thought to be, in itself, a criterion for surgical selection. The effective use of tetracycline hydrochloride as a sclerosing agent in the treatment of malignant pleural effusions is well documented. Its action in producing symphysis is thought to be related to its low pH (2.0). This procedure is safe, simple, cost effective, and well tolerated by patients. It obviates the need for excision in patients who fulfill the aforementioned criteria.

The efficacy of simultaneous fine-needle aspiration and large-needle biopsy of the thyroid gland.

Fine-needle aspirations and cutting needle biopsies were performed on 415 patients with solitary thyroid nodules. All nodules were considered hypofunctioning by scintiscans. Specimens were adequate in 399 patients. Ten percent of these patients had thyroid cancers documented by thyroidectomies. Results from either or both procedures were positive or suspicious in 58 patients (14.5%). Thyroid cancers were found in 40 of the 58 patients (69%). Aspirates alone detected 34 of 40 cancers (85%) and biopsy specimens alone detected 30 of 40 cancers (75%). All thyroid cancers were detected when both results were considered together, demonstrating that needle aspirates and cutting needle biopsies are complementary. The difficulty of making definitive diagnoses of follicular neoplasms by needle aspirates or cutting needle biopsies is reemphasized.

Needle biopsy in the assessment and management of hypofunctioning thyroid nodules.

Needle biopsy of hypofunctioning solitary thyroid nodules provides direct diagnostic information which would be otherwise obtainable only by surgery. The technique is safe and cost-effective. It provides a high diagnostic yield. It is also useful in planning surgery and reducing dependence on frozen-section diagnosis, which is often difficult with thyroid nodules. Technical and interpretative precautions are discussed. Of 192 patients undergoing this procedure, a satisfactory specimen was obtained in 95 percent. Needle aspiration biopsy (fine needle) was done in 110 patients with good cytologic correlations. Of 52 glands subsequently excised, carcinoma was present in 22 (42 percent). The preoperative diagnosis had been made in 19 (86 percent) of the latter group. This procedure is recommended for consideration in the assessment and management of hypofunctioning thyroid nodules.

Averages of glutamine synthetase molecules as obtained with various skin and electron dose conditions.

Averaged projections of individual glutamine synthetase molecules have been obtained by using electron microscopy and image processing. The methodology of correlation averaging under low dose conditions is described in detail. Because of their low signal-to-noise ratio, images made under low dose conditions cannot be directly interpreted in terms of high resolution features. Computer averaging of these images reveals a division of the subunit projection into two domains whose sizes agree with results of Lei et al [2] limited proteolysis experiments.

The tear-drop capsulectomy and capsulorrhaphy: a new approach in aiding the soft tissue repair of hallux abducto valgus.

Capsular correction is an important part of the repair of hallux abducto valgus. In this paper, the authors discuss the tear-drop method of capsular repair--a method that can be used in all hallux valgus corrections, either alone or in conjunction with the dorsolinear capsulotomy and repair. They believe the tear-drop method has many advantages, among which is the fact that severe splinting and/or casting is not needed and the patient can walk in a surgical shoe almost immediately after surgery. Excellent results were obtained in a high percentage of their 288 cases.

Reconstruction of glutamine synthetase using computer averaging.

The axial projection of the glutamine synthetase molecule has been reconstructed from electron micrographs of a stained preparation by using a new method of correlation search and averaging. The average over 50 individual molecules appears as a radial pattern with sixfold symmetry. The handedness evident in the average is attributed to nonuniformity of the negative stain.

A study of psychopathology of parents of psychotic children by structured interview.

To improve observer uniformity and objectivity in the psychiatric appraisal of parents of psychotic children, structured psychiatric interviews were administered to 64 parents of psychotic children, including 28 husband--wife pairs and 8 single parents. Judgments were recorded on the Spitzer--Endicott Psychiatric Status Schedule and the past section of their Current and Past Psychopathology Scales. There were no significant differences between fathers and mothers of organic and nonorganic children (children with and without evidence of neurological dysfunction). As a whole, the 56 parents in the 28 participating husband-wife pairs fell between a contrast group of 55 adult subjects attending a psychiatric clinic and another contrast group of 130 subjects living in the community in upper Manhattan in their trends to pathological symptoms as judged by the Psychiatric Status Schedule. Similarly, in the past section of the Current and Past Psychopathology Scales the parents showed a trend to more psychopathology than a community sample of 36 nonpatient adults. Finally, computer diagnoses based on the Psychiatric Status Schedule showed more schizophrenia in the parents of the psychotic children than in a sample of 130 nonpatient adults in the community. The data thus tend to support findings based on the unstructured interview of elevated schizophrenia rates in parents of psychotic children.