Clinical challenges in thyroid disease: Time for a new approach?

Thyroid disease is common, and the prevalence is rising. Traditional diagnosis and monitoring relies on thyroid stimulating hormone (TSH) levels. This does not always result in symptomatic improvement in hypothyroid symptoms, to the disappointment of both patients and physicians. A non-traditional therapeutic approach would include evaluation of GI function as well as a dietary history and micronutrient evaluation. This approach also includes assessment of thyroid peroxidase (TPO) antibodies, T3, T4, and reverse T3 levels, and in some cases may require specific T3 supplementation in addition to standard T4 therapy. Both high and low TSH levels on treatment are associated with particular medical risks. In the case of high TSH this is primarily cardiac, whereas for low TSH it is predominantly bone health. This article discusses these important clinical issues in more detail, with some practical tips especially for an approach to the "non-responders" to the current traditional therapeutic approach.

Critical realism: distinguishing the psychological subjectivity of the analyst from epistemological subjectivism.

To clarify the concepts of critical realism, subjectivity, and subjectivism, distinctions are drawn among ontological subjectivism, moral subjectivity, psychological subjectivity, and epistemological subjectivism. Psychological subjectivity, including the ongoing affective life of the analyst, is an essential aspect of the analyst's response to the patient, and may either facilitate or distort an adequate observation of transference and countertransference dynamics and of the psychic reality of the patient. Subjectivism in current psychoanalytic literature involves an argument that there is an "irreducible" subjectivity in the analyst, who is bound to see things from an incorrigibly personal point of view, such that there is no substantial subject-object differentiation between analyst and patient. Issues of authoritarianism in the analyst, or of pathological certainty, should not be confused with the issues of epistemological objectivism. The concept of critical realism or scientific objectivism includes the essential idea that there is no pure knowledge, no complete knowledge, that often evidence is insufficient for knowledge of some aspect of nature, and that care must be to taken understand what is sufficient knowledge in a given area, in this case clinical psychoanalysis. The question is raised whether "projective identification" makes the sorting out of "what comes from whom" impossible. It is argued that when free association is sufficiently facilitated, when there are enough corrections of the distortions wrought by transference and countertransference, when defenses are analyzed, and when sufficient subject-object differentiation is recovered, the analyst can get to know enough of the patient's psychic reality for the therapeutic and scientific purposes of psychoanalysis.

Methods in leukocyte cytochemistry.

During the development and maturation of hematopoetic precursors, certain enzymes and associated substances, such as glycogen, are produced in the developing cells (1,2), which, if detected, can provide important clues to the lineage and classification of leukemias. Although the evaluation of abnormal populations of white blood cells has been greatly refined by the use of immunohistochemistry, flow-cytometric analysis (3), and molecular studies, cytochemistry still plays an important role in the assessment of the abnormal marrow and peripheral blood smear. Cytochemical studies, therefore, still have a role to play in the evaluation of leukemias and other hematological diseases see Fig. 1 ). Fig. 1. Uses of cytochemical studies in the evaluation of blood and bone marrow smears.

Acantholytic variant of squamous cell carcinoma of the breast: a case report.

Primary squamous cell carcinoma of the breast is a rare clinical entity. Two large review series found only five cases out of a total of 8351 breast malignancies. This case report presents a patient with metaplastic, pseudoangiosarcomatous carcinoma or acantholytic variant of a squamous cell carcinoma of the breast. This diagnosis was based on the histological finding of highly atypical, acantholytic squamous cells. Because the tumor stained positive for keratin and negative for factor VIII, the diagnosis of angiosarcoma was ruled out. Although only scattered case reports have been published on this histological variant, these tumors tend to follow an aggressive course.

Leiomyosarcoma of the colon: a second malignant neoplasm after treatment for a Wilms' tumor.

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms' tumor. A review of the prior and current treatment for Wilms' tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.

Cervical carcinoma demonstrating tumor-associated tissue eosinophilia: a clinicopathological study of 17 patients.

OBJECTIVES: Our objective in this study was to evaluate the clinicopathological significance of tissue eosinophilia associated with invasive cervical carcinomas. MATERIALS AND METHODS: All cases of cervical carcinoma treated at the Medical College of Georgia between October 1982 and October 1989 were reviewed. We obtained data regarding all cases, including age at diagnosis, stage of disease, therapy, and outcome. Pathological review of all cases was undertaken to identify those patients in whom invasive carcinoma was associated with an intense infiltrate of eosinophils. RESULTS: A total of 441 patients with invasive cervical carcinomas were treated at the Medical College of Georgia between October 1982 and October 1989. Of these patients, 403 had squamous carcinomas, 34 had adenocarcinomas, 4 had adenosquamous carcinomas, and 18 demonstrated tumorassociated tissue eosinophilia (TATE). In all cases TATE was associated with squamous cell carcinomas. Patients in whom TATE was identified were younger (range, 20-67 years; mean, 40.2 years) than were those patients without TATE (range, 17.5-93.5; mean, 54.8 years; p = .0004; t = 3.626, with 233 degrees of freedom) No significant difference was noted with regard to size of tumor, stage at diagnosis, outcome, or length of survival. CONCLUSION: Although it is an interesting and unusual finding when identified in relationship to cervical carcinoma, TATE is of no prognostic significance.

Jejunal cirsoid aneurysm: a rare cause of massive lower gastrointestinal hemorrhage.

Diverticulosis and angiodysplasia are the most common causes of massive lower gastrointestinal hemorrhage. Lower gastrointestinal hemorrhage frequently resolves without determination of a definitive source. An uncommon cause of lower gastrointestinal tract hemorrhage is the small intestinal submucosal aneurysm. This poorly described entity, more commonly recognized as Dieulafoy's disease in the gastric mucosa, has been documented only rarely in the jejunum. We describe a case report of a 27-year-old man with a massive lower gastrointestinal hemorrhage. Diagnostic evaluation failed to identify the source on initial admission. The patient re-presented to the emergency room with recurrent bleeding, anemia, and hypotension. During a period of active bleeding, a number of diagnostic studies ultimately revealed the source to be the proximal jejunum. Inspection of the resected specimen identified a submucosal aneurysm on the mesenteric border. Histologic evaluation identified the pathologic entity as a cirsoid aneurysm.

Aspergillus: a rare primary organism in soft-tissue infections.

Nonclostridial necrotizing soft-tissue infections are usually polymicrobial, with greater than 90 per cent involving beta-hemolytic streptococci or coagulase-positive staphylococci. The remaining 10 per cent are usually due to Gram-negative enteric pathogens. We describe the case of a 46-year-old woman with bilateral lower extremity fungal soft tissue infections. She underwent multiple surgical debridements of extensive gangrenous necrosis of the skin and subcutaneous fat associated with severe acute arteritis. Histopathological examination revealed Aspergillus niger as the sole initial pathogen. Despite aggressive surgical debridement, allografts, and intravenous amphotericin B, her condition clinically deteriorated and she ultimately died of overwhelming infection. Treatment for soft-tissue infections include surgical debridement and intravenous antibiotics. More specifically, Aspergillus can be treated with intravenous amphotericin B, 5-fluorocytosine, and rifampin. Despite these treatment modalities, necrotizing fascitis is associated with a 60 per cent mortality rate. Primary fungal pathogens should be included in the differential diagnosis of soft-tissue infections.

Visceral leishmaniasis in North West Saudi Arabia: a new endemic focus of L. donovani or further evidence of a changing pathogenic role for L. tropica?

OBJECTIVES: The objective of this study was to evaluate patients with VL from the city of Tabuk, Kingdom of Saudi Arabia, with particular reference to the possibility that a focus of VL exists in the North West Province of Saudi Arabia, an area where it had not previously been reported. SETTING: North West Armed Forces Hospital, Tabuk, Saudi Arabia. DESIGN: Retrospective evaluation of all cases of infantile visceral leishmaniasis diagnosed in Tabuk, Saudi Arabia between 1989 and 1994. RESULTS: 5 cases of infantile visceral leishmaniasis were reviewed. In four cases, no evidence of travel outside Tabuk could be identified, suggesting primary infection by viscerotropic Leishmanial organisms in this area of Saudi Arabia. CONCLUSIONS: Visceral leishmaniasis has been identified in an area previously not considered endemic for L. donovani. This observation may indicate either, a previously unrecognized focus of L. donovani or provide further evidence of a changing pathogenic role for L. tropica.

Characteristics of patients with rapidly growing cervical cancer.

Between April 1983 and December 1990, 387 newly diagnosed cervical cancer cases were managed at our institution. We retrospectively reviewed 59 of those cases, which were identified as having developed within 3 years of the patients' last normal Pap smear. Squamous cell carcinoma was found in 45 patients, and 33 had poorly differentiated lesions. Six cases had typical histology. However, 27 cases (82%) had distinctive histologic features that have not been previously described in rapidly progressive cervical cancer. Thirty-seven patients had surgical treatment; 7 (19%) died of disease. Twenty-two patients had radiation; 10 (45%) died of disease. Patients who have invasive cervical cancer after a recent normal Pap smear may have unusual histologic types, and some with early-stage disease may have better outcome if treated with radical surgery.

Massive ovarian enlargement in primary hypothyroidism.

OBJECTIVE: To report a case of ovarian cyst formation and myxedematous infiltration of the ovary in a subject with primary hypothyroidism. DESIGN: Retrospective case report. SETTING: University hospital. PATIENT(S): A 16-year-old female adolescent with pelvic pain, galactorrhea, irregular menses, and ovarian cysts on pelvic examination. INTERVENTION(S): Laparotomy with bilateral ovarian wedge resection and thyroid replacement therapy. MAIN OUTCOME MEASURE(S): Ovarian histopathology, thyroid function tests, and menstrual history. RESULT(S): Resolution of patient's pain, galactorrhea, and resumption of normal menses. CONCLUSION(S): Ovarian cyst formation may accompany primary hypothyroidism in the child with accelerated or delayed sexual maturation. To date, the underlying pathophysiology of the morphological changes in the ovary remain enigmatic. This case report provides the first insight into the actual histologic changes that occur in ovaries of subjects with primary hypothyroidism without secondary ovarian pathology such as torsion. There is clear evidence of myxedematous infiltration into the ovarian stroma without luteinization of the theca interna. These microscopic findings suggest that local changes occurring independent of gonadotropin stimulation may contribute significantly to altered morphology of the ovaries in primary hypothyroidism.

Atypical glandular cells of undetermined significance and adenocarcinoma in situ: summoning colposcopic expertise?

In comparison with cervical squamous neoplasia, glandular cell neoplasia is uncommon. The evaluation of a patient with atypical glandular cells of undetermined significance is challenging because subtle colposcopic signs are frequently inaccessible to view and cytologic interpretations are extremely challenging for many cytopathologists.

'Narrative', now and then: a critical realist approach.

The author argues that the idea of a 'narrative approach' in psychoanalysis has come to imply that the history of the psyche of a patient is inaccessible and that what the analyst should aim to achieve is the co-construction of a 'story' agreed to by both analyst and patient. She examines some critical realist views on narrative that engage with the problem of how the past determines story-telling in the present. The narrative-hermeneutic perspective has emphasised how much a telling is shaped by the transference, in order, it seems, to urge analysts to forgo a 'naïve realism', an attempt to get at some 'bare facts' of the past, which would lose the bearing of much the patient is communicating in the present. This, as a technical reminder, is excellent. However, critical realism in psychoanalysis has always been sophisticated as opposed to naïve, because of our concern with the workings of oedipal and post-oedipal transformations, and with the workings of the transference. It is the thesis of this paper, written from the perspective of critical realism, that every interpretation, in so far as it contains a narrative truth, that is, speaks adequately of coherence and transference issues, will also refer to a significant aspect of the history of the patient's psyche.

Epidermal inclusion cysts of the clitoris as a complication of female circumcision and pharaonic infibulation.

Female circumcision and pharaonic infibulation is still performed on young females in many parts of the world. It is estimated that two thousand young women living in Britain undergo this ritual every year. The most common complication of this procedure is epidermal inclusion cysts within the infibulation cicatrix. We report the clinical and pathological findings in 10 cases of clitorial inclusion cysts seen at the North West Armed Forbes Hospital, Tabuk, Saudi Arabia between 1989 and 1993. The clinical diagnosis in six cases was that of "clitoral tumor". Two patients presented with complaints of localized pain, one patient presented with dyspareunia and one patient presented with the complaint of a sporadic discharge of white fluid from the circumcision scar. The pathological findings were those of an implantation dermoid in all cases except in two patients where cysts had ruptured and had become inflamed and/or infected. Four cysts were multilocular.

Pilomatrical carcinosarcoma of the cheek with subsequent pulmonary metastases. A case report.

We report a case of malignant pilomatrixoma with a pronounced biphenotypic morphology. The lesion, which was excised from the cheek of a 36-year-old man, was composed of a large pilomatrixoma lying within a spindled, sarcomatoid stroma. Fourteen months later, the tumor metastasized to the right upper lobe of the lung. We describe the tumor's pathology, histology, and immunochemistry and discuss the differential diagnosis. We also speculate on its histogenesis.

Inverted papilloma of the middle ear.

Inverted papilloma is a benign neoplasm confined almost exclusively to the sinonasal tract. We present the first known case report of an inverted papilloma arising from the middle ear. In this paper we discuss the pathophysiology and review the literature of this interesting clinical entity.

Sado-masochism in Charlotte Brontë's Jane Eyre: a ridge of lighted health.

Charlotte Brontë's Jane Eyre contains a paradox of character: Jane Eyre is an assertive successful woman, who marries, after every obstacle is overcome, the man she loves; she is also a traumatised, terrorised child, who later becomes deeply involved, to the point of losing herself, with a moral sadist. In the critical literature on Jane Eyre there is controversy concerning Brontë's aims in the characterisation of her fictional autobiographer. Did Brontë's artistic control of character slip and result in Jane Eyre's irreconciliable attributes? Did she mean to give us an assertive feminine heroine and instead reveal her own castration complex in the marriage to a maimed and near-blind man? The hypothesis of this paper is that the multiple functions of masochism--adaptive, defensive and gratifying--the multiple defence mechanisms at work in masochism--denial, introjection and projection--and the special layering of masochism at each developmental level--oral, anal, and phallic--are mirrored in Brontë's characterisation. The irreducible complexity of the clinical concept of masochism finds its match in Brontë's characterisation of Jane Eyre.

Case report: salmonellosis complicated by leukocytoclastic vasculitis.

We report the case of a healthy young Hispanic man with Salmonella typhimurium bacteremia and leukocytoclastic vasculitis. Leukocytoclastic vasculitis has not been previously reported as a complication of salmonella gastroenteritis and bacteremia. Salmonella gastroenteritis is rarely associated with bacteremia in healthy young adults.

Acute tropical polyarthritis in Zimbabwe: a prospective search for a gonococcal aetiology.

Fifteen consecutive patients with acute arthritis were studied. Careful culture and microscopy of swabs from mucosal sites were performed to examine the hypothesis that the acute tropical polyarthritis commonly seen in Zimbabwe is due to undiagnosed gonococcal infection. Rheumatic fever and Reiter's disease accounted for two cases each. Gram negative intracellular diplococci were found in three patients who would otherwise have been diagnosed as having tropical polyarthritis. Except for two of the remaining eight patients, who had raised anti-streptolysin O titres suggesting recent streptococcal infection, no explanation for the arthritis was found. The clinical entity of tropical polyarthritis may not be due to a single aetiological agent.