[A woman with a painless swelling on her shoulder]. / Een vrouw met een pijnloze zwelling op de schouder.

A 84-year-old woman presented with a swelling located over the acromioclavicular joint, known as a Geyser sign. A Geyser sign occurs in the presence of full-thickness rotator cuff tears. Fluid exudes through the AC-joint creating a cyst. If a wait-and-see approach is not effective, lateral clavicle resection could be considered.

Follow-up of premalignant lesions in patients at risk for progression to gastric cancer.

BACKGROUND AND STUDY AIMS: A recent international guideline recommends surveillance of premalignant gastric lesions for patients at risk of progression to gastric cancer. The aim of this study was to identify the role of the distribution and severity of premalignant lesions in risk categorization. PATIENTS AND METHODS: Patients with a previous diagnosis of atrophic gastritis, intestinal metaplasia, or low grade dysplasia were invited for surveillance endoscopy with non-targeted biopsy sampling. Biopsy specimens were evaluated by pathologists (four general and one expert) using the Sydney and the operative link for gastric intestinal metaplasia (OLGIM) systems, and scores were compared using kappa statistics. RESULTS: 140 patients were included. In 37 % (95 % confidence interval [CI] 29 % - 45 %) the severity of premalignant lesions was less than at baseline, while 6 % (95 %CI 2 % - 10 %) showed progression to more severe lesions. Intestinal metaplasia in the corpus was most likely to progress to more than one location (57 %; 95 %CI 36 % - 76 %). The proportion of patients with multilocated premalignant lesions increased from 24 % at baseline to 31 % at surveillance (P = 0.014). Intestinal metaplasia was the premalignant lesion most frequently identified in subsequent endoscopies. Intestinal metaplasia regressed in 27 % compared with 44 % for atrophic gastritis and 100 % for low grade dysplasia. Interobserver agreement was excellent for intestinal metaplasia (k = 0.81), moderate for dysplasia (k = 0.42), and poor for atrophic gastritis (k < 0). CONCLUSIONS: Premalignant gastric lesions found in the corpus have the highest risk of progression, especially intestinal metaplasia, which has excellent interobserver agreement. This supports the importance of intestinal metaplasia as marker for follow-up in patients with premalignant gastric lesions.

Expression of the alphav integrin adhesion molecule during development of preimplantation human embryos.

OBJECTIVE: To investigate the expression of alphav integrin in developing human embryos. DESIGN: Observational study. SETTING: University medical center. PATIENT(S): Women undergoing IVF cycles. INTERVENTION(S): Immunofluorescent monoclonal antibodies against alphav integrin were used to stain human preimplantation embryos. MAIN OUTCOME MEASURE(S): Immunofluorescence microscopy and computerized image analysis were used to evaluate both qualitative and quantitative expression of integrins in human embryos. RESULT(S): The alphav integrin subunit was found to be expressed in human embryos throughout their development (from two-cell stage up to blastocyst). The expression of alphav integrin subunit gradually increased throughout embryo development as measured quantitatively by image analysis. CONCLUSION(S): The expression of alphav integrin subunit throughout the development of preimplantation human embryos reinforces the concept of a role for integrins in the process of implantation.

Flexor digitorum longus transfer with medial displacement calcaneal osteotomy. Biomechanical rationale.

The rationale behind combining a medical displacement calcaneal osteotomy with a flexor digitorum longus (FDL) transfer is to realign the valgus heel under the mechanical axis of the leg and to reduce the deforming valgus moment of the gastrocnemius soleus muscle group on the hindfoot. This reduces the antagonistic force on the relatively weak FDL transfer. This combination has a potential for producing a more mechanically balanced foot and acts as a double tendon transfer in which the Achilles tendon is transferred medially in addition to the FDL transfer, which substitutes for the degenerative posterior tibial tendon.

A single mid-follicular dose of CDB-2914, a new antiprogestin, inhibits folliculogenesis and endometrial differentiation in normally cycling women.

Previous studies in women have shown that the antiprogestin mifepristone delays or inhibits folliculogenesis. The purpose of this study was to explore whether a new analogue, CDB-2914, has similar effects on folliculogenesis, ovulation, or on subsequent luteal phase endometrial maturation. Forty-four normally cycling, healthy women recorded urine LH and vaginal bleeding during pre-treatment, treatment, and post-treatment cycles. At a lead follicle diameter of 14-16 mm, a single oral dose (10, 50, 100 mg) of CDB-2914 or placebo was given, and daily ultrasound, oestradiol and progesterone were obtained until follicular collapse; an endometrial biopsy was obtained 5-7 days later. Single doses of CDB-2914 were well tolerated. Mid-follicular CDB-2914 suppressed lead follicle growth, causing a dose-dependent delay in folliculogenesis and suppression of plasma oestradiol. At higher doses, a new lead follicle was often recruited. Although luteinized unruptured follicles were observed at the 100 mg dose, all women had follicular collapse. There was a significant delay in endometrial maturation after CDB-2914 at all doses. The treatment cycle was lengthened by 1-2 weeks in 30% at 100, 27% at 50 and 9% at 10 mg. CDB-2914 altered ovarian and endometrial physiology without major effects on menstrual cyclicity and may have therapeutic utility.

Is blastocyst transfer useful as an alternative treatment for patients with multiple in vitro fertilization failures?

OBJECTIVE: To determine whether blastocyst transfer is of benefit to patients with multiple IVF failures. DESIGN: Retrospective cohort study. SETTING: The George Washington University Medical Center. PATIENT(S): Patients undergoing IVF between October 1, 1997, and November 30, 1998, who had previously undergone three or more unsuccessful IVF cycles. Patients who had at least three embryos at the 8- to 12-cell stage available on day 3 were eligible for the study. INTERVENTION(S): Patients were given the option of day 3 ET (group A) or blastocyst transfer (group B). MAIN OUTCOME MEASURE(S): Blastocyst-formation rate, clinical pregnancy rate (PR) per transfer, and implantation rate per transfer. RESULT(S): Groups A and B were similar in terms of age, the number of previous failed IVF cycles, fertilization rate, and the number of fertilized oocytes per cycle. The blastocyst-formation rate was 51.0%. Clinical pregnancy and implantation rates per transfer were statistically significantly higher in the blastocyst-transfer group. There were no multiple pregnancies after blastocyst transfer. CONCLUSION: Blastocyst transfer increases implantation rates and PRs in patients with multiple failed IVF cycles, without increasing the risk of multiple pregnancy.

Efficacy of sinus irrigation versus sinus irrigation followed by functional endoscopic sinus surgery.

Sinus irrigation is the traditional treatment for chronic maxillary sinusitis. Functional endoscopic sinus surgery (FESS) restores aeration and allows secretions to be removed from an infected sinus. This study compares the efficacy of sinus irrigation with that of sinus irrigation followed by FESS in 89 patients. We measured the effects by way of sinus radiographs, nasendoscopic findings, and patient complaints. When we analyzed the data in terms of intent to treat, we found significantly favorable results for sinus irrigation followed by FESS at the end point, though only for loss of smell and purulent rhinitis. Treatment consisting of sinus irrigation alone prevented surgery in 58% of all patients for 1 year. Both treatment methods were combined with a 10-day course of loracarbef, which might have contributed to the outcome. We conclude that a good option for treatment of chronic maxillary sinusitis seems to be sinus irrigation in combination with a broad-spectrum antibiotic followed by FESS.

Value of sinus radiographs in the diagnosis of maxillary sinus disease: interobserver agreement on sinus radiographs by otolaryngologists and radiologists.

Variability between observers and specificity of sinus radiographic findings are subject to discussion. The aim of this study was to assess interobserver variability, between four physicians, two otolaryngologists and two radiologists, in the evaluation of 100 maxillary sinus radiographs. Equal agreement was found within the specialties when rating radiographs as normal or abnormal (80%). Kappa values for interobserver agreement were 0.45 for otolaryngologists and 0.58 for radiologists, both representing fair to good agreement. Otolaryngologists reported more abnormalities (67 vs, 57). Agreement on specific findings (complete opacity, fluid level and mucosal swelling) was fair to good (kappa values between 0.38 and 0.83). Agreement between the four physicians was lower on all outcomes. It is concluded that interobserver variability is within acceptable limits and justifies the continued use of conventional sinus radiographs for confirmation of maxillary sinus disease.

Microbiology of chronic maxillary sinusitis in adults: isolated aerobic and anaerobic bacteria and their susceptibility to twenty antibiotics.

In a comparative study on the efficacy of two surgical treatment procedures, 90 patients diagnosed with chronic maxillary sinusitis received antimicrobial prophylaxis. Maxillary sinus fluid samples were taken from these 90 patients before the initiation of antimicrobial prophylaxis, and were cultured for aerobic and anaerobic bacteria. In 81% of all samples, bacterial growth was present. Anaerobic bacteria were present in 29% of the cases (5% pure anaerobic and 24% mixed aerobic and anaerobic). Predominant aerobic bacteria were staphylococci, in 42% of all samples (mainly coagulase-negative), and streptococci (32%). Predominant anaerobic bacteria were Propionibacterium species (18%) and Gram-negative rods (9%). The antimicrobial susceptibility was determined for 20 antibiotics, and the beta-lactamase production was investigated. The prevalence of beta-lactamase-producing bacteria was unexpectedly high (isolated from 36% of all patients). The findings in this study indicate that not all antimicrobial agents used against upper respiratory tract infections are suitable for treatment of this group of patients when the susceptibility of bacteria present in sinus fluid is taken into account. The high prevalence of beta-lactamase-producing bacteria could influence the course of the disease, due to the breakdown of antibiotics by such strains. Recommendations are given for criteria to use when choosing antimicrobial agents to treat bacterial infections it) patients with chronic maxillary sinusitis.

MRI of injury to the lateral collateral ligamentous complex of the ankle.

We retrospectively evaluated the lateral collateral ligamentous complex of 43 patients who had complained of ankle pain following ankle sprain. The MR signs of ligamentous abnormality included discontinuity or absence, increased signal within the ligament, and ligamentous irregularity or waviness with normal thickness and signal intensity. Using these criteria, 30 anterior talofibular, 20 calcaneofibular, and no posterior talofibular ligament injuries were diagnosed. Compared with surgery (nine patients), MRI demonstrated six of seven anterior talofibular ligament injuries and six of six calcaneofibular ligament injuries. Magnetic resonance showed ligamentous abnormalities in 12 of 23 cases with normal stress radiography. Magnetic resonance imaging provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain.

Treatment of the unstable intertrochanteric fracture. Effect of the placement of the screw, its angle of insertion, and osteotomy.

We created unstable intertrochanteric fractures with a large posteromedial defect in eighteen pairs of fresh-frozen femora from cadavera, and used the femora to evaluate the stability of six combinations of treatment with sliding compression screws and sideplates. The variables that were tested were high (150-degree) angle plates compared with low (130-degree) angle plates, the position of the lag-screw in the femoral head and neck (in the center of the head as seen on both anteroposterior and lateral roentgenograms compared with posteroinferiorly), and whether or not medial cortical contact had been re-established with a limited osteotomy of the greater trochanter. The femora were loaded to the point of failure. The mode of failure, maximum load to failure, and bending rigidity of each method of fixation were measured. Of the six types of treatment, the use of a 150-degree-angle plate, position of the lag-screw in the center of the head as seen on both anteroposterior and lateral roentgenograms, and osteotomy of the greater trochanter resulted in the highest mean load to failure and the greatest rigidity. Over-all, re-establishment of medial cortical contact by means of an osteotomy of the greater trochanter significantly improved the mean load to failure and the rigidity of the fixation. The higher-angle plate, although more difficult to insert, increased the mean load to failure but had no effect on rigidity. The position of the lag-screw (in the center of the head as seen on both anteroposterior and lateral roentgenograms or posteroinferiorly) had no bearing on the mean load to failure, but it significantly affected the mode of failure.

[The microbiological status of dry sausage in East Netherlands]. / De microbiologische gesteldheid van droge worst in Oost-Nederland.

Dry fermented sausage (dfs) was the food most suspected in a number of outbreaks of salmonellosis and staphylococcal enterotoxaemia. Data on formulation and processing showed that over 75 per cent of 76 producers still manufactured dfs in a traditional manner: fermentation and drying at ambient temperature for ten days on an average, green room facilities not present. 'Modern' processes were characterised by fermentation in green rooms at elevated temperatures, thus limiting production time to six days on an average. However, precautions to prevent luxurious growth of S. aureus under these conditions were not adopted to any appreciable extent. Consequently, high S. aureus levels (greater than 10(4) cfu/g) were detected precisely in dfs from five manufacturers using rapid processes. Colony counts of Enterobacteriaceae were low in dfs (81 per cent of 151 samples less than 10(3) cfu/g), associated with relatively low pH and aw levels and a high concentration of salt. However, Salmonella was detected in 16 (11%) of the samples, both from 'traditional' and 'modern' producers. Improvement of manufacturing practices in the manufacture of dfs should be stimulated to guarantee wholesome and safe products.

Effects of D,L-buthionine-S,R-sulfoximine on cellular thiol levels and the oxygen effect in Chinese hamster V79 cells.

The role of glutathione (GSH) and total non-protein thiols (NPSH) in repairing radiation-induced free radical damage incurred under aerated and hypoxic conditions was investigated using Chinese hamster V79 cells cultured in vitro. GSH and NPSH levels were depleted in V79 cells of varying cell densities using the gamma-glutamyl-cysteine-synthetase inhibitor, D,L-Buthionine-S,R-sulfoximine (BSO). A small change in hypoxic cell radiosensitivity could be attributed to the loss of GSH while depletion of thiols to lower levels affected both aerated and hypoxic cell radiosensitivity, resulting in no change in the OER. Only a long term incubation with BSO produced a large change in the OER, by which time many other biochemical pathways using GSH and amino acids are likely to be affected.

Occurrence of Yersinia enterocolitica in Poultry Products.

In a study on isolation of Yersinia enterocolitica from poultry products, usefulness of the following enrichment media was evaluated: phosphate-buffered saline solution with and without addition of 1% sorbitol plus 0.15% bile salts, modified Rappaport medium and selenite broth. Plating was performed on MacConkey agar directly from the incubated broths and after treatment of the enrichment broths with a potassium hydroxide solution. Seventy-three of 108 (68%) samples of poultry products contained Y. enterocolitica . Y. enterocolitica was isolated most frequently after enrichment in phosphate-buffered saline solution with sorbitol and bile salts. Nearly all Y. enterocolitica strains were found after KOH-treatment. Serotyping showed that the isolated strains mainly belonged to the category of the non-pathogenic, so called "environmental" strains.