Eosinophilic granuloma of the liver: a characteristic lesion with relationship to visceral larva migrans.

Children with the clinical syndrome of visceral larva migrans as a result of Toxocara species have typical lesions in the liver and other viscera, consisting of palisading granulomas that contain numerous eosinophils and often Charcot-Leyden crystals; recognizable parasites are uncommon. Similar eosinophilic granulomas that are found incidentally in adults often cause diagnostic problems. To define better the clinical, laboratory, and pathologic features of these lesions, we reviewed 43 cases of hepatic eosinophilic granuloma (excluding cases of Langerhans' cell histiocytosis) collected in the files of the AFIP over a period of 31 years. The eosinophilic granulomas were found in patients of all ages (range 12 months to 77 years); 30% were younger than 20 years. There were 26 male and 17 female patients. Most patients (26 of 43; 60%) were asymptomatic, and the lesions were discovered incidentally. Others had fever (20%) or abdominal pain (20%). The granulomas were typically multiple (61%), with central necrosis surrounded by a mixed inflammatory infiltrate with numerous eosinophils and variable numbers of neutrophils. lymphocytes, and a palisade of epithelioid histiocytes and/or giant cells. Charcot-Leyden crystals were present in 19 cases (44%). Remnants of parasites (eight Toxocara sp., two Capillaria sp.) were identified in the tissue in 10 patients. There was a positive serologic test for Toxocara sp. in five additional cases. Immunohistochemical staining using polyclonal antiserum against Toxocara canis larvae demonstrated positivity in macrophages in eight of 13 cases tested. We conclude that identification of an eosinophilic granuloma in the liver should suggest the diagnosis of visceral larva migrans and prompt a search for the causative organism with serial sectioning of the block and serologic tests for Toxocara and other causative parasites.

Multiple myeloma-associated amyloidosis manifesting as fulminant hepatic failure.

We report a case of amyloidosis associated with K light chain multiple myeloma in a 42-year-old African American man. The patient initially had mild dyspepsia, which rapidly progressed to include anorexia, fulminant hepatic failure, and death within 9 weeks. This is only the fourth reported case of hepatic failure from myeloma-associated amyloidosis and the second reported case of light chain myeloma with amyloidosis resulting in a progressive clinical course of hepatic failure. Our patient was unique in that, despite severe disease, he had mild symptoms without laboratory abnormalities until 2 weeks prior to death.

Thought disorder in schizophrenia and mania: impaired context.

This research studied hypotheses that positive thought disorder in schizophrenia is influenced by patients' not taking in immediate target contextual material, thereby losing vital cues that guide thought processes. We assessed 164 acute inpatients (including 55 schizophrenia and 31 bipolar disorder patients), using standardized measures of thought disorder. We also used new measures that assessed (1) total ignoring of context, and (2) straying from the context. Results were as follows: (1) only 9 percent of the schizophrenia patients showed strong evidence of completely ignoring the external context; (2) straying from the external context while simultaneously maintaining part of the context was significantly more common than complete absence of context (p < 0.01); (3) patients with thought disorder strayed from the context significantly more than patients without thought disorder (p < 0.001); and (4) straying from the context was involved in the thought disorder of some, but not all, schizophrenia and mania patients. The data suggest that thought disorder in schizophrenia is not typically due to a failure to "hear" or to take in the relevant contextual material necessary for an appropriate response. Loss of context is involved in some, but not all, thought disorder in schizophrenia and mania.

Liver involvement in Langerhans' cell histiocytosis: a study of nine cases.

Nine cases of Langerhans' cell histiocytosis (LCH) of the liver are presented. Five of the patients had liver involvement only. Other organ systems, notably the lymph nodes and skin, were involved in the other four patients. Four of the patients had sclerosing biliary disease with infiltration of the bile ducts by Langerhans' cells, whereas in two other patients, the biliary sclerosis was not associated with direct hepatic involvement by Langerhans' cells. Histologically, the lesions were composed of focal aggregates of Langerhans' cells in a polymorphous background of mature eosinophils, lymphocytes, neutrophils, and plasma cells. LCH encompasses a syndrome that has a broad range of clinical presentations and that might involve the liver solely as tumor-like lesions or cystic lesions, or as part of systemic disease. Even when Langerhans' cells are not demonstrable, sclerosing cholangitis can be seen in LCH.

Psychosis and functioning as risk factors for later suicidal activity among schizophrenia and schizoaffective patients: a disease-based interactive model.

The present research explores the relationship of positive symptoms, negative symptoms, and posthospital functioning to subsequent suicidal behavior over a 7 1/2-year period, and examines whether these patterns vary with diagnosis. The results support a multifactor model of suicide risk. Both psychosis and poor functioning show some relationship to later suicidal activity for both schizophrenic and schizoaffective patients. Psychosis may remain a risk factor for suicidal activity for schizoaffective patients, even when functioning is partialed out. This is in contrast to the schizophrenia patients, for whom funtioning seems to mediate the effects of psychosis on later suicidality. In general, adequacy of overall posthospital functioning mediates the effects of some risk factors on suicidal activity within different diagnostic groups.

Hippocrates, Maimonides and the doctor's responsibility.

Jack Kevorkian criticizes the Hippocratic tradition in Greek medicine, which bans the physician from giving his patient a lethal medication. He sees this prohibition as potentially bringing harm to a suffering patient and not reflective of the larger Greek society which was tolerant and even approving of suicide. However, Kevorkian's advocacy of doctor-assisted suicide can be seen as the polarity of doctor abandonment of the suffering patient rather than as an antidote to it. Both positions involve an outcome of physician removal from the suffering patient, which can be contrasted with Maimonides' command to the physician to watch over the life and death of his patients.

Effect of the doctor on college students' attitudes toward physician-assisted suicide.

Ninety-six students were presented with eighteen different vignettes describing different types of active and passive observed suicide, assisted suicide, and euthanasia. Attitudes regarding the morality and desired legality of each situation were measured. Results indicated that the interaction between the doctor and the patient, and, to a lesser extent, the active or passive nature of the agent of death, were more important than the actual actions of the doctor in allowing or causing death to occur.

Gender, pain, and doctor involvement: high school student attitudes toward doctor-assisted suicide.

The present study concentrates on the attitudes of high school students toward active doctor-assisted suicide as described in hypothetical doctor-patient scenarios, orthogonally manipulating doctor's reaction to patient's wishes to end his/her life (whether discussed, accepted or encouraged), presence of patient's physical pain, presence of patient's emotional pain, and the gender of the hypothetical patient. Doctor-assisted suicides thoroughly discussed with the patient are judged to be more moral, acceptable, and "legal" than assisted suicides that are simply accepted by the doctor or actively encouraged by him. Significantly, this is not a distinction that is relevant in the eyes of the law. Further, the presence of both physical and emotional pain on the part of the patient make the patient death more acceptable in the eyes of high school students. This latter effect is striking, given the result of the Wooddell and Kaplan (1999-2000) study showing that patient depression tends to weaken acceptability of death. Finally, respondents, both male and female, tend to view deaths of patients of the opposite gender as more acceptable than patients of the same gender.

Doctor assisted suicide: an analysis of public opinion of Michigan adults.

Michigan public opinion on Doctor Assisted Suicide (DAS) was assessed in January 1997 (N=603). Asked if they would consider DAS for themselves, two-thirds would if being kept alive by machine or were experiencing chronic pain; one-half would if they experienced a loss in mobility or independence, became a burden to others, or were diagnosed with a terminal disease; and one-third would if they were incontinent or going to a nursing home. A series of demographic and attitudinal comparisons were made for support for the concept of DAS and as a hypothetical consideration for oneself. The highest support for the concept of DAS was found among the following: men eighteen to twenty-four years old, some college education, $35-60,000/year income, Caucasian, Democrat, liberal, Protestant, and frequent church attendee. The highest self-consideration of DAS was found among the following: men, fifty to fifty-five years old, post-graduate education, $35-60,000/year income, Caucasian, Democrat, liberal, Protestant, and infrequent church attendee.

Psychosocial versus biomedical risk factors in Kevorkian's first forty-seven physician-assisted deaths.

This article examines biomedical and psychosocial data on the first forty-seven cases of physician-assisted suicide (PAS) of Kevorkian as collected by means of both a physical autopsy and a preliminary psychological autopsy. The following patterns emerge: 1) The physical condition of these PAS patients was not typical of the conditions that lead to death in the United States. 2) Consistent with the above findings, our pilot data indicate that only 31.1 percent of these patients were terminal. While 73.9 percent were described as reporting pain, only 42.6 percent were revealed at autopsy to have a specific anatomical basis for their pain. However 36 percent were described as depressed, 66 percent as having some disability, and perhaps of key importance, 90 percent expressed a fear of dependency. Most important, our pilot data suggest the possibility of large gender differences, since 3) 68.1 percent of these forty-seven PAS's are women and only 31.9 percent are men. This represents the reverse of the gender pattern for completed suicides in the United States in 1995, resembling instead the approximate pattern for unsuccessful suicide attempts. 4) Approximately 75 percent of both men and women in the above sample were described as reporting pain. Men were almost twice as likely to have had an anatomical basis for the pain and three times as likely to be terminal. Our pilot data indicate PAS women are more likely to be described as depressed and twice as likely to have had a history of previous unsuccessful suicide attempts. 5) Kevorkian's patients were older than the typical unaided suicides in America. Reported pain decreases with age as does depression; however anatomical basis for pain increases slightly with age, and no age effect emerges for terminality. 6) Approximately two-thirds of those physician-assisted suicides were at middle SES levels. History of disability was the biggest risk factor for the low SES patients and fear of dependency for the high SES patients.

An update on the Kevorkian-Reding 93 physician-assisted deaths in Michigan: is Kevorkian a savior, serial-killer or suicidal martyr?

This report presents an update of the Kevorkian-Reding physician-assisted (or physician-aided) deaths to include the ninety-three publicly acknowledged cases as of November 25, 1998. These deaths are divided into ten distinct time phases. The following trends emerge. Over two-thirds of the decedents are women, the ratio of females to males varying widely with phase. The proportion of women seems to be the highest when Kevorkian is free to act as he wants and lowest when he seems to be acting under legal or political restraints. Based on autopsy results, only 29.0 percent of the cases are terminal, this percentage being higher among men (37.9%) than among women (25.4%). However, 66.7% of the decedents were disabled, no significant difference emerging between men and women. Further, five out of the six decedents showing no apparent anatomical sign of disease at autopsy were women. Over 80 percent of the physician-assisted deaths are cremated, approximately twice as high a proportion as that emerging for suicides in Michigan and four times as high as cremations occurring with regard to overall deaths. Finally, death by carbon monoxide decreases dramatically with time phase while the use of the contraption dubbed the "suicide machine" increases, suggesting an increasing routinization over time. Finally, during the ninth and tenth phases, Kevorkian's aims and his own suicidality emerge more clearly involving 1) harvesting organs and 2) threat of starving himself in prison if he is convicted. Phase 10 can be seen as an escalation from assisted death to overt euthanasia, repeating the same need for a demonstration (Thomas Youk) that was first exhibited in Phase I (Janet Adkins).

Kevorkian, Martha Wichorek and us: a personal account.

In this short article, the authors describe their attempt to do suicide-prevention with a patient that ultimately died as the result of a physician-assisted suicide. Autopsy revealed no sign of physical disease but the patient's letters indicate a preoccupation with independence as the definition of life, and conviction that people who lose independence are no longer alive.

Michigan versus Kevorkian.

Our personal reflections on the Michigan versus Kevorkian trial highlight the following issues: 1) the switch from physician-assisted suicide to euthanasia, 2) the television showing of the death, 3) the dropping of the prosecution of the charge of physician-assisted suicide, 4) Kevorkian serving as his own defense attorney, trying to argue that ALS was a secondary cause of Thomas Youk's death, 5) Kevorkian's attempt to employ a logical syllogism to demonstrate that euthanasia need not be murder, 6) Kevorkian's initial reference to the civil rights tradition but sudden change to the medical analogy of Nazi medicine: a final solution, 7) the insistence of Kevorkian on "all or nothing" sentencing, 8) the irony of Kevorkian being finally convicted by a prosecutor who was elected on a platform of not prosecuting Kevorkian, 9) Kevorkian hiring a lawyer after the verdict is in, and 10) Kevorkian's threat to starve himself to death if sent to prison.

Positive and negative symptoms as risk factors for later suicidal activity in schizophrenics versus depressives.

Seventy schizophrenia patients and 97 depressives were studied prospectively while in the hospital and at periodic follow-ups. Positive symptoms, negative symptoms, and post-hospital functioning were assessed at the 2-year follow-up; and suicidal activity, at the 7.5-year follow-up. The results support an interactive model of suicide risk. Psychotic symptoms (i.e., hallucinations, delusions) predict later suicidal activity only for the schizophrenia patients. Deficit symptoms (psychomotor retardation, concreteness) predict later suicidal activity only for the depressive group. Adequacy of overall functioning predicts later suicidal activity for both diagnostic groups and appears to mediate the effects of psychosis in the schizophrenia group.

Angiographic coronary morphology in postinfarction angina.

To investigate the pathophysiologic relevance of angiographically irregular coronary stenoses in postinfarction angina (PIA), we analyzed the clinical course and coronary angiograms of 73 patients studied within 30 days of infarction. Coronary lesions were classified as smooth or irregular. Thirty-six patients had PIA (Group 1) and 37 had an uncomplicated course (Group 2). Irregular lesion(s) in patent infarct-related arteries were found in 77% of Group 1 vs. 24% of Group 2 patients (P less than 0.005). Irregular lesion(s) in any coronary artery were found in 58% of Group 1 versus 19% of Group 2 patients (P less than 0.002). Other univariate predictors of PIA included older age, hypertension, angina before myocardial infarct, lower peak creatine kinase, three-vessel disease, and higher modified Gensini score. Multivariate analysis ranked lesion irregularity as the strongest predictor of PIA. Our data suggests that ruptured atherosclerotic plaques may be important in the pathogenesis of PIA. It is possible that lesion irregularity is associated with an active process and/or a residual thrombus, which may be responsible for postinfarction angina.

Identification of patients at risk for anaphylaxis due to streptokinase.

To identify patients at risk for immediate-type allergic reactions to streptokinase, we performed streptokinase skin tests on patients immediately before planned administration of intravenous streptokinase for treatment of acute myocardial infarction. Forty-five patients had negative skin tests and received streptokinase without allergic reaction. One patient had a positive skin test and was given urokinase instead, without incident. Positive skin tests were also present in a patient who had recently had an anaphylactic reaction to streptokinase, and in two physician volunteers who had been sensitized to streptokinase during initial determination of the optimal skin testing dose. Immunoassays for IgE to streptokinase were performed on serum samples from skin-tested patients and volunteers, and on 16 other patients who had not been skin tested but had previously received streptokinase without allergic reactions. The skin test was a sensitive and specific indicator of elevated levels of IgE to streptokinase. We propose that skin testing immediately before streptokinase administration is a practical approach for identifying patients at risk for immediate-type allergic reactions to streptokinase, and its use may possibly prevent anaphylaxis and death.