Signs, symptoms, and ill-defined conditions in Persian Gulf War veterans: findings from the Comprehensive Clinical Evaluation Program.

OBJECTIVE: The purpose of this study was to analyze the type and frequency of signs, symptoms, and ill-defined conditions (SSID; International Classification of Diseases-9th Revision, Clinical Modification (ICD-9-CM) codes 780-799) identified by physicians evaluating Persian Gulf War veterans; to determine the influence of the extent of evaluation on the type and frequency of SSID diagnoses; and to search for evidence for a new illness, or illness related to wartime exposures, in veterans with ill-defined conditions. METHOD: Comprehensive examinations were provided for 21,579 consecutive Persian Gulf War veterans with symptoms or health concerns after the war. Data recorded on all individuals includes demographics, self-reported exposures, symptoms, and physician-assigned ICD-9-CM primary and secondary diagnoses. A detailed psychosocial history, including a multidisciplinary discussion, was incorporated for a subset of participants. RESULTS: SSID conditions were primary diagnoses for 17.2% of veterans, and either primary or secondary diagnoses for 41.8%. Although some SSIDs were objective conditions (eg, sleep apnea), most were simply symptoms. More comprehensive evaluation, especially the multidisciplinary discussion of findings, decreased the frequency of symptoms as diagnoses and increased the number of DSM-IV psychiatric diagnoses. Ill-defined conditions were not associated with particular self-reported exposures or demographic variables. CONCLUSIONS: Ill-defined conditions identified by physicians in Gulf War veterans are most often symptoms. More definitive, often psychological, diagnoses can be made by increasing the intensity of the evaluation and by multidisciplinary input. Evidence for a new or unique illness related to wartime exposures did not emerge from this analysis.

Symptoms in 18,495 Persian Gulf War veterans. Latency of onset and lack of association with self-reported exposures.

Toxic or environmental exposures have been suggested as a possible cause of symptoms reported by Gulf War veterans. To further explore this hypothesis, we analyzed findings in 18,495 military personnel evaluated in the Department of Defense Comprehensive Clinical Evaluation Program. The program was established in 1994 to evaluate Persian Gulf veterans eligible for Department of Defense medical care who had health concerns after service in the Persian Gulf during Operation Desert Shield/Desert Storm. The evaluation included a structured clinical assessment, a physician-administered symptom checklist, and a patient questionnaire addressing self-reported exposures, combat experiences, and work loss. Among 18,495 patients examined, the most common symptoms were joint pain, fatigue, headache, memory or concentration difficulties, sleep disturbances, and rash. Symptom onset was often delayed, with two-thirds of symptoms not developing until after individuals returned from the Gulf War and 40% of symptoms having a latency period exceeding one year. There was no association between individual symptoms and patient demographics, specific self-reported exposures, or types of combat experience. Increased symptom counts were associated with work loss, the number of self-reported exposures, the number of types of combat experience, and certain ICD-9 diagnostic categories, particularly psychological disorders. Prolonged latency of symptom onset and the lack of association with any self-reported exposures makes illness related to toxic exposure less likely.

Evaluation of the effectiveness of a community-based enriched model prenatal intervention project in the District of Columbia.

OBJECTIVE: To evaluate an enriched prenatal intervention program designed to reduce the risk of low birth weight. STUDY SETTING: Freestanding community-based prenatal intervention project located in a poor inner-city community, serving mostly African American women. STUDY DESIGN: All women less than 29 weeks pregnant were eligible to participate. They were compared to women who lived in neighborhoods with similar rates of poverty. DATA COLLECTION: The birth certificate was the source of data on maternal age, education, marital status, timing and frequency of prenatal care attendance, parity, gravidity, prior pregnancy terminations, fetal and child deaths, and birth weight. PRINCIPAL FINDINGS: Thirty-eight percent of the women who delivered live-born infants in the study area participated in the program. There were no differences in low- and very low birthweight rates in the study and comparison groups. In a secondary analysis comparing participants and nonparticipants in the study census tracts, participants were at higher risk for low and very low birth weight, and they adhered more closely to the schedule of prenatal visits than nonparticipants. Low- and very low birthweight rates were lower among participants than among nonparticipants and comparison women. CONCLUSION: The Better Babies Project did not have an effect on the overall low- and very low birthweight rates in the study census tracts. This was probably due to the low participation rates and the high population mobility.

Anastomotic leak after double-stapled low colorectal resection.

PURPOSE: Anastomotic leaks after double-stapled low anterior resection were associated with a number of factors related to patient condition, level of anastomosis, and variety of surgery-related and antitumor therapy-related factors. This retrospective analysis of a group of patients with consistent length of rectal stump was undertaken to determine the risk factors of anastomotic leak after low colorectal resection related to surgery and to intraperitoneal chemotherapy. METHODS: A group of 165 patients treated with surgery only, surgery with early postoperative intraperitoneal chemotherapy, and surgery with hyperthermic intraoperative and early postoperative intraperitoneal chemotherapy. All patients underwent surgery that used the double-stapled technique with transection of the rectum through its middle third. In univariate and multivariate analysis, the relationship between anastomotic leak rate and extent of colon resection, length of residual colon, presence of left colon, and type of applied treatment was studied. RESULTS: With a full length of residual colon, leak rate was 1 percent but increased progressively with the extent of proximal colon resection. Removal of the left colon was associated with the 2.7 odds ratio for anastomotic disruption. Leak rate after surgery only was 6 percent; surgery with normothermic intraperitoneal chemotherapy was 5 percent; and surgery with heated intraperitoneal chemotherapy was 20 percent. CONCLUSIONS: In this group of patients with consistent length of residual rectum, the incidence of anastomotic disruption was related to extent of proximal colon resection. Anastomotic integrity was not compromised by normothermic intraperitoneal chemotherapy. Hyperthermic intraperitoneal chemotherapy was associated with high leak rate only when extensive resection of the colon was performed. Variables other than extent of rectal excision are important in causing a leak of colorectal anastomosis.

Peritoneal carcinomatosis from adenocarcinoma of the colon.

Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. In the past patients with this condition have had a lethal outcome. In this study, 64 consecutive patients were treated by the cytoreductive approach, which involved surgery to maximally resect all cancer in the abdomen and pelvis, early postoperative intraperitoneal chemotherapy with 5-fluorouracil (5-FU) and mitomycin C, and three cycles of adjuvant intraperitoneal 5-FU with systemic mitomycin C. The clinical features that may affect prognosis were assessed and critically analyzed statistically. Peritoneal implant size of < 5 cm present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p < 0.0001), as did complete cytoreduction with tumor removed to nodules < 2.5 mm (p < 0.0001). Involvement of only one or two of the five abdominopelvic regions, compared to three or more regions, was a significant determinant of prognosis (p < 0.0001). Finally, a mucinous histologic type correlated adversely with prognosis when compared to intestinal-type adenocarcinomas (p < 0.001). These data suggest that patients with small-volume peritoneal seeding from colon cancer should be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long-term disease-free survival.

Pathobiology of peritoneal carcinomatosis from ovarian malignancy.

A detailed analysis of the patterns of treatment failure of ovarian malignancy may lead to a more comprehensive understanding of the natural history of the disease. A hypothesis was generated that suggests treatment failure was caused by ovarian cancer persistence and by reimplantation of tumor emboli trapped within surgically traumatized tissues. Nine ovarian cancer patients who had previously undergone standard surgical removal of the primary cancer were prospectively studied at a reoperative procedure. The operative findings at the time of primary cancer surgery and reoperative surgery were scored for the presence of tumor in 9 abdominopelvic regions and 17 abdominopelvic sites. These data were then statistically analyzed. In 7 of the 9 patients ovarian cancer recurrence was associated with an increased intraperitoneal dissemination of tumor. A mean of 3.1 regions were involved at the time of the initial surgery and 5.3 were involved at reoperation. The regions most consistently involved were those in close proximity to the primary cancer. The anatomic sites that showed a preponderance of recurrence were the rectosigmoid colon, cul-de-sac of Douglas, left paracolic gutter, vagina, and abdominal incision. Traumatized sites always showed more cancer recurrence than nontraumatized sites. The vaginal cuff and abdominal incision, sites free of cancer after hysterectomy but at high risk for tumor cell entrapment, were disproportionately common sites for cancer found at reoperation. This study shows that in this reoperative setting ovarian cancer recurrence is most common in the pelvis and the left lower part of the abdomen. The cul-de-sac of Douglas and the rectosigmoid colon are anatomic sites at extreme risk for disease progression. These are sites in which ovarian cancer implants not removed by routine hysterectomy and bilateral salpingo-oophorectomy will persist. Also, sites traumatized by surgery were disproportionately involved by cancer at reoperation. These data may be interpreted to suggest that anatomic sites with cancer persistence and with cancer implantation induced by surgical trauma are the most common sites for ovarian cancer recurrence in this select group of patients.

Prognostic features for peritoneal carcinomatosis in colorectal and appendiceal cancer patients when treated by cytoreductive surgery and intraperitoneal chemotherapy.

Peritoneal carcinomatosis from appendical or colorectal cancer has been regarded as a fatal clinical entity. We used cytoreductive surgery and intraperitoneal chemotherapy to treat consecutive patients with peritoneal carcinomatosis. There were 43 colorectal and 104 appendiceal cancer patients. The mean follow-up was 32 months, with a range of 0-140 months. Clinical features that showed prognostic significance included appendiceal versus colorectal primary (p < 0.0001), grade I versus grades II and III histopathology (p < 0.0001), complete versus incomplete cytoreduction (p < 0.0001), lymph node-negative versus lymph node-positive primary tumor (p < 0.0001), volume of peritoneal carcinomatosis present preoperatively for colon cancer (p < 0.0002), and nonmoderate versus heavy prior surgery (p < 0.0043). Features with no statistical prognostic significance include tumor volume for appendiceal cancer, age, sex, number of cycles of chemotherapy, operative time, complications, blood loss, and institution providing treatment. From these prognostic features, four staging groups were identified and 5 year survival was estimated by the product-limit survival method. Group I patients (n = 61) were those with grade I histology, no lymph node metastases, and a complete cytoreduction (survival at 5 years = 90%). Group II (n = 20) patients are those with grade II or III histology, no lymph node metastases, and a complete cytoreduction (62%). Group III patients (n = 22) had any histology, lymph node metastases, and a complete cytoreduction (45%). Group IV patients (n = 44) had an incomplete cytoreduction (12%). Peritoneal carcinomatosis is a treatable condition in selected patients with a possibility for long-term disease-free survival.

Patterns of spread of recurrent intraabdominal sarcoma.

A prominent site for recurrence of retroperitoneal and visceral sarcoma is the abdominal cavity. In an attempt to understand the causation of local and regional recurrence, 21 sarcoma patients who had previously undergone "complete" surgical removal of the primary tumor were prospectively studied. Data were obtained retrospectively from the first operation and prospectively from the reoperative procedure at the Washington Cancer Institute. At the primary and reoperative surgeries, 9 abdominopelvic regions and 21 sites were scored and then cataloged in a standardized fashion. Tumor locations and surgical resections were statistically analyzed in an attempt to establish patterns of recurrence within the abdomen and pelvis. There was a significant difference in sites of recurrence when sarcomas that involved the parietal structures were compared with those that involved small bowel. Peritoneal implants (nodular recurrences) were uniformly present in both groups. In contrast, resection site recurrences were very common with primary sarcomas invested by parietal peritoneum, while they were absent in those covered by visceral peritoneum. When primary surgeries were compared with reoperations, there was an increasing intraabdominal dissemination; the mean number of regions increased from 1.81 to 5.13. The change in distribution of sarcoma deposits at reoperation was greatest in right upper (because of liver surface) central and pelvic abdominopelvic regions and lowest in the left upper and epigastrium. The four anatomic sites that revealed a significant increase in involvement at the time of recurrence were the greater omentum, liver surface, large bowel, and the cul-de-sac of Douglas (all p < 0.002). Regions with tumor involvement or regions subjected to surgical trauma at the time of primary sarcoma resection were significantly more likely to show sarcoma deposits than to be sarcoma free at reoperation. These data taken together may suggest that sarcoma tumor emboli are frequently present in the abdomen at the time of resection of the primary cancer and that these tumor emboli are entrapped in fibrinous material at or immediately adjacent to sites of surgical trauma and along narrow margins of resection. Tumor cell entrapment of sarcoma emboli released into the peritoneal cavity prior to or at the time of sarcoma resection may help explain the distribution of nodular and fusiform recurrence of abdominopelvic sarcoma.

Abdominal computed tomographic scan in the selection of patients with mucinous peritoneal carcinomatosis for cytoreductive surgery.

BACKGROUND: Cytoreductive surgery and intraperitoneal chemotherapy have been used to treat peritoneal carcinomatosis. A complete surgical resection is required for optimal results to be achieved. This study evaluated the preoperative computed tomographic (CT) findings in patients with mucinous peritoneal carcinomatosis in order to predict the probability of a complete resection. STUDY DESIGN: Computed tomographic scans of the abdomen and pelvis were reviewed retrospectively in 45 patients with a diagnosis of mucinous peritoneal carcinomatosis who were treated with surgery and intraperitoneal chemotherapy. According to the completeness of cytoreduction, patients were divided into two groups. Patients in the first group (n = 25) had complete cytoreduction (CR) with no tumor deposits 2.5 mm in diameter or larger left behind. The surgical resection of tumor was incomplete in the second group of patients (n = 20). Sixteen CT parameters were initially examined in each group of patients and statistically evaluated according to the completeness of the cytoreductive surgical procedure. RESULTS: The incidences of six CT findings were significantly different in the two groups of patients. These findings were: tumor volume in small bowel mesentery (p < 0.001), tumor volume in proximal jejunum (p = 0.003), tumor volume in distal jejunum (p = 0.002), tumor volume in proximal ileum (p = 0.003), mesentery configuration (p < 0.001), and obstruction of bowel segments by tumor (p < 0.001). A statistical approach using a tree-structured diagram showed that patients with both obstruction of bowel segments by tumor and tumor diameter greater than 0.5 cm on small bowel surfaces exclusive of distal ileum on preoperative CT scan, had an 88 percent probability of incomplete resection. Patients without these two CT findings had a 92 percent probability of complete resection. CONCLUSIONS: This study shows that selection criteria for patients with mucinous peritoneal carcinomatosis are available on a preoperative CT scan of the abdomen and pelvis. Patients whose scans show obstruction of bowel segments by tumor and tumor diameter greater than 0.5 cm on small bowel surfaces exclusive of distal ileum are unlikely to be candidates for cytoreductive surgery for the treatment of peritoneal carcinomatosis.

Characteristics of persons served by private psychiatric hospitals, United States: 1986.

Overall about 71,000 persons were under care in the inpatient, outpatient, and partial care programs of private psychiatric hospitals in the United States on April 1, 1986, and about 300,000 persons were admitted to these programs during 1986. Inpatient programs served the largest number of people, 223,851; outpatient programs served 133,217; and partial care programs served a much smaller population, only 13,541. The relative distribution of persons admitted, versus persons under care, differed considerably by type of program. Although the number of those admitted was larger than the number of those under care for both inpatient and outpatient programs, the difference between the two populations was much more pronounced within inpatient programs (chart A). Most of the persons admitted to private psychiatric hospitals in 1986 were admitted to inpatient programs, 207 thousand or 69 percent of all admissions, while most of those under care were outpatients, 47 thousand or 66 percent of all those under care on a single day. Children and youth under age 18 comprised the largest percentage of persons under care in inpatient programs, while persons in the 25-44 age group comprised the largest percentage of those admitted to inpatient programs. Approximately 41 percent of all persons under care in inpatient programs were under 18 years of age, compared with only 20 percent of all persons admitted to inpatient programs. The large number of children and youth found in the population under care within inpatient programs indicates the high median length of inpatient stay for persons within this age group (41 days compared with 24 days overall). Children and youth and the 25-44 year group each represented over one-third of those admitted to outpatient programs. The 25-44 age group made up the largest percentage of persons under care in outpatient programs and among those admitted to partial care programs. Among those under care within partial care programs, differences among age groups were not statistically significant. Of persons admitted to partial care programs, 92 percent had a history of some type of prior mental health treatment; for those admitted to inpatient and outpatient programs, the corresponding percentages were 70 percent and 48 percent, respectively. Affective disorders were a frequently occurring diagnostic grouping, comprising almost half of all persons admitted to and under care in inpatient programs, approximately one-third of those admitted and those under care in partial care programs, and around one-fourth of those admitted to and under care in outpatient programs.(ABSTRACT TRUNCATED AT 400 WORDS)

Validation of a retrospective questionnaire assessing diet 10-15 years ago.

In 1985, 216 men, participants in the Baltimore Longitudinal Study of Aging, were asked to report on their usual diet during the period 1971-1975. The reference data for past diet consisted of multiple seven-day records collected between 1971 and 1975. The group was randomly assigned to complete the diet history either by personal interview or by mailed self-administered questionnaire. The items and response categories were identical in both cases. For both groups, the mean nutrient intake estimated by questionnaire was within +/- 10 per cent of the past diet record values for most nutrients. When the questionnaire was administered by an interviewer, correlations with past diet were approximately as good as those obtainable with present diet in other studies and indicate that useful studies of past diet can be performed with this questionnaire. Correlations for the mail group were considerably lower and suggest that assessment of past diet using this questionnaire format without personal instruction or callbacks may yield poor results. The effect of age was negligible, but response errors and change in diet since the target period had important effects on correlations with past diet in both interview and mail groups.

Epidemiology of vomiting in early pregnancy.

Factors associated with early pregnancy vomiting were investigated in 9098 first-trimester registrants in the Collaborative Perinatal Project. Vomiting in the absence of hyperemesis or gastroenteritis was noted in 56% of all women, and was more common among primigravidas (P = .002), younger women (P less than .001), women with less than 12 years of education (P less than .001), nonsmokers (P less than .001), and women weighing 77.1 kg (170 lb) or more (P = .003). Adjustment for confounders did not change these associations. Women reporting vomiting were less likely to experience miscarriage or stillbirth (P = .002) and delivery before 37 weeks' gestation (P = .004), but there was no difference in infant birth weight between mothers with and without vomiting (P = .48). Women who vomit in one pregnancy are more likely to vomit in subsequent pregnancies than are comparable women who did not vomit.

Kawasaki syndrome. A case-control study during an outbreak in Maryland.

An outbreak of 30 cases of Kawasaki syndrome (KS) occurred in Maryland from January through May 1983. The mean age of patients was 27 months; 60% were male. Rug shampoo exposure within one month and within six months of illness was not significantly greater in the 30 epidemic and seven sporadic cases than in their neighborhood and pediatric controls. These findings suggest that rug shampoo exposure may not be an important risk factor in the outbreak of KS in Maryland.