Factors that influence the decision to do an adequate evaluation of a patient with a positive stool for occult blood.

OBJECTIVE: The factors that influence the decision to do an adequate evaluation for a positive test for fecal occult blood in a middle-aged or elderly patient are largely unknown. Our study was undertaken to determine whether factors such as the number of positive Hemoccult II card windows, age, gender, family history of colon cancer, the patient's concern that he or she might have colon cancer, or history of rectal bleeding influence the evaluation performed. METHOD: A mass screening program for colon cancer was performed using unrehydrated Hemoccult II cards in the Boston area. RESULTS: Among the 23,593 Hemoccult II cards returned to Beth Israel Deaconess Medical Center, cards from 1,112 patients (4.7%) were found to be positive for one or more of the six possible card windows. Ninety percent, or 940 patients, over 40 yr of age had follow-up information available. As the number of positive windows increased from one to four, there was a significant trend (p < 0.001) for the adequacy of the evaluation to increase. Family history (p = 0.044) and a patient's worry that he or she might have colon cancer (p = 0.003) significantly improved a patient's chance for an adequate evaluation. CONCLUSIONS: Hemoccult testing is not followed by an adequate evaluation in a significant proportion of patients. Our study points out for the first time that the number of positive Hemoccult windows significantly influences the decision-making.

Prospective evaluation of multilayered epithelium in Barrett's esophagus.

OBJECTIVE: We recently identified a distinctive type of multilayered epithelium in two patients with Barrett's esophagus, which shows morphological characteristics of both squamous and columnar epithelium. This study was performed to prospectively evaluate the prevalence of multilayered epithelium in patients with Barrett's esophagus. METHODS: Mucosal biopsies were obtained from the squamocolumnar junction (Z-line) of 58 patients with endoscopic evidence of esophageal columnar epithelium and from the gastroesophageal junction in 21 patients without endoscopic evidence of esophageal columnar epithelium. Specimens were evaluated for the presence of multilayered epithelium and goblet cells. RESULTS: Twenty-four of 58 (41%) of the patients with endoscopic evidence of esophageal columnar epithelium had multilayered epithelium compared with only one of 21 patients (5%) in the control group (p = 0.005). Of the 58 patients in the study group, 43 had goblet cell metaplasia and 15 did not (p < 0.001). Only patients with goblet cell metaplasia had multilayered epithelium. Shorter lengths of columnar epithelium were noted in the 24 patients with goblet cells and multilayered epithelium compared with the 19 patients with goblet cells and no multilayered epithelium (p < 0.05). CONCLUSIONS: Multilayered epithelium is strongly associated with goblet cell metaplasia in patients with endoscopic evidence of esophageal columnar epithelium. These data support the hypothesis that multilayered epithelium may represent a transitional stage in the development of Barrett's esophagus.

An association between migraine and cutaneous allodynia.

Recent animal studies on the mechanism of migraine show that intracranial pain is accompanied by increased periorbital skin sensitivity. These findings suggest that the pathophysiology of migraine involves not only irritation of meningeal perivascular pain fibers but also a transient increase in the responsiveness (ie, sensitization) of central pain neurons that process information arising from intracranial structures and skin. The purpose of this study was to determine whether the increased skin sensitivity observed in animal also develops in humans during migraine attacks. Repeated measurements of mechanical and thermal pain thresholds of periorbital and forearm skin areas in the absence of, and during, migraine attacks enabled us to determine the occurrence of cutaneous allodynia during migraine. Cutaneous allodynia is pain resulting from a nonnoxious stimulus to normal skin. In 79% of the patients, migraine was associated with cutaneous allodynia as defined, and in 21% of the patients it was not. The cutaneous allodynia occurred either solely within the referred pain area on the ipsilateral head, or within and outside the ipsilateral head. Cutaneous allodynia in certain well-defined regions of the skin during migraine is an as yet unreported neurological finding that points to hyperexcitability of a specific central pain pathway that subserves intracranial sensation.

Long-term retention of transient news events.

Many retrospective analyses of remote memory have demonstrated recency effects in that memory for events proximal to the time of testing is superior to memory for events from remote time periods. However, the rate at which information decays over time and the specific pattern of forgetting may vary depending upon the distinct attributes of stimuli used as indices of memory. Studies examining long-term forgetting of well rehearsed, conceptually integrated information underscore preservation of remote events, some of which are thought to be permanently stored in memory. A different pattern of forgetting emerges in relation to recall of discrete facts whereby recall declines according to a negatively accelerated decay curve. In the current study long-term retention of transient news events was examined. Results were examined in relation to the effects of age and sex. All age groups demonstrated recency effects in that events from the recent past were recalled better than remote events. Age did not exert a negative influence on recall of remote or recent events with the exception of younger participants who did not recall items predating their dates of birth. Older female participants were less adept at recalling very old events than their male counterparts.

Lateral asymmetry in activation of hypothalamic neurons with unilateral amygdaloid seizures.

PURPOSE: Reproductive disorders are unusually frequent among women with temporal lobe seizures. The particular type of disorder may be related to the laterality and focality of epileptiform discharges. Here we examined whether unilateral amygdaloid seizures activate hypothalamic neurons involved in reproductive function and reproductive endocrine secretion in female rats and whether such activation shows lateral asymmetry. METHODS: Numbers of Fos-immunoreactive (Fos-ir) neurons in various hypothalamic regions were compared for three groups of animals: (a) unilateral amygdala-kindled, (b) implanted but unstimulated, and (c) unimplanted. RESULTS: Fos-ir neurons showed strong ipsilateral occurrence in the medial preoptic, ventrolateral part of the ventromedial, and ventral premammillary nuclei, sexually dimorphic regions involved in reproductive endocrine regulation. No significant lateral asymmetry was observed for other investigated hypothalamic regions. CONCLUSIONS: Unilateral amygdaloid seizures activate hypothalamic neurons that regulate reproductive endocrine secretion in a laterally asymmetric fashion. This may explain the clinical association of different reproductive endocrine disorders with left and right temporal epileptiform discharges.

Inventory-derived task handedness preferences of nine professions and their associations with self-report global handedness preferences.

The handedness preference (laterality) of 1,196 professionals grouped in nine professions previously reported using self-reported global handedness and scores on a modified Edinburgh Handedness Inventory was further defined by evaluating the association between profession and the 10 manual tasks of the inventory. The previously reported ranking of professions in order of increasing righthandedness of laterality score arose from the handedness of specific inventory tasks. A similar association was found for self-reported global handedness. The evidence continues to support the hypothesis of an association between handedness preference and specific aptitudes or skills in this sample of professional persons.

Pancreatic duct stricture length at ERCP predicts tumor size and pathological stage of pancreatic cancer.

OBJECTIVE: To determine whether findings on endoscopic retrograde cholangiopancreatography (ERCP) could provide useful prognostic information in resectable pancreatic cancer. METHODS: We retrospectively identified 18 patients with resectable pancreatic cancer (defined as no evidence of metastatic disease or vascular involvement on CT scan) who had undergone ERCP prior to an attempt at curative resection between 1991 and 1996. Common bile duct and pancreatic duct stricture lengths were measured on ERCP and compared with the size of the resected tumor. Magnification was controlled for by comparison with endoscope diameter. Stricture length was plotted against actual tumor size, and a correlation analysis was performed. RESULTS: Pancreatic duct stricture length measured on ERCP correlated with both size (p < 0.001) and stage (p < 0.002) in resectable pancreatic cancer. CONCLUSIONS: ERCP may provide useful preoperative prognostic as well as diagnostic information in pancreatic cancer.

Assessment of preclinical problem-based learning versus lecture-based learning.

Academic performance on a standardized oral comprehensive exam (OCE) was compared for students taught basic science in a problem-based learning (PBL) curriculum and a lecture-based learning (LBL) curriculum. The OCE was administered to the graduating classes of 1991-1994 (n approximately 20/class) six months after completion of their basic science courses. The OCE contained six components including: Organization and Thoroughness, Diagnosis, Primary Treatment Plan, Alternate Treatment Plan, Science and Medical Knowledge, and Dental Knowledge. Six to eight examiners graded each of the students by using a standardized scoring system and by subjective comments. The class of 1991 was taught by LBL, classes of 1993 and 1994 by PBL, and the class of 1992 by an incomplete PBL teaching method. Mean OCE scores were not significantly different between classes; however, the Science and Medical Knowledge component score was significantly better for the class of 1994 than for 1991 (p < 0.05). There was a non-significant 40 percent increase (p = 0.07) in honors and a 269 percent (p < 0.001) increase in cumulative positive examiner comments between 1991 and 1994.

Utilization patterns of tricyclic antidepressants in a multidisciplinary pain clinic: a survey.

OBJECTIVES: Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic and headache pain syndromes regardless of the presence of depression. There is a high incidence of depression in patients with chronic pain, thereby making tricyclic antidepressants particularly suitable for chronic pain patients. We wanted to study patterns of use of tricyclic antidepressants in our Pain Management Center (Beth Israel Hospital, Boston, MA, U.S.A.) primarily to answer four questions: (1) What percentage of all patients were treated with tricyclic antidepressants? (2) How many patients were treated with each antidepressant, and what was the dose range used for individual antidepressants? (3) Were tricyclic antidepressants beneficial for chronic pain, and was that response dependent on a particular dose? (4) Did patients receive an adequate TCA trial, and what factors led to the discontinuation of a TCA trial? METHODS: A total of 1,145 pain clinic patient charts were reviewed in alphabetical sequence. A total of 282 patients were identified as being treated with tricyclic antidepressants. Data were obtained from these 282 charts regarding the patient's age, diagnosis, tricyclic antidepressant use and dose, other pain treatments, response to treatment, and side effects. The existing diagnosis of depression was documented if possible. Tricyclic antidepressant doses were defined as low doses when the equivalent of 50 mg or less of amitriptyline was used, and as full doses when the equivalent of at least 150 mg of amitriptyline was used. Response to treatment was noted as mild, moderate, or marked improvement. Patients reporting mild improvement were considered nonresponders. RESULTS: Of 1,145 patients, 282 were treated with tricyclic antidepressants. A total of 205 (73%) of the patients were treated with low doses and only 34 (12%) with full doses. The remaining 43 (15%) received intermediate doses. Amitriptyline was the most commonly used drug (58%). Amitriptyline and doxepin appeared to be more effective than other tricyclic antidepressants. The rate of response to our treatment among the 31 patients with a coexisting diagnosis of depression was similar to the patients without documented depression. In patients with tricyclic antidepressants as the only treatment, there was only a trend toward greater response with full dose. In terms of side effects causing dose limitation or discontinuation of the drug, clomipramine, amitriptyline, and doxepin appeared to be worse than imipramine, desipramine, and nortriptyline. CONCLUSION: Tricyclic antidepressants were used in 25% of patients referred to a multidisciplinary pain center and were commonly used in low to intermediate doses, even in situations in which there were neither side effects nor optimal clinical response.

Three patterns of catamenial epilepsy.

PURPOSE: On the basis of the neuroactive properties of estradiol and progesterone and the menstrually related cyclic variations of their serum concentrations, we propose the existence of three hormonally based patterns of seizure exacerbation. Because previous reports both support and refute the concept of catamenial epilepsy, we test the hypothesis by charting seizures and menses and measuring midluteal serum progesterone levels to estimate the frequency of epileptic women with catamenial seizure exacerbation. METHODS: One hundred eighty-four women with intractable complex partial seizures (CPS) charted their seizure occurrence and onset of menstruation on a calendar for one cycle during which they had a midluteal blood sample taken for serum progesterone determination on day 22. Levels >5 ng/ml were considered ovulatory. The cycle was divided into four phases with onset of menstruation being day 1: menstrual (M) = -3 to +3, follicular (F) = 4 to 9, ovulatory (O) = 10 to -13, and luteal (L) = -12 to -4. Average daily seizure frequency for each phase was calculated and compared among phases by repeated-measures analysis of variance (ANOVA) and the Student-Newman-Keul's test, separately for ovulatory and anovulatory cycles. RESULTS: The 1,324 seizures recorded during 98 ovulatory cycles occurred with significantly greater (p < 0.001) average daily frequency during the M (0.59) and O (0.50) phases than during the F (0.41) and L (0.40) phases, offering support for perimenstrual (catamenial 1) and preovulatory (catamenial 2) patterns of seizure exacerbation. The 1,523 seizures recorded during 86 anovulatory cycles occurred with significantly lower (p < 0.001) average daily frequency during the F phase (0.49) than during all other phases (M = 0.78, O = 0.74, L = 0.74), offering support for seizure exacerbation throughout the second half of inadequate luteal phase cycles (catamenial pattern 3). Although 71.4% of the women with ovulatory cycles and 77.9% with inadequate luteal phase cycles had seizure exacerbation in relation to one of the three patterns of catamenial epilepsy, approximately one third of the women showed at least a twofold increase in average daily seizure frequency. We propose a twofold or greater increase as a reasonable definition of catamenial epilepsy. CONCLUSIONS: Charting of seizures and menses and determination of day 22 progesterone levels during each cycle may be sufficient to establish the existence of three distinct patterns of catamenial epilepsy. Approximately one third of women with intractable CPS may have catamenial epilepsy.

Decreased inotropic but relatively preserved relaxation response to cyclic adenosine monophosphate-dependent agents in myopathic human myocardium.

BACKGROUND: Increased intracellular concentrations of cyclic adenosine monophosphate (AMP) stimulate a positive inotropic and lusitropic response in healthy myocardial tissue. Heart failure results in an attenuated inotropic response to cyclic AMP-dependent agents. This study compares the inotropic versus relaxation response to cyclic AMP-dependent and cyclic AMP-independent agents in myocardium from patients with end-stage heart failure and control patients without heart failure. METHODS AND RESULTS: Fifty-four control and 59 myopathic human ventricular trabeculae, 1 mm or less in diameter were placed in physiologic saline, 2.5 mM Ca2+, and stretched to the length at which maximal isometric force developed at 30 degrees C, 0.33 Hz. Dose-response curves plotted as percentage change from baseline versus concentration of drug were determined for acetylstrophanthidin, isoproterenol, isobutylmethylxanthine, and milrinone. Acetylstrophanthidin, a cyclic AMP-independent agent, showed similar increases in peak tension relative to baseline over the entire dose range tested for both control and myopathic heart muscle; its effect on relaxation of control and failing cardiac muscle was equivalent over the dose range tested. In contrast, the inotropic actions of the cyclic AMP-dependent agents, isoproterenol and the phosphodiesterase inhibitors, were significantly decreased in myopathic muscle compared with control muscle, but effects on relaxation in the control and myopathic groups remained relatively preserved. CONCLUSIONS: A relatively preserved relaxant effect is associated with the cyclic AMP-dependent agents, despite significant diminution of their inotropic effects. Thus, in advanced heart failure, patients may continue to benefit from the lusitropic effects of the cyclic AMP-dependent agents, even when the inotropic effects of these agents are severely attenuated.

Gadolinium-enhanced MR imaging demonstrates abduction-caused hip ischemia and its reversal in piglets.

PURPOSE: To determine if gadolinium-enhanced MR imaging can detect early reversible ischemia of the capital femoral epiphysis and physis induced by hip hyperabduction in piglets. MATERIALS AND METHODS: Thirteen 1- to 3-week-old piglets were placed in maximal bilateral hip abduction and then studied with dynamic gadolinium-enhanced MR imaging 1-6 hr later to assess ischemia of the 26 femoral heads. The piglets were then allowed to ambulate freely for 1 or 7 days and reimaged in neutral position to assess reperfusion. We evaluated enhancement on MR images and compared them with histologic findings. RESULTS: Decreased or absent enhancement, interpreted as ischemia, developed after maximal hip abduction in all 26 cartilaginous epiphyses and 85% of the 26 physes. The most frequently seen abnormality was a sharply marginated, nonenhancing area in the anterior part of the femoral head. A smaller area of decreased enhancement developed in the posterior part of the femoral head adjacent to the acetabular rim. The secondary center of ossification was ischemic in 10 (56%) of the 18 hips after 1 hr of abduction and in all 8 hips after 4 or 6 hr (p = .02). The overall severity of ischemia was greater with longer abduction times (p < .001) and greater degrees of abduction (p < .01). Reperfusion was complete in two (17%) of the 12 hips after 1 day of ambulation and in all 10 (100%) after 1 week of ambulation. CONCLUSION: Enhanced MR imaging detects early ischemia of the epiphyseal and physeal cartilage and the epiphyseal marrow. In piglets, ischemia due to maximal abduction is reversible if corrected within 6 hr.

Handedness distributions in nine professional groups.

The relationships between profession and handedness were studied in approximately equal numbers of accountants, architects, dentists, lawyers, librarians, mathematicians, orthodontists, orthopedic surgeons, and psychiatrists (ns = 133 +/- 36; N = 1196). Handedness was estimated using laterality scores derived from the Edinburgh Handedness Inventory and self-reported global handedness preference scores. Architects and lawyers had the most lefthanded average laterality scores. Orthopedic surgeons, mathematicians, and librarians had the most righthanded average laterality scores. Psychiatrists and lawyers had the most ambilateral laterality scores, mathematicians and librarians the least. These findings are discussed in relation to theories of handedness and cerebral localization of visuospatial and language function.

Long-term impact of recombinant human erythropoietin on transfusion support in patients with chronic renal failure.

Published reports on the impact of recombinant human erythropoietin (r-HuEpo) on transfusion requirements of patients with chronic renal failure have been limited to small populations and relatively brief follow-up. In this study we reviewed the effects of this drug on 86 patients with well-characterized transfusion requirements, followed for 18 months at seven dialysis centers. The median red blood cell transfusion requirements per patient per year decreased from 14 in 1987 and 1988 to 11 in 1989, when r-HuEpo was licensed in the United States (p <.01) and fell to 2 in 1990 (p <.01). The proportion of patients who became transfusion-independent increased from 34 percent in 1989 to 69 percent in 1990 (p <.001). These data demonstrate that r-HuEpo significantly decreases transfusion requirements of patients with chronic renal disease.

Diurnal variation of urinary leukotriene E4 and histamine excretion rates in normal subjects and patients with mild-to-moderate asthma.

BACKGROUND: Leukotriene E4 (LTE4) and histamine excreted into the urine reflect the in vivo synthesis and release of cysteinyl leukotrienes and histamine, respectively. We examined the diurnal variation of the excretion rate of these mediators over 4 consecutive days in normal subjects (n = 5) and patients with stable mild-to-moderate asthma (n = 8). METHODS: Sixteen consecutive 6-hour urine samples were collected over 4 days. Urinary LTE4 concentrations were determined by reverse-phase high-pressure liquid chromatography, followed by ELISA. Urinary histamine concentrations were measured by ELISA. The excretion rates of these compounds were normalized relative to urinary creatinine content. RESULTS: The mean urinary LTE4 excretion rate was 83.8 +/- 38.2 pg/mg creatinine (mean +/- SD) in normal subjects; in patients with asthma, the urinary LTE4 excretion rate (110.0 +/- 59.2 pg/mg creatinine) was significantly higher than that in normal subjects (p < 0.05). The urinary histamine excretion rate was not different between normal subjects (24.0 +/- 12.5 ng/mg creatinine) and patients with asthma (31.5 +/- 25.8 ng/mg creatinine). A robust and systematic within-day variation (p < 0.01), but no day-to-day variation, was observed in histamine excretion rate. Although the magnitude of variation in LTE4 excretion within a day was significantly greater in patients with asthma than in normal subjects (p < 0.05), we could not identify any specific diurnal variation pattern in either the normal or the asthma group. No significant correlation was observed between urinary LTE4 and histamine excretion rate within any subject. CONCLUSIONS: Patients with asthma excrete LTE4 in the urine at a greater rate than normal subjects. Although no systematic variation in urinary LTE4 excretion rates over the course of a day was observed in either normal subjects or patients with stable asthma, the presence of a systematic diurnal variation of urinary histamine excretion exists in both groups.

Influence of glutathione S-transferase B (ligandin) on the intermembrane transfer of bilirubin. Implications for the intracellular transport of nonsubstrate ligands in hepatocytes.

To examine the hypothesis that glutathione S-transferases (GST) play an important role in the hepatocellular transport of hydrophobic organic anions, the kinetics of the spontaneous transfer of unconjugated bilirubin between membrane vesicles and rat liver glutathione S-transferase B (ligandin) was studied, using stopped-flow fluorometry. Bilirubin transfer from glutathione S-transferase B to phosphatidylcholine vesicles was best described by a single exponential function, with a rate constant of 8.0 +/- 0.7 s-1 (+/- SD) at 25 degrees C. The variations in transfer rate with respect to acceptor phospholipid concentration provide strong evidence for aqueous diffusion of free bilirubin. This finding was verified using rhodamine-labeled microsomal membranes as acceptors. Bilirubin transfer from phospholipid vesicles to GST also exhibited diffusional kinetics. Thermodynamic parameters for bilirubin dissociation from GST were similar to those for human serum albumin. The rate of bilirubin transfer from rat liver basolateral plasma membranes to acceptor vesicles in the presence of glutathione S-transferase B declined asymptotically with increasing GST concentration. These data suggest that glutathione S-transferase B does not function as an intracellular bilirubin transporter, although expression of this protein may serve to regulate the delivery of bilirubin, and other nonsubstrate ligands, to sites of metabolism within the cell.

Selectively distributed processing of visual object recognition in the temporal and frontal lobes of the human brain.

Evoked potentials to visually driven cognitive tasks were recorded through depth electrodes placed bilaterally within the amygdala, hippocampus, midtemporal and inferotemporal cortex, and lateral frontal cortex of 6 epileptic patients. Task-related differential response patterns were used to identify the recording sites engaged by specific aspects of visual encoding. In this group of 6 patients, the amygdala was most frequently engaged in encoding the familiarity of faces; midtemporal and inferotemporal cortex, in encoding perceptual identity and object categorization; and lateral frontal cortex, in holding visual object information in working memory. The two aspects of encoding that most frequently engaged the hippocampal region were related to working memory and object categorization. The processing of complex visual knowledge is thus anatomically distributed but regionally specialized. These experiments also showed that identical input and output parameters can engage different areas of the brain depending on the nature of the instructional set.

The effects of hyaluronidase on local anesthesia: a prospective, randomized, controlled, double-blind study.

Hyaluronidase, an enzyme that breaks down intercellular cement, has been advocated as an additive to local anesthetics because it allows injected solutions to spread and penetrate tissues. Because epinephrine is commonly used in conjunction with local anesthetics, the combined effects of both hyaluronidase and epinephrine were studied in a prospective, controlled, double-blind manner. The forearms of volunteers ranging in number from 15 to 23 were injected with 0.5 ml of lidocaine to which graded doses of hyaluronidase and epinephrine had been added. At various intervals after injection, the areas of anesthesia were measured. From these data, the time to reach peak area of anesthesia (onset), the size of the peak area of anesthesia, and the time until disappearance of anesthesia (duration) were computed and analyzed. We found that epinephrine has a more profound effect on the onset, area, and duration of anesthesia than hyaluronidase. Epinephrine delayed the time to reach peak area of anesthesia (onset) relative to lidocaine alone more than hyaluronidase (0.28 h versus 0.04 h). When both agents were used together, the effect was subtractive (0.28-0.04 = 0.24 h, compared with 0.22 h observed). This suggests a negative interaction (inhibition) because hyaluronidase decreased the epinephrine effect by 21 percent. Concerning the size of peak area of anesthesia, epinephrine increased the area relative to lidocaine alone more than hyaluronidase (626 versus 221 mm2). When both agents were used together, the effect was additive (626 + 221 = 847 mm2, compared with 848 mm2 observed). This suggests that the two agents acted independently of each other in relation to area of anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

A review of scrotal violation in testicular cancer: is adjuvant local therapy necessary?

High inguinal orchiectomy is the standard initial treatment for suspected testicular carcinoma. Nonstandard surgical approaches (scrotal violations), including scrotal orchiectomy, open testicular biopsy and fine needle aspiration, have historically been condemned as significantly compromising patient prognosis. Patients with scrotal violation are often subjected to potentially morbid or disfiguring local therapies. In addition, patients with scrotal violations are usually disqualified from surveillance protocols. A review was conducted of all published series of testicular cancer patients in whom scrotal violation occurred. A meta-analysis was then performed to choose a subset for critical analysis on the effect of scrotal violation on patient prognosis. Of 1,182 cases included in the final analysis scrotal violation occurred in 206. The rates for local recurrence, distant recurrence and survival were analyzed separately for all patients, patients with stage I disease and patients with pure seminoma or nonseminomatous germ cell tumor. Additionally, the effect of local treatment for scrotal violation on prognosis was examined. Although statistically significant differences were found in the local recurrence rate among the scrotal violation and inguinal group studies, the overall local recurrence rates were small (2.9% versus 0.4%, respectively). There were no statistical differences in distant recurrence or survival rates in all groups analyzed. Patients with scrotal violation who did not receive any local therapy fared as well as those who did receive local therapy. Although the standard treatment of primary testicular cancer remains high inguinal orchiectomy, these data suggest that scrotal violation does not impart a significantly worse overall prognosis. These data would also indicate that patients with stage I disease and scrotal violation should not necessarily be disqualified from surveillance protocols or subjected to adjuvant local therapy.

Gadolinium-enhanced MR imaging demonstrates abduction-caused hip ischemia and its reversal in piglets.

Purpose. To determine whether gadolinium-enhanced MR imaging can detect early reversible ischemia of the capital femoral epiphysis and physis induced by hip hyperabduction in piglets. Materials and methods. Thirteen 1- to 3-week-old piglets were placed in maximal abduction of both hips and studied with dynamic gadolinium-enhanced MR imaging 1-6 h later to assess ischemia of the 26 femoral heads. They were then allowed to ambulate freely for 1 or 7 days, and reimaged in neutral position to assess reperfusion. Enhancement was evaluated on MR images and compared with histologic findings.Results. Ischemia after hyperabduction developed in all 26 cartilaginous epiphyses and in 85 % of the physes. The most frequent abnormality was a sharply marginated nonenhancing area in the anterior part of the femoral head. A smaller area of ischemia developed in the posterior part of the femoral head, adjacent to the acetabular rim. The secondary center of ossification was ischemic in 56 % of the hips after 1 h of abduction and in all hips after 4 or 6 h (p = 0.02). The overall severity of ischemia was greater with increasing abduction time (p < 0.001) and increasing degree of abduction (p < 0.01). There was partial reperfusion in 83 % of the hips after 1 day of ambulation and complete reperfusion in all 26 hips (100 %) after 1 week.Conclusion. Enhanced MRI detects early ischemia of the epiphyseal and physeal cartilage and the epiphyseal marrow. In piglets, ischemia due to hyperabduction is reversible if corrected within 6 h.