Treatment of stripping perforations.

Strippings are problems that are frequent on thin and concave roots. Treatment and prognosis differ from that of a lateral root perforation because of the size, oval shape, and thin edges of the striping. We propose a two-step technique: an endodontic phase in which the root canal system is sealed with gutta-percha overflowing through the stripping perforation and a surgical second step that will allow elimination of this excess.

Interobserver variability in the diagnosis of high-grade prostatic intraepithelial neoplasia and adenocarcinoma.

High-grade prostatic intraepithelial neoplasia (PIN) is a strong predictor of carcinoma when identified in small-needle biopsy specimens. However, the diagnostic variability of PIN is unknown. Eight pathologists reviewed 321 prostatic biopsy specimens to assess the variability of the diagnosis of high-grade PIN and carcinoma. All of the specimens were classified as negative, high-grade PIN, suspicious for high-grade PIN, carcinoma, or suspicious for carcinoma, more than one diagnosis was permitted, except for negative. We compared diagnoses made by two observers by pairing them for negative versus high-grade PIN, negative versus carcinoma, high-grade PIN versus carcinoma, and all diagnostic categories together. Mean kappa coefficient values for 28 interobserver combinations were 0.451, 0.845, 0.669, and 0.482, respectively, for each of the four comparison combinations considered. Our results indicate a high level of agreement, "almost perfect" (kappa = 0.81-1.0) for carcinoma, "moderate" (kappa = 0.41-0.60) for high-grade PIN, and "substantial" (kappa = 0.61-0.81) for high-grade PIN versus carcinoma. We found that variability was related to the level of interest in prostatic pathology, the conditions of the study, the subjective application of diagnostic criteria, and the influence of peers and clinical colleagues.

A comparison of the systemic bioactivity of inhaled budesonide and fluticasone propionate in normal subjects.

1. The aim of this study was to compare the systemic bioactivity of low and high doses of inhaled budesonide and fluticasone propionate given by respective dry powder inhaler devices. 2. A randomised, single blind cross-over design was used in nine healthy subjects who were given 800 micrograms day-1 of budesonide Turbohaler (B800) for 1 week, followed by 1 week of 1600 micrograms day-1 (B1600), or fluticasone Diskhaler 750 micrograms day-1 (F750) for 1 week followed by 1 week of 1500 micrograms day-1 (F1500). There was a 1 week washout between treatments with fluticasone or budesonide. A twice daily dosing regime was used and mouth-rinsing was employed to reduce gut bioavailability as well as to obviate local adverse effects. 3. Parameters of hypothalmic-pituitary adrenal (HPA) axis activity and bone metabolism were measured at baseline (B0/F0), at the end of each week of treatment and after the 1 week washout (F0 or B0). 4. Both fluticasone and budesonide significantly (P < 0.05) attenuated the post tetracosactrin serum cortisol at low and high doses whilst early morning cortisol was unchanged. No dose-response effect was observed with either drug, and there was no significant difference between treatment with fluticasone or budesonide. 5. Neither budesonide nor fluticasone produced significant suppression of plasma osteocalcin, although the higher doses of both drugs significantly reduced fasting urinary calcium levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Field evaluation of the NOVA Celltrak 12 hematology analyzer.

An evaluation of the NOVA Celltrak 12 was performed over a 6-week period. Precision, linearity, carryover, and reproducibility of values compared favorably to manufacturers' claims. The correlation was performed using the Coulter S Plus VI as the reference instrument and yielded coefficients of correlation for measured parameters of greater than .98 with the exception of RDW at r = .84, MCV at r = 0.96, and MPV at r = .92. Three-part differential information and an expanded flagging system affords increased clinical information and trouble-shooting guides. The three-part differential information compared favorably with that of the Coulter S Plus VI with lymphocyte percentage r = .96, granulocyte percentage r = .94, and monocyte percentage r = .50. We conclude that this instrument performed well in a clinical setting.

Warthin's tumor-associated neoplasms: report of two cases and review of the literature.

The association of Warthin's tumor with another neoplasm of a different histological type in the same salivary gland is extremely rare. The literature includes 42 such cases to date. A case of malignant lymphoma developing within Warthin's tumor and another case of oncocytoma synchronous with Warthin's tumor in the same parotid gland are reported. The relation of Warthin's tumor to other neoplasms is discussed.

Primary lymphoma in the salivary glands: report of five cases and review of the literature.

The finding of a lymphoma in a major salivary gland could mean one of two things: either it is part of a disseminated process, or it is the first clinicopathologic evidence of lymphoma. In the latter instance, whether the disease originated in the glandular stroma itself or in a paraglandular lymph node and then invaded the stroma, the lymphoma is defined as primary, as long as there is no detectable disease outside the salivary gland. Five cases of primary salivary gland lymphomas are described. All had a complete clinical staging including chest x-ray, bilateral bone marrow biopsy, liver-spleen scan, bilateral pedal lymphangiography and/or abdominal CT scan. There was no evidence of lymphoma outside the gland in any of the patients described; hence, these can be labeled as primary lymphomas of the salivary gland. Review of the literature suggests that this presentation of the disease is extremely rare. Although 324 cases of salivary gland lymphomas have been described in the literature, only six may be considered primary by our criteria. The remaining patients were either not adequately staged or had documented evidence of disease elsewhere at the time of diagnosis. The diagnosis of primary salivary gland lymphoma should not be made unless complete staging is performed.

Glycogen storage disease type I: laboratory data and diagnosis.

A study of 20 cases of glycogen storage disease type I has shown differences from the classical picture. Hyperuricemia was observed in fewer than half of the cases. All patients had increased triglycerides in serum, but fewer than two thirds had increased concentrations of total cholesterol. There was a consistent increase of aminotransferases in serum. Many textbooks discuss hyperuricemia, lactic acidemia, and lipidemia in this disease without mentioning aminotransferases, and above-normal values for these enzymes ought to be given consideration, to avoid misdiagnosis. Glycogen storage disease type IB was detected by comparing glucose-6-phosphatase (EC 3.1.3.9) activity in frozen and unfrozen portions of the same liver biopsy. Latent activity, which appeared after freezing, increased the total activity to within the normal range (4.7-9.1 mumol/min per gram of tissue, wet weight) in type IB, but not in type IA.

Primary small intestinal lymphoma in adults. A comparative study of IPSID versus non-IPSID in the Middle East.

Seventy-five cases of primary small intestinal lymphoma (PSIL) were diagnosed in adults at the American University of Beirut Medical Center (AUBMC) during the period from 1961 to 1980. Two additional cases of immunoproliferative small intestinal disease (IPSID) in the premalignant phase also were studied. Thirty-two patients had IPSID; 27 non-IPSID; and in 18 patients it was difficult to distinguish IPSID from non-IPSID. While the former was shown to be a distinct disease entity with characteristic clinical, pathologic, and immunologic features, the latter was found to have no particular features in this part of the world. In addition to alpha heavy chain protein (AHCP) which is the biological marker of IPSID, the most important finding that distinguished the two diseases was that IPSID was always associated with a dense, compact mucosal cellular infiltrate (MCI) that was continuous and uninterrupted all along the length of the small intestine. In non-IPSID, MCI was lacking and the pathology was confined to sites of gross abnormalities. Sites distant to the primary lesion were free of disease. It was reported previously that the MCI in IPSID is characteristically diffuse plasmacytic or lymphoplasmacytic (DLP). Our study indicates that in addition to this infiltrate, the disease may be associated with another type of infiltrate which is follicular lymphoid (FL). Sixteen patients had DLP; ten, FL; and three, mixed infiltrate. The relationship of AHC disease and IPSID is discussed. AHCP may be found in intestinal fluid, serum, within the abnormal cell, or at its surface. Immunofluorescence and immunoperoxidase studies must be done on all intestinal and nodal tissue specimens in all patients with PSIL for the detection of AHCP, particularly in those where serum and intestinal fluid are negative for this protein. The hypothesis that the DLP infiltrate represents the secretory form of IPSID, while the FL the nonsecretory form, is introduced. IPSID is an ideal model for the study of the etiology and pathogenesis of lymphoma in man.

Extradural spinal angiolipoma.

Two cases of extradural spinal angiolipomas are reported. The literature is reviewed and the entity of extradural spinal angiolipoma proposed. A tumor of adulthood, unassociated with bony changes, it occurs mainly in the mid-dorsal spine. Paraparesis progresses over a period of 1-2 years and may wax and wane with pregnancy or body weight changes. Characteristically, the tumor lies over the dorsal aspect of the dura, from which it may be peeled off easily. Its port-wine color contrasts strikingly with the contiguous epidural fat. A benign condition, it responds favorably to surgical excision.

Non-Hodgkin's lymphomas in the Middle East. A study of 417 patients with emphasis on special features.

A total of 417 evaluable patients with non-Hodgkin's lymphomas were diagnosed between January 1974 and December 1983 at the American University of Beirut Medical Center in Beirut, Lebanon. Of these, 179 (43%) patients had nodal lymphomas, and 183 (44%) had extranodal lymphomas. The commonest lymphoma was diffuse large cell (27%), followed by large cell immunoblastic (21%). The histopathologic pattern was follicular in 18% of the nodal lymphomas and in 5.3% of the extranodal forms. The most common site of extranodal lymphoma was the gastrointestinal tract (46.5%), followed by Waldeyer's ring (19%). Small intestinal lymphomas were three times more common than gastric lymphomas. Immunoproliferative small intestinal disease (IPSID) was diagnosed in 20 of 59 patients who had primary small intestinal lymphoma. Of the 34 patients who had Waldeyer's ring lymphoma, 7 had gastrointestinal involvement at some time during the course of the disease. Nodal lymphomas were associated with poor prognostic factors: 82% were diffuse; 77% had advanced disease at presentation; 77% had intermediate- or high-grade malignancy lymphoma; 40% had marrow involvement; and 46% had B symptoms. In children, the most common lymphoma was Burkitt's, and 80% of pediatric lymphomas were high-grade malignancy. In conclusion, this study delineates the special features of non-Hodgkin's lymphomas in the Middle East: The presence of IPSID; the high incidence of extranodal forms, in particular the intestinal ones; and the rarity of follicular lymphomas.

Burkitt's lymphoma in the Middle East. A study of 34 cases.

The clinical features of 34 patients with Burkitt's lymphoma diagnosed at the American University Medical Center (AUMC) are described. Ages ranged between 3 and 20 years (median, 7 years). Seventy-three percent of the patients were younger than 8 years. Three cases occurred among siblings. The primary site of disease at presentation was the abdomen, 23 patients; jaw, 6; jaw and abdomen, 2; Waldeyer's ring, 2; and mediastinum, 1. Of those who had abdominal disease, the involvement was diffuse and extensive in abdomen and pelvis in 9, apparently confined to the ileocecal region in 5, mesenteric nodes and small intestine in 5, large intestine in 1, and ovary in 3. One patient presented with paraplegia. The bone marrow was studied in 19 patients; it was positive in 5 and suspicious in 2. None had frank leukemia. CSF was studied in 4 patients at presentation and was negative. Eight patients developed meningeal lymphoma during the course of the disease. Liver involvement was documented in 3 patients. Peripheral lymphadenopathy was observed at presentation in 11 patients (9, neck; 2, inguinal + axillary). In contrast to African Burkitt's, the majority of our patients presented with abdominal disease, and in contrast to the American form, our patients were younger with a median age similar to that of African Burkitt's. Thirty percent of the patients had jaw tumor at presentation--a figure intermediate between the African and the American Burkitt's.

Burkitt's lymphoma in the Middle East.

The clinical features of 30 retrospectively diagnosed cases of Burkitt's lymphoma (BL) at the American University Medical Center (AUMC) in Beirut differed from those of African Burkitt's in that the majority of the AUMC patients presented with abdominal disease, and from the American form, in that the AUMC patients were younger, with a median age similar to that of African BL patients.

A functioning catecholamine-secreting vagal body tumor. A case report and review of the literature.

There are few cases of catecholamine-secreting paragangliomas of the neck reported in the literature, most of these being of the carotid body and glomus-jugulare type. This report cites the second case of a functioning vagal body tumor secreting norepinephrine predominantly and producing labile hypertension and symptoms of pheochromocytoma. A brief update on vagal body tumors and a review of the functioning paragangliomas of the head and neck are also presented.

Anaplastic transformation of thyroid cancer: report of two cases and review of the literature.

Transformation of well-differentiated thyroid adenocarcinoma to anaplastic cancer has been occasionally reported. Two new cases of such transformation are now described. The time interval from diagnosis to the development of anaplastic cancer was 15 years in the first patient and 10 years in the second. Both patients ultimately developed extensive bilateral pulmonary metastases and died within 6 months from the diagnosis of the transformation. Hypotheses concerning the pathogenesis of the transformation and the literature were reviewed. We believe that histopathological confirmation of recurrent and rapidly progressive thyroid tumors is necessary prior to initiation of therapy.

Evolution of liver disease in morbid obesity after small-intestinal bypass and its restoration. A case report.

We studied a woman who underwent a jejunoileal bypass for the treatment of morbid obesity and in whom severe jaundice and hepatic failure developed six months later; these developments prompted restoration of the normal continuity of the small bowel. Four serial wedge biopsy specimens of the liver were taken during a three-year follow-up. The first biopsy was performed before the bypass surgery, the second six months after the operation, the third three months after restoration of normal continuity of the bowel, and the fourth three years later. The biopsy specimens clearly showed the morphologic changes of the liver in obesity, the effect of small intestinal bypass and its reversal on hepatic structure, and the natural evolution of liver disease in morbid obesity.

Pulmonary fibrosis after prolonged treatment with low-dose cyclophosphamide. A case report.

Interstitial pulmonary fibrosis is described in a 26-year-old woman with malignant lymphoma after prolonged intake of cyclophosphamide. Cyclophosphamide was given over a period of 13 years in an oral daily dose of 50-100 mg. Lung biopsy revealed extensive fibrosis with no evidence of malignancy or infection. Cyclophosphamide is considered the most likely cause of pulmonary fibrosis in this patient.