Human granulocytic ehrlichiosis in pancreas transplant recipients.

Human ehrlichioses are tick-borne infections caused by bacteria in the genus Ehrlichia of the family Rickettsiaceae. To date there have been three cases of ehrlichiosis reported in the transplant population, a human monocytic ehrlichiosis (HME) infection in a liver transplant recipient and two cases of human granulocytic ehrlichiosis (HGE) in kidney transplant recipients. We report three pancreas transplant patients who developed HGE in the last two years at a single southeastern center in the United States. All three patients had clinical, laboratory, and pathophysiologic findings on bone marrow biopsy and peripheral blood smears consistent with HGE, and responded to doxycycline therapy. In the setting of potent immunosuppression, ehrlichiosis should be considered in the differential diagnosis of transplant patients presenting with persistent fever, pancytopenia, and abnormal liver function. Patients with ehrlichiosis infection may be at risk for developing other opportunistic infections or lymphoproliferative disease.

Nodular melanosis due to epithelial neoplasms: a finding not restricted to regressed melanomas.

Nodular or tumoral melanosis consists of nodular or sheetlike deposits of melanophages in the dermis. When nodular melanosis is present, a completely regressed malignant melanoma is a major diagnostic consideration. We present a case of nodular melanosis due to regression of a pigmented basal cell carcinoma with pilar differentiation. In addition to this case, we present five additional cases of epithelial neoplasms with melanin deposition in the stroma. In each case, the source of the melanin was non-neoplastic dendritic melanocytes intermingled among the tumor cells. Therefore, if nodular melanosis is found, pigmented epithelial neoplasms should also be considered in the differential diagnosis.

A cephalometric study of children with chronic perennial allergic rhinitis.

This study compared the cephalometric features of a group of one hundred children aged from six to sixteen years suffering from chronic perennial allergic rhinitis of differing grades of severity with those of 99 control subjects of similar age. Both samples were drawn from a Children's Hospital which has a large population of patients with chronic perennial allergic rhinitis attending the Allergy Clinic. Lateral cephalometric head films of each subject were recorded and a series of measurements made to assess and compare the craniofacial morphology. The data were statistically analysed. The study found that the children suffering from chronic perennial allergic rhinitis had longer and more divergent facial patterns as well as horizontally shorter maxillae than those in the control group. In addition, those parameters associated with increased vertical dimension and hyperdivergence demonstrated progressive expression with increasing severity of the chronic perennial allergic rhinitis.

The gasless laparoscopic Burch bladder neck suspension: early experience.

PURPOSE: We evaluated the gasless extraperitoneal laparoscopic Burch bladder neck suspension. MATERIALS AND METHODS: This retrospective study included 47 patients with type II stress urinary incontinence treated sequentially with this technique between September 1994 and September 1995. Balloon dissection was used to develop the extraperitoneal space. A mechanical retraction system was used with conventional laparotomy instruments to perform laparoscopic Burch bladder neck suspension. RESULTS: Of the 47 patients who underwent this procedure 3 (6%) required conversion to an open operation. Obesity and previous pelvic surgery were not contraindications to this technique. The only major complication involved blood loss necessitating conversion to an open operation. Average operative time was 96.4 minutes and average hospital stay was 3.5 days. Followup at 2 to 15 months (mean 8.2) indicated successful results (that is no pads were required) in 44 patients (90%). CONCLUSIONS: Gasless laparoscopic bladder neck suspension has a lower open surgery rate, and may be performed more rapidly than conventional carbon dioxide laparoscopic Burch bladder neck suspension. Previous multiple operations and obesity are not contraindications to the technique.

Correlation between Banff classification, acute renal rejection scores and reversal of rejection.

The Banff classification of acute rejection is based on histologic grades and scores for borderline changes, glomerular, vascular, interstitial and tubular lesions. We reviewed 56 episodes of acute rejection occurring in 44 kidney allograft recipients (30 cadaveric and 14 living donor transplants), comparing Banff classification to degree of reversibility of rejection. Rejection reversal was defined as complete if serum creatinine returned < or = 25% of baseline, partial if creatinine was > 25% to < 75% of baseline, and irreversible if creatinine was > or = 75% of baseline or graft loss occurred. Eight biopsies were classified as borderline (SUM score 1.6 +/- 0.5), 14 grade I (SUM score 3.3 +/- 0.4), 19 grade II (SUM score 4.2 +/- 0.3), and 15 grade III (SUM score 8.5 +/- 0.4). SUM distinguished borderline and grade III rejections, but not grades I and II. Clinically, grade and SUM score correlated with rejection reversal. Complete reversal of rejection occurred in 93% of patients with grade I rejection, while 47% of patients with grade III had irreversible rejection. The mean SUM for complete reversal was 3.9 +/- 0.34 and was different from SUM of partial (6.0 +/- 0.86) and irreversible (8.5 +/- 0.93), P < 0.006. Meanwhile, vascular scores were similar for rejections with complete (0.9 +/- 0.2) or partial (1.0 +/- 0.4) reversal, but significantly higher in those with irreversible rejection (3.0 +/- 0.4, P < 0.000). Likewise, mean scores for tubulitis and interstitial inflammation were significantly higher for irreversible rejection. Resolution of rejection by steroids was correlated to low vascular score (steroid sensitive 0.65 +/- 0.25 vs. steroid resistant 1.42 +/- 0.18, P < 0.01), and low SUM score (steroid sensitive 3.7 +/- 0.5 vs. steroid resistant 5.22 +/- 0.43, P < 0.04). Neither scores for tubulitis nor interstitial cellular inflammation were predictive of steroid sensitivity. These data demonstrate that Banff scoring has clinical relevance in predicting rejection reversal and has implications to first-line therapy of rejection episodes.

Nucleolar organizer regions in adenocarcinoma of the uterine cervix.

BACKGROUND: Nucleolar organizer regions (AgNORs) are associated with proliferative activity and ploidy in many tumors. The endocervical growth pattern of cervical adenocarcinoma renders tumor volume assessment more difficult, necessitating additional prognostic indicators. METHODS: Thirty-five cases of cervical adenocarcinoma were evaluated by reviewing charts and histologic sections. Nucleolar organizer regions were stained and counted manually; the mean number per cell and the percentage of cells with more than 5 AgNORs were recorded. Ploidy and S-phase fraction were determined by flow cytometry. RESULTS: Mean AgNOR counts per cell were significantly higher in adenocarcinoma (3.0) and adenosquamous carcinoma (4.3) than in benign endocervical epithelium (1.4). Grade 3 tumors had higher values (4.0) than Grade 1 lesions (2.9), and tumors with lymphovascular space involvement had higher values (3.5) than tumors without such involvement (2.7). No significant correlation was seen with regard to tumor stage or size. Flow cytometric parameters did not correlate with any of the examined parameters, although the DNA index was higher in larger tumors. Correlation between AgNOR counts and flow cytometry was significant only in Grade I tumors. CONCLUSIONS: Nucleolar organizer region counts correlated better with histologic parameters of cervical adenocarcinoma than did flow cytometry. Because it is easily performed and does not require sophisticated equipment, AgNOR counts should be investigated further in a larger group of patients to determine their prognostic value.

Nephrogenic adenoma in a urethral diverticulum. A case report.

A nephrogenic adenoma was identified histologically in the excised specimen of a urethral diverticulum. Urethral diverticulum is a relatively common disorder of the female lower urinary tract, and nephrogenic adenoma is an extremely rare finding: this is the 13th reported case of this association. Of clinical importance is the close histopathologic resemblance of nephrogenic adenoma to clear cell adenocarcinoma. Nephrogenic adenoma is a benign metaplastic change of the urothelium in response to repair.

The presentation of adenocarcinoma of the uterine cervix.

BACKGROUND: Among malignancies of the uterine cervix, the percentage of adenocarcinomas seems to have increased in recent reports. METHODS: The clinical presentation of adenocarcinoma of the uterine cervix during the past 25 years was examined by review of charts and pathologic specimens. The data of a total of 124 patients with cervical adenocarcinoma treated between 1964 and 1988 were evaluated. RESULTS: During the 25-year period, the percentage of adenocarcinoma among all cervical malignancies increased from 9% to 25%. In addition, the average number of new cases per year increased from 3.7 to 10.8. The percentage of women young than 35 years with adenocarcinoma increased from 16% in 1964 to 24% in 1989. Of these younger women, 74% had disease discovered by cytopathology, in comparison with 27% of the patients who were older than 35 years. The overall percentage of patients with disease diagnosed by cytology increased from 24% in the first half to 39% in the second half of the study period. Vaginal bleeding was the most common symptom. In the entire period, 57% of patients had International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, with a median tumor diameter of 1 cm in patients with no symptoms and 3 cm in patients with symptoms. Outcome was inversely related to stage, tumor volume, and the presence of lymph node metastasis but not to histologic tumor type. CONCLUSION: The frequency of adenocarcinoma of uterine cervix is increasing in patients 35 years or younger. Cytopathology is a good screening tool for these patients, leading to earlier diagnosis and improved outcome.

Blocked element compensation in phased array imaging.

In clinical applications using large apertures, a significant number of phased array elements may be blocked due to discontinuous acoustic windows into the body. These blocked elements produce undesired beamforming artifacts, degrading spatial and contrast resolution. To minimize these artifacts, an algorithm using multiple receive beams and the total-least-squares method is proposed. Simulations and experimental results show that this algorithm can effectively reduce imperfections in the point spread function of the imager. Combined with first-and second-order scatterer statistics derived from multiple receive beams, the algorithm is modified for blocked element compensation on distributed scattering sources. Results also indicate that compensated images are comparable to full array images, and that even full array images can be improved by removing undesired sidelobe contributions. This method, therefore, can enhance detection of low contrast lesions using large phased-array apertures.

Photo recall-like phenomenon following the use of cefazolin and gentamicin sulfate.

A twenty-one-year-old woman being treated as an inpatient for a urinary tract infection with cefazolin and gentamicin showed a photodistributed eruption five days into her hospitalization. Photo recall phenomena are well known to occur in patients receiving chemotherapeutic agents after sustaining prior skin damage from radiation therapy or the sun. Similar reports with more commonly used agents are sparse. We report a photo recall-like phenomenon comprised of a similar entity with a different reaction pattern. After reviewing the literature on photo recall phenomena, we compare and contrast our case with those previously reported.

Primary yolk sac (endodermal sinus) tumor of the prostate: case report and review of the literature.

A primary yolk sac (endodermal sinus) tumor of the prostate is described in a 40-year-old male. This is the second documented case of a yolk sac tumor occurring in the prostate gland. Treatment included surgical removal and subsequent combination chemotherapy. Four months following diagnosis, the patient died of complications. At autopsy, no residual tumor was detected. The role of combination chemotherapy as potentially curative therapy in the treatment of extragonadal yolk sac tumors is discussed.

A comparative study of intravenous urograms and radionuclide renal scans in diagnosis of renal trauma.

We analyzed 31 patients who underwent intravenous urograms (IVU) and radionuclide renal scans (RNRS) in the investigation of blunt abdominal trauma, and compared the IVU to the RNRS in the definition of blunt renal injuries, and their correlation with patients' symptoms and signs. Thirteen patients had abnormal IVU and 12 had abnormal RNRS (42% of the 31 patients). In 8 patients findings on IVU correlated with those on RNRS (62%), and in 5 patients findings were different (38%). Only 2 patients (6.5%) had significant differences which may have influenced further treatment. Only 1 patient required operative management. Follow-up IVUs were performed on 6 of the 13 patients who had abnormal radiologic studies. The radionuclide renal scan was shown to be as accurate as the intravenous urogram in defining renal trauma. Patients who undergo liver-spleen scans for investigation of blunt abdominal trauma, and who may have renal trauma, may well undergo RNRS at the same time and obviate the need for an IVU, without any diagnostic compromise.

Phase aberration measurements in medical ultrasound: human studies.

Using a modified real-time phased array sector scanner, phase aberrations and amplitude fluctuations across the imaging aperture have been measured in a number of human subjects. Data from these subjects were classified into two categories based on the quality of conventional longitudinal images of the liver. Measured phase aberrations were very small in all subjects exhibiting high quality images. In contrast, large phase aberrations were measured in subjects producing low quality images. However, there were no significant amplitude variations across the array for all subjects studied. These results suggest that the absence of significant phase aberrations is a necessary condition for high quality phased array imaging. If so, improvements in clinical image quality in such subjects may be possible.

Phase-aberration correction using signals from point reflectors and diffuse scatterers: basic principles.

Methods for correction of phase aberrations induced by near-field variations in the index of refraction are explored. Using signals obtained from a sampled aperture (i.e. transducer array), phase aberrations can be accurately measured with a correlation approach similar to methods used in adaptive optics and radar. However, the method presented here has no need for a beacon or an ideal point reflector to act as a source for estimating phase errors. It uses signals from random collections of scatterers to determine phase aberrations accurately. Because there is no longer a need for a beacon signal, the method is directly applicable not only to medical ultrasound imaging but also to any coherent imaging system with a sampled aperture, such as radar and sonar.

Phase-aberration correction using signals from point reflectors and diffuse scatterers: measurements.

A method for phase-aberration correction of phased-array images is tested using a model of near-field velocity inhomogeneities. A set of grooved room-temperature vulcanizing plates was constructed to simulate near-field aberrations encountered in clinical ultrasound imaging. As expected, large image distortion was experienced when grooved plates producing significant aberrations were placed near the surface of the array. An iterative aberration correction procedure based on cross-correlation measures between neighboring elements in a phased array, using signals reflected from diffuse scatterers, significantly reduced the effects of these aberrations, producing images nearly identical to those generated in the absence of aberrations. The results suggest that a practical phase-aberration correction system can be constructed for medical ultrasound imaging and possibly all coherent imaging systems by using a sampled aperture.

Quantitative US attenuation in normal liver and in patients with diffuse liver disease: importance of fat.

Two methods are used to estimate ultrasound attenuation in liver. These were based on amplitude change and frequency change as a result of depth dependent attenuation. Evaluation of the two methods against a family of calibrated phantoms yielded correlation coefficients of 0.98 and 0.99, respectively. Liver attenuation in 26 control subjects was 0.50 and 0.52 dB/MHz/cm, respectively. Liver attenuation was estimated in 50 patients who later underwent liver biopsy. Comparison with quantitative histologic results showed that the presence of fat alone accounted for the increased attenuation associated with cirrhosis. Similar high attenuation values were found in patients with fatty infiltration. Fibrosis alone did not result in elevated liver attenuation. Cirrhotics without fatty infiltration had attenuation similar to that of the controls. Mechanisms of action are discussed.