Long-term consequences after jejunoileal bypass for morbid obesity.

This study assesses the long-term results of jejunoileal bypass (JIB) in 43 prospectively followed patients whose surgical bypass remained intact. Follow-up was 12.6+/-0.25 years from JIB. Weight loss and improved lipid levels, glucose tolerance, cardiac function, and pulmonary function were maintained. Adverse effects such as hypokalemia, cholelithiasis, and B12 or folate deficiency decreased over time. The incidence of diarrhea remained constant (63% vs 64% at five years), while the occurrence of hypomagnesemia increased (67% vs 43% at five years, P < 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patients and was progressive. Overall, after more than 10 years, 35% of patients appeared to benefit from JIB as defined by alleviation of preoperative symptoms and the development of only mild complications (vs 47% at five years). On the other hand, irreversible complications appeared to outweigh any benefit derived from the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIB remain at risk for complications, particularly hepatic fibrosis, even into the late postoperative period.

Leiomyoma of the seminal vesicle.

Leiomyoma of the seminal vesicle is exceedingly rare, with only a few cases reported in the literature. To our knowledge we present the first case of primary leiomyoma of the seminal vesicle to be evaluated by magnetic resonance imaging using a rectal coil.

MR imaging of prostate cancer with an endorectal surface coil technique: correlation with whole-mount specimens.

PURPOSE: To evaluate the diagnostic accuracy of magnetic resonance (MR) imaging in staging prostate cancer with an endorectal surface coil technique. MATERIALS AND METHODS: The authors prospectively evaluated MR images obtained with an endorectal surface coil from 70 consecutive patients with known prostate cancer. Gadopentetate dimeglumine was administered to 40 patients. Multiple sequences were used, including conventional and fast spin echo, with and without fat suppression. The readers were blinded to the MR findings unless bone or nodal metastasis was present. MR images were compared with whole-mount sections. RESULTS: The prospective staging accuracy for MR imaging was 51% (36 of 70 patients). Stage B disease was present in 27 patients (38%), stage C in 42 (60%), and stage D in one (1%). The retrospective staging accuracy was 67% (47 of 70 patients). Of the 42 patients with stage C disease, positive surgical margins were present in 36 (85%). Gadopentetate dimeglumine did not help detect or stage tumors. CONCLUSION: Further studies must be performed to determine the role of endorectal coil MR imaging in the staging of prostate cancer.

Intestinal motility changes in rats after enteric serotonergic neuron destruction.

The myenteric plexus consists of several subpopulations of morphologically and chemically distinct neurons known to contain a variety of peptides and amines, one of which is serotonin (5-hydroxytryptamine). These neurons are considered essential for nerve-to-nerve transmission. In the present study, we investigated the effect of 5,6- and 5,7-dihydroxytryptamine (5,6-DHT; 5,7-DHT), indoleamine neurotoxins that selectively and irreversibly injure the serotonergic neurons of the myenteric plexus. Treatment with 5,6-, or 5,7-DHT caused marked disruption of the activity front of the migrating myoelectric complex (MMC), increased its duration, and decreased its propagation velocity. At higher doses, 5,7-DHT also reduced the slow-wave frequency. Immunohistochemical techniques showed that tissue from rats treated with 5,7-DHT was depleted of serotonin-like immunoreactivity within the myenteric plexus neurons. Reserpine also caused motility and immunohistochemical changes similar to those induced by the two neurotoxins. Therefore, destruction of enteric serotonergic neurons disrupts the MMC. These studies support the cellular concepts that serotonergic neurons function as interneurons in the myenteric plexus, modulating and processing the neural stimuli, and that serotonin is an important neurotransmitter in the small intestine.

Fine needle aspiration of breast masses. An analysis of 276 aspirates.

A study of 276 consecutive fine needle aspirations (FNAs) of the breast in 240 cases is presented. Of these cases, 108 underwent subsequent biopsy of the breast; correlations between the FNA cytology and the surgical pathology findings revealed that FNA had a sensitivity of 79.4%, a specificity of 100% and a predictive value of a positive diagnosis of 100%. The overall diagnostic accuracy was 92.4%. These results are compared with those in other published series, and the pitfalls in and methods of improvement of breast FNA are discussed.

Reduced myocardial neutrophil accumulation and infarct size following thromboxane synthetase inhibitor or receptor antagonist.

Since thromboxane A2 (TXA2) release may relate to the extension of myocardial injury following coronary ligation, the authors examined the effects of pretreatment with a selective TXA2 synthetase inhibitor U-63,557A, or a TXA2 receptor antagonist SQ-29,548, on myocardial infarct size forty-eight hours following left coronary ligation in rats. Myocardial infarct size (as percent of left ventricle, LV) was decreased from 44 +/- 3% in saline-treated control animals to 34 +/- 4% (P less than 0.05) in U-63,557A-treated animals and to 32 +/- 4% (P less than 0.05) in SQ-29,548 treated animals (U-63,557A-treated vs SQ-29,548-treated, P = NS). LV creatine kinase (CK) was 5.08 +/- 0.42 IU/mg protein in noninfarcted untreated rats and 1.79 +/- 0.21 IU/mg protein in saline-treated infarcted rats. LV CK was 2.86 +/- 0.40 IU/mg protein in U-63,557A-treated rats and 3.11 +/- 0.51 IU/mg protein in SQ-29,548-treated infarcted rats (both P less than 0.05 compared with saline-treated rats). The beneficial effects of U-63,557A and of SQ-29,548 were not accompanied by reduction in indices of myocardial oxygen demand (heart rate and arterial pressure). However, neutrophil accumulation in the infarcted myocardium was markedly decreased by U-63,557A and SQ-29,548 pretreatment. Myocardial myeloperoxidase activity, a specific marker of neutrophil infiltration, was also decreased (P less than 0.02) in U-63,557A- and SQ-29,548-treated animals (0.09 +/- 0.03 and 0.07 +/- 0.02 units/100 mg, respectively) compared with saline-treated infarcted rats (0.19 +/- 0.04 units/100 mg). In vitro incubation of U-63,557A and SQ-29,548 caused a significant and similar reduction in f-MLP-induced neutrophil chemotaxis, and U-63,557A increased prostacyclin formation in whole blood. These data suggest that reduction in the extent of myocardial injury by TXA2 synthetase or receptor inhibitors may, in part, relate to a decrease in neutrophil accumulation in the infarcted tissue. In spite of differences in mechanisms of action of U-63,557A and SQ-29,548, both agents exert a similar protective effect on the extent of myocardial injury following coronary ligation. Reduction in neutrophil accumulation in the infarcted zone, as well as in f-MLP-directed chemotaxis in vitro, suggests that TXA2 inhibition may modulate neutrophil migration.

Effects of cardiopulmonary bypass on pulmonary leukostasis and complement activation.

We measured white blood cell counts and complement component (C3a, C4a, and C5a) and prostacyclin levels, and studied lung biopsy specimens, in 16 patients undergoing cardiopulmonary bypass and compared them with four patients undergoing other pulmonary procedures. Bypass caused no significant elevation in peripheral venous white blood cell counts. Higher counts were present in the right atrium compared with the left atrium. Patients who underwent bypass had elevated complement component and prostacyclin concentrations before operation and these levels increased further during operation. Trapping of polymorphonuclear leukocytes occurred in pulmonary alveolar capillaries and venules after bypass. We conclude that bypass activates complement components primarily of the alternative pathway and leads to increased blood prostacyclin levels. These changes are accompanied by polymorphonuclear leukocyte accumulation in the lungs and may be important in initiation of the adult respiratory distress syndrome in these patients.

Two distinct pathologic types of giant cell tumor of the vulva. A report of two cases.

Giant cell carcinoma of the vulva has been described as a distinctive primary tumor of the vulva associated with multinucleated tumor giant cells and nuclear pleomorphism. These tumors have been reported to have a poorer prognosis than does squamous cell carcinoma, to which they are thought to be related. Two women were treated for primary vulvar malignancies possessing the morphologic features of giant cell tumor. Electron microscopy was not beneficial in distinguishing the tumors. A panel of immunoperoxidase procedures, including AE 1/3, 35 beta H-11, carcinoembryonic antigen, epithelial membrane antigen, HMB-45, S-100, leukocyte common antigen, placentalike alkaline phosphatase, alpha-1-antichymotrypsin and vimentin made it possible to distinguish the two tumors and characterized one as a nodular amelanotic melanoma with multinucleate tumor giant cells and the second as a squamous cell carcinoma with tumor giant cells. The latter term should replace the term giant cell carcinoma. Histologic criteria can help define this tumor.

Neuroendocrine (Merkel cell) carcinoma of the skin. Its natural history, diagnosis, and treatment.

Over 400 cases of neuroendocrine (Merkel cell) carcinoma of the skin (NCS) have been reported. This tumor continues to pose problems in diagnosis and effective treatment for physicians unfamiliar with its biological characteristics. Reported here are five additional cases of NCS and the literature for this rare neoplasm is comprehensively reviewed. An early and accurate diagnosis is made possible by combining clinical presentation with results of histologic study, immunoperoxidase staining for neuron-specific enolase (NSE), epithelial membrane antigen (EMA), cytokeratins, and electron microscopy. NCS is an aggressive tumor. Depending on the length of follow-up, up to 40% of tumors locally recur, 55% develop regional nodal metastases, and 36% undergo distant metastasis. Survival is sex, but not age, dependent, with an overall 2-year survival rate of 72% (males 58% vs. females 79%). No standard procedure for initial and/or follow-up treatment for NCS exists. The authors recommend that NCS be treated, whenever possible, using the same rationale as applied for the treatment of squamous cell carcinoma of the skin.

Reduction in myocardial neutrophil accumulation and infarct size following administration of thromboxane inhibitor U-63,557A.

We examined the effects of a new selective thromboxane A2 (TXA2) synthetase inhibitor, U-63,557A, on myocardial infarct size 48 hours following left coronary ligation in rats. With a single 8 mg/kg dose of U-63,557A (furegrelate) administered prior to coronary ligation, platelet aggregation and serum TXA2 formation declined significantly (p less than 0.02) for up to 48 hours. Myocardial infarct size, as measured by planimetry of serial left ventricular sections, was decreased from 44 +/- 3% (saline-treated control rats) to 34 +/- 4% (p less than 0.05). Left ventricular creatine kinase (CK) following coronary ligation was also preserved in U-63,557A vs saline-treated control animals (p less than 0.05). These beneficial effects of U-63,557A were not accompanied by reduction in the indices of myocardial oxygen demand (heart rate and arterial pressure). Furthermore, neutrophil accumulation in the infarcted myocardium was significantly decreased by U-63,557A (26 +/- 6 vs 96 +/- 3/high-power field [p less than 0.01]). These data suggest that administration of a single dose of selective TXA2 synthetase inhibitor prior to coronary ligation modulates platelet function for up to 48 hours and reduces the extent of myocardial injury, which may, in part, relate to decrease in neutrophil accumulation.

Amiodarone pulmonary toxicity presenting as bilateral exudative pleural effusions.

Therapy with the antiarrhythmic drug amiodarone has been associated with drug-related side effects. In addition to pulmonary fibrosing alveolitis, anecdotal reports have alluded to incidental pleural involvement associated with amiodarone. We describe an unusual manifestation of amiodarone-induced pulmonary toxicity in a patient with bilateral exudative pleural effusions and toxic involvement of other organs. We review amiodarone-associated pleural reactions reported in the literature.

Transfer of hepatitis B virus by contaminated reusable needle electrodes after electrodesiccation in simulated use.

Reusable needle electrodes have been standard for electrodesiccation procedures commonly done by dermatologists. This study investigates the risk of transmission of hepatitis B virus by such electrodes during simulated use with electrodesiccation. Sterile needle electrodes were inoculated with either purified hepatitis B surface antigen (HBsAg+) concentrate or serum positive for both HBsAg and deoxyribonucleic acid (DNA) polymerase activity (a measure of infectious and replicating hepatitis B virus), followed by simulated use for electrodesiccation at various settings and rinsing of the tip with negative serum. The rinse serum was then assayed for HBsAg, DNA polymerase activity, and the presence of viral particles by electron microscopy. HBsAg could be transferred through the electrodesiccation procedure at all settings used. Although DNA polymerase activity was negative in the rinse serum, electron microscopy demonstrated transfer of HBsAg forms and complete virus. These results suggest a potential risk of spread of hepatitis B virus by reusable needle electrodes for electrodesiccation.

Haemophilus influenzae meningitis and Waterhouse-Friderichsen syndrome in an adult.

An otherwise healthy 36-year-old man had abdominal pain, vomiting, sepsis, and disseminated intravascular coagulation (DIC). Negative exploratory laparotomy was shortly followed by death. Autopsy showed Haemophilus influenzae (type B) meningitis, multiple organ involvement with DIC, and bilateral adrenal hemorrhagic necrosis (Waterhouse-Friderichsen syndrome). This patient is the fourth reported adult with H influenzae meningitis and hemorrhagic infarction of the adrenals, and the first such patient with an apparent abdominal catastrophe.

Laser angioplasty with angioscopic guidance in humans.

An experimental study was conducted in 11 patients to evaluate the immediate effects of laser recanalization during peripheral arterial bypass surgery. Angioscopy allowed precise localization and identification of the occlusion. A 1 or 2 mm optical fiber probe was used. Laser energy was regulated using the least amount of energy necessary for recanalization. New vascular channels were made in 10 of the 11 patients. After recanalization the arterial segment was excised for histologic evaluation. Smaller channel diameters were made with the 1 mm probe (1.5 +/- 0.6 mm) than with the 2 mm probe (3 +/- 0.3 mm) (p less than 0.05). Flow through channels (mean pressure 80 mm Hg) made with the 2 mm probe was greater than that through channels made with the 1 mm probe (150 +/- 102 versus 19.7 +/- 10 cc/min) (p less than 0.05). The amount of debris formed was small with both probes. Vascular perforations were less frequent with the 2 mm probe (two of nine arteries) compared with the 1 mm probe (four of four arteries). Successful recanalization with flow rates expected to maintain vascular patency was achieved only with the 2 mm probe. Histologic studies at nonperforated sites demonstrated that the elastica of the artery appeared to be preserved whereas the overlying plaque and underlying media were thermally disrupted. This suggests that the elastic tissue acts as an optical window allowing the argon beam to go through it without causing morphologic damage. Except for fresh thrombus, atheromas including calcific plaque and old organized thrombus were readily vaporized. These results are encouraging for the use of the laser for vascular recanalization in humans.

The presence of benign prostatic glands in perineural spaces.

The close neural-epithelial interaction seen in cases of prostatic carcinoma often is a criterion for malignancy. In a retrospective histological study of 26 nonneoplastic prostate glands obtained at autopsy benign glands were found in the perineural spaces in 6. In 5 of these cases the glands were cytologically benign, with a double layer of epithelial cells without nuclear pleomorphism, hyperchromatism and eosinophilic nucleoli. The remaining case involved an atrophic gland. Owing to the small size, nuclear hyperchromatism and, sometimes, crowded architectural arrangement atrophic glands may mimic malignant glands. This could be a potential cause of concern for the surgical pathologist when these glands appear around nerves. Perineural invasion should be interpreted cautiously when used as a criterion for malignancy.

The healing process in normal canine arteries and in atherosclerotic monkey arteries after transluminal laser irradiation.

To evaluate the healing response of both normal and atherosclerotic arteries to laser radiation, 7 mongrel dogs and 4 hypercholesterolemic atherosclerotic monkeys underwent catheterization with a right Judkins catheter-optical fiber system designed to maximize arterial wall injury. Argon laser radiation was then delivered to the abdominal aorta and iliofemoral arteries. In the 11 animals, a total of 917 sites were irradiated in 33 arteries. Angiography did not reveal dissection or aneurysm formation; occlusive thrombosis was found in 2 arteries. Perforation of the arterial wall was a frequent complication. In animals killed between 1 hour and 4 days, light and electron microscopy of lased sites showed craters filled with a coagulum of blood and cellular debris with only a few adherent platelets. Healing occurred with a minimal inflammatory response and involved both fibroblasts and smooth muscle cells. Reendothelialization was seen in all animals killed between 7 and 14 days after lasing and was complete by 30 to 60 days. Within this period, no accelerated atherosclerosis was seen at lased sites in the hypercholesterolemic monkeys. It is concluded that transluminal lasing of normal arteries in dogs and in atherosclerotic arteries of monkeys is followed by healing and reendothelialization within a few weeks.

Anaplastic neoplasm in a patient with hairy cell leukemia.

A 63-year-old white man had a history of recurrent pneumonia, pancytopenia, and splenomegaly when the diagnosis of hairy cell leukemia was made on bone marrow biopsy examination. Splenectomy confirmed that diagnosis and his pancytopenia moderately improved. Three years following the diagnosis, the patient developed an upper abdominal mass involving the stomach wall that was found to be an anaplastic "large cell" neoplasm. Palliative radiotherapy was started, but the patient died 2 months later. Cytochemical studies of the anaplastic gastric neoplasm revealed cytoplasmic tartrate resistant acid phosphatase activity. Electron microscopy showed no epithelial differentiation. These observations suggest that the gastric neoplasm represented an evolution of hairy cell leukemia into a more aggressive tumor analogous to the transformation that occurs in other B-cell neoplasms.

Laser recanalization of occluded atherosclerotic arteries in vivo and in vitro.

Controlled laser irradiation was used to recanalize atherosclerotic stenoses in vivo and in vitro. In 15 rabbits with atherosclerotic arteries a catheter was positioned in the distal aorta for angiographic examination and as a guide for a small silica optical fiber. Both Nd-YAG and argon lasers were used for recanalization with varying power and duration. As determined by angiographic studies the severity of iliofemoral stenoses in eight 15 arteries decreased from 78 +/- 18% to 32 +/- 11% (mean +/- SD). In one additional artery the stenosis improved from 45% to 25%, but this was associated with perforation. The other six arteries were perforated (two after fiber manipulation, four after laser discharge) without obvious improvement in severity of stenosis. No angiographic loss of distal circulation was noted. To better define tissue- laser interactions in the live-rabbits, lasing of 15 totally occluded atherosclerotic rabbit arterial segments in vitro was done while the optical fiber was advanced or fixed. When the fiber was fixed, serial sections showed that the new lumen was flame shaped. The width and depth of the lumen increased with increasing laser energy. When the fiber was advanced, histologic examination showed a smooth cylindrical vascular channel with limited lateral tissue damage. This study demonstrated that lasers can recanalize atherosclerotic stenoses in a live animal preparation; however, arterial perforation remains a problem.

Squamous carcinoma arising in a pilonidal sinus.

A patient with squamous cell carcinoma arising from an extensive pilonidal sinus was treated with wide local excision, resulting in an apparent cure over a 1-year follow-up period. Review of the literature revealed 32 previously reported cases of this entity. Forty-four percent of these patients developed recurrences or metastases, and 22% died of their disease. The largest historical treatment group with at least 1-year follow-up (19 patients with localized disease) underwent wide excision. Forty-two percent of these patients recurred or developed metastases. Ultimately, 89.5% of these patients were reported cured, but only five survivors were followed for as long as 5 years. Historical experience appears to identify pilonidal tract squamous carcinoma as an aggressive tumor. The reported success of wide local excision is based on a small number of patients followed for short periods of time. Continued experience with this disease should be reported to verify the adequacy of local excision or identify the need for adjunctive therapy.