Insertion of foreign bodies into the abdominal cavity. An unusual form of self-mutilation.

Self-mutilation is self-infliction of bodily injury without a conscious suicidal intent. Repeated self-inflicted abdominal stab wounds with insertion of foreign bodies into the abdominal cavity is an uncommon form of self-mutilation. We describe such a case in a 35-year-old male inmate who committed suicide by hanging. At autopsy metallic foreign bodies were found in the liver and paraduodenal soft tissue. Because of its high prevalence in the incarcerated population, self-mutilation among prisoners should be given attention. Self-mutilation should also be considered in cases of atypical behavior, psychiatric disorders, intoxication, mental retardation, and sudden death from unexplained causes.

Fatal acute pancreatitis caused by valproic acid.

We describe a case of a 31-year-old woman with cerebral palsy who developed fatal acute hemorrhagic pancreatitis while being treated with valproic acid to control her seizure activity. Acute pancreatitis is usually due to alcohol ingestion or biliary tract disease, and unusual causes include trauma, metabolic diseases, or drugs. Valproic acid is considered a safe drug, although rare cases of severe toxicity such as hepatitis and acute pancreatitis, including two fatalities, have been reported. Our review of the literature revealed that most patients who developed acute pancreatitis had serum levels of the drug within the therapeutic range, and most of the cases occurred either secondary to a recent increase in the dose or to initiation of treatment. It also appeared that the fatalities occurred due to a delayed diagnosis of acute pancreatitis, either resulting from an unsuspected diagnosis or to the deteriorated mental status of the patients receiving the drug, which precluded their ability to elaborate symptomatology. We believe that early diagnosis and withdrawal of the drug are significant factors determining the course of valproic-acid-associated pancreatitis.

Risk factors for breast cancer in women undergoing mammography.

To determine risk factors for carcinoma of the breast, we compared women with cancer on screening and diagnostic mammography with those in whom cancer was not detected. For 39 months, medical histories were collected by mammography technologists on 3492 women having routine screenings or diagnostic mammograms at our institution. Potential risk factors of women with biopsy-proved breast cancer were compared with those in women who had normal findings on mammograms or negative biopsy results (control subjects). Of the 3492 women, 49 had biopsy-proved breast cancer. There were 3361 patients in the control group, including those women with normal findings on mammograms (3294) and those with negative biopsy results (67). Eighty-two women had incomplete questionnaires or were lost to follow up. Nearly all of the patients with breast cancer were postmenopausal compared with 68% of the control subjects. The mean length of lactation for breast cancer patients was significantly less than for control subjects: 5.6 vs 7.5 weeks (p = .015). This was true also for the postmenopausal patients: 8.1 vs 6.1 weeks (p = .041). Postmenopausal breast cancer patients had menstruated significantly more years (p = .016) than the postmenopausal control subjects: 34 vs 31 years, although the mean age at menarche was not different. When corrected for age, there was no significant difference in the total duration of menstruation in the postmenopausal cancer patients compared with the postmenopausal control subjects. Postmenopausal breast cancer patients had a significantly greater (p = .021) average body weight than postmenopausal control subjects: 71.7 vs 66.7 kg, although body weight was the same when all patients were considered. Similar results were found when Quetelet's index for obesity (weight in kg/height in cm2) (p = .004) was calculated for postmenopausal patients: 28 for cancer patients and 26 for control subjects. There was no significant difference in height between the cancer patients and control subjects when all patients or just the postmenopausal patients were considered. History of oral contraceptive use was significantly less common among postmenopausal breast cancer patients than among postmenopausal control subjects: 9% vs 20%. Patients with breast cancer had lower parity than the control subjects. In our series of patients, women in whom breast cancer was detected on mammography lactated less, showed no significant difference in years of menstruation when corrected for age, had a greater average body weight, used oral contraceptives less often, and had fewer children than women in whom no cancer was detected on mammography.

PIP: To determine risk factors for carcinoma of the breast, the authors compared women with cancer on screening and diagnostic mammography with those in whom cancer was not detected. For 39 months, medical histories were collected by mammography technologists on 3492 women having routine screenings or diagnostic mammograms at their institution. Potential risk factors for women with biopsy-proven breast cancer were compared with those in women who had normal findings on mammograms or negative biopsy results (controls). Of the 3492 women, 49 had biopsy-proven breast cancer. There were 3361 patients in the control group, including those women with normal findings on mammograms (3294) and those with negative biopsy results (67). 82 women had incomplete questionnaires or were lost to follow up. Nearly all of those with breast cancer were postmenopausal compared with 68% of the controls. The mean length of lactation for breast cancer patients was significantly less than for the controls; 5.6 vs 7.5 weeks (p=.015). This was also true for the postmenopausal patients; 8.1 vs 6.1 weeks (p=.041). Postmenopausal breast cancer patients had menstruated significantly more years (p=.016) than postmenopausal control subjects: 34 vs 31 years, although the mean age at menarche was not different. When corrected for age, there was no significant difference in the total duration of menstruation in the postmenopausal cancer patients compared with the postmenopausal controls. Postmenopausal breast cancer patients had a significantly greater (p=.021) average body weight than postmenopausal control subjects: 71.7 vs 66.7 kg, although body weight was the same when all patients were considered. similar results were found when Quetelet's index for obesity (weight in kg/height in cm2 (p=.004) was calculated for postmenopausal patients: 28 for cancer patients and 26 for controls. There was no significant difference in height between cancer patients and controls when all subjects or just those who were postmenopausal were considered. History of oral contraceptive (OC) use was significantly less common among postmenopausal breast cancer patients than among postmenopausal controls: 9% vs 20%. Patients with breast cancer had lower parity than the controls. In this series of patients, women in whom breast cancer was detected on mammography lactated less, showed no significant difference in years of menstruation when corrected for age, had a greater average body weight, used OCs less often, and had fewer children than women in whom no cancer was detected on mammography.

Dipstick evaluation of hematuria in abdominal trauma.

Urine microscopic evaluation of hematuria has traditionally been used to determine the need for an intravenous pyelogram (IVP) in individuals with blunt abdominal trauma. An IVP is generally advocated in cases where greater than 5-10 red blood cells per high power field (RBC/HPF) are identified. Various laboratories have advocated the use of dipstick examination of these urine specimens as a replacement for microscopic examination. Urine specimens from 178 consecutive patients with blunt abdominal injury were evaluated by dipstick (Chemstrip 9, Cat. No. 417190, Boehringer Mannheim Diagnostics) and microscopic examination. Sensitivity of dipstick testing for microscopic hematuria was 100% as compared to microscopic examination (positive greater than or equal to 5RBC/HPF); specificity was 58.6%. Predictive value of a positive test (PVP) was 60.8%; predictive value of a negative test (PVN) was 100%. Evaluation of proteinuria performed as an additional means of assessing renal integrity was found to be less sensitive, but more specific than, dipstick evaluation of hematuria. Poor correlation was seen between the degree of positivity by dipstick testing and the actual degree of microscopic hematuria. It is concluded that specimens which are negative for hematuria by dipstick do not need further testing by microscopic examination. All specimens which contain blood by dipstick evaluation need to be examined microscopically to predict the need for IVP.

Quality assurance programs cope with today's demands.

Pathologists face new demands resulting from malpractice litigation, health regulations, increased competition, and heightened consumer activism. Yet despite the concerns about quality and cost that beset the field, the pathologist's mission remains the same: the provision of quality care. Against the backdrop of current pressures, the authors describe the benefits and organization of a quality assurance program to help achieve this goal.

Risk management enhances quality care and protection from liability.

Two externally imposed economic pressures that grip the health care industry are on a collision course: tightening reimbursement and exploding costs of malpractice litigation and insurance. Physicians practice defensive medicine to cope with the latter, but regulatory agencies are no longer willing to pay for this habit. Pathologists must be aware of the laboratory's liability exposure, which is likely to increase in the future. Hospitals and physicians are turning to risk management programs to help limit potential losses and monitor performance.

The effect of time and cholecystectomy on experimental biliary tree dilatation. A multi-imaging evaluation.

The changes of the biliary tree following distal bile duct obstruction and its release were confirmed by biliary scintigraphy and monitored by serial ultrasonography, computed tomography, and values of serum bilirubin and alkaline phosphatase in 14 mongrel dogs. The degree and rate of biliary dilatation were independent of cholecystectomy. The most rapid rate of extrahepatic dilatation occurred within the first 48 hours, while dilated intrahepatic ducts were first recognized three to six days after obstruction. Following release of the obstruction, the degree and rate of resolution of the biliary dilatation were independent of the duration of ligation (one vs. two weeks) and cholecystectomy. The dilatation resolved slowly. Dilated intrahepatic ducts were recognized for as long as eight to 13 days, while extrahepatic biliary dilatation was still present for 13 weeks, at which time the experiment was terminated. It is postulated that the extrahepatic biliary dilatation will approach a plateau approximately one month after total biliary obstruction. It appears that if the obstruction lasts more than one week, it results in irreversible damage to the elasticity of the extrahepatic ducts. Thus, after release of the obstruction, serial biliary imaging is indicated until a new baseline of the biliary tree diameter has been established.

Acute febrile neutrophilic dermatosis (Sweet's syndrome) associated with lymphoma.

A case of Sweet's syndrome (acute febrile neutrophilic dermatosis) in a patient in whom lymphoma subsequently developed is presented. The literature concerning Sweet's syndrome in association with malignancy is reviewed. Awareness of this potential association is imperative for the early detection of the neoplasm and for the institution of appropriate follow-up care.

Studies on the pathogenesis of atherosclerosis. I. Adhesion and emigration of mononuclear cells in the aorta of hypercholesterolemic rats.

In rats with diet-induced hypercholesterolemia, two concomitant changes began to occur within 1 week and persisted for 1 year: an increase in total plasma cholesterol and an increase in the number of mononuclear cells adhering to the aortic intima (up to values 50 times normal). Adherent cells were approximately 90% monocytes and approximately 10% lymphocytes. Adhesion was focal, with some preference for ostia of aortic branches; it was followed by migration into the subendothelial space. The subendothelial monocytes/macrophages progressively became foam cells, thus giving rise to microscopic "fatty streaks." Ultimately, typical atherosclerotic plaques were formed. Four possible mechanisms of increased cell adhesion are suggested. Endothelial changes were mild; myelin figures arising from the endothelial surface were seen by electron microscopy. Endothelial denudation was never observed, neither in light-microscopic preparations stained with AgNO3 nor by ultrastructure. Platelet participation was minimal. It is concluded that in this model atherosclerotic plaques are initiated by mononuclear cell adhesion and emigration; endothelial denudation is not a necessary step in their pathogenesis.

Diagnosis of peritoneal mesothelioma: computed tomography, sonography, and fine-needle aspiration biopsy.

The diagnosis of peritoneal mesothelioma was made prospectively and noninvasively in four patients with the use of sonography, computed tomography, and sonographically guided fine-needle aspiration biopsy. The imaging methods revealed information similar to the operative findings, with clear superiority of computed tomography over sonography. These noninvasive methods may be used as screening tools, especially among groups or in regional areas with a high risk for asbestos exposure. The findings included soft-tissue masses with invariable involvement of the omentum; small intraperitoneal nodules; thickened peritoneum, mesentery, and bowel wall; pleural plaques; and usually minimal, if any, ascites. Since the differential diagnosis from peritoneal carcinomatosis may be difficult, sonographically (or CT) guided aspiration biopsy is needed to produce diagnostic cytologic specimens. The use of this type of biopsy should obviate surgical exploration.

Inflammatory polyp of the renal pelvis simulating transitional cell carcinoma.

An inflammatory polyps of the renal pelvis that caused a mass effect at excretory urography simulated transitional cell carcinoma. In the differential diagnoses of intracalyceal masses, therefore, inflammatory polyp must be considered.

Two agarose electrophoretic systems for demonstration of oligoclonal bands in cerebrospinal fluid compared.

Demonstration of oligoclonal bands by electrophoresis of cerebrospinal fluid is an important aid in establishing the diagnosis of multiple sclerosis. Electrophoretic systems vary in their effectiveness in doing so. We compared two systems in this respect. For a thin-layer agarose system, sensitivity was less (47%) than for a high-resolution agarose system (87%). Each system had good specificity (92 and 85%, respectively). Interpretation of electrophoretic patterns for cerebrospinal fluid should be available in clinical laboratories. Further, the best available system should be used for demonstration of oligoclonal bands.

Serum sialic acid levels in lung cancer patients.

The levels of N-acetyl neuraminic acid (sialic acid) in normal men and pre-and post-menopausal women were determined. Smoking post-menopausal estrogen therapy, oral contraceptives, and refreezing had no effects on sialic acid levels. Pre-treatment values from patients with lung carcinoma showed markedly elevated levels of sialic acid (0.697 +/- 0.149 muM/ml) as compared to those from normal controls (0.432 +/- 0.067 muM/ml). The potential usefulness of sialic acid as a biological marker is discussed.