Unnecessary diagnostic investigations in benign acute childhood myositis: a case series report.

Benign acute childhood myositis (BACM) is a rare, acute, self-limiting muscle disorder, mainly affecting school-aged boys, with an excellent prognosis, requiring no therapeutic intervention. We report a series of seven previously healthy school-aged children with clinical and laboratory findings suggesting BACM where no specific diagnostic investigations were performed. All of the children were hospitalized without any specific therapeutic intervention and were discharged after two or three days free of symptoms, residual impairment or other complication. This report emphasizes that the correct diagnosis of BACM, by considering the characteristic clinical and laboratory findings of this syndrome and by recognizing more severe pathological conditions, which must be excluded from the diagnosis, can prevent unnecessary diagnostic investigations and reassure both parents and patients of the excellent prognosis.

Subcutaneous pheohyphomycotic cyst from a traumatic injury: reactivation after thirty-five years.

Pheohyphomycoses are an uncommon diverse group of dematiaceous fungi present in soil and plant material and are potential pathogens. We report the case of a 45-year-old white Hispanic woman who presented with a hard round cyst on the dorsum of her right foot caused by a traumatic implantation of a piece of wood thirty-five years earlier. The cyst was surgically excised and the patient empirically treated with a two-month course of oral itraconazole. To our knowledge, this represents a case of the longest-lived asymptomatic pheohyphomycotic cyst in an immunocompetent person ever reported. The clinical manifestations, treatment options, and disease course are reviewed.

Intraperitoneal adhesions in laparoscopic and standard open herniorrhaphy. An experimental study.

BACKGROUND: Intra-abdominal complications from transabdominal properitoneal (TAP) laparoscopic herniorrhaphy that would not be expected to occur in an open herniorrhaphy are possible. In a previous study, we reported the incidence of significant intra-abdominal adhesions from TAP herniorrhaphies using polypropylene in pigs. METHODS: To compare this with an open herniorrhaphy technique, we performed open herniorrhaphies on 31 pigs. Additional animals underwent TAP herniorrhaphy with PTFE. Data were collected on operative and trocar-site adhesions. Graft incorporation was recorded. RESULTS: No intra-abdominal adhesions were found in the 31 animals undergoing open herniorrhaphy. Fifteen adhesions were found in the 31 pigs that underwent TAP herniorrhaphy. These adhesions were graded and there were a total of nine significant adhesions with the TAP procedure. A total of 124 trocar sites resulted in two adhesions. Laparoscopically placed polypropylene was better incorporated than PTFE. The laparoscopically placed PTFE grafts commonly were poorly incorporated. CONCLUSIONS: We conclude that there is a risk of intraabdominal adhesions to either the operative site or the trocar sites in TAP herniorrhaphy that is not present in open techniques. One should, therefore, be circumspect in the choice of TAP herniorrhaphy as a primary repair.

Actinic cheilitis: a premalignant condition.

Actinic cheilitis is a premalignant, irreversible disease that frequently affects the vermilion border of the lower lip. Since there is no correlation between clinical appearance and histologic aggressiveness, a biopsy is mandated. A vermilionectomy procedure is described, as well as the most frequently encountered complications.

Allergic reactions to local glyceryl trinitrate administration.

To assess the exact cause and extent of transdermal glyceryl trinitrate (GTN)-induced allergic reactions, a study of continuous and intermittent use of GTN patches was conducted in 320 patients with New York Heart Association (NYHA) class II and III angina pectoris. Three commercially available GTN patch systems were used. Twenty-one patients (6.5%) developed cutaneous reactions. In 17 patients (5.3%), the reactions were confined to the area of application and were characterised as irritant reactions. Four patients (1.2%) developed both localised and remote from the area of application lesions and one patient developed a generalised anaphylactic reaction. The rate of discontinuation of therapy was 3.4%. The irritant skin reactions were mainly due to contaminants and additives. Changing to a different transdermal system reduced the incidence of local reactions--a particularly desirable effect in patients who respond well to GTN therapy.

Pregnancy-induced increase of supraventricular arrhythmias in Wolff-Parkinson-White syndrome.

Six women suffering from Wolff-Parkinson-White syndrome and who were previously asymptomatic or nearly asymptomatic, were followed prospectively during and after their subsequent pregnancies. Three women experienced several attacks of supraventricular tachycardia (SVT) for the first time and the rest experienced an increase in their attacks. It seems that there is an increased tendency for SVT in pregnancy. Increased adrenergic sensitivity by estrogens, increased plasma volume, stress, and anxiety during pregnancy may be some of the causative factors.

The relationship between basal cell epithelioma and seborrheic keratosis. A study of 60 cases.

BACKGROUND: Various skin tumors can be seen rarely in association with seborrheic keratosis. We present 60 cases of seborrheic keratosis related to a basal cell epithelioma in the same specimen. OBJECTIVE: To report association of basal cell epithelioma with seborrheic keratosis and discuss the possibility of malignant change in seborrheic keratosis. METHODS: Sixty cases of seborrheic keratosis associated with basal cell epithelioma were studied. Tissues were fixed in neutral buffered formalin, processed, and stained with standard hematoxylin and eosin techniques. RESULTS: Histological evaluation showed a seborrheic keratosis associated with basal cell epithelioma in all of the cases. Basal cell epithelioma was attached with seborrheic keratosis in a majority of the cases (40/60) and appeared to represent a part of the same tumor. Both tumors were lying adjacent to each other in the rest of the cases (20/60). CONCLUSION: Malignant change in seborrheic keratosis is controversial. We recommend the histological evaluation of seborrheic keratosis especially when inflamed or atypical in appearance. This should not be taken as a mandate for pathological evaluation or for treatment of every seborrheic keratosis as though it was potentially malignant.

An assessment of potential complications caused by intraperitoneal gallstones.

Perforation of the gallbladder with spillage of stones into the peritoneal cavity occurs frequently during laparoscopic cholecystectomy. In order to study the effects of these stones, the authors placed no gallstones (Group I, n = 6), one stone (Group II, n = 12), or five stones (Group III, n = 12) within the peritoneal cavity of Sprague-Dawley rats. One-third of the animals in each group were then killed at intervals of 2, 4, and 8 weeks. At necropsy, the location of each stone was noted as well as any evidence of adhesion, fistula, perforation, or obstruction. No difference between groups with respect to presence of adhesions, density of adhesions, or stone location was noted, though there was a trend toward more stones becoming fixed within the abdomen over time. Perforation of the gallbladder with spillage of sterile stones does not appear to cause increased morbidity during or after laparoscopic cholecystectomy.

Acroangiodermatitis: a study of ten cases.

BACKGROUND: Acroangiodermatitis is a benign vesicular process encountered on the lower extremities that histologically resembles the superficial form of stasis dermatitis, but is clinically characterized by circumscribed violaceous, brown or dusky macules, papules, or plaques. Furthermore, unlike stasis dermatitis, acroangiodermatitis is usually associated with minimal epidermal changes and eosinophils in the inflammatory infiltrate in the dermis. Kaposi's sarcoma, pigmented purpura, vasculitis, and lichen planus are other conditions that should be considered when making a diagnosis of acroangiodermatitis. METHODS: Ten patients with acroangiodermatitis were referred to us by area physicians. Hematoxylin and eosin, periodic acid-Schiff, Pearl's (an iron stain), and an immunoperoxidase stain for Factor VIII were performed on routinely embedded paraffin sections. RESULTS: All cases showed new vessel proliferation, perivascular inflammation of superficial and mid-dermis, consisting of lymphocytes, histiocytes, eosinophils, occasional plasma cells, extravasation of red blood cells, and hemosiderin pigment deposition. Dermal fibrosis was observed in all cases. None of the patients showed changes of vasculitis or Kaposi's sarcoma. Only one patient displayed significant epidermal changes of spongiosis and mild acanthosis. CONCLUSIONS: Acroangiodermatitis is an uncommon entity with peculiar clinical and histologic features and should be confirmed by histologic tests.

Abdominal adhesions in laparoscopic hernia repair. An experimental study.

Laparoscopic herniorrhaphy is becoming an increasingly common procedure. The possible creation of intraperitoneal adhesions during laparoscopic herniorrhaphy has not been examined. For the transperitoneal hernia repair to be an acceptable option, the hypothesis that this approach will incite significant adhesions must be rejected. To test this hypothesis, 21 pigs underwent laparoscopic herniorrhaphy using a standard procedure with the implantation of a polypropylene mesh graft on one side while a sham procedure was performed on the other. These animals were later examined laparoscopically for adhesion formation and the condition of the graft. None of the 21 animals developed adhesions to the trocar sites, 12 animals developed adhesions to the area of the polypropylene mesh, and 3 developed adhesions to the side of the sham procedure. There were no adhesions involving the small intestine. It is therefore concluded that the hypothesis should be rejected and that laparoscopic herniorrhaphy does not incite significant adhesions.

Selective monitoring in abdominal aortic surgery.

Monitoring via a pulmonary artery catheter has been advocated for all patients undergoing abdominal aortic surgery. This study was performed to identify a subgroup of patients who could be safely monitored with a central venous catheter. One hundred twenty-eight consecutive patients undergoing elective infrarenal abdominal aortic surgery were prospectively evaluated for risk of developing perioperative myocardial dysfunction based on criteria determined by the history and physical examination, chest radiography, and electrocardiography. Forty-five patients were identified as having no clinical evidence of coronary artery disease. These patients were then monitored perioperatively using a central venous catheter. All patients monitored via a central venous catheter underwent surgery for abdominal aortic aneurysmal disease (66.7%) or aortoiliac disease (33.3%) without intraoperative complications. There were 15 postoperative complications in 12 (26.7%) patients, comprised mainly of pulmonary (7) and gastrointestinal (3) complications. The cardiac-related morbidity was 4.4 per cent and consisted of congestive heart failure (1) and renal failure (1). No perioperative myocardial infarctions were detected. One (2.2%) postoperative death secondary to aspiration pneumonia occurred. The results of this data suggest that there exists a subgroup of patients undergoing elective infrarenal abdominal aortic surgery that can be monitored safely via a central venous catheter in the perioperative period.

Tyrosine phosphorylation of phospholipase C concomitant with its activation by platelet-activating factor in a human B cell line.

Platelet-activating factor (PAF) is a powerful inflammatory mediator in a variety of systems. Upon binding its receptor on B lymphocytes, it activates phospholipases C and A2, thus initiating a cascade of events culminating in changes in the program of the target cell. We have now extended our previous studies of the effects of PAF on EBV-transformed human B cell lines to examine the mechanism by which phospholipase C (PLC) is activated. PAF-induced incorporation of 32P into phosphatidylinositol (PtdIns) was markedly diminished by the tyrosine kinase inhibitors, genistein, and those of the tyrphostin family, tyrphostins 25, 47, and 51. The generation of inositol phosphates induced by PAF was also significantly inhibited by these inhibitors. Correlating with this inhibition of PtdIns turnover, the elevation of intracellular calcium concentrations stimulated by PAF was observed to be inhibited in the presence of inhibitors of tyrosine kinases. In addition, the induction of expression of the proto-oncogene, c-fos, was substantially attenuated by these inhibitors. Finally, employing anti-phosphotyrosine immunoprecipitates of lysates from PAF-stimulated cells in an in vitro PLC assay, we have provided evidence for an increase in the tyrosine phosphorylation levels of PLC upon stimulation, and the inhibition of this increase by tyrosine kinase inhibitors. In summary, we have shown that in B cells tyrosine kinase activity is essential for the PtdIns turnover, the generation of inositol phosphates, and the calcium flux induced by PAF and that platelet-activating factor-induced tyrosine phosphorylation of PLC is likely to be required for the activation of this enzyme.

Primary lymphoma of the rectum.

Primary lymphoma of the rectum is rare. Its usual grouping with primary lymphoma of the gastrointestinal tract leaves little in the literature that deals specifically with a primary rectal lymphoma. Various treatments have been reported ranging from abdominoperineal resection with adjuvant chemotherapy and radiation therapy to chemotherapy or radiation therapy alone. A case of primary rectal lymphoma is presented and the literature is reviewed. In the few cases reported in the literature, patients treated surgically had a better prognosis than those treated nonsurgically with an overall 5-year survival of 50 per cent. Recommended treatment includes varying forms of surgical therapy ranging from local resection to abdominoperineal resection. Adjuvant chemotherapy, radiation therapy, or both should be considered.

Usefulness of preoperative laboratory assessment of patients undergoing elective herniorrhaphy.

Preoperative laboratory utilization was evaluated in a retrospective review of 169 adults undergoing elective inguinal herniorrhaphy at a county/university hospital and at a private/community hospital. Tests monitored included a complete blood cell count, urinalysis, serum electrolytes, chest roentgenography, and electrocardiography. Abnormal results and results that altered the patients' treatment were sought. Two groups of patients were evaluated. Group 1 (n = 105) had no disease except for the inguinal hernia; group 2 (n = 64) had evidence of another disease process. Preoperative evaluation of patients in group 1 was similar at the county/university hospital and at the private/community hospital except for increased electrolyte screening at the county/university hospital among patients younger than age 40 years. No differences between hospitals were present among patients in group 2. Abnormal results not predicted by medical history or physical examination were found in 1% of patients in group 1 and 1.4% of patients in group 2. Only four patients (2%) had their treatment altered by these findings. Preoperative laboratory evaluation of these patients revealed that an abnormal test result not predicted by history and physical examination is rare. Routine preoperative laboratory testing is of little value in this patient population.

Carcinoma of the thyroglossal duct.

A review of 39 instances of excision of a cyst of the thyroglossal duct performed at St. Paul Medical Center, Dallas, Texas, revealed two patients with carcinoma of the thyroglossal duct. A review of the English literature yielded 146 instances of this uncommon tumor. Eighty-four per cent were papillary adenocarcinoma of thyroid type and 5 per cent were squamous cell carcinoma. The patients were from six to 81 years old with a 2:1 female to male ratio. Metastatic disease to lymph nodes was noted in 11 per cent and invasion of overlying strap muscles was found in 4 per cent. Carcinoma of the thyroid gland occurred in 14 per cent. Preoperative diagnosis was rare. The Sistrunk procedure is recommended for initial surgical therapy with further surgical or adjuvant therapy dependent on associated clinical findings. Prognosis for carcinoma of the thyroglossal duct of thyroid type parallels that of carcinoma of the thyroid gland.

Lentigo maligna. The use of rush permanent sections in therapy.

Lentigo maligna is often treated with superficial therapies that are associated with high recurrence rates. The high recurrence rates are a result of incomplete destruction or removal of tumor from clinically inapparent but histologically positive areas. We describe the use of the Mohs technique with rush permanent sections for the complete removal of this melanocytic neoplasm.

Left ventricular excursions and velocities during coronary arterial ligation. Effects of nitroglycerin infusion in an experimental model.

To determine the effects of intravenous nitroglycerin on the velocities and excursions of the acutely ischemic myocardium, 20 open-chest dogs were studied by use of ultrasound. In 10 dogs with acute septal ischemia, the posterior wall excursion during contraction (B-C excursion), the mean systolic posterior wall velocity, and the posterior wall excursion remained unaltered. Nitroglycerin, however, increased all these parameters (P less than 0.01). In 10 dogs with acute posterior wall ischemia the B-C excursion (aneurysmal bulging) increased (P less than 0.01), but the mean systolic posterior wall velocity and posterior wall excursion decreased (P less than 0.01). Nitroglycerin increased even more the aneurysmal bulging (P less than 0.01) and the other parameters (P less than 0.01). Increased regional blood flow, reduced afterload, and mechanical pulling of the ischemic myocardium seem to be a possible mechanism. The measurements were obtained using the recently described method of the specific points.