Training for Iowa physicians

"Autonomous" thyroid nodule is a localized nodular lesion of the thyroid gland characterized by growth, iodine uptake and function, all independent from TSH control. These nodules represent a heterogeneous anatomic and clinical entity. The clinical diagnosis is based upon a negative suppression of nodule iodine uptake and scan imaging by T3 administration. The nodule function is determined by high serum thyroid hormone levels and/or low TSH (measured by ultrasensitive assay). Etiology and pathogenesis of these nodules is not yet completely clarified. Both genetic and environmental factors determine nodule growth and function: thyroid cells, in fact, are genetically heterogeneous and may have intrinsic (congenital) characteristics that may promote the growth of cellular clones having mitotic and functional activity that is partially independent of TSH. In these particular cell clones, environmental factors like iodine deficiency or other goitrogens may favour the growth of autonomous nodules and also, by activating their function, may induce toxicity. The autonomous thyroid nodules need to be treated only when they become toxic: in this case both surgical excision or radioiodine may be used.     

"En-bloc" vertebrectomy in the mobile lumbar spine

BACKGROUND: Primary tumors of the vertebral bodies have previously been treated with total or subtotal excision in a piecemeal fashion (intralesional excision). Radiation therapy has been used to help control tumor growth. Recurrence rates with an intralesional, piecemeal removal of vertebral tumors have been unacceptably high. This study describes a method to excise a lumbar vertebra "en-bloc," and in the process, to perform a marginal (extralesional) resection of a primary tumor of the mobile lumbar spine that allows for a potential surgical cure. METHODS: A combined posterior-anterior procedure allows for an extralesional, marginal resection of the tumor and the involved vertebra. All posterior bony elements, including the pedicles and the adjacent intervertebral discs, are removed via a posterior approach. An anterior, retroperitoneal approach is then used to remove the vertebral body/tumor as a single specimen. The nerve roots at the involved levels are spared and the spine is instrumented and fused both posteriorly and anteriorly. RESULTS: Three patients successfully had combined posterior-anterior resections of lumbar vertebral chordomas. No permanent neurological complications occurred. Overall morbidity of the procedure was acceptable. At 31-month follow-up, no tumor recurrence has been detected. CONCLUSIONS: "En-bloc" resection of a primary vertebral tumor of the lumbar spine is technically demanding, but potentially curative. The alternative approaches-intralesional excision, radiation therapy, or a combination-are unable to cure these tumors. Long-term, 10-year follow-up will be necessary to confirm whether this en-bloc approach provides a surgical cure.     

Conservative management of follicular non-Hodgkin's lymphoma in childhood

Among 447 children with non-Hodgkin's lymphoma (NHL) on the childhood U.K. registry, seven children with follicular (NHL) were identified. Four were male and their age ranged from 4.25 to 13.5 years (median 7.5); all had localized disease, Murphy's stage I (n = 4) and II (n = 3). Sites involved at presentation were cervical lymph nodes and tonsils (n = 5), ileum (n = 1) and parotid gland (n = 1). Three had complete surgical excision only and four had complete (n = 1) or incomplete excision (n= 3) followed by a short multi-agent chemotherapy regimen (UKCCSG 9001 protocol). With a median follow-up of 1.5 years (range 0.25-5 years) from diagnosis, six are alive in complete remission (CR) including three who had no chemotherapy. These results confirm previous reports that follicular lymphomas in children are rare (1.5%) and tend to be localized at presentation. Their rarity makes it difficult to produce guidelines about treatment, but in localized cases a period of non-intervention may be justified.     

Panoramic radiography using an intraoral tube. Method, anatomy, radiography and dosimetry

BACKGROUND: There are two techniques giving a panoramic view of the dental arch: orthopantomography and intraoral tube panoramic radiography. The last one is not very well known because images, with a characteristic and variable deformity if compared with orthopantomography are not useful for routinary use in dentistry. The poor radiographic and pathologic anatomy knowledge of intraoral tube panoramic radiography, and the slight improvements brought to the method particularly in order to reduce the dose, partly depend on the scant attention given to the method by investigators, and partly on the dyshomogeneous anatomic sites enlargement and overlapping with consequent deformity of all of them. With intraoral tube panoramic radiography, X-ray exposition is emitted using a miniaturized cylindrical source placed inside the oral cavity and the radiographic film is in contact with the skin of the face. Based on the orientation of the collimator and the inclination of the tube major axis in the oral cavity, a central technique (exposition of either superior or inferior dental arch) and a lateral technique (simultaneous exposition of the two hemiarches of the same side) are recognized. The aim of this study is to give a significative contribution to maxillo-facial characteristic appearance and dosimetry knowledge in intraoral tube panoramic radiography. METHODS: It consists of: a) a "laboratory" part concerning the evaluation of the enlargement, deformation and visibility of different structures, obtained by positioning about fifty different markers in different maxillary and mandibular anatomic sites, and b) an in vivo dosimetry part obtained with intraoral and extraoral termoluminiscent dosimeters. An original dispositive allowed the right positioning of the film and its adherence to the screen. Deformity characteristics are analitically described and discussed in relation with the different sites. RESULTS AND CONCLUSIONS: The use of intensifying screens allowed a good reduction of dose, (mean absorbed doses ranging from 25 microGy in the intraoral sites to 1936 microGy in the extraoral sites) without reducing the image quality thanks to the device performed "ad hoc".     

Reconstruction of intraoral defects using facial artery musculomucosal flap

The facial artery musculomucosal flap, technically a combination of the nasolabial flap and the buccal mucosal flap, has been a reliable, versatile flap, either superiorly or inferiorly based for reconstruction of a wide variety of postcancer excision intraoral mucosal defects including defects of the palate, alveolus, lips and floor of mouth. We have used it 17 times in 16 patients with no failures and one flap with terminal necrosis. Almost all flaps developed venous congestion which settled on its own by conservative management.     

Early excision and grafting versus conservative management of burns in the elderly

Elderly burn patients have significantly higher mortality rates than younger patients with similar burns over the total body surface area. Two theories exist regarding treatment of burns in the elderly: a traditional approach to limit physiologic stress by avoidance of operative intervention in the early post-burn stage and eschar excision and wound closure within the first week of hospitalization. We examined retrospectively the outcome in patients 70 years or older, hospitalized in the University of Kentucky Burn Unit between 1975 and 1995. In the first decade (1975 to 1983), patients were managed conservatively, namely, with spontaneous eschar separation and late skin grafting. In the second half of the study period (1984 to 1994), elderly patients were managed by early operative excision (<7 days) and grafting. A total of 73 elderly patients were admitted to the unit, 6 of whom were not resuscitated and died shortly (<96 hours) after admission. Twenty-eight patients had early excision and grafting (average age 78.1 years, total body surface area 23.6 percent), and 39 were managed conservatively (average age 79.3 years, total body surface area 20.9 percent). The mortality rate was 57 percent in the first group and 41 percent in the second group (p = 0.22). In an effort to further define the two groups, the other patient variable that contributes to burn mortality besides age and total body surface area, inhalation injury, was subtracted and the mortality rates were recalculated. Excluding patients with inhalation injury, the mortality rate was 48 percent in the first group and 27 percent in the second group (p = 0.15). We conclude that, in our unit, the management of elderly patients by early excision and grafting was of no benefit and may have resulted in a higher mortality rate.     

Gastric inflammatory myofibroblastic proliferation in children

Gastric inflammatory myofibroblastic proliferation (IMP) is an extremely rare entity in children, which to our knowledge has only been mentioned in case reports. We describe the ninth pediatric case and review the literature concerning the etiology, clinical and laboratory features, pathology, treatment, and outcome. There has been a predominance in preschool females. Abdominal pain, upper gastrointestinal hemorrhage, and an abdominal mass, either isolated or associated, have been the main clinical features. Iron-deficiency anemia has been a constant finding. Lesions are elevated and involve the full thickness of the gastric wall, usually with ulceration of the luminal surface; extragastric extension suggesting malignancy is frequent. Diagnosis is made by histology after surgical excision. There was no mortality directly related to gastric IMP, and only one case recurred after surgical excision. The pathogenesis is controversial, but the finding of Helicobacter pylori in our case may indicate an inflammatory origin. Awareness of this benign lesion and its mimicry of malignancy is important so that inappropriately aggressive therapy can be avoided.     

Being "Clinical"--Positively.

This column provides comments on David Lynn's letter in the May "American Psychologist" (1956). Most clinicians will agree heartily with Lynn's opinion that caution should be exercised in communicating "clinical" impressions to others. Irresponsible or "wild" interpretation is usually harmful and rarely harmless, in any setting. One gets the impression that Lynn feels that being "clinical" usually involves communication of one's inferences to others and that such inferences are predominantly negative and destructive. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Avoidant coping as predictor of mortality in veterans with end-stage renal disease": Response to Jewett, Newton, Smith, & Thombs (2010).

Responds to the comments by L. R. Jewett, E. G. Newton, S. Smith, and B. D. Thombs (see record 2010-14873-001) on the current authors' original article, "Avoidant coping as predictor of mortality in veterans with end-stage renal disease" (see record 2009-06704-009). In their commentary, Jewett et al note that oddities often encountered in very small datasets—such as the one used by Wolf and Mori—and, as a result, stronger evidence must be accrued from larger, more robust samples. In this response, Jewett et al acknowledge that theirs is a preliminary study of a small and highly select sample and recognize the limited generalizability of our results. Jewett et al maintain that they do not assert that there should be radical changes in clinical or research programs based on their study results, but instead, suggest that further follow-up would be valuable and that readily available and commonly used assessment and intervention procedures may be appropriate in ameliorating avoidant coping in the endstage renal disease (ESRD) population. At the same time, given the focus on mortality, the risk of doing nothing because the evidence is preliminary far outweighs the minimal costs associated with assessing and addressing avoidant coping, particularly since psychological assessment, including of coping behavior, is part of the standard of practice in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Windmill-plasty" for coverage of large defects of the scalp

The closure of large circular defects on the scalp is technically difficult and cosmetically often not satisfying, if a free transplant is necessary. Following the technique of Tillmann described first in 1908, several flaps shaped like a windmill can be combined. We report on 14 patients (ages 41-88 years) where large defects resulting from the excision of various tumors (5 melanomas, 5 basal cell carcinomas, 1 keratoacanthoma, 1 trichilemmal cyst, 1 squamous cell carcinoma, 1 skin metastasis) were successfully closed by this method. The diameter of the defect ranged between 4 and 8 cm (mean 5.7 cm). Size and number of the rotating flaps (3 or 4) was varied according to the size of the defect and the mobility of the surrounding tissue. The procedure was performed with local anesthesia in all cases. Wound healing occurred without complications except in 3 cases. 2 patients (63 years, 70 years) developed small necrotic areas on the tips of the flaps. In a 74 year old man with a very large defect of 8 cm diameter, one flap of four underwent total necrosis. The cosmetic result was rated "very good" in 71.4% and "good" in 14.3%. The preservation of the terminal hair turned out to be of special advantage. The "windmill procedure" is an important addition to the surgical approaches for closure of large defects on the scalp, particularly in young patients.     

Methotrexate disposition following concomitant administration of ketoprofen, piroxicam and flurbiprofen in patients with rheumatoid arthritis

We report an unusual case of vulvar acantholytic dermatosis with features of pemphigus vegetans in a 22-year-old Indian girl who presented with a "warty" lesion in her left labium majus. Following excision of this lesion, she presented with 2 localized recurrent lesions on the left and right labia majora about 2 1/2 years later which were also excised. All 3 biopsies showed histological features typical of pemphigus which included extensive suprabasal acantholysis with bullae formation, prominent villus-like processes at the base of the bullae, focal hyperkeratosis and papillomatosis, and the occasional mixed neutrophil and eosinophilic intraepidermal abscess. IgG and C3 immunofluorescence was positive in the intercellular spaces of the epidermis. These lesions, which probably represent a form of pemphigus vegetans, have not been previously reported as a cause of localized vulvar acantholytic dermatosis.     

On the "folkloric" psychotherapy to schizophrenic patients--based on phenomenological study

Psychotherapeutic treatment of schizophrenia is generally considered difficult. One reason for this is that the doctor and patient can easily fall into a relationship of conflict with each other concerning the propriety of "judgments which are morbidly and mistakenly made (K. Jaspers)", referred to as delusions. We carried out close phenomenological structure-analyses of the delusions and of patients' fundamental experiences, based on the premise that a patient with delusions probably has some actual grounding for these in the patient's own concepts, considering the fact that the patient firmly believes these delusions. As a result, we have clarified the following matters from the primary experience of delusions. 1) We found that patients are in a conflicted mental condition which can be considered a collapse of adaptability to "Seken". 2) In this condition of conflict, patients feel guilt relative to "Seken" or feel that they are indebted and should be punished. When patients complained of their primary experience, we were able to persuade them to reserve their judgment of their primary experience, by 3) having each patient listen to the folktale "Torikuyou" in which the "logic of stealing" and the "logic of being stolen", appear in a reciprocal relationship relative to the constitution of crime and punishment, by 4) explaining to each patient about the ambiguity and reciprocity of reality experienced, 5) instead of disputing the propriety of patient's judgment about primary experience, doctor and patient worked together to enable the patient to form a positive understanding of the primary experience. 6) We reduced the patient's psychological conflict relative to primary experience, and were able to defuse and distance the patient's delusions caused by erroneous judgment of primary experience. 7) Regarding the area in which this type of psychotherapeutic approach shows efficacy, we analyzed the concept of "Seken" as a world which can cause conflicts relative to primary experiences. 8) We also analyzed "Giri" as a norm of "Seken" from which patients misconceive that they have deviated, in addition, 9) from the viewpoints of anthropology and cultural anthropology, we analyzed the bases for "Kotowaza (proverbs)" and "Monogatari (folktale)" such as "Torikuyou", which themselves can show psychotherapeutic efficacy. We consider that the psychotherapeutic approach has previously been developed around the concepts of the "individual" and "society", but we made our psychotherapeutic approach from the concept of "Seken" (yononaka = hito: person) that is a structure with deep strata of tradition and culture in Japan, and have reported its concrete development through the presentation of 3 typical cases of schizophrenia with difficulty in adapting to society due to showing the delusion of persecution in their foreground.     

Workshop "Radio-oncology and the Law"

From 25 to 27 Sept 1997, a workshop was organized at the Essen Medical School (Universit?tsklinikum Essen), at which radiooncologists and jurists from universities and courts as well as lawyers contributed their views on mutual problems. The following topics were discussed by papers and in round table meetings: "Requirements on the patient's information", "definition of therapeutic guidelines-limits of clinical research and standard treatments", "treatment documentation", "liability of the physician for treatment faults" and "technical standard and preserve of quality". The consensual guidelines to the topics "patient's information", "therapeutic guidelines" and "liability" are presented here.     

Estimated numbers of deaths from coronary heart disease "caused" and "prevented" by alcohol: an example from Finland

OBJECTIVE: Epidemiological studies show that moderate alcohol consumption rather than abstention is associated with a lower risk of coronary heart disease (CHD) mortality. Our objective was to adjust established methods for calculating attributable fractions to a situation where the risk function is J-shaped and to estimate the number of CHD deaths "caused" and "prevented" by alcohol in Finland. METHOD: Point estimates of relative risk were obtained by a meta-analysis. They were pooled by fitting a nonparametric cubic smoothing spline to the data. Alcohol consumption distribution was estimated from survey data (N = 4,818; 2,488 women). The consequences of various assumptions about changes in alcohol consumption distribution on CHD mortality were estimated. The most detailed analyses are presented for men aged 30-69. The results for the men and women aged 30-79 are summarized. RESULTS: Among men aged 30-69, the beneficial effects of light to moderate alcohol consumption "prevent" some 400 CHD deaths each year which corresponds to 12-14% of the observed CHD deaths. Around 20 CHD deaths are "caused" by alcohol consumption exceeding the estimated optimum level. Among men aged 70-79 and women aged 30-79, the numbers of CHD deaths "prevented" by alcohol consumption were approximately 200 and 100, respectively, whereas there were only a few CHD deaths "caused" by alcohol. CONCLUSIONS: Our best estimates suggest that approximately one-tenth of the observed number of CHD deaths among middle-aged men in Finland is "prevented" by alcohol, while the relative effect is considerably smaller among older men and all women.     

Cutaneous findings associated with cardiac myxomas

The clinical diagnosis of cardiac myxomas remains a challenge despite the advent of echocardiographic technology. These tumors may produce a variety of clinical and laboratory findings that can mimic systemic disease and obscure the proper diagnosis. Although histologically benign, cardiac myxomas may cause significant morbidity and mortality via intracardiac obstruction and arterial embolism. Possible long-term sequelae may be avoided by early recognition and prompt surgical excision. We briefly review the various findings associated with cardiac myxomas (nonfamilial and familial) with emphasis on cutaneous presentations. An illustrative case of left atrial myxoma with cutaneous findings contributing to the diagnosis is discussed. Certain skin lesions and multifocal clinical findings should alert the clinician to consider cardiac myxoma in the differential diagnosis.     

Intravertebral spinal neurenteric cysts: a unique radiographic sign--"the hole-in-one vertebra"

A well-defined circular defect in the midst of a complex vertebral anomaly, visible on a plain radiograph, is diagnostic of an intravertebral extension of a neurenteric cyst. It may represent a connecting stalk between a mediastinal cyst and an intraspinal lesion. The "hole-in-one" vertebra is an indication for a magnetic resonance imaging (MRI) scan. When surgical excision of a mediastinal cyst is undertaken, the intravertebral tract should be curetted to avoid recurrence.     

Chronic graft-versus-host disease treated with UVB phototherapy

Chronic graft-versus-host disease (cGVHD) is a major complication of allogeneic bone marrow transplantation. Immunosuppressive treatment regimens carry the potential of causing severe morbidity and mortality, so that additional modes of therapy with fewer side-effects are clearly needed. Five cGVHD patients (sclerodermoid cGVHD in two patients, lichenoid cGVHD in one patient and intraoral cGVHD in two patients), who had not responded to standard immunosuppressive drugs, were treated with adjuvant UVB phototherapy. The patient with lichenoid cGVHD experienced complete clearing of cutaneous lesions, whereas both patients with sclerodermoid cGVHD experienced significant relief of pruritus, but showed no change of the sclerodermoid skin lesions. Intraoral lesions cleared in one patient. The effects of UVB phototherapy were furthermore documented by measurement of skin viscoelasticity and mouth opening. No side-effects were encountered. This preliminary study suggests that UVB phototherapy is useful as an adjuvant therapeutic modality in intraoral and cutaneous lichenoid cGVHD.     

Electroclinical manifestations elicited by intracerebral electric stimulation "shocks" in temporal lobe epilepsy

In patients with severe drug-resistant partial epilepsy, undergoing Stereo-EEG investigations, spatial definition of the "epileptogenic area" is mainly based on spontaneous seizures recordings, but also on seizures induced by intracerebral electrical stimulation (ES). Only "trains" ES (TES, 50 pps) are currently used with this aim; "shocks" ES (SES, 1 pps) are principally applied to localize motor pathways. We have shown, during a prospective study concerning 10 temporal lobe epileptic patients, that SES could frequently induce seizures, especially when stimulation is applied in the anterior part of the Ammon's horn. Even if its efficacy seems lower than by TES, this kind of stimulation, in the majority of the cases, does reproduce isolated ictal subjective symptomatology, allowing the visualization of the progressive organisation of ictal electrical discharges, and avoids "unexpected" ("false positive"?) clinical responses.     

Arterial anatomy of the oral cavity: an analysis of vascular territories

Knowledge of the specific cutaneous or surface regions supplied by constant named arterial sources has allowed for increasing clinical application of flap transfers of tissue. Despite the routine use of intraoral flaps for reconstruction of congenital or acquired defects of the oral cavity and pharynx, no previous investigation has centered on understanding the surface or mucosal arterial territories of the oral cavity. In a cadaver study, six mucosal territories of the intraoral cavity were defined using selective ink and lead oxide injections through named arteries. The anatomical boundaries of these territories are predictable and constant in location for different cadavers. The six contiguous territories are based on the buccal, labial, inferior alveolar, ascending palatine, ascending pharyngeal, and lingual arteries. This study supports the safe vascular basis of existing clinical procedures of the intraoral cavity and may have implications for the design of new intraoral reconstructive procedures.     

Spinal intradural cerebellar ectopia

We present a case of multilocular cystic nephroma with an unusual localization treated by a nephron-sparing procedure. A 21-year-old white woman presented with a history of hematuria and right lumbar pain. Imaging techniques revealed a multilocular cystic mass originating from the renal parenchyma but mainly involving the renal pelvis. The lesion was localized almost entirely within the renal pelvis at surgery and was treated by excision. Pathologic analysis was consistent with multilocular cystic nephroma. The patient remains free of recurrence with 10 years of follow-up. We conclude that multilocular cystic nephroma may present as a cystic lesion localized within the renal pelvis, and we advocate simple excision of these lesions.