Thyroid cancer in pregnant women: diagnostic and therapeutic management

There is considerable literature on the effect of pregnancy on established thyroid cancer. In contrast, there are only isolated case reports of management of thyroid cancer diagnosed de novo during pregnancy. We describe four such patients. We recommend fine-needle aspiration biopsy (FNA) of solitary thyroid nodules found early in pregnancy. When the cytopathology is diagnostic of thyroid cancer, thyroidectomy under local or general anesthesia is advised. The patient should be given levothyroxine in a dose sufficient to keep serum thyroid-stimulating hormone (TSH) low. Serum thyroglobulin is a valuable noninvasive method of evaluating completeness of this therapy. The work-up of a nodule found late in pregnancy is best deferred until after delivery.     

Laparoscopic cholecystectomy and gallbladder cancer: a diagnostic and therapeutic dilemma

The correct treatment strategy of patients with unsuspected gallbladder cancer undergoing laparoscopy, and the prevention of delayed diagnosis are current issues. We report a case of late diagnosis with umbilical metastasis and poor survival. A policy of careful inspection of the gallbladder and a cautious strategy in the case of gross alteration of its external morphology seems advisable during laparoscopic cholecystectomy. Although no agreement exists concerning the best treatment in the event of delayed diagnosis, the adopted strategy is contingent on patient status, disease stage and the possibility of performing appropriate follow-up.     

Thyroid cancer. Epidemiological, diagnostic and therapeutic features

This study presents a survey on the demand for out-patient neurological-neuropsychological rehabilitation. Neurologists working in acute care and in in-patient rehabilitation settings as well as neurologists and neuropsychologists with out-patient practice were asked to rate the demand for and the present means to realize out-patient neuropsychological rehabilitation. The results show a great demand for out-patient rehabilitation. The preferred concept and model of out-patient rehabilitation depends on the setting where the participants of the study work with a tendency to favour flexible programs close to patients' habitation.     

Cystic tumours of the pancreas: a diagnostic dilemma

Pulsatile lavage is an effective means of irrigation for grossly contaminated wounds. Pulse lavage was first used by oral surgeons in the U.S. Army during the war in Vietnam, and U.S. military investigators pioneered its early development and scientifically validated its efficacy. Modern pulse lavage units are ideally suited for military use because they enable first- and second-echelon medical personnel (including nonphysicians) to rapidly and effectively decontaminate combat wounds with minimal logistic burden. Pulse lavage units should become standard issue in all combat medical supply canisters or Authorized Medical Allowance blocks, and medical personnel should be trained in their use.     

Brain abscess: diagnostic and therapeutic problems

The uropygial gland of the white stork secrets mono- and diester waxes as well as triglycerides, all of which contain unbranched medium chain fatty acids. n-Decanol and n-dodecanol have been the only alcohols detected in both types of waxes. The diester waxes contain 2-hydroxy fatty acids.     

Tumor-reactive immunoglobulins in ovarian cancer: diagnostic and therapeutic significance? (review)

Inhibition of the immune system has been observed in association with most stages of ovarian cancer; however, the mechanisms involved in the induction and maintenance of this chronic immune unresponsiveness associated with cancer progression are poorly understood. This immunosuppressed state is primarily defined as the failure to eradicate the tumor. This immunosuppressed state is generally associated with decreased numbers and reactivity of lymphoid cells in women with ovarian cancer. The degree of immune dysfunction in ovarian cancer patients has been demonstrated to correlate with patient survival. While ovarian cancer patients generally fail to exhibit effective immunosurveillance, as manifested by continued tumor growth and progression, the presence of tumor-reactive immunoglobulins can be demonstrated in these women, indicating the continued presence of immune recognition. We have not only demonstrated the presence of tumor-reactive antibodies in ovarian cancer patients, but have also shown that the levels of these antibodies increase as the disease progresses. The antigens recognized by the patients' humoral response have been identified as either membrane-associated or intra-cellular. In general, the localization of these antigens tend to be linked to the patient's prognosis. The presence of a humoral response against intracellular proteins are correlated with poor prognosis, while autoantibodies reactive with surface components appear to have a better prognosis. In addition to general antigen recognition, these reactive antibodies have been utilized to define specific epitopes on tumor-associated proteins. Certain specific antigenic epitopes exhibit common recognition among patients with the same tumor type. The specific recognition of certain epitopes can provide early evidence of aberrant protein expression and this aberrant expression of certain proteins, such as procathepsin D, appear to be linked to the tumor's acquisition of specific malignant characteristics, including metastasis formation and chemoresistance. Despite the existence of circulating tumor-reactive immunoglobulins, their presence correlates, in general, with poor prognosis and poor host survival. Since tumor-reactive immunoglobulins are elicited and can be detected early in the development of tumors and their enhanced synthesis is induced prior to the clinical manifestation of recurrence, the assessment of the tumor-reactive immune response against specific antigenic epitopes should represent an early significant diagnostic and prognostic marker in ovarian cancer.     

Locally advanced adenocarcinoma of the pancreas: current therapeutic modalities

Pancreatic cancer still have bad prognosis. At the time of diagnosis, less than 10% of patients can undergo surgery with an overall 5-year survival rate of less than 2%. For patients with localized pancreatic adenocarcinoma, the combination of radiation therapy and chemotherapy has been shown to control symptoms and to enhance patient survival. This treatment should be proposed to all the patients with good performance status and without icterus. Pain management should be optimized and often need morphinic and co-antalgic (anticonvulsivants, steroids) consumption. The celiac plexus block with alcohol gives an excellent pain relief and should be more frequently used.     

Psychophysiology of pain: diagnostic and therapeutic implications

Pain problems occupy muct of the time and therapeutic efforts of physicians. Nonmedical practitioners and cultists have likewise attracted many people seeking pain relief. In many cases the cultists seem to do as well as the ethical practitioner. A realistic view of pain takes into account the significance of the pain to the individual, the degree of anxiety and/or depression that contributes to the aggravation and prepetuation of the pain, and finally the manipulative and defensive value that the pain may have to the individual. A purely mechanistic approach which would attempt to distinguish "real pain", ie, pain associated with a demonstrable lesion, and "imagined pain" will prove counterproductive. Likewise accusations of consciously pretended pain or malingering tend to be nontherapeutic. A sound therapeutic approach is to regard all pain as real, realizing that the pain of depression may be the most unendurable type of pain. Major psychotropic drugs for relief of anxiety and for treatment of depression have appplication in the management of selected pain problems.     

Closed abdominal trauma: diagnostic and therapeutic orientations

In France, traumas are the third leading cause of mortality. There are no clear statistics concerning abdominal injuries among all traumas. Nevertheless abdominal traumas are directly responsible for 10 to 30% of traumatic death. Over the past few years, improvement in imaging technics has allowed to establish very precise damage toll and to consider new therapy approaches. The development of conservative treatments has led to a reduction in the number of unnecessary coeliotomy. The treatment of such pathologies requires a multidisciplinary, effective and constantly available staff.     

Right-sided diverticulitis: new diagnostic and therapeutic aspects

Because of its rarity in the Western World, diverticulitis of the ascending colon is often not taken into account in the differential diagnosis of abdominal pain in the right lower quadrant or is misdiagnosed as appendicitis. Of five patients who were treated for right-side diverticulitis in our hospital between April 1995 and April 1996, one underwent right hemicolectomy and one laparoscopic diverticulectomy. In three cases we succeeded with antibiotics alone. In three cases the diagnosis was made on the basis of CT-scan, prompted by peridiverticular changes. In one case the diagnosis was made at laparoscopy and confirmed by CT. In one case diagnosis and therapy were carried out only by laparoscopy. From the moment of diagnosis the average stay in hospital was twelve days and no complications occurred. During an average follow-up time of twelve months, all patients remained free of pain. On the basis of the case reports and a literature review we discuss the diagnostic value of CT and laparoscopy as well as the benefit of conservative therapy, which to us--in contrast to other authors--seems appropriate at least for the first bout of uncomplicated diverticulitis.     

Duodenal Crohn''s disease: diagnostic and therapeutic complexity

In this paper the authors present the antimicrobial and antifungical tests of some new 3-methylpyrimidine compounds. The test was performed using the diffusimetric method with rustlessteel cylinders based on the diffusion of the tested substances on the gelose surface. The comparative analysis of the obtained data leads to the following conclusions concerning the relation between structure and biological activity in the pyrimidine series: 1. The pyrimidinium ylides are less active comparatively with the corresponding salts. That means that the zwitter ionic structure did not favour the activity. 2. Comparative with the corresponding pyridazine(1,2-diazine) derivatives, the pyrimidine(1,3-diazine) compounds are more active. The increase of activity of the pyrimidine compounds could be attributed of the influence of the pyrimidine ring. 3. The most active pyrimidine compound which is tested is that one in which radical R is an amide group. 4. In the case when the radical R is a phenyl ring, the substitute from para position of benzoylic radical does not appear decisive towards activity, these affecting especially the selectivity.     

Evidence of new diagnostic and prognostic human astrocytoma tumor markers. Potential therapeutic applications. II

Human astrocytic tumors grow into the normal brain parenchyma either as localized tumors, or as highly diffuse neoplasms. The diffuse phenotype relates to a specific sub-type of neoplastic astrocytes with a high motility and invasion capacity. Motility features refer to locomotion while invasion features refer to protease secretion. Our data reveal that several peptides belonging to the gastrin/cholecystokinin peptide class are able to significantly (and in certain cases very significantly) modify the level of tumor growth (at the level of cell proliferation and/or cell death), of motility and of invasion in various experimental models of human astrocytic tumors. We are synthesizing various gastrin/cholecystokinin-related peptides in order to develop clinical applications with which we want to inhibit astrocytic tumor growth, individual neoplastic astrocytic motility and the invasion of the normal brain parenchyma.     

Vitamin D-retinoid association: molecular basis and clinical applications

BACKGROUND AND PURPOSE: The role of single-photon emission CT (SPECT) in the prognosis of cerebral infarction is controversial, but most studies report that SPECT using a variety of radiopharmaceutical agents gives useful prognostic information. Only one study has questioned whether acute perfusion deficits independently add to a valid clinical prognostic score. This study was limited to middle cerebral artery territory infarcts and was negative. We present data on the prognostic utility of SPECT using 99mTc-hexamethylpropyleneamine oxime (HMPAO) in cerebral infarction, unselected by site. METHODS: Fifty consecutive unselected patients admitted to the hospital with acute cerebral infarction, of whom 10 died and 7 withdrew, had SPECT performed serially at onset and at 1 week and 3 months after stroke onset using 99mTc-HMPAO and the NOVO 810 dedicated high-resolution head tomograph. Clinical severity at presentation and outcome was measured with the Canadian Neurological Scale and the Barthel Index. Infarct volumes were measured from both the SPECT and CT scans. The data for the 43 subjects who completed the study or died were evaluated to determine the most powerful prognostic measures. Predictors were the Canadian Neurological Scale score at onset and 1 week, the Barthel Index at 1 week, the CT infarct volume typically done between 3 and 7 days after stroke onset, and the infarct volumes at the first and second SPECT. Outcome measures were the Canadian Neurological Scale score and Barthel Index score at 3 months, scored as zero for those patients who died. RESULTS: The clinical prognostic indicators correlated with the outcome measures, with coefficients between .617 and .821 (P < .0006 in all cases). The Canadian Neurological Scale score measured at 1 week was the best of these. Infarct volumes measured from SPECT correlated less well (coefficients between -.518 and -.683, P < .0019 in all cases). CT infarct volume was the poorest predictor. Although SPECT infarct volumes predicted outcome, they did so less well than clinical examination. Spontaneous infarct reperfusion did not affect outcome. CONCLUSIONS: Although the measurement of infarct volume on SPECT using 99mTc-HMPAO provides a predictor of stroke outcome, it is not a better predictor than the Canadian Neurological Scale score.     

Somatostatin receptors in meningioma: diagnostic and therapeutic value

OBJECTIVE: We discuss the diagnostic and therapeutic usefulness of the presence of somatostatin receptors (SR) in meningiomas. DEVELOPMENT: The SR are membrane receptors, may be saturated, have great affinity and pharmacological specificity for somatostatin (SS) and its analogues. SR have been found in 100% of the meningiomas studied. The presence of a large number of SR in different tumours permits gammagraphic detection in vivo by marking SS analogues with 1-231-DTPA and subsequent visualization using a gamma camera. This study may help to differentiate between meningiomias and other tumour lines. Experiments using different SS analogues have shown different degrees of affinity of these SS analogues for the different receptors. In various animal models a potent inhibitor effect on tumour growth has been seen following SS and its analogues. Unlike in hypophyseal adenomas and endocrine gastro-entero-pancreatic tumours, neither SS nor its analogues have shown any direct inhibitory action on the growth of meningioma cell cultures. Quite the opposite occurs. A small but significant stimulation of growth was seen in the presence of SS. CONCLUSIONS: We consider the detection of SR by isotopic marking of SS analogues is useful in the differential diagnosis of meningiomas. The therapeutic usefulness of the analogues of SS for treatment of meningiomas remains controversial. Further study of the different types of receptors and analogues is necessary.     

Verrucous squamous cell carcinoma of the larynx: diagnostic and therapeutic considerations

Certain prostaglandins acting as inflammatory mediators have been implicated in the aetiology of perennial allergic rhinitis (PAR). Inhibition of prostaglandin synthesis in the nasal mucosa might therefore influence the symptoms associated with PAR. A randomised, doubleblind, placebo-controlled cross-over trial using 0.1% Diclofenac eye-drops has been conducted to investigate this hypothesis. Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), reduces prostaglandin synthesis through the inhibition of the cyclo-oxygenase pathway. Twenty-five patients with significant PAR and positive skin tests to relevant perennial allergens were recruited and two drops of the given preparation were administered bilaterally q.d.s.. Thirteen patients completed the study. Nasal symptom score (itch, rhinorrhoea, sneezing, and blockage), smell test score, saccharin transit time, total nasal airflow resistance, and nasal inspiratory peak flow measurements were obtained at each of three study visits. No significant treatment effects were found. The daily nasal symptom score over the entire study period showed no significant variation. Adverse effects such as local invitation, dry nose or throat were rare. No untoward changes in haematological, biochemical profiles and urinalysis occurred. In conclusion, topical 0.1% Diclofenac eye-drops applied nasally have no significant effect on PAR. Prostaglandins alone may not play a major role in mediation of symptoms in this condition.     

Amyloidosis: a review of recent diagnostic and therapeutic developments

Amyloid deposition is associated with a diverse range of disorders that includes Alzheimer's disease, type II diabetes mellitus and dialysis arthropathy. Although less common, systemic AA and AL amyloidosis remain important because effective treatments have increasingly become available. The pathology in all forms of amyloidosis involves the extracellular deposition of protein as characteristic fibrillar aggregates which interfere with tissue structure and function. Amyloid fibrils are derived from different unrelated proteins in the different forms of the disease but share many common properties, including the capacity to bind the normal plasma protein serum amyloid P component (SAP). This is the basis for our development of radiolabelled SAP as a nuclear medicine tracer for the diagnosis and quantitative monitoring of amyloid. Serial studies have shown that the deposits are far from inert but are actually turned over quite rapidly in many patients. The treatment of amyloidosis involves supportive measures whilst every effort is made to reduce the supply of the respective fibril precursor protein. Under favourable circumstances further amyloid deposition will be prevented. existing deposits will regress and improvement of organ function will occur. Since this strategy is not always possible or may fail, new approaches to inhibit fibril formation and promote regression of amyloid are being pursued.