Epithelioid smooth-muscle tumors of the uterus: a clinicopathologic study of 18 patients

Epithelioid smooth-muscle tumors of the uterus are uncommon neoplasms for which prognostic factors have not been well established. A retrospective follow-up study of 18 uterine epithelioid smooth-muscle tumors was performed. Patients ranged in age from 27 to 83 years (mean, 45 years) and were separated into three groups based on the nuclear grade of the epithelioid tumor cells. Two tumors had grade 1 nuclei; both were examples of intravenous leiomyomatosis. They had highest mitosis counts of 1 and 3 mitotic figures (MF)/10 high-power fields (HPF), no tumor cell necrosis was found, and both patients were alive with no evidence of disease at 64 and 5 months' follow-up. Ten tumors had grade 2 nuclei. All had highest mitosis counts of 0 to 3 MF/10 HPF, except one (5 MF/10 HPF). Tumor cell necrosis was absent in nine and only one had an infiltrative border. Tumor size ranged from 1.5 to 14 cm. Two tumors contained pleomorphic ("symplastic") multinucleated giant cells similar to those seen in bizarre leiomyomas. All nine patients with follow-up were alive with no evidence of disease 5 to 203 months postoperatively (median, 74 months). One patient had also received adjuvant radiation therapy. Six tumors had grade 3 nuclei. Highest mitosis counts of 4 to 9 MF/10 HPF were found in five; one had 1 MF/10 HPF. Maximum tumor size ranged from 4.5 to 13 cm. Two had tumor cell necrosis, and two had an infiltrative border. Two of these patients died of tumor 11 and 132 months postoperatively. The former had widespread metastases at initial surgery (stage IVb); the latter patient (stage I) developed the first of seven tumor recurrences 3 years postoperatively. Both patients had also received adjuvant chemotherapy. Of the remaining four patients, two were alive with no evidence of disease at 48 and 83 months, one was alive (tumor status unknown) at 28 months, and one was lost to follow-up. Based on our findings and those in the literature, we conclude that uterine smooth-muscle tumors with a predominance of epithelioid cells are extremely uncommon and metastasize infrequently. No single histologic feature is predictive of metastatic potential. Clinically malignant tumors (i.e., epithelioid leiomyosarcomas) typically have the combination of significant nuclear atypia (either grade 2 or grade 3 nuclei) and some mitotic activity (usually at least 3 to 4 MF/10 HPF); most also have tumor cell necrosis.     

Concurrent gout and Mycobacterium tuberculosis arthritis

CLOser is a new, one-step, qualitative anti-Helicobacter pylori immunoglobulin G test having the advantage of convenience and simplicity. We aimed to evaluate its diagnostic accuracy and to compare it with a quantitative enzyme-linked immunosorbent assay (ELISA) (HEL-pTEST II) in a study of 86 adult dyspeptic patients by using the results from histology and urease testing of gastric biopsies as a "gold standard." Forty-six patients were H. pylori positive. The sensitivities, specificities, and positive and negative predictive values were 95.7, 72.5, 80.0, and 93.5%, respectively, for CLOser and 93.5, 92.5, 93.5, and 92.5%, respectively, for HEL-pTEST II. The grade of the colored test bands in CLOser was correlated with antibody titers in HEL-pTEST II (r = 0.71; p < 0.001). The mean antibody titers were 13, 74, 186, and 328 U/ml for the negative, faint, thin, and thick bands, respectively, of CLOser. We concluded that the CLOser rapid serological test yielded sensitivity similar to that of the conventional ELISA. Although CLOser is not suitable for epidemiologic screening for H. pylori infection on account of lower specificity, it is particularly convenient and very easy to perform. Therefore, it may eventually become widely used in the office-based care of patients and lead to more cost-effective patient management decisions.     

Pretransplant renal dysfunction predicts poorer outcome in liver transplantation

BACKGROUND: Numerous clinicians and researchers have expressed concern about the necessity and potential adverse consequences of many cesarean births in the United States. The purpose of this study was to explore college students' attitudes and beliefs about cesarean section. METHODS: One hundred two college students (66% women) completed a 20-item questionnaire that asked if they viewed cesarean delivery as a potentially negative experience, as a normal or acceptable method of childbirth, and as medically necessary, and asked about their beliefs concerning risk and prevention of cesarean birth. RESULTS: The number of "undecided" responses in the study was striking (7.8% to 69.6% across the 20 items). In general, women and men responded similarly, although women were significantly more likely than men to say they would be profoundly disappointed if their babies had to be delivered by cesarean section. Despite expressing cynicism about the cesarean birth rate (40% agreed that many unnecessary cesarean births occurred) and not viewing the procedure as a normal way of giving birth (47%), most respondents (over 70%) disagreed that giving birth by cesarean would be a negative experience or would make a woman feel like a failure. CONCLUSION: A high level of uncertainty exists about certain aspects of cesarean birth among young women and men, highlighting the need for information for prospective parents. Most college students did not view the cesarean birth experience as either potentially negative or normal. Future research should explore coverage of cesarean birth in childbirth education classes and the roles physicians, nurses, and midwives play in preparing expectant parents for the possibility of cesarean delivery.     

Successful management of the gingival tissues for aesthetic restorative procedures

A sage advisor once said, "Why is it that we (dentists) never seem to have the time to do all steps the first time around, but then find the time when something goes amiss?" Many of us are caught up in a prison called time that directly dictates our every move. We must be released from this mindset and rediscover the importance of patience and devotion to technique. That same wise man added, "The definition of a short cut is the longest distance between two points." The moral is time spent to gain tissue health will be returned a thousand fold. Cases will be completed with greater patient comfort and doctor satisfaction.     

Maximizing drug compliance in the elderly. Tips for staying on top of your patients' medication use

The old joke goes, "I finally got it all together, but now I forget where I put it. "So it is for many older patients facing complicated disease management plans. They think they understand, but then the instructions blur or they forget if they took the medications or they become concerned that the drugs cost too much and decide to cut back. Taking care of themselves is suddenly just too complicated. Drs Ennis and Reichard look at the issues and present some strategies to improve compliance among the elderly.     

Determination of the seven apparent equilibrium constants for the binding of oxygen by hemoglobin from measured fractional saturations

Subunit dissociation has to be taken into account in the determination of the oxygen binding constants of hemoglobin, as described by Ackers and Halvorson in 1974. The seven apparent equilibrium constants for a particular set of conditions can be determined by using extrapolations to determine the fractional saturations YT of tetramer and YD of dimer from measured values of the fractional saturation Y of partially dissociated hemoglobin. Analytical methods are used to show that YT as a function of [O2] for tetramers can be calculated from Y of hemoglobin by linear extrapolation of measured Y values at high [heme] versus [heme]-1/2 to [heme]-1/2 = 0. YD for dimers can be calculated from measured Y values by linear extrapolation of Y versus [heme] to [heme] = 0 if sufficiently low [heme] can be used. These extrapolations have been tested with numerical calculations of Y for a particular hemoglobin as a function of [heme] and [O2] by using the seven apparent equilibrium constants determined by Mills, Johnson, and Ackers in 1976. The proposed procedure also yields the apparent association constant K" for 2TotD = TotT, where TotD is the sum of the dimers and TotT is the sum of the tetramers. This thermodynamic analysis of experimental data to determine the seven apparent equilibrium constants is independent of the model used to interpret the values of the thermodynamic parameters.     

Effects of changing diagnostic criteria on the risk of developing diabetes

OBJECTIVE: The American Diabetes Association (ADA) has recommended that the fasting plasma glucose (FPG) level used to diagnose diabetes be changed from 7.8 mmol/l (the level recommended by the National Diabetes Data Group [NDDG] in 1979) to 7.0 mmol/l. We examined the impact of this change on rates of progression to overt diabetes from different levels of FPG. RESEARCH DESIGN AND METHODS: Using the laboratory database of Mayo Clinic, we assembled a cohort of 8,098 nondiabetic Olmsted County residents 40 years of age or older on 1 July 1983. Subjects were followed for a median of 9 years. RESULTS: Among 7,567 individuals with follow-up FPG data, 778 (10.3%) progressed to ADA diabetes and 513 (6.8%; P < 0.0001) progressed to NDDG diabetes. The risk of developing ADA diabetes was 7, 19, and 39% for individuals with initial FPG values in the ranges of <5.6, 5.6-6.0, and 6.1-6.9 mmol/l, respectively. For progression to NDDG diabetes, the respective risks were 3, 11, and 25%. A clear gradient of risk was observed within the "normal" range of FPG (<5.6 mmol/l). Among the 793 individuals who developed ADA diabetes, 222 (29%) developed NDDG diabetes simultaneously and 291 (37%) developed NDDG diabetes later. In all FPG subgroups, progression to ADA diabetes occurred approximately 7 years sooner than progression to NDDG diabetes. CONCLUSIONS: The baseline level of FPG is a major predictor of an individual's risk of developing diabetes. The proposed change in the diagnostic criteria for diabetes will lead to earlier diagnosis among individuals who are destined to develop the disease.     

Comparison of two digital hearing aids

OBJECTIVE: The objective of this investigation was to compare real and perceived benefit for two currently marketed digital hearing aids, the Oticon DigiFocus and the Widex Senso. The hearing aids have different philosophies of design and fitting strategies; as a result, it was hypothesized that there would be performance differences. DESIGN: Twenty subjects with documented sensorineural hearing losses were fit with each of the two digital hearing aids. After 4 wk of use with each hearing aid, a battery of objective and subjective tests was completed to assess hearing aid benefit. RESULTS: No significant differences were found between the hearing aids as revealed by the objective testing of speech recognition and self-report inventories of hearing aid benefit. The DigiFocus was shown by real ear measurements to provide more high-frequency gain than the Senso. The Widex Senso was preferred by 13 of the 20 subjects (seven of 10 of the new hearing aid users). This may be explained, in part, by the increased high-frequency gain provided by the Oticon DigiFocus, which was perceived as having greater "harshness." CONCLUSIONS: Based on the results of this investigation, neither hearing aid processor was shown to be superior to the other. In addition, the least amount of objective benefit was shown in the presence of background noise.     

Normal glucose-induced suppression of glucose production but impaired stimulation of glucose disposal in type 2 diabetes: evidence for a concentration-dependent defect in uptake

The present studies were undertaken to determine whether people with type 2 diabetes are resistant to the effects of glucose as well as insulin. Diabetic and nondiabetic subjects were studied on three occasions. Hormone secretion was inhibited with somatostatin. Insulin concentrations were kept at "basal" levels (referred to as low insulin infusion) from 0 to 180 min then increased to approximately 200 pmol/l from 181 to 360 min (referred to as high insulin infusion). Glucose concentrations were clamped at either approximately 95, approximately 130, or approximately 165 mg/dl on each occasion. In the presence of basal insulin concentrations, a progressive increase in glucose from 95 to 130 to 165 mg/dl was accompanied by a comparable and progressive decrease (P = 0.001 to 0.003 by analysis of variance [ANOVA]) in endogenous glucose production (measured with [6-(3)H]glucose) and total glucose output (measured with [2-(3)H]glucose) and incorporation of 14CO2 into glucose (an index of gluconeogenesis) in both diabetic and nondiabetic subjects, indicating normal hepatic (and perhaps renal) response to glucose. In the nondiabetic subjects, an increase in glucose concentration from 95 to 130 to 165 mg/dl resulted in a progressive increase in glucose disappearance during both the low (19.9 +/- 1.8 to 23.6 +/- 1.8 to 25.4 +/- 1.6 micromol x kg(-1) x min(-1); P = 0.003 by ANOVA) and high (36.4 +/- 3.1 to 47.6 +/- 4.5 to 61.1 +/- 7.0 micromol x kg(-1) x min(-1); P = 0.001 by ANOVA) insulin infusions. In contrast, in the diabetic subjects, whereas an increase in glucose from 95 to 130 mg/dl resulted in an increase in glucose disappearance during both the low (P = 0.001) and high (P = 0.01) dose insulin infusions, a further increase in glucose concentration to 165 mg/dl had no further effect (P = 0.41 and 0.38) on disappearance at either insulin dose (low: 14.2 +/- 0.8 to 18.2 +/- 1.1 to 18.7 +/- 2.4 micromol x kg(-1) x min(-1); high: 21.0 +/- 3.2 to 33.9 +/- 6.4 to 32.5 +/- 8.0 micromol x kg(-1) x min(-1) for 95, 130, and 165 mg/dl, respectively). We conclude that whereas glucose-induced stimulation of its own uptake is abnormal in type 2 diabetes, glucose-induced suppression of endogenous glucose production and output is not. The abnormality in uptake occurs in the presence of both basal and high insulin concentrations and is evident at glucose concentrations above but not below 130 mg/dl, implying a defect in a glucose-responsive step.