A mortality study of workers at seven beryllium processing plants. The International Agency for Research on Cancer (IARC) has found that the evidence for the carcinogenicity of beryllium is sufficient based on animal data but "limited" based on human data. This analysis reports on a retrospective cohort mortality study among 9,225 male workers employed at seven beryllium processing facilities for at least 2 days between January 1, 1940, and December 31, 1969. Vital status was ascertained through December 31, 1988. The standardized mortality ratio (SMR) for lung cancer in the total cohort was 1.26 (95% confidence interval [CI] = 1.12-1.42); significant SMRs for lung cancer were observed for two of the oldest plants located in Lorain, Ohio (SMR = 1.69; 95% CI = 1.28-2.19) and Reading, Pennsylvania (SMR = 1.24; 95% CI = 1.03-1.48). For the overall cohort, significantly elevated SMRs were found for "all deaths" (SMR = 1.05; 95% CI = 1.01-1.08), "ischemic heart disease" (SMR = 1.08; 95% CI = 1.01-1.14), "pneumoconiosis and other respiratory diseases" (SMR = 1.48; 95% CI = 1.21-1.80), and "chronic and unspecified nephritis, renal failure, and other renal sclerosis" (SMR = 1.49; 95% CI = 1.00-2.12). Lung cancer SMRs did not increase with longer duration of employment, but did increase with longer latency (time since first exposure). Lung cancer was particularly elevated (SMR = 3.33; 95% CI = 1.66-5.95) among workers at the Lorain plant with a history of (primarily) acute beryllium disease, which is associated with very high beryllium exposure. The lung cancer excess was not restricted to plants operating in the 1940s, when beryllium exposures were known to be extraordinarily high. Elevated lung cancer SMRs were also observed for four of the five plants operating in the 1950s for workers hired during that decade. Neither smoking nor geographic location fully explains the increased lung cancer risk. Occupational exposure to beryllium compounds is the most plausible explanation for the increased risk of lung cancer observed in this study. Continued mortality follow-up of this cohort will provide a more definitive assessment of lung cancer risk at the newer plants and among cohort members hired in the 1950s or later at the older plants. Further clarification of the potential for specific beryllium compounds to induce lung cancer in humans, and the possible contribution of other exposures in specific processes at these plants, would require a nested case-control study. We are currently assessing whether available industrial hygiene data would support such an analysis.


Coal workers' pneumoconiosis: a historical perspective on its pathogenesis. The earliest observations on coal workers' pneumoconiosis identified fundamental factors and posed particular problems in its genesis. Among the former, intensity of exposure and particle size were recognized, while argument commenced on the roles of stone dust, thus anticipating the quartz question, and of complicating pulmonary states, which introduced the idea of infection. Major studies of the disease were precipitated by its greatly increased prevalence, which became evident among South Wales coal workers from the 1930s. The principal directions of enquiry remained the same as in Scotland a century before, namely the components of coal mine dust responsible for fibrosis and the additional factor required for the development of massive fibrosis. The combined human and experimental evidence now makes possible conclusions in which confidence may be placed.


Racial differences in the prevalence of intraocular lens implants in the United States. We generated population-based estimates of the prevalence of intraocular lens implants by using the 1988 Medical Device Implant Supplement to the National Health Interview Survey. This national survey of a probability sample of the civilian noninstitutionalized United States population comprised 47,485 households and 122,310 persons. To produce national projections, we used survey respondent-reported data based on 1,941 reported intraocular lenses in 1,337 persons. Projected to the United States population, an estimated 2.6 million people had a total of 3.8 million lens implants. The predominant reason for the implant was cataract. The intraocular lens replacement rate was 0.9%. The use of intraocular lens implants was statistically significantly different from the general population in persons with the following socioeconomic characteristics: age (65 years or older), race (white), gender (female), annual family income (less than $20,000, although more commonly at or above the poverty threshold), and education (less than high school). The prevalence rates per 1,000 persons according to age were as follows: 0.3 for persons 44 years old or younger, 9.9 for persons 45 to 64 years old, 33.3 for persons aged 65 to 69 years, 63.5 for persons aged 70 to 74 years, and 113.5 for persons 75 years old or older.(ABSTRACT TRUNCATED AT 250 WORDS)


11-0 mersilene as running suture for penetrating keratoplasty. We evaluated astigmatic results and complications of the combined suturing technique in penetrating keratoplasty by using 11-0 Mersilene as a running suture. Twenty-seven grafts were studied for a follow-up that ranged between ten and 46 months (mean, 27.2 months). During the study, complications included three graft failures, one instance of inadvertent breakage of the running suture, one instance of one suture bite cutting through the recipient cornea, and suture microabscesses in two eyes. Keratometric astigmatism was 2.5 +/- 2.1 diopters at six months, was 2.4 +/- 2.3 diopters at 12 months, and was 2.5 +/- 2.0 diopters at 24 months. Our data indicate that 11-0 Mersilene is suitable for the running suture in corneal transplants in the combined technique. Spontaneous suture dissolution did not occur throughout the follow-up period. The use of a less biodegradable suture enables the maintenance of low levels of astigmatism for longer periods when compared with a previous study that used 11-0 nylon suture.


Surgical management of myokymia of the superior oblique muscle. In the past 15 years, we have examined 20 patients in whom myokymia of the superior oblique muscle was diagnosed. Medical treatment (carbamazepine) failed in three patients, and one patient did not accept drug therapy. These four patients (20%) were operated on for persistent oscillopsia and diplopia. One patient underwent only a superior oblique muscle myotomy, but required an inferior oblique muscle myectomy six months later because of iatrogenic superior oblique muscle palsy. The other three patients underwent simultaneous superior oblique muscle myotomy and inferior oblique muscle myectomy. The symptoms resolved postoperatively in all four patients. Symptomatic patients with superior oblique muscle myokymia in whom medical treatment fails or is intolerable can benefit from surgical treatment consisting of combined superior oblique muscle/inferior oblique muscle myectomy.


Intraocular fluid cultures after primary pars plana vitrectomy. To determine what organisms enter the eye and remain in the eye after pars plana vitrectomy, vitreous cavity aspirates were cultured postoperatively. Two of 33 (6%) consecutive eyes undergoing primary pars plana vitrectomy had positive cultures. One sample grew a single colony of Staphylococcus epidermidis, the second grew two colonies of Acinetobacter lwoffi. Neither of these eyes developed endophthalmitis. This study demonstrates that bacteria enter the eye at a low rate during pars plana vitrectomy and that the eye on which a vitrectomy has been performed is capable of clearing a low inoculum of bacteria.


Criteria to detect minimal expressivity within families with autosomal dominant aniridia. Autosomal dominant aniridia with complete penetrance without Wilms' tumor in five generations with 27 affected family members has been reassigned from chromosome 2p25 to chromosome 11p13. Clinically, aniridia was obvious in affected individuals with variable expressivity when they had rudimentary iris stumps, typical or atypical iris colobomata, or round, eccentric pupils. However, iris and retinal fluorescein angiography was required to detect abnormal vascular remodeling that resulted in incomplete iris collarettes and decreased retinal foveal avascular zones in 27 family members at risk with round, central pupils. These angiograms distinguished five affected and 22 unaffected individuals, and were the critical criteria required to detect minimal expressivity of aniridia in family members with round, central pupils.


Causes of reduced visual acuity on long-term follow-up after cataract extraction in patients with uveitis and juvenile rheumatoid arthritis. We reviewed the long-term follow-up on a consecutive series of 16 eyes from ten patients with juvenile rheumatoid arthritis-associated cataracts that were removed by using pars plana lensectomy and vitrectomy. All patients had prominent cataracts, chronic uveitis, posterior synechiae, and vitreitis preoperatively, and had at least 12 months of follow-up postoperatively. The median length of follow-up was 51 months (range, 12 months to ten years). In the early postoperative period, a visual acuity of 20/70 or better was obtained in 13 of 16 eyes (81%). With longer follow-up, the final visual acuity was 20/70 or better in only nine of 16 eyes (56%). The primary categories of delayed visual loss in these cases were glaucoma and macular disease (chronic cystoid macular edema, macular hole, hypotony maculopathy, and recurrent macular pucker). Despite these limitations in maintaining good visual acuity, a pars plana lensectomy and vitrectomy approach is effective for cataracts in these patients with uveitis.


Prediction of visual recovery after scleral buckling of macula-off retinal detachments. Patients with rhegmatogenous retinal detachments involving the fovea have visual loss that may not be recoverable despite anatomically successful surgery. Few guidelines exist to predict ultimate visual outcome with any certainty. We found that despite macular detachment, a device commonly used to predict visual acuity in cataractous eyes, the Potential Acuity Meter (Mentor O & O, Inc., Norwell, Massachusetts), provided acuity measurements even when Snellen visual acuity levels were poor or unmeasurable. In a study of 50 consecutive patients with clear media, we investigated a possible correlation between postoperative Snellen visual acuity with the preoperative Potential Acuity Meter results. We found that actual visual improvement correlated well with potential visual improvement as determined by Potential Acuity Meter measurements (R = .92). Preoperative assessment of patients with this device was a better predictor of final visual outcome than preoperative Snellen visual acuity, the extent of retinal detachment, or the duration of the retinal detachment by history.


Prevalence and risk factors of diabetic retinopathy among noninsulin-dependent diabetic subjects. In a population-based study in Taiwan, 11,478 subjects aged 40 years or older were screened for diabetes in one urban and five rural areas. Among the 715 subjects proven to have diabetes, 527 subjects underwent ophthalmoscopy. Diabetic retinopathy was present in 184 of the 527 subjects (35.0%), including background diabetic retinopathy in 157 subjects (30.0%), preproliferative diabetic retinopathy in 15 subjects (2.8%), and proliferative diabetic retinopathy in 12 subjects (2.2%). Diabetic retinopathy was correlated with the duration of diabetes and age at onset of diabetes, type of diabetes treatment, higher serum creatinine levels, and lower serum cholesterol levels. Several other factors, including gender, age, residential area, family income, educational level, control and family history of diabetes, body mass index, physical activity, exercise, cigarette smoking, stroke, ischemic heart disease, leg vessel disease, hypertension, and proteinuria, had no significant association with retinopathy. By multiple logistic regression analysis, duration of diabetes was the most important risk factor related to retinopathy. Diabetic subjects treated with insulin had a higher risk of developing retinopathy than those treated with dietary control (relative risk, 1.57; .05 < P < .10). The univariate analysis disclosed that proliferative diabetic retinopathy was related to older age at examination, older age at onset of diabetes, type of diabetes treatment, and presence of leg vessel disease. Insulin-treated diabetic subjects also had a higher risk of proliferative diabetic retinopathy than patients in whom diabetes was controlled by diet, with a relative risk of 2.51 (.05 < P < .10) in the multiple logistic regression analysis.


Cytokines in the vitreous of patients with proliferative diabetic retinopathy. Sixteen vitreous and paired serum samples from 13 patients with proliferative diabetic retinopathy, vitreous samples from seven cadaveric control subjects, and aqueous humor samples from 15 normal control subjects were assayed for the cytokines interleukin-1, tumor necrosis factor-alpha, interleukin-6, and interferon-gamma. Interleukin-6 was detected in 15 of 16 vitreous samples (94%) from diabetic patients, but it was not detected in any of the aqueous humor samples. Vitreous interleukin-6 levels positively correlated with ocular disease activity. Interleukin-1 was detected in seven of 16 vitreous samples (44%) and in four of ten aqueous humor samples (40%), whereas tumor necrosis factor-alpha and interferon-gamma were never detected in vitreous or aqueous fluid. Serum samples from diabetic patients and control subjects contained comparable low levels of interleukin-6. Interleukin-1, tumor necrosis factor-alpha, and interferon-gamma were not found in any of the sera. Because interleukin-6 can function as B-cell differentiation factor, this cytokine may have a role in immunoglobulin deposition in the ocular tissues and in the immunopathologic characteristics of proliferative retinopathy.


Results of intraoperative 5-fluorouracil supplementation on trabeculectomy for open-angle glaucoma. The success rate of filtration surgery has been increased by the postoperative subconjunctival injection of 5-fluorouracil, a potent antimetabolite. However, the optimal route of administration has not been determined. Trabeculectomy was performed on one eye each of 14 patients. Topical 5-fluorouracil was applied intraoperatively (50 mg/ml for five minutes) and subconjunctival 5-fluorouracil was injected postoperatively (an average of 5.8 injections) (mean total dose, 29 mg). Seven of the 14 eyes had primary open-angle glaucoma, and seven eyes had open-angle glaucoma with either uveitis, aphakia, or previous failed trabeculectomy. Mean preoperative intraocular pressure was 24.7 mm Hg during treatment with an average of three antiglaucoma medications, and mean final intraocular pressure was 11.9 mm Hg during treatment with an average of 0.2 medication. Thirteen of 14 eyes (93%) had final intraocular pressure of 18 mm Hg or less. Mean follow-up was 6.4 months (range, four to nine months). No remarkable complications occurred. Visual acuity remained stable in 13 of 14 eyes (93%). Intraoperative 5-fluorouracil may be a helpful adjunct in achieving low final intraocular pressure after trabeculectomy.


Ultrastructural findings in an autopsy eye from a patient with Usher's syndrome type II. We studied an eye taken at autopsy from a 55-year-old woman with retinitis pigmentosa and partial deafness (Usher's syndrome type II). Two years before her death, her visual acuity was R.E.: 20/80 and L.E.: 20/50, and visual fields were constricted to a 30- to 40-degree diameter with a V4e white test light. Both rods and cones were present across the retina except for areas of the midperiphery; remaining photoreceptors had shortened or disrupted outer segments, or both, and some cones had inclusion bodies in inner segments. In the macula, most of the connecting cilia of photoreceptors appeared abnormal, with either extra microtubules or an apparent disruption of the nexin link between doublet microtubules. The pigment epithelium was abnormal across the eye, with diminished apical microvilli and basal infoldings of the plasma membrane. Possible mechanisms by which abnormal cilia could lead to photoreceptor cell death are considered.


Visual field defects in patients with normal-tension glaucoma and patients with high-tension glaucoma. We compared the automated visual field test results of 24 patients with normal-tension glaucoma and 24 patients with high-tension glaucoma who were closely matched for the amount of visual field loss to determine any differences in the characteristics of visual field defects between the two groups. Patients were matched with a maximum allowable difference in mean deviation of 0.3 dB. Although the normal-tension group had a greater amount of focal visual field loss (pattern standard deviation), the difference was not statistically significant (P = .628). Additionally, there was no statistically significant difference in the amount of diffuse or focal visual field damage in the superior hemifields between the two groups; however, the patients with normal-tension glaucoma had a significantly greater amount of localized visual field loss in the inferior hemifield than the patients with high-tension glaucoma (P = .015). Our data support the hypothesis that a vascular mechanism may have a greater role in the pathogenesis of optic nerve damage and visual field loss in patients with normal-tension glaucoma than in patients with high-tension glaucoma.


Cross-cultural assessment of process skills. A standardized activities of daily living evaluation that has acceptable psychometric qualities, can relate discrete component skills to functional performance, includes culture-relevant test items, is standardized on culture-specific samples, and is free of cultural bias is needed to evaluate diverse cultural populations. The Assessment of Motor and Process Skills (AMPS) (Fisher, 1990a) offers a unique solution. The AMPS consists of 35 motor and process skill items assumed to represent two universal taxonomies that are free of cultural bias. The study described in this paper focused on the 20 process skill items of the AMPS process skills scale. To test the hypothesis that the AMPS process skills scale is suitable for cross-cultural applications, a translation of the AMPS was calibrated on a group of 20 Taiwanese subjects. The validity and reliability of the AMPS process skills scale were examined when applied to this sample. Examination of reliability included the extent to which rater scoring remained stable over time. The results revealed that the AMPS process skills scale has high intrarater reliability and is valid when applied to young nondisabled Taiwanese subjects. The results suggested that the AMPS could be applied to Taiwanese samples. However, further investigation is needed to determine whether Taiwanese activities can be calibrated onto the same scale as North American activities to make a single cross-cultural AMPS.


Deficits of reaching in subjects with left hemiparesis: a pilot study. Therapy to restore functional movement of stroke patients is based on assumptions about the deficits that occur in motor control as a result of stroke. Success has been limited, perhaps as a result of insufficient information concerning the characteristics of movement after stroke. In this pilot study, the Waterloo Spatial Motion Analysis Recording Technique (WATSMART), an optoelectric motion analysis system, was used with surface electromyography to measure voluntary reaching in the impaired and unimpaired arms of 5 subjects with left hemiparesis. The ability to reach in a smooth coordinated way was significantly poorer in the impaired arms than in the unimpaired arms, for which scores were essentially normal. The patients were less able to activate the muscles of the impaired arm and, as a result, used a greater percentage of the maximum activity they could generate to complete the unresisted reaching task. The electromyographic differences between arms, however, did not reach significance. The results corroborate previous findings and show that movement deficits of particular patients can be diagnosed precisely with kinematic analysis and electromyography. If greater precision in diagnosis were available clinically, more effective therapy might be developed.


Fine motor activities in elementary school: preliminary findings and provisional implications for children with fine motor problems. This study was designed to obtain a detailed picture of the fine motor requirements in regular elementary school classrooms. This knowledge is critical for occupational therapists in working with children with fine motor and handwriting problems who are main-streamed into regular classes. The allocation of time to fine motor activities and the types of fine motor tasks children are expected to perform in elementary school were investigated through the observation of six elementary school classrooms. A written minute-by-minute record of one whole day's activities in each classroom showed that 30% to 60% of the day was allocated to fine motor activities, with writing tasks predominating over other manipulative tasks. Implications for children with fine motor difficulties include the need for modifications to volume of work, types of tasks, and materials.


Activity positioning and ischial tuberosity pressure: a pilot study. Ipsilateral ischial tuberosity pressure of 12 subjects seated in wheelchairs was measured during reach to an activity positioned on both an upright and a flat plane. Ischial tuberosity pressure during cross-body, forward, and lateral reach was measured with a static pressure measurement device. Differences between flat-plane readings and upright-plane readings were analyzed with a t test; no significant difference was obtained. A repeated-measures analysis of variance revealed significant differences in ischial tuberosity pressure between cross-body, forward, and lateral reach in the flat plane activity. However, no significant difference was found between cross-body, forward, and lateral reach in the upright-plane activity. Results of this study support the theory that forward and lateral positioning of activity can supplement standard techniques for relieving pressure.


Effects of linear vestibular stimulation on body-rocking behavior in adults with profound mental retardation. The effects of linear vestibular stimulation on body-rocking behaviors in adults with profound mental retardation were studied. A single-system multiple base-line design across 3 subjects was used. The design included three phases spread over a period of 9 weeks. An interval time sampling procedure was used to collect data. Data from the 3 subjects were graphed and interpreted through visual inspection. Trend lines were computed with the celeration line approach to supplement the visual inspection of the data. The results demonstrated a decrease in body-rocking behaviors during the treatment and follow-up phases for Subject 2 but no obvious change in performance for Subjects 1 and 3. A lengthier treatment period and selection of subjects with similar body-rocking frequencies are suggested for further research.


Occupational adaptation: toward a holistic approach for contemporary practice, Part 2. This paper introduces a practice model based on the occupational adaptation frame of reference (Schkade & Schultz, 1992). The occupational adaptation practice model emphasizes the creation of a therapeutic climate, the use of occupational activity, and the importance of relative mastery. Practice based on occupational adaptation differs from treatment that focuses on acquisition of functional skills because the practice model directs occupational therapy interventions toward the patient's internal processes and how such processes are facilitated to improve occupational functioning. The occupational adaptation practice model is holistic. The patient's occupational environments (as influenced by physical, social, and cultural properties) are as important as the patient's sensorimotor, cognitive, and psychosocial functioning and the patient's experience of personal limitations and potential is validated. The integration of these concepts drives the treatment process. Through a description of treatment with a variety of patients, this paper presents the model's diversity and illustrates the relationship between the concepts. The occupational adaptation practice model reflects the uniqueness of occupational therapy and integrates the profession's historical practice with contemporary interventions and methods.


Clinical reasoning process for service provision in the public school. This paper outlines the clinical reasoning process used to guide decisions on the provision of occupational therapy services in the Wake County Public School System in North Carolina. The process is based on a theoretical framework derived from occupational therapy theory and public law. Benefits of using the clinical reasoning process include (a) increased consistency of decision making among therapists; (b) increased appropriateness of decisions regarding whether a student needs educationally based occupational therapy services, what type of occupational therapy service would meet the student's need, and how often this service should be provided; and (c) improved ability of therapists to articulate to all those involved with a student the reasoning behind decisions to provide educationally based occupational therapy services. The schematic diagrams that depict this process provide a useful tool for therapists with varied work experiences entering school-based practice.


Continuing education requirements to maintain occupational therapy licensure. Different states use a variety of regulatory mechanisms to monitor the quality of practice in occupational therapy. The requirement for mandatory continuing education has been adopted by fewer than half of American states, but there is reason to predict that this trend will increase. This study investigates the patterns linking licensure to continuing education and recommends actions to ensure uniformity and accountability.


Recovering relationships: a feminist analysis of recovery models. Two models of recovery based on the concepts of independence and interdependence are contrasted from a feminist perspective. Drawing on social and psychological analyses, the authors critique the overemphasis of independence as the goal of health care and instead advocate a more relational model of therapy that reinforces social and emotional connections between people. Two narratives from occupational therapy are used to illustrate the differing assumptions underlying these models. The authors discuss some of the structural and interactional barriers to the expression of interdependence in health care institutions. They suggest that through purposefully sharing practice experiences and instating collaborative, nonhierarchical models of organization, practitioners can begin to overcome these barriers.


Gender differences in dementia management plans of spousal caregivers: implications for occupational therapy. Occupational therapists treating older people with Alzheimer disease know that they must also consider the others who are affected by the disease, the informal caregivers. Intervention is most effective when it enables both the impaired person and the primary caregiver to manage the secondary symptoms of dementia. Unfortunately, little is understood about how caregivers approach and carry out their tasks and about why male and female caregivers respond differently to their caregiving role in terms of depression, burden, stress, and substance abuse. This paper discusses the effects of gender on dementia management plans of spousal caregivers. Husbands and wives have different approaches to caregiving; each approach has consequences. Male caregivers adopt a task-oriented approach to their duties and carry out their activities in a linear fashion; female caregivers use a parent-child approach and nest activities inside one another in a constant stream of work. Two cases are presented to illustrate gender differences in dementia management plans. Implications for occupational therapy include suggestions for supporting men and women in their caregiving role, modulating the negative consequences of caregiving, and conducting research to demonstrate the efficacy of an occupational therapy approach.


Interwoven threads: occupational therapy, feminism, and holistic health. Occupational therapy is a predominantly female profession; 93% to 95% of occupational therapists are women. The implications and ramifications of this reality have seldom been directly addressed. In this article, beliefs about balance, activity, environment, and autonomy are explored from the perspectives of occupational therapy, feminism, holistic health, and medicine. The assertion that occupational therapy has more in common philosophically with feminism and holistic health than it does with medicine is supported. This awareness provides a new framework for examining current issues of concern to the profession, such as support for purposeful activity, existence outside the mainstream of power holders, and problems and powers inherent in being seen as a women's profession. Recommendations are made that occupational therapists commit more money and energy to encourage, facilitate, and support female leadership; develop innovative strategies for keeping members who take time out to raise families informed; support more holistic and feminist reorganization of work settings; instill awareness of these issues in our students; and address our strengths as a women's profession. All occupational therapists must also confront their own anti-women prejudice.


Women, HIV infection, and AIDS: tapestries of life, death, and empowerment. Women, the minority population in the human immunodeficiency virus (HIV) pandemic, are fast becoming one of the highest subgroups to be infected and affected by the disease. In the United States, most of these women are black or Hispanic, poor and urban dwellers, and addicted to drugs. This paper discusses the physical, psychological, and social manifestations of HIV disease in women, such as diminished activity tolerance, neurologic or cognitive changes, occupational and social role imbalance, and stigma and discrimination, and describes the sociocultural aspects of women's lives for assessment and treatment of women with HIV. Health promotion, education, and AIDS prevention and wellness programming are emphasized as strategies toward facilitation of self-empowerment for women with HIV disease. These health promotion and wellness strategies include learning of new and adaptation of current roles; learning strategies for self-care that include care for one's physical, psychosocial, spiritual, and sexual health; and learning and developing action plans toward healthy living and self-empowerment.


Embracing our past, informing our future: a feminist re-vision of health care. Using a feminist perspective, this paper explores the roots of the practice of healing and medicine. It traces the role of women in health care from prehistorical times, through the present, and into the future discussing the changing paradigms that the author identifies as (a) the Prototypic Paradigm: Mysticism and Healing; (b) the Scientific Paradigm: Curing; and (c) the Paradigm of Inclusion: Caring, Curing, and Healing. The role and status of women in society are reflected within these paradigms, and the changing status of the profession of occupational therapy is discussed within this framework. The unique skills and contributions of occupational therapy more closely fit within the Paradigm of Inclusion and can support us as health care leaders within the changing world of the 21st century.


A mother's work: two levels of feminist analysis of family-centered care. The following case describes 5 years of a mother's care for her child with multiple chronic conditions, in the neonatal intensive care unit and at home. Because caregiving is primarily a female activity, a feminist approach is used. This mother's efforts on behalf of her son show how work within the domains of direct medical care, normal mothering care, coordination of equipment and supplies and professionals, and synthesis of meaning emanated from her definition of motherhood. The case suggests interventions in family-centered care, offers an examination of two levels of feminist analysis for their usefulness to occupational therapy, and provides an opportunity to examine the topic of motherhood within feminism.


A woman's place: unpaid work in the home. Household work has only recently become a valid topic of study. Feminist scholars were among the first social scientists to draw attention to women's unpaid work in the home. Although household work occupations are frequently used for assessment and treatment within practice, occupational therapy literature demonstrates a paucity in the area of these occupations. This review of the feminist literature summarizes theory and research that explore the historical, political, social, and personal meanings of household work. Feminist analysis of household work may sensitize occupational therapists to the complex interactions of these meanings and lead them to the realization that women's responsibility for unpaid work in the home may have repercussions in the daily lives of both women and men.


Opening feminist histories of occupational therapy. This paper frames the history of occupational therapy in feminist terms. It focuses on gender segregation in occupational therapy, the influence of class and race in shaping opportunities for occupational therapists, and the place of feminism in the goals and achievements of the occupational therapy profession. Such issues have been addressed by feminist scholars in histories of women in medicine, nursing, and other helping professions. These sources help place the achievements of occupational therapy within the context of women's historic entry and advancement in the American work force.


Shanidar 1: a case of hyperostotic disease (DISH) in the middle Paleolithic. The Shanidar 1 Neandertal partial skeleton presents osteophytic lesions on its vertebrae and appendicular skeleton which appear independent of the multiple traumatic and degenerative joint disease lesions on the individual. In particular, the large flowing osteophyte on the L3 body, a smaller one on the L5 body, and enthesopathic osteophytes on both calcaneal tuberosities, both patellae and the left ulnar olecranon, support a diagnosis of hyperostotic disease (DISH). The diagnosis is supported by small enthesopathic osteophytes on the preserved femoral greater trochanter and scapular corocoid process. This diagnosis would make it the oldest hominid specimen clearly presenting this systemic condition.


Obstetric dimensions of the true pelvis in a medieval population from Sudanese Nubia. Functional analysis of the true pelvis (defined as that portion lying below and including the pelvic brim) was undertaken on a sample of 36 females from the Medieval site of Kulubnarti in Sudanese Nubia. Standard obstetric measurements were taken and compared to four additional prehistoric skeletal samples and to modern American standards for the same obstetric dimensions. Relative to the other prehistoric populations, the Kulubnarti pelves are smaller in most dimensions and, when compared to modern American standards, from one-third to one-half would be diagnosed as contracted in one or more planes. Given the meager, fluctuating resources of these Medieval Nubians' harsh desert environment, pelvic size reduction is a likely result of body size reduction as one biological response to nutritional stress (Mittler and Van Gerven, 1989; Moore et al., 1986; Van Gerven et al., 1981). It is argued, however, that size reduction created a high potential for either maternal-neonatal morbidity and mortality due to fetopelvic disproportion or neonatal loss due to low birth weight. In either case, it is suggested that the Kulubnarti population paid a significant biological price for this aspect of size reduction.


Evaluation of the obstetric significance of some pelvic characters in an 18th century British sample of known parity status. The excavations at Christ Church, Spitalfields (1984-86) produced a sample of 968 human skeletons which were interred between 1729 and 1859. Of these, 387 were recovered in association with coffin plates stating name, age at death, and date of death. There are 138 adult females in the named sample and the obstetric histories of 94 have been reconstructed from historical documentation. Such variables as birth spacing, number of children, and age at first and last births are known for the majority of this sample. Any individual about whose history there is any doubt has been excluded from the analysis. A middle-class group, they were largely of high nutritional status and, by the standards of the day, lived in sanitary and comfortable conditions. Both males and females have a mean age at death of 56 years. The presence or absence, the typology, the severity, the width and the length of the preauricular sulcus, the presence or absence and the number of pits on the dorsal aspect of the pubic body, sulci along the anterior sacrum adjacent to the auricular facet, and the extension of the pubic tubercle were evaluated in relation to the obstetric histories of these females. Statistical analysis has demonstrated a relationship between the presence of pubic tubercle extension and parity status and between the degree of extension and the number of children borne (P < .02). Statistically there is no significant relationship (P > .05) between either the preauricular sulcus or pubic pitting and parity status. Sacral scarring is significantly associated (P < .05) with parity status, but as it was evident in only eight females it has little practical application. Sample sizes are small, and it must be considered that statistical evaluation of larger samples might detect associations between variables not demonstrated here. There is no significant relationship between any of the cortical variants under consideration and age at death.


Gene geography of South America: testing models of population displacement based on archeological evidence. Gene frequencies for 13 marker systems are used to construct synthetic gene frequency maps of South America. The surfaces generated using the first three principal components exhibit clines which validate models of population displacement based on archeological data and a previous analysis of craniometrical variation.


Longitudinal analysis of adolescent growth of ladino and Mayan school children in Guatemala: effects of environment and sex. The rate of growth in height and the timing of adolescent growth events are analyzed for two samples of Guatemalan children. One sample includes Mayan school children, 33 boys and 12 girls between the ages of 5.00 to 17.99 years, living under poor conditions for growth and development. The second sample includes ladino children, 78 boys and 85 girls of the same age range, living under favorable conditions for growth. The Preece-Baines model I function is used to estimate mean values for rates and timing of childhood and adolescent growth events for the two groups. Significant statistical contrasts (t-tests) of these means show Mayan boys reach the age of "take-off" (TO; the onset of the adolescent growth spurt) 1.45 years later, achieve peak height velocity (PHV) 1.68 years later, and continue growing for about 2.0 years longer than do the ladino boys. Despite the Mayan boys' increased duration for growth they grow significantly more slowly than the ladinos. Mayan boys are 6.60 cm shorter than ladinos at the age of TO and are estimated to be 7.71 cm shorter than the ladinos at adulthood. Mayan girls reach the age of TO 0.93 years later than do the ladina girls, but the two groups do not differ in the age at PHV or the age at adulthood. The mean height of Mayan girls is significantly less than that of ladinas at the age of TO (6.5 cm), and this difference increases to an estimated 11.14 cm at adulthood. Possible causes of these ethnic and sex-related differences in amounts and rates of growth are discussed in relation to hypotheses about the genetic and environmental determinants of human development.


Cross-cultural analysis of migration rates: effects of geographic distance and population size. A model is developed that treats migration rates among populations as a function of the geographic distance between them and the size of both sources and recipient population. Specifically, mij/mjj = a(Ni/Nj)pe-bd, where mij/mjj is the relative migration rate into population j from population i, Ni is the size of the source population, Nj is the size of the recipient population, d is the geographic distance between populations i and j, p is a measure of differential density-dependence, b is a measure of distance decay, and a is an adjustment parameter with little demographic meaning. Methods of parameter estimation and hypothesis testing using maximum likelihood are outlined. These methods are applied to migration matrix data from 13 samples obtained from the literature representing a wide range of ecological settings. All samples show a significant effect of geographic distance on migration, and all but one show a significant effect of differential population size. All but one sample show an overall tendency for migration to be negative density-dependent; that is, the relative migration rate is greater from larger populations to smaller populations than the reverse.


Human marriage systems and sexual dimorphism in stature. Contemporary populations of Homo sapiens are sexually dimorphic on a variety of traits. In terms of stature, men are reliably between 4% and 10% taller than women in well-sampled human populations. Are cross-cultural differences in the magnitude of sexual dimorphism consistent with expectations from sexual selection theory? Prior studies have provided conflicting answers to this question in part because they failed to agree on how the force of sexual selection should or could be operationalized. Here we offer a simple and unbiased method for operationalizing sexual selection and retest two separate predictions from earlier work (Alexander et al., 1979) about its expected impact on stature dimorphism in a sample of 155 societies. Neither prediction matches the observed cross-cultural distribution of dimorphism. However, this is not the consequence of a random distribution of dimorphism across societies. Instead, the data exhibit a robust and unexpected pattern.


Interobserver reproducibility in the diagnosis of ductal proliferative breast lesions using standardized criteria. Although the categorization of proliferative breast lesions provides valuable information regarding subsequent risk of breast cancer, the ability of pathologists to classify such lesions in a reproducible fashion has not been adequately evaluated. To assess further interobserver reproducibility in the categorization of proliferative breast lesions, six pathologists each reviewed 24 proliferative ductal lesions and classified them as either usual hyperplasia (H), atypical hyperplasia (AH), or carcinoma in situ (CIS). Before evaluation of the study slides, all the participants were instructed to use the diagnostic criteria of Page and co-workers and were provided with both a written summary of these criteria and a set of teaching slides with representative examples of each type of lesion. Complete agreement among all six pathologists was seen in 14 cases (58%); five or more agreed in 17 cases (71%); and four or more arrived at the same diagnosis in 22 cases (92%). No pathologist consistently rendered more "benign" or "malignant" diagnoses than any other. After assigning numerical values for each diagnostic category (H = 1, AH = 2, CIS = 3), the scores for the group of 24 cases did not differ significantly by pathologist (p = 0.68; average score range, 1.7-2.0). Our results indicate that with the use of standardized criteria, interobserver concordance in the diagnosis of proliferative ductal breast lesions can be obtained in the majority of cases.


Chondroid chordomas and low-grade chondrosarcomas of the craniospinal axis. An immunohistochemical analysis of 17 cases. The classification of cartilaginous neoplasms of the craniospinal axis is controversial. Indeed, the very existence of chondroid chordomas has recently been questioned. In an effort to clarify the direction of differentiation of cartilaginous neoplasms of this region, 17 neoplasms obtained from 17 patients with cartilaginous tumors of the craniospinal axis were examined by immunohistochemistry with a panel of antibodies. The panel included antibodies to cytokeratin (CK), epithelial membrane antigen (EMA), vimentin (VIM), S-100 protein, carcinoembryonic antigen (CEA), and type II collagen. Areas with cartilaginous differentiation were present in all 17 neoplasms. These areas were characterized by a matrix of amorphous blue ground substance with lacunae that contained enlarged and slightly atypical cells. This cartilaginous matrix stained strongly for type II collagen. Thirteen of the 17 neoplasms had a biphasic growth pattern in which areas with conventional chordoma were admixed with areas with cartilaginous differentiation. The cells within the cartilaginous components of these 13 neoplasms stained for CK (10 of 12 cases), EMA (10 of 13 cases), VIM (12 of 12 cases), S-100 protein (seven of 12 cases), and CEA (two of nine cases). Similarly, the conventional chordoma components of these same 13 neoplasms stained for CK (12 of 12 cases), EMA (13 of 13 cases), VIM (12 of 12 cases), S-100 protein (nine of 12 cases), and CEA (two of nine cases). The hyaline-appearing areas between the cords and sheets of cells of the conventional chordoma components of these 13 tumors also stained with type II collagen. These 13 tumors with both neoplastic cartilage and conventional chordoma were classified as chondroid chordomas. One of the 17 cases was composed entirely of neoplastic cartilage; however, the cells within the matrix of the cartilage of this neoplasm stained with the epithelial markers (CK and EMA). Based on the presence of epithelial differentiation within this otherwise cartilaginous neoplasm, it was also classified as a chondroid chordoma. In contrast, the remaining three cases without histologic evidence of chordoma differentiation did not stain for CK or EMA, but they did stain for S-100 protein (three of three cases) and VIM (three of three cases). These three tumors were therefore classified as chondrosarcomas. For purposes of comparison, 19 conventional chordomas without cartilage and 29 peripheral chondrosarcomas were also stained. The 19 conventional chordomas stained in a pattern similar to the conventional chordoma components of the chondroid chordomas, whereas the 29 peripheral chondrosarcomas stained in a pattern similar to the three chondrosarcomas of the craniospinal axis.(ABSTRACT TRUNCATED AT 400 WORDS)


Well-differentiated thymic carcinoma. An organotypical low-grade carcinoma with relationship to cortical thymoma. Based on a study of 26 cases, the well-differentiated thymic carcinoma is described as a distinct organotypical carcinoma of the thymus with low-grade malignancy. It is characterized by a predominance of epithelial cells with usually low mitotic rate, an epidermoid differentiation with slight to moderate cytological atypia, the constant presence of interepithelial immature cortical thymocytes, lobular growth, and formation of epithelial palisades around perivascular spaces. The tumor occurs at age 14 to 76 years in both sexes. An association with myasthenia gravis is found in 77% of the patients, and 83% of the tumors show invasion of adjacent organs or endothoracic metastasis at primary operation. This rate is higher than in cortical thymomas (47%) but lower than in other thymic carcinomas (92%). Two of 18 patients with follow-up died of tumor recurrence and pleural metastasis. Well-differentiated thymic carcinoma can be related to cortical thymoma by common morphological features and a similar immunophenotype of epithelial cells. It must be differentiated from the lymphocyte-depleted cortical thymomas after corticosteroid treatment and from the benign epithelial-rich medullary thymomas.


Clear cell sarcoma of soft tissues. Mayo Clinic experience with 35 cases. Thirty-five cases of clear cell sarcoma of soft tissues were studied to determine the clinical or morphologic features that are important in predicting prognosis. Tumors occurred most commonly in the extremities, and the majority of the patients were young women. Surgery was the elected treatment in every case. Five patients experienced local recurrences, and metastases developed in 22. Fifty-four percent of the patients died of tumor, 11% are alive with disease, and the remaining 34% are alive and well; the average survival for each group was 67 months, 113 months, and 103.5 months, respectively. This sarcoma is characterized by small clusters of polygonal to spindle cells featuring clear to slightly basophilic cytoplasm and vesicular nuclei with prominent nucleoli. The clusters are separated by delicate fibrous septa. In a deletion, clear cell sarcoma has low mitotic activity, little or no necrosis, and mild nuclear pleomorphism. Tumor size and the presence of necrosis are statistically significant predictors of prognosis. All 12 patients with tumors measuring > 5 cm died of disease or are alive with disease. Eleven of the 20 patients with tumors measuring < 5 cm are alive with no evidence of disease. Tumor necrosis was present in 10 cases; eight of these patients died of disease and one is alive with disseminated metastases.


Sclerosing inflammatory pseudotumor of the urinary bladder in a child. A case of inflammatory pseudotumor of the urinary bladder in a 2-year-old child is presented. It was characterized by nodular intravesical growth and massive infiltration of the bladder wall. Microscopically, the lesion showed in its largest part a relatively paucicellular spindle cell growth and a sclerotic appearance with a thin superficial cellular zone resembling granulation tissue. Another morphological characteristic was a marked capillary proliferation revealed by immunohistochemical reactions to factor VIII-associated protein, laminin, and collagen IV. The last feature appears to be an integral part of the process, which most closely resembled fibromatosis of the adult type, a rare pattern of growth in inflammatory pseudotumor.


Myofibromatosis-like hemangiopericytoma metastasizing as differentiated vascular smooth-muscle and myosarcoma. Myopericytes as a subset of "myofibroblasts". A thyroid hemangiopericytoma that was resected in a 5-year-old boy recurred insidiously in the larynx 8 years later. Marked cicatricial mucosal inflammation prevented a definitive pathologic diagnosis of recurrence until a nodule grew to obstruct the airway 15 years after initial surgery. After excision of the nodule, a larger sarcomatous metastasis was discovered in the upper esophagus and resected, but the patient eventually succumbed to widespread disease at the age of 20 years. The original tumor contained atypical pericytes and bundles of hyalinizing smooth muscle abutting on "staghorn vessels," a pattern similar to infantile myofibromatosis. Desmin immunostaining was negative in the pericytes but positive in smooth-muscle cells dispersed singly as well as in bundles. Both elements reacted strongly for vimentin and the alpha-isoform of actin (alpha-SMA) found in normal smooth muscle and pericytes. A third cell type showing dendritic processes and immunoreactivity for all three antigens was interpreted as a myopericyte. Spindled cells in multiple subsequent mucosal biopsy specimens stained retrospectively also positive for these antigens. Large bundles of vascular smooth muscle surrounded by radiating myocytes characterized the occluding laryngeal nodule. In the esophageal metastasis, which showed no histologic features typical of hemangiopericytoma, numerous mitotically active, small, vimentin+, desmin+, alpha-SMA+ cells often maintained shortened processes and tended to form nodular aggregates about capillaries. Single rows of pericytes accreted to endothelial tubes. Ultrastructurally, some cells contained myofilaments and irregular dense material or showed rare cell junctions and variable investment by a basal lamina.(ABSTRACT TRUNCATED AT 250 WORDS)


Cytokine expression by head and neck squamous cell carcinomas. Cytokines are known to play an important role in host defense by regulating the function, growth, and differentiation of the cells of the immune system. We hypothesize that, in the tumor microenvironment, tumor cells and resident tissue cells (e.g., fibroblasts) also produce cytokines that may regulate the local immune response to tumors. Initially, homogenates of eight head and neck squamous cell carcinomas (HNSCC) were assayed for the presence of interleukin-1 (IL-1), interleukin-4 (IL-4), interleukin-6 (IL-6), and granulocyte-macrophage colony-stimulating factor (GM-CSF) to establish the presence of these cytokines in the tumors in vivo. We detected IL-1 in all tumor homogenates and IL-4, IL-6, and GM-CSF in some homogenates. To assess the ability of HNSCC to produce these cytokines, supernatants of short-term primary cultures of HNSCC were assayed for the same cytokines. No IL-1 was detected, although baseline levels of IL-4, IL-6, and GM-CSF were present. However, the stimulation of primary tumor cultures with exogenous IL-1 induced or significantly enhanced production of IL-4 (p < 0.01), IL-6 (p < 0.001), and GM-CSF (p < 0.02). These results support our hypothesis that HNSCC secrete cytokines that may influence the response of local immune cells. Our data also suggest that IL-1 may have a central role in regulating the local immune response through the enhancement or induction of cytokine production by tumor and/or resident tissue cells.


Localized carcinoma of the external ear is an unrecognized aggressive disease with a high propensity for local regional recurrence. Management problems in patients with recurrent squamous cell carcinoma (SCC) of the external ear (pinna) have prompted a review of the management and treatment outcomes of patients who present with localized disease. Forty patients were seen over a 15-year period (1972 to 1991). Thirty-six were men, and 4 were women, with an age range from 43 to 93 years (average age: 71 years). Presenting TNM status was stage 0 in 2 patients, stage I in 15 patients, stage II in 13 patients, stage III in 2 patients, stage IV in 4 patients, and unknown stage in 4 patients. Thirty-six patients had clinically negative nodes at presentation (N0), and 4 had palpable nodes (N+). The primary treatment was local excision in 13 patients, Mohs' micrographic surgery in 16 patients, local excision plus external beam radiotherapy in 4 patients, and radical resection (parotidectomy/neck dissection/mastoidectomy) with or without radiotherapy in 5 patients. Two patients with stage IV disease died after diagnosis and prior to treatment, and two other patients with stage IV disease received palliative chemotherapy. Twenty patients developed recurrence from 2 months to 8 years. It included nine local recurrences, eight regional recurrences (parotid/neck/mastoid), and three distant metastases (lung or brain). After treatment of the recurrences in 20 patients, 8 are alive 15 months to 16 years later, 2 patients died of other diseases, and 10 patients died of SCC. The recurrences were managed by reoperation, radiotherapy, or chemotherapy. From the results of this study, we conclude that localized carcinoma of the external ear has a high propensity for local and regional failure and merits more aggressive treatment of the primary lesion and elective treatment of the regional lymph nodes and parotid gland in high-risk patients.


Prognostic significance of cervical lymph node metastases in differentiated thyroid cancer. During the last decade, several analyses of prognostic factors for differentiated thyroid cancer (DTC) have been reported. Although these studies have established a framework for rational treatment planning, they have not fully answered questions regarding the prognostic significance of cervical lymph node metastases. An analysis of patients treated for DTC at our institution over a 34-year period has shown several factors to be significant by log-rank analysis, including the presence of cervical lymph node metastases, age greater than or equal to 50 years, a primary cancer size of greater than 3.0 cm, and distant metastases. Further analysis has shown the node-negative and node-positive patient groups to be similar in regard to age, size of primary cancer, and the presence of distant metastases. This report compares our data with those of other studies that have investigated the association of cervical lymph node metastases and a poorer prognosis in patients with DTC. When considered as a group, these studies support the finding of the prognostic significance of cervical lymph node metastases, particularly that of palpable lymphadenopathy in older patients.


Comprehensive treatment strategy for oral and oropharyngeal cancer. This prospective nonrandomized study analyzes the effectiveness of the following treatment protocol for oral and oropharyngeal cancers: (1) radical initial surgery; (2) elective modified or selective neck dissection for NO necks; (3) jaw preservation unless gross invasion is present; (4) radial forearm freeflap reconstruction; (5) elective tracheotomy; (6) postoperative radiotherapy unless previously given; and (7) active oral rehabilitation. Between 1987 and 1992, 75 patients (55 men and 20 women) with a median age of 58 years had this treatment. Fifteen had been previously treated with radiotherapy. Clinical stages of untreated patients were as follows: 4 patients, stage I; 25 patients, stage II; 12 patients, stage III; and 19 patients, stage IV. Ten patients had segmental jaw resection, 26 had a marginal mandibulectomy, and 26 had a jaw swing. There were no operative deaths, and only one flap (1.2%) failed. Median times for oral feeds and hospital stay were 8 and 17 days, respectively. Forty-four patients had postoperative radiotherapy. Median follow-up time is 30 months, and locoregional control is 95% for previously untreated patients and 54% for previously treated patients. Thirteen patients have died of disease, 8 with locoregional recurrence and 5 with distant metastases alone. We conclude that this treatment strategy is highly effective in previously untreated patients but less effective in salvaging patients in whom radiotherapy has failed.


Results of surgical treatment of T3 and T4 tumors of the oral cavity and oropharynx. The combined use of surgery and radiotherapy is commonly accepted as the most effective treatment for locally advanced head and neck cancers. T3 and T4 tumors of the oral cavity and oropharynx often necessitate extensive local surgery. From 1981 to 1988, 199 patients with T3 and T4 tumors of the oral cavity and oropharynx were treated. One hundred seventeen patients underwent surgery plus postoperative radiotherapy; 78 had flap reconstructions. This series is extremely homogeneous because surgery was always performed by two surgeons, whereas radiotherapy was the responsibility of the same physician. The results of this study show a 96% local control rate at the end of treatment among the patients with combined treatment. The average time by which hospitalization was prolonged due to surgery was 29 days. The type and delay of recurrences and survival in relation with node involvement are also discussed. Extensive surgery in association with radiotherapy remains a reliable treatment in such patients.


Results of surgical resection of pulmonary metastases of squamous cell carcinoma of the head and neck. In this retrospective review of 58 patients (12 females and 46 males) with pulmonary metastases of squamous cell carcinoma of the head and neck treated between January 1, 1970, and December 31, 1989, we evaluated their clinical courses and analyzed the outcomes of those who underwent pulmonary resection. For the entire group of patients, factors predictive of survival in those patients with a diagnosis of pulmonary metastases included pulmonary resection of metastases (p = 0.0001), locoregional control of the head and neck primary tumor at the time of diagnosis of pulmonary metastases (p = 0.007), TNM stage of the head and neck primary tumor (p = 0.02), a single nodule seen on the chest radiograph (p = 0.02), and disease-free interval (DFI) from the primary tumor of the head and neck of 2 years or more (p = 0.05). Twenty-four of 58 patients underwent thoracotomy for resection of metastases. Four (17%) were found to have a second primary tumor of the lung. Of the 20 remaining patients who underwent explorative surgery for possible pulmonary resection, 18 (90%) underwent complete resection of all malignant disease with an estimated 5-year survival of 29%. In these patients, a DFI of less than 1 year was associated with a 5-year survival rate of 0%, whereas a DFI of 1 to 2 years was associated with a 5-year survival rate of 43% and a DFI of 2 years or longer had a 5-year survival rate of 33%. The number of malignant pulmonary nodules that were resected ranged from one to five and was not significant in predicting survival (p = 0.19). Of eight patients who underwent the resection of more than one malignant pulmonary nodule, 50% survived 2 years, but none survived 5 years. Resection of a solitary pulmonary metastasis from squamous cell carcinoma of the head and neck resulted in long-term survival in selected patients. Important prognostic factors included locoregional control of the head and neck primary tumor, the number of nodules seen on chest radiograph, the TNM stage of the primary tumor, and the DFI from the head and neck primary tumor. The value of resection in patients with more than one malignant pulmonary nodule remains to be defined for this group of patients.


Patterns of failure after radical neck dissection for recurrent nasopharyngeal carcinoma. Radical neck dissection (RND) for recurrent nasopharyngeal carcinoma (NPC) after radiotherapy was retrospectively evaluated in 38 patients treated between April 1986 and December 1991. Thirty patients (79%) had advanced-stage disease. Four patients required nasopharyngectomy as well as RND. The mortality was 0%, and the morbidity was 13%. The actuarial survival rates at 5 years from the time of initial radiotherapy and RND were 50% and 25%, respectively. Of the 21 patients with relapses after surgical salvage, 5 had recurrences in the nasopharynx, 3 had recurrences in the neck, and 13 had distant metastases. We conclude that RND for recurrent NPC is safe and efficacious; however, it is associated with a significant (34%) incidence of distant metastases. These results can be improved by evaluating patients for distant metastases and excluding those with distant metastases. Improvement in the treatment of distant metastases is also needed.


Role of frozen section and clinical parameters in distinguishing benign from malignant follicular neoplasms of the thyroid. The determination of malignancy preoperatively or intraoperatively is difficult in patients with follicular neoplasms of the thyroid. This study reviews a series of 395 patients treated for follicular neoplasms at the Vancouver General Hospital and the British Columbia Cancer Agency between the years of 1955 and 1988, 198 of whom had frozen section at the time of surgery. Frozen section was 79% accurate in differentiating follicular adenomas from carcinomas, with a sensitivity of 52% and a specificity of 100%. The positive predictive value of a frozen section showing carcinoma was 100%, and the negative predictive value was 73%. An incorrect diagnosis of a benign lesion was made in 21% of patients in whom the final diagnosis by fixed section was carcinoma. These same statistics were calculated for patients aged greater than 50 years, tumor size greater than 3 cm, and patients with a history of previous neck irradiation, three clinical factors shown in a previous study to be strong prognostic indicators of malignancy. The results were compared with those found by frozen section. The implications of these results in terms of patient management are discussed.


Parathyroid re-exploration.

Parathyroid re-exploration. The authors evaluated their experience with 27 patients who required parathyroid re-explorations. The initial exploration was unsuccessful in 20 patients: in 8 because of ectopic lesions, in 2 because of undetected supernumerary glands, and in 10 because of inadequate exploration of the neck. All of the patients with inadequate neck explorations were found to have eutopic disease. Seven patients required re-exploration because of recurrent disease. Localization studies were performed prior to re-explorative surgery in 26 of 27 patients, which resulted in successful placement in 21. Invasive procedures, selective vein catheterization, and/or arteriography were effective in 12 of 15 patients. Noninvasive procedures, including thallium-technetium scintigraphy, magnetic resonance imaging, computed tomography, and ultrasonography, were accurate in 14 of 21 patients. Twenty-three (85%) of 27 patients were cured, including 17 of 20 patients after an unsuccessful initial exploration and 6 of 7 patients with recurrent disease. Careful review of operative and pathology reports from the initial surgery was essential in determining the adequacy of the exploration, the presence of microscopic abnormalities, and the glands that were positively identified. Such analysis, in conjunction with noninvasive localization studies, will lead to successful re-exploration in the majority of cases.


Phorbol dibutyrate plus ionomycin improves the generation of cytotoxic T cells from draining lymph nodes of patients with advanced head and neck cancer. Fifty-one cervical nodes from 19 patients with advanced head and neck cancer were stimulated with phorbol dibutyrate and ionomycin (PDBu + Io) to determine the effect of such stimulation on the generation of cytotoxic T cells and whether this stimulation could bypass the need for autologous tumor stimulation. Lymphocytes stimulated with PDBu + Io demonstrated a sixfold greater in vitro expansion and significantly increased DNA synthesis. Whereas fresh lymphocytes displayed no cytotoxicity, stimulation with PDBu + Io and culture in interleukin-2 (IL-2) led to significant cytotoxicity equivalent to that of lymphocytes stimulated with autologous tumor and IL-2. T cells with the greatest cytotoxicity were generated from patients with nodal metastases. In patients with stage IV tumors, effector cells demonstrating greater lysis of natural killer-resistant targets (Daudi cells) were associated with higher rates of recurrence (50% versus 12%, respectively, p < 0.001). Stimulation with PDBu + Io augments growth and proliferation of lymphocytes from draining lymph nodes and preserves cytotoxicity without the need for autologous tumor. Excluding the need for antigenic stimulation by autologous tumor may prove useful in adoptive immunotherapy procedures.


Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck. The pectoralis major myocutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant donor site deformity, especially in women. This study compared 30 patients with major head and neck cancer-related defects who underwent reconstruction with a rectus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was significantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruction methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.


Postlaryngectomy quality-of-life dimensions identified by patients and health care professionals. We compared the quality-of-life (QOL) dimensions after laryngectomy in patients with advanced larynx or pharynx cancer that were elicited from 20 consecutive laryngectomy patients and 20 health care professionals working in the Regional Head and Neck Oncology Service. Subjects in both groups were asked to identify important QOL items after recovery from laryngectomy and to rank and rate each on a vertical visual analogue scale. Health care professionals ranked impaired communication and self-image/self-esteem as the two most important QOL dimensions, whereas patients ranked the physical consequences of surgery, e.g., tracheal mucous production, and interference with social activities as the two most important items. The results indicate that the responses of health care professionals do not fully correlate with patient priorities. These findings are relevant to researchers developing treatment-specific QOL measures and to health care professionals when presenting treatment options to patients.


Optimizing primary treatment for advanced laryngeal and pyriform sinus carcinoma. Advocates of chemotherapy plus radiation as the definitive treatment for patients with advanced laryngeal cancer often cite older studies that attribute cure rates of less than 50% to laryngectomy plus radiation. The outcomes of patients with stage III and IV laryngeal and pyriform sinus carcinoma from 1980 to 1989 (96 patients) were compared with those of patients treated from 1962 to 1977 (84 patients). Demographics, the extent of disease, and nodal involvement were similar between the groups. There were more operative complications (45% versus 22%; p < 0.01) and deaths (10% versus 2%; p < 0.01) in the patients who underwent irradiation preoperatively. Overall survival was improved in the recent group compared with the early group (73% versus 54% at 5 years; p < 0.03), as was disease-free survival (64% versus 38% at 5 years; p < 0.02). Results of treatment for advanced laryngeal and pyriform sinus carcinoma have improved significantly. These modern results should be used to evaluate newer treatment modalities.


Identification of the external branch of the superior laryngeal nerve during thyroidectomy. Seventy-six patients underwent preoperative vocal evaluation and were randomized into 3 groups: (1) those with the superior thyroid pole dissected by the first author, with the external branch of the superior laryngeal nerve (EBSLN) identified by means of a nerve stimulator; (2) those patients whose dissection was executed by a resident, with no nerve search; and (3) those whose dissection was undertaken by the first author, without any nerve search. Postoperative analysis consisted of voice evaluation and electromyography of the cricothyroid muscle. No lesion occurred in patients in group 1. Twenty-eight percent of patients in group 2 and 12% in group 3 experienced a complete lesion of the EBSLN (p = 0.0123). When the patients in group 1 were compared with the patients with 62 nerves corresponding to nonoperated thyroid lobes, patients in group 1 exhibited no increased risk, whereas a significantly increased hazard was evident in both groups 2 (p = 0.0002776) and 3 (p = 0.0346393). In this study, effective prevention of iatrogenic EBSLN lesions during thyroidectomies was achieved only by the intraoperative identification of the nerve with the nerve stimulator.


DNA image cytometric analysis of differentiated thyroid adenocarcinoma specimens. A total of 117 differentiated thyroid adenocarcinomas that had been removed by total thyroidectomy were studied. Seventy (60%) were papillary, 36 (30%) were follicular, and 11 (10%) were Hürthle cell adenocarcinomas. The mean length of follow-up was 57.7 months. Adverse prognostic factors according to multivariate analysis were adjacent tissue infiltration (p = 0.0004), histologic type (p = 0.0049), and patient age (p = 0.033). The nuclear DNA content of tumor cells and of morphologically normal adjacent tissue was assessed by image cytometry, and correlations between nuclear DNA content and prognostic factors were examined. Fifty-four (75%) adenocarcinomas were classified as aneuploid, 9 (13%) as diploid, and 9 (12%) as borderline. Thirty-four (60%) specimens of morphologically normal adjacent tissue were classified as aneuploid, 18 (32%) as diploid, and 5 (8%) as borderline. The correlation between tumor ploidy and selected prognostic factors was statistically significant for patient age (p = 0.004) and histologic type (p = 0.033). Despite the fact that ploidy could not be identified as a prognostic factor, we suggest that, because of its correlation with age and histologic type, it might prove prognostic if the number of patients were increased. We also emphasize the importance of evaluating morphologically normal adjacent tissue because of the high rates of aneuploidy in these areas.


Temporal bone resections for carcinoma of the middle ear and the external ear canal. Petrosectomy has been used in the management of carcinoma of the external ear canal and the middle ear for the last 45 years. In recent years, there have been conflicting reports; some authors advocate a conservative approach, whereas others support an ultraradical approach. Most retrospective studies report patients who have been treated with radiotherapy or surgery as having undergone the primary modality depending on where the patient first presented. No selection criteria seem to have been employed. Although radiotherapy was used postoperatively, the problems of wound healing were not addressed. This study presents our experience with temporal bone resection as described by Lewis and shows that, in combination with patient selection and proper choice of incision, reconstruction and timely postoperative radiotherapy can achieve better results, and the patient's quality of life can be preserved.


p53 overexpression correlates with increased survival in patients with squamous carcinoma of the tongue base. Epidermal growth factor receptor (EGFR), transforming growth factor alpha (TGFA), and p53 are frequently overexpressed in squamous cell carcinomas (SCC) of the upper aerodigestive tract. We chose to study SCC of the tongue base, which is often advanced at presentation and fatal, to evaluate whether overexpression correlates with survival. Complete follow-up was available for 20 patients, 18 of whom had stage III or IV disease. A number of clinical (age, sex, stage of disease) and histologic (tumor grade, keratinization, mitotic rate, perineural invasion, lymphatic invasion, vascular invasion, host response) variables were analyzed. None of these variables correlated with survival. Immunohistochemical analysis was performed on paraffin-embedded tissue from each patient. Because EGFR and TGFA expression were routinely found in normal squamous epithelium, overexpression was considered present if greater uptake of the antibody was manifested by a deeper immunostain. In contrast, p53 oncoprotein was not detected in normal epithelium, so detection of the antibody was believed to indicate overexpression. EGFR was overexpressed in 60% of tumors, TGFA in 35%, and p53 in 20%. Those patients who had an overexpression of p53 had a greater mean survival than those who did not (48 versus 16 months, respectively, p = 0.06). This difference was significant for patients with clinical stage IV lesions (p = 0.03). EGFR overexpression and TGFA overexpression did not correlate with survival. p53 may serve as a biologic marker indicative of improved survival potential.


Role of ultrasound in the management of thyroid nodules. One hundred twenty patients undergoing thyroid surgery for thyroid nodules or goiter were examined by preoperative ultrasound and fine needle aspiration (FNA) cytology. In the determination of whether a lesion was malignant, FNA had sensitivity, specificity, and positive predictive values of 86%, 85%, and 58%, respectively. Ultrasound had sensitivity, specificity, and positive predictive values of 74%, 83%, and 51%, respectively. The different types of thyroid pathology showed different ultrasonic features in most cases, although no single feature was pathognomonic. Malignant lesions tended to be solid and hypoechoic without a halo, but there was a cystic element in 26% of the lesions and calcification in 37%. Ultrasound was superior to FNA in diagnosing nodular goiter with sensitivity, specificity, and positive predictive values of 70%, 93%, and 92%, respectively, compared with 55%, 86%, and 83%, respectively. The two modalities are complementary.


Prognostic factors in differentiated carcinoma of the thyroid gland. A retrospective review of a consecutive series of 931 previously untreated patients with differentiated thyroid carcinoma treated over a 50-year period was undertaken to analyze prognostic factors. Data pertaining to demographic status, clinical, operative, and pathologic findings, and survival were analyzed. Univariate statistical analysis was performed based on the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed to assess the independent effect of these variables using the Cox model. There were 630 female and 301 male patients, with an average age of 43 years. A total of 532 patients were younger than 45 years. Seven hundred thirty-one patients had either pure or mixed papillary carcinoma, and 200 had follicular carcinoma. In 153 patients, lesions were larger than 4 cm. Extrathyroidal extension was noted in 71 patients. Multifocal lesions were present in 159 patients. Regional lymph node metastasis was present on admission in 451 patients, and distant metastases were noted on presentation in 45 patients. Determinate survival for all patients was 87% at 10 years. Favorable prognostic factors using univariate analysis included female gender, multifocal primary tumors, and regional lymph node metastases. Adverse prognostic factors included age over 45 years, follicular histology, extrathyroidal extension, tumor size exceeding 4 cm, and the presence of distant metastases. On multivariate analysis, the only factors that affected the prognosis were patient age, histology, tumor size, extrathyroidal extension, and distant metastases. These observations support findings of reports from the Mayo Clinic and Lahey Clinic regarding the significance of prognostic factors for differentiated carcinoma of the thyroid gland.


Healing of microvascular free skin flaps in irradiated recipient tissue beds. This laboratory study compared the biomechanical and biochemical healing of microvascular free skin flaps in irradiated and nonirradiated recipient areas. In the adult rat, the skin of the right groin region was exposed to a single fraction dose of 20 Gy, using a linear megavoltage accelerator. The left groin was shielded. One week after radiotherapy, the left femoral artery and vein were divided, and an anastomosis was created in situ at the site of the epigastric pedicle. The epigastric skin flap was crossed over to replace the central area of the irradiated skin in the contralateral right groin. The healing of the interface between the irradiated recipient skin and the transferred free epigastric flap was studied at 4 weeks. A comparison was made with the microvascular free flaps of nonirradiated control animals. An additional group of control animals was used to verify the retarding effect of the 20-Gy radiation dose on wound healing. In control animals, the single dose of 20 Gy decreased the tensile strength of standardized surgical wounds by 23% (p = 0.03). Clinical healing of the transferred microvascular free flaps between the irradiated and control recipient areas was comparable, and the flaps showed no significant differences in the mechanical incorporation. The biochemical assays of the DNA, RNA-ribose, total nitrogen, and hydroxyproline contents of the flap showed an increased concentration of proteins (total nitrogen) expressed per cell count (DNA) (25%, p = 0.04), reflecting the excessive accumulation of organic matrix and a relatively decreased number of cells in irradiated recipient tissues. We conclude that there are no major differences in the healing capacity of microvascular free skin flaps between irradiated and nonirradiated recipient areas.


Value of fine needle aspiration biopsy of salivary gland masses in clinical decision-making. The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physician's initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses.


Prognostic factors and management considerations in patients with cervical metastases of thyroid cancer. Included among the controversies involving thyroid cancer are the risk factors and treatment decisions in patients with nodal metastases. We have reviewed selected clinical, pathologic, and therapeutic parameters in patients who present with cervical node metastases and related these parameters to disease outcome. There were 108 patients (68 women, 40 men), who had a mean age of 54 years. Univariate analysis showed a significantly increased risk of recurrence to be associated with the presence of primary tumor invasion (vascular, lymphatic, nerve, or muscle), the age and sex of the patient, the presence of mediastinal nodes, and adjuvant treatment with iodine 131. The presence of tumor invasion, the age and sex of the patient, and the presence of mediastinal nodes were significantly associated with higher rates of recurrence when tested by multivariate analysis. The 5- and 10-year disease-free survival rates were 76% and 72%, respectively, with a mean follow-up of 86 months. A comparison of recurrence and survival rates in thyroid cancer patients who were either node positive or node negative during the same 10-year period (152 patients) showed no statistically significant differences. However, node-positive patients with the risk factors of tumor invasion, age over 45 years, and positive mediastinal nodes had more aggressive disease. Although thyroid cancer patients with nodal metastases generally have a good prognosis, high-risk subgroups have been identified who may benefit from a more aggressive therapeutic and follow-up approach.


Osseointegrated implants and functional prosthetic rehabilitation in microvascular fibula free flap reconstructed mandibles. The mandibulectomy deformity can be alleviated by immediate mandibular reconstruction using the microvascular fibula free flap. Before the advent of microvascular reconstruction, conventional and maxillofacial prosthetic rehabilitation offered limited success after surgery due to the failure to reestablish the bony foundation and soft tissues (tongue, floor of mouth, vestibule) anatomically and physiologically. With proper multidisciplinary pretreatment planning and postoperative treatment, osseointegrated implants can be strategically placed in patients with these reconstructed mandibles to restore occlusal and masticatory function. The records of seven patients who underwent reconstructive surgery and osseointegrated implants were reviewed, with an emphasis on the variety of prosthetic designs and principles used to maximize long-term efficiency and preservation of tissues.


Prognostic factors for survival in patients with T3 laryngeal carcinoma. In a total of 511 patients with T3,N0-3,M0 laryngeal carcinoma, 24 possible prognostic factors were analyzed retrospectively. The factors were age, sex, mode of treatment, duration of several clinical symptoms, the presence of sore throat, otalgia, dyspnea, and dysphagia, previous tracheotomy, tumor extension, lymph node status (five items), histologic grading, smoking habits, and alcohol intake. For 300 patients in whom surgery was part of the primary treatment, pathologic staging of the primary tumor and of lymph nodes in neck dissection specimens, cartilage invasion, radicality of the operation, differentiation grade, and subglottic extension ware also evaluated. In a univariate analysis for the whole group, tumor extension (limited to the glottic region), lymph node status (clinically palpable lymph nodes, cytologically confirmed positive lymph nodes), level of lymph node metastasis (high and midjugular site), histologic grading (poor differentiation grade), and treatment modality (planned combined therapy) were considered to be prognostic factors of corrected actuarial survival. In the group that underwent surgery, all factors derived from specimens of the larynx and neck dissections had prognostic significance. Multivariate analysis revealed that the glottic site of the tumor, the presence of cyto- and histopathologically proven metastatic lymph nodes, pretreatment tracheotomy, positive resection margins, and planned combined treatment had a significant influence on corrected actuarial survival.


Health Locus of Control in Chukotka children. Two groups of children in the cities of Anadyr and Pevek in the Chukotka Region of the Soviet Far East were administered a Russian translation of the Children's Health Locus of Control Scale in July, 1991. Results were analyzed to assess the similarities between response patterns among the Russian children and those found in American children. The analyses revealed a consistency in the data suggesting both face and theoretical validity of the Scale. It appears that the underlying mediating variable related to the children's perceived control over their health is operating in this Region of Russia in much the same way that it does in the United States.


The Alaska Trauma Registry.

The Alaska Trauma Registry. Recognizing that injury is the leading cause of death and disability for virtually all age groups in Alaska, a trauma task force was developed in the Anchorage area in the early 1980s. This task force established the trauma registry pilot project in the state of Alaska. The Emergency medical Services Section, Department of Health and Social Services provided the funding to the Southern Region Emergency Medical Services Council, Inc. and the Alaska Chapter of the American College of Surgeons Committee on Trauma to develop this pilot project. The funding originated from a federal grant from the National Highway Traffic Safety Administration. Seven hospital participated in the pilot project which lasted approximately two and one half years. There were 5,087 entries into the registry with information on 4,860 patients. The rationale, methodology, and development of the registry, as well as some of the data accumulated is presented. The potential usefulness of the registry as a quality improvement tool and as an extensive data base for injury prevention and trauma care research also is discussed.


Peripherally inserted central catheters--review and case reports. Patients have been receiving intravenous therapies in their homes since the early 1980s. Peripherally inserted central catheters have recently played a major part in the successful transition from hospital to home. These catheters are less invasive, have a lower overall infection rate and are less costly than other central venous catheters. This review and presentation of two case studies illustrates the advantages of this type of catheter for patients receiving home intravenous therapy.


A weekend with Joseph Lopiccolo, M.D.

A weekend with Joseph Lopiccolo, M.D. There were many interesting issues discussed at the workshop and I will explore them more in-depth in later issues. For now, enjoy the transitions of the season and I'll be returning back to infertility in the next issue.


Where is the drug problem?

Where is the drug problem? This article traces the history of drug use from its earliest use to the present time. It treats alcohol and the "other drugs," but deals more with alcohol since this has been the major drug of use. It outlines the many problems associated with use and abuse, the legislation passed as an effort to control these and finally, the effect of the Uniform Alcoholism Act of 1970. This was followed by changing public attitudes toward alcohol and the development of many effective treatment programs, while the "other drug" problem remains unresolved in spite of a similar attempt through the Uniform Controlled Substances Act of 1970.


[Premedication in retrobulbar anesthesia. A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam]. Benzodiazepines for sedation may decrease the PaO2, the arterial O2 saturation (SaO2), and the CO2 response more in the elderly than in the young. The purpose of this study was to assess changes in blood gases due to i.v. midazolam or sublingual flunitrazepam given as premedication in elderly patients for unilateral cataract surgery. METHODS. Fifty patients over 65 years of age with treated arterial hypertension and other co-existing diseases (ASA III-IV) were randomly assigned to have: (1) i.v. midazolam titrated until they became drowsy (17 patients; 2.85 +/- 0.84 mg [mean +/- SD]); (2) sublingual flunitrazepam (16 patients; 0.005 mg/kg); or (3) no sedation (17 patients; controls). On entering the operating theatre, the radial artery was cannulated and the first blood gas analysis was obtained. The premedication was then given. At 5, 10, 20, and 30 min after premedication, before and 10 min after retrobulbar block, before operation, 5 and 15 min after the beginning of the operation, 10 and 20 min after administration of 500 mg acetazolamide i.v. during the operation, and 10 and 20 min after the operation additional arterial blood samples were analysed (a total of 15 measuring points). Pulse oximetry, invasive blood pressure, and ECG were continuously monitored. All patients received oxygen 3 l/min during the operation by nasal cannula. Differences between the three groups were analysed by Student's t-test or U-test and a P value < 0.05 was considered significant. RESULTS. The patient demography, including duration of anaesthesia and operation, was similar in the three groups (Table 1). No significant differences were seen in heart rate, mean arterial pressure, PaO2, pulse-oximetric oxygen saturation (SpO2), base excess, or serum bicarbonate levels. The PaCO2 increased in patients after midazolam (P < 0.01) and flunitrazepam (P < 0.05) until the beginning of the operation compared with the control group (Fig. 3); 20 min after the operation there was still a significant difference between the midazolam group and the controls. SaO2 was significantly (P < 0.05) lower in the midazolam group 10 and 20 min after administration of premedication compared with the control group, but was within physiological limits (Fig. 5). Despite titration, 2 patients had severe respiratory insufficiency 3 min after midazolam: the SpO2 decreased below 85% and the paO2 below 55 mmHg. The paCO2 was higher (P < 0.05) in the midazolam group 10 min after acetazolamide compared with the controls. CONCLUSIONS. The results of the study show the potential hazards of i.v. midazolam in the elderly. If sedation is required for cataract surgery under local anaesthesia, we recommend sublingual flunitrazepam or the use of benzodiazepines with lower hypnogenic effects in the elderly. A thorough preoperative discussion of anaesthesia and the operation might be an adequate substitute for any premedication in high-risk patients; the best blood gas analysis results were obtained in the control group.


[Suppression of the adrenal cortex by enoximone. A proband study with documentation of the hemodynamic course]. In contrast to the bipyridine derivatives amrinone and milrinone, the phosphodiesterase III/IV inhibitor enoximone is an imidazolone that creates the possibility of inhibiting adrenal steroid synthesis, as has already been demonstrated for other imidazoles, e.g. ketoconazole and etomidate. To clarify this point we carried out a double-blind sequential study in seven healthy volunteers. METHODS. After obtaining the approval of the ethics committee and the written consent of the volunteers, 1.25 mg/kg enoximone or saline was infused intravenously over a period of 20 min using a randomized crossover design with an interval of at least 5 days between the two trials. Twenty minutes after administration of the drug, 250 micrograms ACTH was injected. Plasma cortisol was measured prior to stimulation of the adrenal cortex and 30, 60 and 120 min afterwards; levels of aldosterone and 11-desoxy-cortisol were determined after 60 min. Standard radioimmunoassays were used. Haemodynamic parameters were measured non-invasively. RESULTS. In contrast to the placebo, enoximone resulted in a significant (P < 0.01) increase in the cardiac index (from 3.2 +/- 0.7 to 3.9 +/- 0.9 l min-1 m-2) and heart rate (from 69 +/- 11 to 81 +/- 8 min-1) and a decrease in peripheral resistance (from 1120 +/- 202 to 894 +/- 183 dyn s cm-5); blood pressure fell only slightly. Following injection of ACTH there were significant increases in cortisol (from 63 +/- 29 to 274 +/- 58 micrograms/l), aldosterone (from 86 +/- 37 to 300 +/- 105 ng/l) (both P < 0.001) and 11-desoxycortisol (from 5.3 +/- 1.2 to 9.8 +/- 4.6 micrograms/l; P < 0.05). There was no difference between enoximone and placebo at any time (P > 0.2). CONCLUSIONS. This study confirms the inodilation caused by enoximone. The normal response to ACTH rules out a direct inhibitory effect of a loading dose of 1.25 mg enoximone on the adrenal cortex. As the concentration of the major metabolite of enoximone, the sulphoxide, has been shown to surmount that of the parent drug after 40 min, this also holds true for the metabolite. We conclude that in contrast to etomidate, which causes a substantial reversible adrenal suppression after a single dose of 0.2 mg/kg, enoximone 1.25 mg/kg did not interfere with corticosteroid synthesis or release. Taking into account the metabolism and pharmacokinetics of this inodilator, there is no reason to expect an inhibitory effect even after repeated dosage.


[Subdural intra-arachnoid spread of local anesthetics. A complication of spinal anesthesia]. Accidental subdural injections and catheterisations are a complication of epidural and spinal anaesthesia. The incidence of subdural spread in myelographies is estimated to be over 10% by the spinal technique. With spinaloscopy in an anatomic human model, we analysed the puncture process and the influence of different needle types on the incidence of subdural injection. We compared 22-gauge Sprotte, Quincke, and 18-gauge Tuohy needles in median and paramedian approaches with various bevel orientations. METHOD. The studies were performed in a preserved and recently expired cadaver donated to the Institut für Anatomie, Westfälische Wilhelms-Universität, Münster. The spinal column from T12 to S1, together with the back musculature (in order to preserve the normal curvature of the spine), were removed from the cadaver. Spinaloscopy was performed with a 4-mm endoscope with a 0 degree optic (Storz, Tuttlingen, Germany). All observations were made in the lumbosacral region of the dissected preparation. The endoscope was inserted from the caudal end of the spinal canal and, depending on the observations being made, the spinal canal was filled with air or artificial cerebrospinal fluid (CSF). To obtain information on the distribution of local anaesthetics injected into the subarachnoid space, 0.5% bupivacaine was coloured with a small amount of 1% methylene blue. The distribution of the coloured anaesthetic was clearly visible during and after injection. RESULTS. Needle insertion: Multiple observations were made using median or paramedian advancement of the needle into the spinal canal. With all needles, including the pencil-point, we saw an unexpected inward movement of the dura to the epidural space before penetration. This dural movement was independent of the direction of the dural fibres in the lumbar area. Distribution of local anaesthetics: Our observations indicate that difficulty with injecting drugs occurred when needle insertion was stopped too close to the dura, especially with the Sprotte needle. After manually registered penetration of the dura, the lateral opening of the needle only partially penetrates the dura. This allows CSF to appear in the needle hub, and injection into the vertical subdural space is possible. In all cases with the Sprotte needle, we could reproduce deposition of methylene-blue-coloured local anaesthetics into the subdural space. With the Quincke and Thuohy needles, it was not possible to deposit local anaesthetics into the subdural space in this model. CONCLUSION. Spinaloscopy was done in a non-fixated anatomic preparation of a spinal column with a 4-mm, 0 degree endoscope. From these observations we conclude that both manually registered penetration of the dural and the appearance of CSF in the needle hub can mimic correct needle position. Especially with the lateral opening of the Sprotte needle, deposition of local anaesthetics in the subdural space is possible.