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Abstracts of scientific papers.

Section on Cardiology

*N-Terminal Pro-BNP Levels in Patients with Congestive Heart Failure and Implantable Cardioverter-Defibrillator or Biventricular Pacemaker-Defibrillator Therapies.

Fabian Arnaldo, MD, Nikolaos Anatoliotakis, MD, David Nabert, MD, Steve Hsu, MD, University of Florida, Health Science Center Jacksonville, Shands Hospital, Jacksonville, FL.

Objectives: B-type natriuretic peptide (BNP) levels have been associated with sudden cardiac death among patients with congestive heart failure (CHF). However, the relationship between BNP levels and arrhythmogenic substrates is poorly understood. We assessed whether there is a correlation between N-terminal pro-BNP levels (ProBNP) and device therapies in patients with CHF and defibrillators (ICD) or biventricular pacemakers-ICD (BiV-ICD).

Methods: ProBNP levels were analyzed in 24 patients (19 men, age 64.2 [+ or -] 12 years) with dilated cardiomyopathy (DCM), CHF, and ICD or BiV-ICD. Levels were studied among patients with and without device therapies. In patients with therapies, baseline ProBNP measurements were compared with the closest-to-therapy level. A two-tailed paired t test analyzed differences of mean ProBNP plasma levels.

Results: Eighteen patients had ischemic and six nonischemic DCM; left ventricular ejection fraction. 25.1 [+ or -] 6.1%. Twelve patients had BiV-ICD and 12 had ICD. Ten patients received therapies during a mean follow-up of 171 days; five appropriate therapies for VT/VF and five inappropriate therapies for atrial tachycardia. No change in the functional class of CHF preceded device therapies. There was no difference between baseline ProBNP levels in patients with therapies versus no therapies (therapies, 1800 [+ or -] 1712 pg/mL; no therapies, 2587 [+ or -] 2433 pg/mL; P value, 0.56). In the group with therapies, closest-to-therapy ProBNP levels drawn within 3 days were higher than baseline levels in the limit of statistical significance (therapies, 3816.2 [+ or -] 2842 pg/mL vs baseline, 1860.6 [+ or -] 1398 pg/mL; P value, 0.05).

Conclusions: In patients with CHF and defibrillation devices, baseline ProBNP levels were not different among patients that received device therapies as compared with patients without therapies. Closest-to-therapy ProBNP levels showed a trend to higher levels as compared with baseline. More severe left ventricular damage and greater hemodynamic derangement may account for higher proBNP levels in patients with device therapies.

*Stress Troponin Radionuclide in Predicting Events Study (Stripes).

Esam Baryun, MD, James K. Crager, MD, Silvestre Cansino, MD, Todd Gress, MD, and Mark Studeny, MD. Department of Cardiovascular Services, Marshall University--Joan C. Edwards School of Medicine, Huntington, WV.

Objectives: Cardiac enzyme elevation and abnormal cardiac perfusion imaging have been shown to be strong predictors of cardiac events. No study to our knowledge was done to evaluate if post-exercise-stress troponin elevation has any prognostic value. This is the first study to address the hypothesis that stress test induced cardiac enzyme elevation could further enhance the predictive value of noninvasive testing.

Methods: Eighty-seven patients previously scheduled for outpatient exercise radionuclide stress testing were enrolled. Cardiac enzyme profiles were obtained immediately before and 18 to 24 hours after exercise stress test. After 6 months, patients were contacted to gather information about cardiac events. Baseline characteristics, enzyme levels, perfusion images, and 6-month event data were statistically analyzed.

Results: Major adverse cardiac events correlated with previously defined predictability of perfusion cardiac imaging. Patients with moderate to severe ischemia on myocardial perfusion scan had no troponin elevation.

Conclusions: Our small study suggests that routine cardiac enzyme evaluation during outpatient stress testing does not improve the predictive nature of radionuclide stress testing and therefore would not be cost-effective. Exercise-induced ischemia was not associated with troponin elevation.

*Hyperlipidemia Management in Patients Undergoing Percutaneous Coronary Intervention: A Comparison of Inpatient Versus Outpatient Population.

Farhan Aslam, MD, J.C. Blankenship, and T.R. McConnell. Geisinger Medical Center, Danville, PA.

Objectives: To compare the adequacy of hyperlipidemia management in patients who underwent percutaneous coronary intervention as inpatient versus outpatient.

Patients and Methods: We studied the first 60 inpatients and first 60 outpatients undergoing percutaneous coronary intervention after July 1999. Charts were reviewed with respect to lipid management from 6 months before and 6 months after the percutaneous coronary intervention. NCEP guidelines were used to determine the need for or adequacy of treatment. The primary end point was adequate evaluation and treatment of hyperlipidemia during the index PCI admission.

Results: Ninety percent of inpatients versus 50% had lipid profiles done during the index admission (P = 0.001); 40% of inpatients vs 60% of outpatients who were checked were found to have elevated cholesterol or LDL levels (P = 0.07). Of patients with the hyperlipidemia diagnosed during index admission, 92% of inpatients vs 65% of outpatients had treatment started; 65% of inpatients vs 35% of outpatients had lipid levels mentioned in the discharge instructions (P = 0.005).

Conclusions: Patients who underwent PCI as an outpatient received significantly better diagnosis and management of hyperlipidemia as compared with patients who had elective procedures done as an outpatient. These results suggest that a more aggressive approach is needed in diagnosis and managing hyperlipidemia during the brief admission for elective PCI.

Section on Emergency Medicine

The Chitosan-Based Hemostatic Dressing: Experience in Current Combat Operations.

John G. McManus, MD, Ian Wedmore, MD, Anthony E. Pusateri, PhD, and John B. Holcomb, MD, US Army Institute of Surgical Research, Fort Sam Houston, TX, and Madigan Army Medical Center, Fort Lewis, WA.

Background: Hemorrhage remains a leading cause of death in both civilian and military trauma patients. The HemCon[R] chitosan-based hemostatic dressing is a US Food and Drug Administration (FDA)-approved bandage for hemorrhage control. Previous animal data have shown the HemCon[R] dressing to reduce hemorrhage and improve survival. The purpose of this case series is to report the hemostatic efficacy of the dressing in combat casualties.

Methods: A request for case information on use of HemCon[R] dressings in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) was sent to combat medics, physicians, and physician assistants.

Results: Forty-eight uses of the HemCon[R] dressing were reported and reviewed by two US Army emergency medicine physicians. Four of the 48 cases were determined duplicative, resulting in a total of 44 combat uses. Dressings were used externally on the chest and abdomen in 19 cases, on extremities in 23 cases, and on neck or facial wounds in two cases. Dressings were appropriately used after gauze failed 66% of the time. In 42 (95%) of the cases, the use of the HemCon[R] dressing resulted in a cessation or marked improvement in hemostasis. Dressings were reported to be most useful in areas where a tourniquet could not be applied to control bleeding. The dressings were reported to be most difficult to use in extremity injuries where they could not be easily placed onto or into the wounds. No complications were reported.

Conclusions: The HemCon[R] dressing appears to be an effective hemostatic agent for combat casualties.

Recurrent Pericardial Effusion in a Patient After Pericardial Window.

Christine M. Carr, MD, FACEP, Sam Kini, MD, FACEP, and Jen Stoeber, MS. Division of Emergency Medicine, Department of Internal Medicine, Medical University of South Carolina, Charleston, SC.

Background: A 45-year-old white female presented to the Emergency Department (ED) with a 4-day history of worsening chest pain and shortness of breath. The patient was status post an allogenic stem cell transplant in 2001 secondary to a myeloproliferative disorder and had a medical history significant for graft-versus-host-disease, CMV-positive antigenemia, hypertension, and mitral valve prolapse and history of acute renal failure secondary to cyclosporine, currently resolved. She was hospitalized in October 2004 for recurring episodes of chest pain and shortness of breath.

Methods and Results: One week before being seen in our ED, the patient was seen by a physician in Chicago who diagnosed her with acute pericarditis and started her on naprosyn. She had some relief but presented to our ED 1 week later after her symptoms worsened. In our ED the patient was found to have tachypnea, JVD, hypotension, and an enlarged cardiac silhouette on chest x-ray. She was also found to have pulsus paradoxus of 14 mm Hg. An emergent echocardiogram was performed at this time, which showed a large circumferential pericardial effusion with diastolic collapse of the right ventricle consistent with pericardial tamponade. After becoming unstable in the ED, the patient was taken emergently to the OR, where a pericardial window was placed and approximately 700 mL of blood-stained fluid was drained acutely. An extensive workup was done because of the concern for an infectious cause of the pericarditis secondary to her stem cell transplant and immunosuppressive medications including aerobic, anaerobic, fungal, and AFB cultures, which were all negative. A CMV PCR was also negative. Titers for EBV, HSV, Coxsackie A9 and B, and HIV were all normal. ANA titers were also negative. Her pericardial biopsy at the time of the window showed fibrinous pericarditis. The hematology consultant did not believe the pericardial effusion was related to her stem cell transplant or was consistent with graft-versus-host disease. Ultimately the pericardial effusion was believed to be idiopathic in nature and to have occurred as a result of her acute pericarditis the preceding week. After the pericardial window, a chest x-ray revealed a left retrocardiac opacity concerning for pneumonia versus atelectasis. To further delineate these possibilities, the patient underwent a CT scan of the chest that showed moderate bilateral effusion with associated atelectasis but no evidence of pneumonia. She was still given a 7- to 8-day course of tequin during hospitalization to ensure that a possible infectious pulmonary process was not occurring. A follow-up echocardiogram was performed several days before discharge, which showed no evidence of a pericardial effusion. The patient had an uneventful recovery with no further complaints of tachypnea and was discharged on a 2-week course of NSAIDs. Two weeks later, the patient presented for a second time to our ED with symptoms similar to her first ED visit but with less intensity. A bedside echocardiogram done in the ED showed a normal ejection fraction and a small to moderate circumferential pericardial effusion without evidence of tamponade. Her blood pressure was stable, with a systolic pressure at her baseline in the 90s and no evidence of pulsus paradoxus. She was admitted to the inpatient cardiology service and placed on the cardiology telemetry unit at this time with her electrocardiograms continuing to show diffuse ST-segment elevation with TR depression consistent with pericarditis. It was believed that she had recurrent pericarditis with effusion and without evidence of tamponade. Due to the recurrence of this patient's pericarditis on high-dose NSAIDs, it was decided to initiate a therapy of colchicines and a slow steroid taper. The patient was begun on prednisone 60 mg PO qd and colchicines 0.6 mg PO qd. Soon the patient was ambulating with only mild pain and was discharged on cColchicine, prednisone taper for 20 days, Protonix 40 mg PO qd, acyclovir 800 mg PO bid, cellcept 500 mg PO bid, and penicillin 250 mg PO bid. This case is unique because of the recurrence of the pericardial effusion even after the pericardial window and drain, Currently, the placement of a pericardial window and subsequent subxiphoid drainage is recognized as a relatively safe and effective treatment of pericardial effusions and cardiac tamponades. Recurrence percentages have remained low in most patients. One article looked at the long-term results of this type of surgical treatment and concluded that "subxiphoid drainage provides a simple, safe, and expeditious treatment of most symptomatic pericardial effusions, with one in 10 patients requiring a repeat drainage for recurrence." The authors suggest a routine echocadiogram at 1 and 6 months to try to catch the recurring effusions. A study from 1995 found that recurrent pericardial effusions necessitated "further surgical intervention ... in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients." A recent study in July of 2003 reported similar results with similar conclusions that stated that "the technique provides accurate diagnosis and effective, durable treatment ... Our results compare with those reported in literature: the operation-related mortality rate was 4.8% and the recurrence rate of the pericardial effusion was 2%."

Conclusions: Although a subxiphoid drain is the current recommended treatment for cases involving a pericardial effusion with subsequent tamponade, the risk of recurring effusions even after surgical drainage remains between 0 and 9.1%, as reported in literature. Patients who undergo this procedure should maintain close follow-up with their physicians and undergo periodic echocardiograms, and clinicians should be attentive to signs and symptoms suggestive of recurrent effusions and treat accordingly.

Cardiac Arrest of Visitors in a Hospital Public Area: Bystander AED is Faster than Standard Cardiac Arrest Team.

LTC Bruce D. Adams, MC, USA, CPT Peter I. Anderson, USAF, MC, FS, and Elaine Stuffel, RN. Brooke Army Medical Center, San Antonio, TX.

Background: Time to defibrillation directly correlates with cardiac arrest mortality. Approximately 1% of in-hospital cardiac arrests will occur in visitors or staff within the building's public areas such as its pharmacy waiting area, gift shop, lobbies, or food courts. Unfortunately, recent evidence shows that standard hospital cardiac arrest team responses within these public areas can be delayed and associated with poor survival outcomes. We investigated whether a bystander automatic external defibrillator (AED) model might improve time to defibrillation for these special locations.

Methods: We simulated the sudden ventricular fibrillation cardiac arrest of a visitor in the hospital lobby by use of a CPR mannequin and a rhythm simulator. Our study compared a standard hospital cardiac arrest team model (whereby the designated cardiac arrest team transports the nearest standard manual defibrillator on a crash-cart to the patient) with that of a bystander AED model (whereby volunteer bystanders use a wall-mounted public access AED). We performed 23 trials for each cohort. We recorded the Utstein-based response intervals for time of collapse; time of arrival of CPR team or bystander with AED; and time of first defibrillatory shock (the primary outcome).

Results: The bystander AED model time to defibrillation was more then twice as fast as the cardiac arrest team model (88.0 seconds vs 196.2 seconds, P < 0.01). The difference resulted predominantly from the improvement in response time (20.4 vs 72.2 seconds, P < 0.01).

Conclusions: Reducing the time to defibrillation can directly reduce mortality rates from cardiac arrest. Our findings demonstrate that a bystander AED response system for the public areas of a hospital can improve this critical parameter by nearly 2 minutes. We propose further research to determine whether prepositioning of AEDs into these public areas improves survival outcomes of cardiac arrests among hospital visitors and staff.

Change in Mental Status from Cerebral Neurocysticercosis.

Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Background: There are a myriad of causes for depressed mental status in adults. However, neurocystercicosis is a rare cause in the United States. A 36 year-old Hispanic male presented with a fall from a witnessed generalized seizure and a large frontal scalp contusion.

Methods and Results: PMH included some unknown brain infection. He took no medication. He drank alcohol occasionally but did not smoke or use illicit drugs. He had a temperature of 36.0[degrees]C, heart rate of 86/min, and respiratory rate of 16/min. His physical examination showed an awake and oriented male. His scalp showed a 6 X 3-cm frontal contusion. There was no obvious deformity to the underlying bones. The remainder of the examination was normal. His 12-lead ECG was normal. His head CT showed a large frontal scalp hematoma. There was an area of low attenuation in the subcortical white matter of the parietal lobe. There were multiple calcifications, which were are consistent with neurocysticercosis. Worldwide neurocysticercosis in the most frequent parasitic disease of the central nervous system. It is the main cause of acquired epilepsy in developing countries and is a growing problem in industrialized countries because of immigration of tapeworm carriers from endemic areas. It results from the ingestion of eggs of Taenia solium (pork tapeworm). Most patients are asymptomatic, but some report headache or dizziness. Epilepsy is the most common presentation, which can be partial or generalized. Other neurologic manifestations include strokes, neuropsychiatric disturbances, diplopia, and hydrocephalus. The diagnosis is easily obtained with CT scan of the head. The vesicular stage shows as a low-density lesion and the colloid stage as a ring enhancing lesions; the calcified stage is caused by dead cysticercosis.

Conclusions: Treatment depends on whether the organism is alive or dead. If alive and evidence of vasculitis, arachnoiditis, or encephalitis, a course of anticysticercal drugs is indicated. If the parasite is dead, treatment is aimed at controlling symptoms. Seizures should be controlled with antiepileptio drugs.

Etiology of Acute Life-Threatening Events in the Emergency Department.

Antonio E. Muniz, MD, Sam Bartle, MD, Chris Woleben, MD, Robin L. Foster, MD, and Steve Liner, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Objectives: An acute life-threatening event (ALTE) can be anxiety-provoking for families and physicians. Few data exist on the diagnostic approach of these infants when presenting to an emergency department. The objective of this study was to determine the underlying causes and diagnostic procedures performed on these infants.

Methods: Prospective evaluations of consecutive infants presenting with an acute life-threatening event. There were no patients excluded.

Results: There were 102 infants; 64 (62.7%) males. There were 62 (60.7%) blacks, 29 (28.4%) whites, 8 (7.8%) Hispanics, and 3 (2.9%) other race. The mean age was 4.9 [+ or -] 0.79 months (95% CI, 3.36; 6.48 months old), with a range of 2 days old to 4 years old. Apnea was seen in all infants and cyanosis was present in 54 (52.9%), hypotonia in 8 (7.8%), and bradycardia in 8 (7.8%). A history of GERD occurred in 13 (12.7%); prematurity was seen in 27 (26.4%). Fever was seen in 5 (4.9%). The EMS system was utilized 22 (21.5%), and 4 (3.9%) required mouth-to-mouth ventilations. Diagnostic tests included CBC count, 68 (66.6%); basic metabolic profile, 62 (60.7%); urinalysis, 47 (46%); blood culture, 49 (48%); urine culture, 45 (44.1%); CXR, 46 (45%); and lumbar puncture, 34 (33.3%). There were 73 (71.5%), with 4 (3.9%) requiring endotracheal intubation. The diagnoses included GERD, 44 (43.1%); idiopathic apnea, 35 (34.3%); UTI, 4 (3.9%); RSV, 4 (3.9%); seizure, 3 (2.9%); periodic breathing, 3 (2.9%); breath-holding spell, 2 (0.19%); pertussis, 2 (1.9%); VP shunt malfunction, 1; SVT, 1; viral meningitis, 1; croup, 1; and pneumonia, 1.

Conclusions: The majority of causes of infants presenting with ALTE in this study included GERD and idiopathic apnea. The utility of diagnostic tests in infants presenting with ALTE is low and the majority of these patients can be managed with a limited diagnostic evaluation and a period of observation.

Gastrointestinal Bleeding in Children Presenting to the Emergency Department.

Antonio E. Muniz, MD, Sam Bartle, MD, Chris Woleben, MD, Robin L. Foster, MD, and Steve Liner, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Objectives: The evaluation of children with gastrointestinal bleeding (GIB) in children is controversial. The purpose of this study was to describe the epidemiology of GIB in children and to evaluate the efficacy of diagnostic tests used to evaluate these children.

Methods: Prospected evaluation of consecutive children less than 18 years old presenting to the ED with gastrointestinal bleeding. There were no children excluded.

Results: There were 146 patients, with 74 (50.7%) females. The mean age was 4.1 [+ or -] 5.4 years (95% CI, 3.2; 5.0 years), with a range from 1 day old to 17 years old. There were 136 (63%) blacks, 44 (30.1%) whites, 5 (3.4%) Hispanics, and 5 (3.4%) other race. Hematemesis occurred in 29 (19.8%), melena in 1 (0.6%), bright red blood from the rectum in 109 (74.6), abdominal pain in 27 (18.4%), and diarrhea in 28 (19.7%). Diagnostic tests included CBC count, 37 (25.3%), with 2 patients with anemia and PT/aPTT 2 (1.3) both being normal. A nasogastric tube lavage was performed in 4 (2.7%), with 1 showing coffee ground material. There were 100 (68.4%) with lower GI bleeding (LGIB), 27 with (18.4%) upper GI bleeding (UGIB), and 19 (13%) with no evidence of GI bleeding. The diagnosis of the UGIB included gastritis/PUD, 15 (10.2%); GERD, 3 (2%); varices, 2 (1.3%); Mallory-Weiss tear, 1; and hyperemsis, 1. The diagnosis of LGIB included gastroenteritis, 33 (22.6%); anal fissure, 17 (11.6%); milk-protein allergy, 14 (9.5%); intussusception, 12 (8.2%); constipation, 8 (5.4%); hemorrhoids, 6 94.1%); volvulus, 4 (2.7%); Crohns, 3 (2%); diaper rash, 3 (2%); perianal streptococcus, 2 (1.3%); anal abscess, 2 (1.3%); ulcerative colitis, 2 (1.3%); mucositis, 2 (1.3%); Meckel diverticulis, 1; coagulopathy, 1; and pyloric stenosis, 1. The diagnosis for those with no GI bleeding included swallowed maternal blood, 5 (3.4%); and thrush, 1.

Conclusions: A complaint of GI bleeding is typically not life-threatening in children. Most cases are from lower GI bleeding and when not associated with diarrhea may have significant causes and warrant a thorough evaluation.

Section on Family Practice

*Descriptive Analysis of Perinatal Factors Among Womean and Vital Statistics of Children Under Age 5 from Various Races in Urban Upstate NY.

Sonali Patel. St. Clare's Hospital Family Health Center, Schenectady, NY.

Objectives: To compare factors relating to pregnant women and vital statistics relating to children of different races from an urban area catered to by a family medicine residency program.

Methods: One hundred fifty records pertaining to children below the age of 5 years were randomly reviewed and categorized by race (Hispanic, black, white, Guyanese, and others). Comparisons were made as follows: perinatal factors: age at pregnancy, social factors, type of delivery, and type of feeds; factors relating to children: birth weight, immunization, growth and development, early intervention, and CPS involvement.

Results: Maternal outcomes: The mean age was lowest among Hispanics (23.5); 21% were teenagers, the youngest being 13. Smoking was highest among blacks (41%). Rates of NSVD and cesarean sections were similar across all races. All Guyanese and 29.3% of Hispanic women were married; 26.7% were employed; 59% bottle-fed, whereas 28% breast-fed, and a further 13% supplemented breast-feeds with formula. All Guyanese and 28% Hispanics breast-fed. Outcomes for children: The average birth weight was 6 lbs, 8 oz., and did not vary widely across the races. Only 5.7% of whites and 8.3% of blacks were below the 10th percentile for growth at 18 months; 95.3% of children met their immunization targets at 6 months, which dropped to 88.9% at 18 months; 21.6% of Hispanic and 17% of white children needed early intervention. CPS was involved with 13.3% of whites and 4% of Hispanics.

Conclusions: There is an alarming rate of teenage pregnancy among Hispanics. Conscious efforts must be made to encourage breast-feeding. Smoking cessation must be emphsized during pregnancy, using this platform to encourage quitting. In general, we did well with reference to rates of vaginal deliveries, birth weight, immunizations, and growth targets.

*Profile of Diabetes Among Immigrants from British Guyana in Schenectady County, NY.

A.S. Bachwani and E.E. Back. St Clare's Hospital Family Health Center, Schenectady, NY.

Background: Schenectady, New York, attracts a large number of Guyanese immigrants due to employment and entrepreneurial opportunities. We provide medical care to approximately 10% of the estimated 6000 immigrants. Physicians have noted a higher incidence of diabetes among relatively lean and younger adults that proves comparably difficult to treat. Literature pertaining to the Guyanese is sparse.

Objectives: Epidemiological: to create a database with an aim to increase awareness within the community and profile risk factors unique to this population; medical: to devise an effective strategy for prevention and treatment.

Methods: A cross-sectional review of 140 random records of resident Guyanese adults (>18 years) who were seen within the past 24 months. Data were compiled using MS-Excel and processed using EpiInfo.

Results: The mean age was 40.2 years (SD [+ or -] 14.9), of which 36.2% were male and 63.8% were female. Prevalence of diabetes was 32.6% (national prevalence, 6.3%). Comorbid hypertension was present in 81%, whereas hyperlipidemia was present in 56.7%. Approximately two thirds of the diabetics had a BMI less than 30, whereas 26% had normal BMI. Lipid profiles displayed low-normal HDL, with high triglycerides. Approximately 40% met criteria for metabolic syndrome X; 10.9% were smokers. None reported substance/alcohol abuse.

Discussion: A large proportion of the "at-risk" Guyanese population aged 25 to 60 years are deprived of health care due to economic constraints and lack of health insurance. Treatment needs to be tailored, depending on suspected biochemical abnormalities and physical profile.

Conclusions: The incidence of diabetes and hyperlipidemia was noted to be relatively higher among the Guyanese and appears to affect younger individuals. We propose this survey as a first step toward a comprehensive diabetic program among Guyanese immigrants, using the principles of community-oriented primary care to improve screening, spread awareness within the community, and provide culturally competent nutritional guidance.

*The Evaluation of Attention Deficit/Hyperactivity Disorder in Family Medicine Residency Programs.

Jason S. Lanham, MD. Lawrence Joel Army Health Clinic, Ft. McPherson, Atlanta, GA.

Objectives: To examine how physicians in family medicine residency programs evaluate for attention deficit/hyperactivity disorder (ADHD) in light of the Practice Guidelines for ADHD published by the American Academy of Pediatrics in 2000. These guidelines include screening for ADHD at routine visits and evaluating for coexisting behavioral conditions.

Methods: A mailed survey was used in a setting of 17 military and 17 civilian programs. The study population included staff and residents. All military programs and their neighboring civilian program were surveyed. Interventions included surveys containing 55 items that were mailed to each program for distribution.

Results: Main outcome measurements were adherence to published ADHD practice guidelines. Statistical tests used were descriptive statistics and [chi square] analysis of dichotomized ordinal variables. Two hundred thirty-five surveys were returned; 156 were from military physicians. Responses were received from each of the 34 programs. Thirty-seven percent of respondents were staff physicians. Only 22% of physicians are familiar with the AAP guidelines and only 12.9% of respondents screen for ADHD during periodic visits. Although staff physicians are more familiar with the guidelines (62.0 vs 31.4%, P < 0.001), no difference in screening rates was observed. Physicians familiar with the guidelines more often screen for ADHD (36.7 vs 20.1%, P = 0.042). Screening physicians assess for coexisting behavioral disorders on a more frequent basis (86.7 vs 67.9%, P = 0.036) and provide a more comprehensive evaluation. Seventy percent of physicians use a child's in-office behavior and 53% use a child's response to stimulants to aid in diagnosis.

Conclusions: Few physicians are familiar with the guidelines or practice their recommendations. The screening rate among all physicians is low. Physicians who screen regularly for ADHD provide a more comprehensive evaluation, to include coexisting disorders such as depression. Many physicians rely on unsound practices, such as response to medication, to make the diagnosis. Residency programs should ensure that the ADHD curriculum is guideline based.

Section on Gastroenterology

*Novel Hepatitis B Immunization Schedule: Seroefficacy of 0, 6 Weeks, and 9 Months Immunization Schedule (Along with DPT, OPV, and Measles) in Comparison to the WHO 0, 1, and 6 Months Schedule.

A.K. Jain and S.K. Mittal. Department of Pediatrics, Medical College of Georgia, Augusta, GA, and Department of Pediatrics, Maulana Azad Medical College, New Delhi, India.

Background: Hepatitis B is a serious global public health problem. The WHO schedule (0, 1, 6 months) for hepatitis B immunization does not coincide with the immunization schedule in developing countries (more than 1 billion people). This causes a great strain on health care facilities and greater immunization visits, resulting in poor compliance, greater dropout rates, incomplete dosing, and nonadherence to the immunization program.

Objectives: This study aimed to evaluate the adequacy of seroconversion when hepatitis B vaccine was given along with other vaccines in developing countries at 0, 6 weeks (along with DPT and OPV), and at 9 months (along with measles).

Methods: This was a randomized trial; 725 infants born to HbsAg-negative mothers were enrolled to receive the hepatitis B vaccine at 0, 6 weeks, and 9 months (group A) or 0, 1, and 6 months (WHO Schedule)--group B. Baseline HbsAg testing was done. Babies were immunized with the first dose of hepatitis B vaccine within 24 hours of birth. Other immunizations were given as per schedule. Serum samples were collected 4 weeks after second and third immunizations; 604 infants (83.3%) completed the study.

Results: The seroconversion rates 4 weeks after the second dose of the vaccine were 90.89% (GMT = 48.23) and 91.82% (GMT = 43.95) (P = 0.8) in group A and group B, respectively. After 4 weeks of the third dose, the seroconversion rates were 98.99 (GMT = 161.12) and 98.45 (GMT = 150.12) (P = 0.17) in group A and group B, respectively. The two schedules were comparable on using the Kruskal-Wallis H method for analysis.

Conclusions: The hepatitis B vaccination schedule of 0, 6 weeks, and 9 months has similar seroefficacy as the WHO schedule; it results in improved patient compliance and decreased health care burden. This schedule could be incorporated into the National Immunization schedules of developing countries.

Section on Medical Management and Administration

*Caring for Kids: A Case Study of Expanded Health Insurance in a Rural Alabama County.

Amit Sharma, MD, Bronwen Lichtenstein, PhD, and John Wheat, MD, MPH. University of Alabama at Birmingham, Birmingham, AL, and University of Alabama, Tuscaloosa, AL.

Background: In 1997, the average number of uninsured children in Bibb County was higher than for the state as a whole. Several key industries had left the area, unemployment had risen, and community-wide effects included declining school performance and child illness. The Bibb County Child Caring Initiative (BCCCI), created by a coalition of interested parties in 1996, coordinated two preexisting federal health plans (Medicaid, All-Kids) and offered insurance to other uninsured children through a state plan. By 2001, the goal of providing health coverage to all children in Bibb County seemed within reach. The present study was conducted as an evaluation of this program.

Objectives: To evaluate the BCCCI program by using parent satisfaction and community information on saturation levels as the defining measures.

Methods: Qualitative research methods were used in this study. In 2003, face-to-face interviews were conducted with 248 parents and with 23 key informants (employers, policy-makers, teachers, physicians, and a school nurse). Additionally, two focus groups of parents were conducted for in-depth information on child health insurance in Bibb County.

Results: The total number of uninsured children in Bibb County decreased over the study period, and parents were grateful for the opportunity to enroll their children in a health plan. Some discrepancies were reported, such as parents not receiving forms or not knowing about the BCCCI program, lengthy waiting periods, ineligibility, providers who billed patients, and in a few cases, discriminatory practices.

Conclusions: The BCCCI apparently improved access to health care for children in Bibb County. Currently, these gains are being threatened by the fiscal crisis affecting states' ability to fund insurance plans, unemployment, and rising premiums that affect parents' ability to provide health insurance for their children.

Section on Medicine

*Does Treatment of Asymptomatic Bacteriuria in Type 2 Diabetic Hispanic Women Reduce the Incidence of Symptomatic UTI?

Asma Ashraf, MD (Resident), James Hanley, MD, and Anshu Bhatla, MD. UTHSCSA-RAHC, Harlingen, TX.

Background: The prevalence of asymptomatic bacteriuria and symptomatic UTI is greater in women with diabetes when compared with women without diabetes. Although it is a common practice in the United States to treat asymptomatic bacteriuria in diabetic women, this is not a universal standard. A recent Canadian study showed that there was no benefit for screening and treating patients for asymptomatic bacteriuria in diabetic women. We had a unique opportunity to confirm this study in a Hispanic population. In our clinic, we observe that some physicians treat type II diabetic women with asymptomatic bacteriuria and others do not. We reviewed a cohort of patients who presented to the clinic in the year 2003 and compared the documented outcome over the course of 1 year between the treated and nontreated group.

Methods: This was a retrospective chart review of 105 women with asymptomatic bacteriuria, 18 years and older, with normal renal functions, followed for 1 year; 55 were in the nontreated group and 50 in the treated group. Asymptomatic bacteriuria was defined as no urinary complaints and positive leukocyte esterase on urinanalysis, which corresponds to 10 leucocytes HPF.

Results: At the end of 12 months, 43% of nontreated patients had bacteriuria compared with 56% of women who received antimicrobial agents. In the nontreated group, 5 of 55 women (9%) and in the treated group, 7 of 50 (14%) developed a symptomatic UTI. The women who received antimicrobial therapy were treated for more days and more than once because of persistence of bacteriuria.

Conclusions: Our study showed that treatment did result in short-term resolution of bacteriuria, but this did not reduce the incidence of complicated UTI in Hispanic women with type 2 diabetes mellitus. We do not recommend that these patients be screened, treated, or cultured.

*Can We Reduce Overuse of Indwelling Urinary Catheters?

Sam Featherston, MD, John W. Mann, MD, and Than Win, MBBS, FACP. Department of Internal Medicine Education, Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah, GA.

Background: An indwelling urinary catheter (IUC) is the major risk factor for nosocomial urinary tract infection. Studies showed persistence of unjustified and prolonged use of IUC.

Objectives: To determine if we can reduce inappropriate use and duration of IUC use by education and daily reminder.

Methods: We determined existing incidence, indications, duration, and appropriateness of IUC use by reviewing 428 hospital discharges from Internal Medicine Teaching Service between June and August, 2002. We then educated residents on the appropriate use of an IUC. We screened 651 consecutive admissions to the same service between January and May 2004 and followed patients who received an IUC. The resident concerned is reminded daily to review the need of an IUC. We collected data on indication, appropriateness, and duration of each IUC use.

Results: One hundred one of 428 patients (23.6%) in the control group and 110 of 651(16.9%) in the study group received an IUC. With intervention, incidence of IUC use declined from 23.6 to 16.9% (P = 0.0001). Inappropriate use of an IUC declined from 43.6% (n = 44) to 14.6% (n = 16) (P = 0.0001). Mean duration of inappropriate IUC use declined from 3.6 days to 2.1 days (P = 0.001). The majority of appropriate IUC use was for close monitoring of urine output in patients unable to collect urine (54 in the control group and 87 in the study group). Duration of IUC use in this cohort did not differ significantly.

Conclusions: With improved awareness of appropriate indications for IUC and reminder system, we can reduce the incidence and duration of inappropriate IUC use.

*Peripherally Inserted Central Catheter (PICC)-Associated Venous Thrombosis: Analysis of Risk Factors in a Large Cohort of Medicine Patients.

Melissa M. King, MD, Jason Stamm, MD, Mark Rasnake, MD, Rechell Rodriguez, MD, and Nancy Riley, RN, CRNI. Wilford Hall Medical Center, Lackland AFB, TX.

Background: PICC lines are increasingly common venous access devices used in medicine patients. Studies examining the incidence of PICC-associated deep venous thrombosis (DVT) have been small in nature and have not examined clinical factors associated with these DVTs.

Objectives: The objective of this study was to investigate in a large cohort of medicine patients the incidence of PICC-associated DVTs, to determine what clinical conditions were associated with an increased risk of thrombosis, and to examine if the use of prophylactic anticoagulants was beneficial.

Design: We performed a retrospective review of all adult patients who underwent placement of a PICC by the vascular nurses at our hospital over a 3-year period (n = 1296). All DVTs were symptomatic and confirmed by ultrasound (n = 27). Case patients were matched to control patients by age and gender. Clinical variables compared between the two groups included indication for PICC, history of cancer (excluding skin cancer), active cancer treatment, history of DVT or pulmonary embolus, diabetes mellitus, and use of prophylactic anticoagulation.

Results: The median age of the patients was 56 years. Indications for PICC placement in this group were antibiotics (65%), chemotherapy (19%), and parental nutrition (7%). The overall incidence of PICC-associated DVT was 2%. Indication for PICC placement, diabetes mellitus, and history of cancer or prior thrombosis were not associated with PICC-associated DVT. Active cancer therapy (OR, 3.5; 95% CI, 1.3 to 9.8) was significantly associated with PICC-associated DVT. The use of prophylactic anticoagulation did not influence the incidence of PICC-associated DVT.

Conclusions: Patients undergoing active treatment for cancer are at increased risk for PICC-associated DVT. This risk does not appear to be lowered by the use of standard prophylactic anticoagulation. These results suggest the need for future prospective studies of effective anticoagulation regimens for patients at high risk for PICC-associated DVT.

*The Etiology of Septic Meningitis in Community Teaching Hospitals Depends on Prevalence of HIV.

Robert Ferguson, MD, Jack D. McCue, MD, Shalinee Khurana, Tarik Haddad, MD, and Sy Sarkar, MD. Union Memorial Hospital and Franklin Square Hospital, Baltimore, MD.

Objectives: We studied the clinical and epidemiologic profiles and prevalence of meningitis in two community hospitals to determine whether presentations were different. We also recorded inpatient HIV prevalence and tried to determine whether bacterial meningitis (BM) could be distinguished from cryptococcal meningitis (CM) at the time of admission, based on clinical findings and cerebrospinal fluid analysis.

Methods: Franklin Square Hospital (located in a working class suburb) and Union Memorial Hospital (located in the inner city) are two community hospitals in Baltimore serving distinctly different populations. HIV prevalence at each institution was determined from DRG billing data. Positive CSF cultures, stains, and antigens were retrospectively identified through computerized microbiology logs in the time frame of January 1, 2001, through June 30, 2003.

Results: Two-year HIV prevalence was 2.8% at Union Memorial and 0.6% at Franklin Square. Twenty-eight cases of meningitis were identified: 15 C neoformans, 8 S pneumoniae, 3 N meningitides, and 2 S aureus. Eleven cryptococcal cases were identified at UMH compared with 4 at FSH, despite the latter having 20% more total admissions. The mean CSF cryptococcal antigen titer was 1:256 (all CM cases that were tested were positive); the mean serum antigen was 1:1026. In BM: mean CSF white count was 793; in CM, 26 (P = 0.035). The mean BM neutrophil percent was 93; in CM, 12 (P < 0.001). In BM, the mean total protein was 595; in CM, 96 (P < 0.001). The most diseriminating clinical findings were the presence of headache and insidious onset in CM and an abnormal CT and seizures in BM; 14% of CM patients died in the hospital; 32% of BM died.

Conclusions: We conclude that the prevalence of CM was proportional to the prevalence of HIV in each hospital and that CM and BM had distinctive laboratory profiles.

*An Artificial Lung: Liquid-Liquid Oxygen Transfer Via Dialysis Membrane.

N. Klawonn, MD, and A. Levitov, MD. Carilion Roanoke Memorial Hospital, University of Virginia Roanoke-Salem Program, Roanoke, VA.

Background: Current methods of positive pressure ventilation (PPV) are fraught with imperfection and limitation in spite of recent advances in ARDS treatment and the advent of ECMO. All aspects of mechanical ventilation produce or further exacerbate lung injury by oxygen toxicity, barotrauma, volutrauma, sheer trauma, and biotrauma; neither is adequate oxygen delivery guaranteed. Present ECMO is cumbersome, expensive, and not suitable for routine care of respiratory failure. Hemodialysis is largely free of those limitations. We attempted to use a dialysis membrane for oxygen exchange. Liquid-liquid gas exchange may be a cheap and effective alternative.

Objectives: Our objective was to prove the efficacy of liquid-liquid gas exchange by using Hemopure Blood Substitute (HBS) via dialysis filter extra corporeally.

Methods: HBS and donor blood (DB) were warmed to 37[degrees]C. The HBS was bubble-oxygenated in a reservoir bag with excess gas vented through an open port. DB and HBS were then passed counter-flow through a dialysis membrane at 300 and 400 mL/min. The P[O.sub.2], PC[O.sub.2], oxygen saturation, and pH were measured on DB and HBS before and after the membrane.

Results: The initial gas content for the donor blood was pH 6.4, PC[O.sub.2] 71 mm Hg, and P[O.sub.2] 37 mm Hg. After the 300 mL/min membrane oxygenation with the HBS, the donor blood content was pH 7.016, P[O.sub.2] 250 mm Hg, and PC[O.sub.2] 16 mm Hg. The 400 mL/min trials were unsuccessful due to clotting.

Conclusions: Hemopure works as an oxygenator fluid in a simple liquid-liquid bypass oxygenation circuit. In addition, PC[O.sub.2] was lowered. This could be used as an alternative to traditional ventilators to allow effective gas exchange in refractory hypoxia, reversible lung damage, and awaiting transplant.

Unruptured Intracranial Aneurysm Presenting as TIA.

Jennifer A. Dowalter, MD, and Michelle L. Wilson, DO, FACP, FABHP. Department of Internal Medicine, Mercer University School of Medicine, Savannah Campus at Memorial Health University Medical Center, Savannah GA.

Background: Intracranial aneurysm is a blood vessel abnormality that often presents to us in the emergency room in the form of subarachnoid hemorrhage. Rarely do we see symptomatic unruptured intracranial aneurysms.

Methods and Results: This is the case of a 68-year-old, white female with hypertension and hypercholesterolemia who came to the emergency department due to episodes of visual loss in the left eye that occurred 4 weeks apart. The left visual loss was sudden, about 75% of the visual field, lasting 8 to 10 seconds, spontaneously resolved, with no other accompanying signs and symptoms. The physical examination and vital signs were unremarkable. Initial laboratory values were all normal. CT scan of the brain did not show any acute process. Carotid Doppler ultrasound showed no hemodynamically significant disease. MRI/MRA of the brain showed an 8-mm paraophthalmic artery aneurysm on the left, with no evidence of acute hemorrhage nor infarct. A cerebral angiogram showed a 1-cm left parophthalmic aneurysm. There was a recurrence of TIA during the angiogram that resolved approximately 2 hours after the procedure and manifested as blurring and visual defect. Endovascular placement of an IRB-approved neuroform stent with endovascular GDC coiling of the large parophthalmic artery aneurysm was done. The patient tolerated the procedure well without recurrence of visual loss.

Conclusions: The prevalence of intracranial aneurysms by radiographic and autopsy series is about 5%, or 10 to 15 million people in the United States. Aneurysmal SAH occurs at an estimated rate of 6 to 16 per population of 100,000. This patient presented to us with amaurosis fugax-like symptoms and had a TIA produced by a parophthalmic artery aneurysm, producing transient visual loss on the left eye.

Spurious Hypophosphatemia Secondary to Paraproteinemia: A Need For Awareness About Clinical Laboratory Techniques in Automated Phosphorus Assays.

Sarah E. Kerr, MD, Joshua J. Kindt, BS, and Sumanth R. Daram, MD. Department of Pathology, University of Virginia Health System, and Medical College of Wisconsin, Department of Internal Medicine, Saint Joseph's Regional Medical Center, Milwaukee, WI.

Background: Phosphorus level abnormalities are commonplace in medical practice. The differential diagnosis for hypophosphatemia is long and involves complex, overlapping physiological systems. Practitioners are often guilty, however, of simply supplementing phosphate without fully investigating the etiology of the problem. A handful of case reports have shown that paraproteins can interfere with commonly used phosphorus assay equipment.

Objectives: The purpose of this case presentation was to illustrate a case of spurious hypophosphatemia that initially led to unnecessary phosphate replacement in a woman with undiagnosed multiple myeloma.

Methods and Results: Mechanisms of reported interference with common assays were reviewed. An 85-year-old black female was admitted to the hospital with CHF exacerbation. The patient was incidentally found to be profoundly hypophosphatemic. Normal phosphorus levels were difficult to maintain despite aggressive replacement. Additionally, oral phosphate replacement caused significant abdominal discomfort. During the same hospitalization, investigation of unexplained leukopenia, anemia, and hyperproteinemia revealed a new diagnosis of multiple myeloma. A serum sample initially shown to have a phosphorus level of 1.4 mg/dL on the Beckman CX7 autoanalyzer was sent for analysis at an outside laboratory to evaluate whether the low phosphorus levels were spurious. A Kodak Ektachem 700 system revealed the phosphorus level to be 4.6 mg/dL on the same sample.

Conclusions: Clinicians should proceed with caution before aggressively treating abnormal phosphorus levels in patients with known paraproteinemia. Conversely, unexplained phosphorus abnormalities should bring disorders associated with paraproteinemia, such as multiple myeloma, into the differential diagnosis. Knowledge of how various phosphorus assays are affected by paraproteins is essential to guiding diagnosis and treatment.

A Rare Complication of Diabetes.

Savio Reddymasu, Ankur Sheth, and Richa Dhawan. LSUHSC-Shreveport, Shreveport, LA.

Background: A rare and catastrophic affect of long-standing and poorly controlled diabetes associated with significant morbidity and mortality rates is presented. A 48-year-old white male with insulin-dependent diabetes mellitus secondary to pancreatectomy from chronic pancreatitis (alcohol related) presented with painful left lower extremity swelling for about 1 week. He had similar complaints on the right side 3 weeks ago, which resolved spontaneously before starting on the left side. On examination, he was afebrile and had nonpitting edema of the left lower extremity with induration and tenderness in the region of the left quadriceps muscles.

Methods and Results: Laboratory values revealed blood sugar of 544 mg/dL, mildly elevated CPK (418 U/L), elevated ESR (66 mm/hr) and CRP at (10 mg/dL), and hemoglobin A1c of 12.7%. Venous Doppler of the left lower extremity showed subcutaneous edema but no DVT. MRI of the left lower extremity revealed diffuse increased signal uptake involving quadriceps and adductor muscle groups consistent with muscle infarction. A diagnosis of diabetic muscle infarction (DMI) was obvious. Typical presentation of DMI is atraumatic painful swelling in the thigh and quadriceps muscles that can later affect the contralateral side or as knee arthralgia. Laboratory abnormalities include raised ESR or CRP and normal to mild elevation of CPK levels but are not conclusive. MRI is suggestive and muscle biopsy establishes diagnosis but rarely needed if MRI is diagnostic. DMI is thought to be secondary to extensive microvascular disease and ischemia-reperfusion injury involving the affected muscles.

Conclusions: Treatment of DMI is with aspirin, rest, analgesia, and good glycemic control. Vascular complications such as nephropathy, retinopathy, and neuropathy are present in 71, 57, and 55% of patients, respectively, at the time of diagnosis of DMI. DMI can occur even after pancreatic transplant secondary to tissue damage from preexisting labile glycemic control. Patients with DMI should be stratified as high risk, requiring close follow-up and aggressive control of their diabetes.

Fever in an International Traveler: Return of the Vivax.

Supriya Mannepalli, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, TN.

Objectives: To recognize malaria as a frequent infection in travellers and to review the diagnosis and treatment of malaria and causes of treatment failure.

Background: A 37-year-old female from Honduras visiting her family in the United States presented with 10 days of headache, fever, abdominal pain, and myalgias. Fever recurred every other day and was associated with chills. The patient was febrile (101.10[degrees]F), tachycardic (115/min), tachypnoeic (23/min), hypotensive (103/63 mm Hg), diaphoretic, and lethargic. The lungs were clear, and tenderness was noted in the left upper quadrant. There were no meningeal signs or rashes.

Methods and Results: Laboratory values were leucopenia, 3.1 th/[mm.sup.3]; total bilirubin, 1.7 mg/dL; blood and bile in urine. Ultrasound abdomen and head CT were negative. The peripheral smear for malarial parasites was positive for plasmodium vivax. There was no history of chemoprophylaxis for malaria. The patient was treated with chloroquine followed by primaquine for 2 weeks.

Conclusions: Although malaria was eradicated in the United States in the 1940s, about 1,000 to 1,400 cases of malaria are reported to CDC each year in immigrants, returning travelers, and military personnel. Malaria is the most common cause (27%) of infections in a returning traveler. Anopheles mosquitoes capable of transmitting malaria exist in the United States, conferring a constant risk or resumption of malaria transmission. Of concern is the rising incidence of malaria attributed to parasite resistance to antimalarials and anopholes mosquito to insecticides combined with increased global travel. Diagnosis requires a high clinical suspicion to obtain thick and thin smears to identify and quantify parasitemia. Treatment typically entails oral chloroquine or intravenous quinidine for severe disease with an additional 2 weeks of primaquine to eradicate the dormant liver forms with plasmodium vivax or ovale infections to prevent relapse. G6PD deficiency should be evaluated before therapy to avoid drug-precipitated hemolysis. The common errors in management are due to a delay in diagnosis, not eradicating the hepatic hypnozoites and prophylaxis failure. A high clinical suspicion, identification of species, and evaluation for resistance are essential for management.

Septic Shock Caused by Disseminated Histoplasmosis.

D. Sula, J. Nijjar, C. Mitchell, R. Washburn, and R. Penn. Section of Infectious Diseases, Department of Medicine, Louisiana State University Health Sciences Center and Overton Brooks VA Medical Center, Shreveport, LA.

Background: A 32-year-old male with hypertension and diabetes mellitus was evaluated as an outpatient in December 2004 for a 2-month history of a painful tongue ulcer.

Methods and Results: Biopsy of the ulcer revealed granulomatous inflammation with yeast forms. The patient was given oral fluconazole in January 2005 with no relief. Three days later he had high fevers with chills, nausea, and vomiting. He was brought to his local hospital, where his vital signs were BP = 75/44, HR = 125, temperature = 98.4[degrees]F, and RR = 24. Pertinent physical findings included a shallow 1-cm tongue ulcer, RUQ tenderness, and guaiac-positive stool. Laboratory examinations revealed anemia, thrombocytopenia, hyponatremia, hyperkalemia, acute renal failure, elevated transaminases, elevated bilirubin, and evidence of disseminated intravascular coagulopathy. He was admitted to the intensive care unit and started on vasopressors, broad-spectrum antibiotics, and fluconazole. He was later transferred to our institution, where he received immediate plasmapheresis. The antibiotics were continued, but fluconazole was switched to caspofungin. ELISA and Western blot HIV tests were positive. The CD4 count was 55 cells/[mm.sup.3] and HIV viral load was 16,383 copies/mL. High fevers persisted, and caspofungin was changed back to fluconazole. When the serum and urine came back strongly positive for Histoplasma antigen, fluconazole was switched to Amphotericin B. The fungal blood cultures grew Histoplasma capsulatum. He clinically improved over the next 2 weeks.

Conclusions: Disseminated histoplasmosis is a recognized complication of AIDS in patients with CD4 count below 100/[mm.sup.3]. Common manifestations include fever, weight loss, hepatosplenomegaly, lymphadenopathy, and pancytopenia. Skin and/or mucosal lesions have been reported to occur in 11%; however, tongue ulcer as initial presentation is rare. Septic shock occurs in less than 10% of patients. This case emphasizes that the first clue to the presence of disseminated histoplasmosis may be a tongue ulcer, and, if unrecognized, may progress to septic shock, and the best empiric therapy is Amphotericin B.

Battling Myeloma Kidney with Early Plasmapheresis.

Vikul Patel, MD, Rohini Alay, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, TN.

Objectives: To demonstrate that oftentimes it is as important to treat the effects of the disease as it is to treat the disease process itself and to illustrate that reducing serum calcium and abnormal immunoglobulins can reverse renal failure even before the induction of chemotherapy in multiple myeloma (MM) complicated by acute renal insufficiency (ARF).

Background: A 54-year-old male presented with low back pain, anemia, acute renal insufficiency, and hypercalcemia.

Methods and Results: Bone scan revealed multiple lytic lesions. Plasma immunoelectrophoresis revealed a monoclonal spike with IgG level of 5.6g/dL. Urine immunoelectrophoresis revealed a monoclonal spike with IgG also. Diagnosis of MM was confirmed with a bone marrow biopsy revealing more than 45% plasma cells. Besides rehydration and pamidronate to correct the hypercalcemia, plasmapheresis was instituted to reduce the abnormal serum immunoglobulins. This reduced serum creatinine from 4.6 to 1.2. Therapy with melphalan and prednisone was begun subsequently. The patient continued to do well, as further therapy for myeloma was contemplated.

Conclusions: Up to 25% of patients with MM present with ARF. The underlying cause of ARF is multifold and includes hypercalcemia, dehydration, hyperuricemia, infections, and deposition of abnormal immunoglobulin in the renal tubules. The amount of immunoglobulin casts in the tubules directly correlates with the burden of disease and renal insufficiency. Plasmapheresis was instituted early and demonstrated improvement in renal function in the patient. This paves the way for more studies regarding early use of plasmapheresis in myeloma kidney.

Symptom-Based Treatments for Menopause: Alternatives to Hormone Replacement Therapy.

Adrian C. Buckner, M.D., PGY-III. Department of Internal Medicine/Psychiatry, Quillen College of Medicine, East Tennessee State University, Johnson City, TN.

Background: The Women's Health Initiative (WHI) is a long-term national health study that focuses on strategies for preventing heart disease, breast and colorectal cancer, and osteoporosis in postmenopausal women. This ongoing study has provided a plethora of new information about the role of hormone replacement therapy (HRT) in relation to menopause, including many increased risks. As HRT has been found to have detrimental effects on women's health, suitable alternatives for the treatment of menopausal symptoms must be explored.

Methods: A literature review of more than 100 journal articles, published over the last year, and 30 various web sites are being reviewed to compile the latest findings on alternatives to HRT. Salient points from some and recommendations from others are to be presented in a concise yet easy to review format. The recommendations and resources are organized in this presentation and handout for use as a reference for healthcare providers.

Results: Symptoms of menopause include physical, sexual, and psychological dysfunction. Alternatives to HRT include botanical products, pharmaceuticals, and behavior modification. Each alternative has its own innate risks and benefits. The decision to use HRT or any alternative should be decided by a collaboration of a knowledgeable practitioner and an informed patient.

Conclusions: With the new research becoming available, a periodic review of recommendations is vital for anyone involved in women's health care. This presentation is an update on symptom-based alternatives to HRT.

Neurologic Manifestations in a Patient with Atrial Fibrillation: Not an Obvious "Stroke" of Diagnosis.

Shadi Ayyoub, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, TN.

Objectives: To recognize the potential causes of neurological manifestations other than embolic cerebrovascular accident (CVA) in patients with atrial fibrillation (AF) and to discuss the presentation and diagnosis of HSV encephalitis.

Background: An 87-year-old male with no history presented with depressed consciousness and rapid AF. On examination, he was afebrile and drowsy. Pupils were 2 mm equal, DTRs symmetrical, flexor plantars, rhythm irregularly irregular. CBC, CMP, and UA were normal. Brain CT was negative. CSF was 1 WBC/mL; normal glucose; proteins, 95 mg/dL. Transthoracic echocardiogram showed no LA thrombi. CSF HSV culture was negative. The patient continued to be drowsy, with no localizing findings. Brain MRI showed no abnormal signal in temporal lobes highly suggestive of HSV encephalitis. The EEG showed slowing in left parietal region. Intravenous acyclovir was started. PCR results 5 days later demonstrated HSV1 DNA in CSF. The patient improved with baseline mental status.

Results: Herpes encephalitis is the most common cause of fatal encephalitis in the United States. Untreated, fatality approaches 70%, and survivors have serious neurologic deficits. Although normal CSF can occur early, it typically shows a lymphocytic, erythrocytosis, and elevated protein. Imaging typically shows temporal lobe lesions. CT brain has only 50% sensitivity. MRI is most sensitive and specific imaging especially early. CSF culture is rarely positive early and only in 5% of patients with brain-biopsy proven HSV encephalitis. CSF PCR assays rapidly and noninvasively detect HSV DNA, with sensitivity and specificity of 94 to 100% and is standard for diagnosis. Patients with longstanding AF have higher insidence of embolic CVA. Neurological manifestations in patients with AF are often attributed to CVA.

Conclusions: This case highlights that Herpes encephalitis may coexist with AF and may have atypical presenting features as in our patient. It is important to have a high index of suspicion to successfully diagnose and treat a life-threatening and potentially disabling but treatable disease such as herpes encephalitis.

Profound Nonhypoxic Bradycardia Following Disconnection from Ventilator with Weaning Attempts.

Greta Warta, DO, MPH, Seema Haq, MD, and John Coyle, MD. Department of Internal Medicine, University of Oklahoma College of Medicine, Tulsa, OK.

Background: During ventilator weaning, disconnection of the patient from the ventilator/reduction in ventilator support often precipitates increased work of breathing, anxiety, and hypoxemia, with resultant sinus tachycardia. The current report describes the case of a patient who had repeated episodes of severe bradycardia on disconnection from a respiratory ventilator and during weaning. These episodes were not consistently related to hypoxemia, hypercapnea, acidosis, or hypertension.

Methods and Results: The patient is a 74-year-old female with episodes of severe bradycardia within seconds of disconnection from continuous ventilatory support. She had been admitted with chest pain and subsequently underwent coronary artery bypass surgery. There was no history of previous bradycardia. The patient's early postoperative course was unremarkable, and she was extubated without event on the day of surgery. The following day, however, she developed worsening of her respiratory status and was reintubated. Several weeks later she underwent tracheostomy after multiple failed weaning attempts. Many (but not all) weaning attempts resulted in bradycardia of 25 to 45 bpm, sometimes with asystole of 3 seconds and normal oxygen saturation. The worst of these spells occurred at night. These episodes resolved after reconnection to the ventilator or increased ventilator support. While on full ventilatory support, she was in sinus rhythm with a heart rate of 70 to 100 bpm. EMG for evaluation of diaphragmatic function gave evidence of possible bilateral phrenic nerve injury. An echocardiogram performed during ventilator withdrawal initially showed normal systolic and diastolic function. Within less than 3 minutes, there was a mild decrease in ejection fraction and a profound decrease in heart rate (56 bpm going to 31 bpm). A pacemaker was implanted with subsequent resolution of bradycardia, but the patient continued to fail weaning attempts. In the absence of sino-atrial node dysfunction and drug effect, heart rate is mostly determined by the balance between vagotonic and sympathetic effects on the SA node. Although excessive pulmonary stretch has been reported to stimulate receptors that can produce bradycardia, apnea is a far more common and potent cause of cardiac decelertion.

Conclusions: Apnea has been shown in some animal models to produce bradycardia in the absence of hypoxemia. In the current case, the most likely cause of profound bradycardia is an apnea-like response related to profound diaphragmatic weakness in conjunction with obesity and generalized debility, with subsequent hypervagotonia. The only similar cases come from a 1991 French report of four patients whose courses differed mainly in that all of those patients were ultimately successfully weaned from the ventilator.

Renal Cell Carcinoma Presenting as Femoral Sensorimotor Neuropathy.

Stephan Schwarz, MD, and Kelly Stacy, MD. Carilion Health System, University of Virginia Roanoke-Salem Program in Internal Medicine, Roanoke, VA.

Background: Renal cell carcinoma (RCC) can present with a wide array of symptoms and/or laboratory abnormalities that can make its diagnosis challenging. A 76-year-old male presented with progressive left lower extremity weakness. His medical history was significant for hypertension and epilepsy, for which he was treated with atenolol, hydrochlorothiazide, irbesartan, phenytoin, and gabapentin. He was well and active until 3 months earlier, when he fell after his "legs gave out." There were multiple subsequent falls due to left leg weakness and a burning sensation in mid-distal left thigh. There was no family history of musculoskeletal or neurologic disorder.

Methods and Results: General physical examination was unremarkable. Neurologically, he was unable to ambulate due to left leg weakness. There was marked atrophy and weakness of left quadriceps (2/5), minimal weakness contralaterally (4/5), absent knee jerks bilaterally, and faint ankle jerks. Sensation was intact. Nerve conduction studies showed unrecordable left femoral motor and left sural sensory activity. Left lower extremity EMG showed decreased motor unit production within the femoral nerve distribution as well as evidence of denervation potentials, both positive sharp waves and fibrillation of potentials scattered throughout left femoral nerve distribution. These findings suggested a femoral neuropathy, possibly due to entrapment of the femoral nerve along its distribution. MRI of the abdomen and pelvis revealed a large right renal mass, but no nerve entrapment. Routine laboratory values were unremarkable. Antibodies to MAG, GMl, Hu, Ri, HBV, HCV, ANA, RF, SSA, and SSB were absent. Serum and urine protein electrophoresis was normal. The patient underwent a right nephrectomy, which demonstrated a well-differentiated renal cell carcinoma. After surgery, his lower extremity strength improved.

Conclusions: Fewer currently diagnosed patients with RCC present with the classic symptoms of the disease, in part because of the increasing frequency of incidental diagnosis. It is estimated that less than 3% of cases present with neurologic manifestations, the pathophysiology of which is still unclear. Clinicians should be aware that RCC could present as an isolated neuropathy.

The Role of Tissue Doppler Imaging (TDI) in the Diagnosis of Cardiac Amyloidosis.

Seema Haq, MD, and Sadaf Saghier, MBBS. The University of Oklahoma College of Medicine, Tulsa, OK, and DOW Medical College, Karachi, Pakistan.

Background: Cardiac amyloidosis should be considered in patients with recurrent exacerbations of congestive heart failure. This report describes the importance of tissue Doppler imaging (TDI) in the diagnosis of restrictive cardiomyopathy in a patient with a history of multiple myeloma and recurrent CHF, suspected to have secondary amyloidosis in whom cardiac biopsy was not feasible. A 66-year-old obese white female was hospitalized several times because of CHF exacerbation with syncope, increasing exertional dyspnea, and recurrent pleural effusions.

Methods and Results: The patient had a history of multiple myeloma, CHF, hypothyroidism, hyperlipidemia, peptic ulcer disease, and depression. An echocardiogram showed ejection fraction of 60%, severe diastolic dysfunction without left ventricular dilation, and enlarged atria. TDI findings were consistent with restrictive cardiomyopathy. The patient declined further intervention, including cardiac biopsy, and she died of complications of her end-stage CHF. Tissue Doppler is a noninvasive form of imaging that allows measurement of motion patterns and velocities of cardiac structures and is increasingly used for the assessment of diastolic function. Taking into consideration the patient's history of multiple myeloma and echocardiogram findings, secondary amyloidosis was the most likely explanation for her recurrent CHF exacerbations. The echocardiographic impression of cardiac amyloidosis was reinforced by the TDI, which demonstrated a characteristic low intramyocardial velocity pattern in addition to the "sparkling" pattern (patchy echoes within the myocardium).

Conclusions: Digitalis, calcium channel blockers, and [beta]-blockers are contraindicated in amyloid-associated cardiomyopathy because they bind easily to amyloid fibrils, causing toxicity at apparently therapeutic levels. In secondary amyloidosis, aggressive treatment of the underlying inflammatory or neoplastic disease can improve symptoms and slow the progression of the disease. Recognition of cardiac amyloidosis is critical in the management of CHF in a patient with multiple myeloma and TDI may facilitate the diagnosis.

Priapism in a Patient Presenting with Pneumonia.

Seema Haq, MD, and Sohail Saghier, MBBS. Department of Internal Medicine, University of Oklahoma College of Medicine, Tulsa, OK, and Sind Medical College, Karachi, Pakistan.

Background: Priapism is a urological emergency characterized by prolonged and painful erection of the penis for more than 4 hours' duration in the absence of sexual stimulation. We describe an interesting case of priapism in an alcoholic male presenting with pneumonia.

Case Presentation: A 58-year-old black male with a history of alcoholism presented with mental status changes, cough, fever, hypoxemia, and repiratory failure requiring intubation and mechanical ventilation. Laboratory investigations showed anemia of chronic disease with mild reactive leukocytosis. Sputum cultures and chest radiographic findings were consistent with Streptococcus pneumonia. The patient was treated with intravenous antibiotics. During his stay in the intensive care unit, the patient developed priapism. There was no history of similar episode. The side effects of the patient's medications were reviewed, which did not identify any possible cause. Hemoglobin electrophoresis was normal. Urology consult was obtained. The patient failed medical treatment with intracavernous phenylpherine injections and so a corpora cavernosus shunting procedure was performed with marked improvement. Over the course of 3 weeks, his priapism significantly improved and the patient was discharged home.

Discussion: There are two types of priapism: veno-occlusive low-flow (ischemic), resulting in little or no blood flow to penis, causing damage, and high-flow-like trauma to the penis, resulting in large amount of blood flow. It is important to distinguish between these two types as choice of treatment is different. Fifty percent of the cases of priapism are idiopathic. Various causes have been proposed, such as disturbed detumescence mechanism, obstruction of draining venules, psychiatric medications, eg, trazodone, pharmacological injection therapy for impotence, sickle-cell anemia, leukemia, marijuana, ethanol, or cocaine.

Conclusions: This case illustrates priapism as an uncommon finding in a patient with pneumonia. Our patient had a low-flow priapism secondary to veno-occlusive mechanism from reactive leukocytosis or hypoxia, causing the blood to thicken or red blood cells to lose their flexibility and mobility. In addition, history of alcoholism is also known to cause priapism by unknown mechanisms. Priapism can be prevented by avoiding the factors that precipitate it, and timely management can restore full potency of the penis in most of the patients.

A Reversible Posterior Leukoencephalopathy Syndrome: Clinical Presentation and Radiological Findings.

Seema Haq, MD, and Sohail Saghier, MBBS. Department of Internal Medicine, University of Oklahoma College of Medicine, Tulsa, OK, and Sind Medical College, Karachi, Pakistan.

Background: The reversible posterior leukoencephalopathy syndrome (RPLS) is an uncommon neurological complication of uncontrolled hypertension. The clinical presentation and radiological findings of RPLS are reviewed.

Case Presentation: A 53-year-old white female with a history of poorly controlled HTN presented to the ER with mental status changes, blurry vision, seizures, and respiratory distress requiring intubation. The patient's vitals revealed markedly elevated blood pressure (200/120). Physical examination revealed disorientation and left ankle clonus. Laboratory investigations showed hemoglobin of 16.6 g/dL, hematocrit of 51.2 vol%, WBC of 12.2, with absolute neutrophil count of 10.25. Serum and urine drug screen as well as heavy metal screen was negative. CSF examination was nonspecific (15 WBC with 75% neutrophils; increased protein, 82 mg/dL; increased glucose, 100 mg/dL). HSV-1 and HSV-2 and VDRL tests were negative. An MRI of the brain revealed marked hyperintensity of the white matter of the occipital lobes bilaterally, including the cerebellum and temporal and parietal lobes, consistent with posterior leukoencephalopathy. The patient was started on antihypertensive medication, empiric acyclovir, decadron, and cerebyx. Over the next few days, her blood pressure was reduced to the normotensive range. The patient's mental status recovered, and she was weaned from the ventilator. The patient was discharged home with advice to strictly control her blood pressure.

Conclusions: RPLS is a condition commonly associated with malignant hypertension, toxemia of pregnancy, or with the use of immunosuppressive agents. Patients may have loss of vision, headaches, vomiting, and altered mental functioning and seizures. Patients have abnormal MRI studies with edema of the white matter of the posterior cerebral hemispheres, which may include the cerebellum and brain stem white matter structures. The neurological deficits usually resolve with normalization of blood pressure, which suggests the need of its early identification to avoid unnecessary diagnostic studies or wrong treatments. It should be distinguished from stroke and intracranial hemorrhage, as the management is different and does not necessarily involve aggressive blood pressure reduction.

Concomitant Intracranial Aneurysm and Carotid Artery Stenosis.

Sankar D. Navaneethan, MD, Ayodele Osowo, and Rakesh Shrivastava, MD. Department of Medicine, Unity Health System, Rochester, NY.

Background: The occurrence of concomitant intracranial aneurysm (ICA) and carotid artery stenosis (CAS) is rare and the treatment options are limited. We present a patient with large middle cerebral artery (MCA) aneurysm and coexistent CAS.

Case: A 65-year-old white male with a medical history of coronary artery disease, diabetes, and hypertension presented with tingling sensation of his hands and face and altered gait of 14 hours' duration. He was hemodynamically stable, and his neurological examination was unremarkable. His workup revealed a 25 X 24-mm MCA aneurysm, 90% occlusion of the left internal carotid artery, and 70% occlusion of the right internal carotid artery. Since the patient was at high risk for an isolated aneurysm repair or carotid end-arterectomy (CEA), a combined endovascular repair of carotid artery along with coil embolisation of ICA was planned.

Discussion: Incidence of patients with concomitant CAS and an ICA is less than 0.5%, and the ICA is usually less than 10 mm. This is the first case report of ICA of 25 mm and bilateral CAS. Although the clipping of the aneurysm first poses the risk of stroke, the correction of carotid stenosis first may result in aneurysm rupture secondary to the increased blood flow. However, there are reports of successful outcome in patients undergoing CEA in presence of ICA less than 10 mm. However, the outcomes in patients with ICA greater than 10 mm is uncertain. The treatment option for these patients includes simultaneous endovascular repair of CAS, along with coil embolization of MCA aneurysm.

Conclusions: Even though the concomitant presence of CAS and ICA is mutually beneficial in preventing stroke and bleeding, primary care physicians treating these patients should refer them to centers specializing in endovascular procedures for simultaneous correction of both lesions.

A Novel Histologic Variant Glomerulopathy.

Ismaila Jibrin, MD, Anitha Nallu, MD, Priyanka Nellori, MD, and Mary Behrens, MD. St Agnes Healthcare, Baltimore, MD.

Background: There are few reports of coexistent membranous nephropathy (MN) and crescentic glomerulonephritis (CGN); not recognized as a distinct histologic entity, it was hypothesized to represent a progression between the two forms or a development of CGN on an existing MN. Adding an interesting dimension to this, we report the first biopsy documented triple histologic picture of membranous and crescentic GN together with plasma cell hyperplasia.

Case: A 60-year-old black female, who was visiting the emergency room because of malaise, cough, and fever, was found to have a rapidly deteriorating renal function. Her serum creatinine rose from 3.8 to 10.3 over a 1-week period before she agreed to be admitted. Her renal function was normal 4 years. She reported a 20-lb weight loss in the last 6 months and had used motrin days before her admission. She appeared chronically ill, with a BP of 146/97, but the rest of her examination was unremarkable. Initial workup revealed anemia with thrombocytosis, mild proteins in the urine, and 2 to 5 RBCs, with few granular casts, and a 24-hour urine protein excretion of 1.737 g/d. She also had hyperglobulinemia (6.2 m/dL) and enlarged kidneys on ultrasound, but HIV screening was negative as well as hepatitis panel, ASO, anti-GBM, ANCA, and other rheumatologic panels. Serum electrophoresis showed no evidence of monoclonal gammopathy. Renal biopsy revealed active pauci immune crescentic GN on a background membranous GN with extensive interstitial inflammation and numerous plasma cells. An abdominal CT scan revealed a right ovarian mass and a CA-125 was elevated at 1669 U/mL. An abdominal MRI reported a neoplastic pelvic mass with multiple intra-abdominal and hepatic seedlings. The patient was managed with hemodialysis, cyclophosphamide, and prednisone and then taken to OR for total abdominal hysterectomy with bilateral salphingo-oophorectomy and extensive pelvic clearing. Intraoperative findings showed widely metastasized ovarian tumor histologically shown to be a high grade undifferentiated carcinoma with staining consistent with primary ovarian carcinoma (stage IIIC). The patient improved clinically, as did her renal function; the last creatinine was 2.1 mg/dL before discharge.

Discussion: Apart from the unusual histologic mix in her renal biopsy, this patient presents a constellation of other challenging clinical problems. Although MN is believed to be caused (in 5 to 10% of cases) by solid tumors, usually colon and lung neoplasms, we did not find any report in the literature of MN associated with malignant ovarian tumor. Furthermore, the incidence of occult malignancies presenting as MN, as in this patient, is exceedingly rare. Associations between MN and CGN usually takes the form of an initial diagnosis of MN followed by development of CGN years later, and often the cause for CGN is evident. This lends credence to the hypothesis of disease progression or superimposed CGN. In our patient, the diagnosis of both MN and CGN occured simultaneously.

Conclusions: A truly idiopathic CGN is now declared a rarity if not unlikely, yet in this patient it is extremely difficult to identify any cause. Patients with pauci-immune crescentic GN usually have features of one of the systemic vasculitides or develop them at a later time. Furthermore, they are almost always ANCA-positive even in those with the so-called renal limited vasculitis. We propose that the coexistence of MN with a possibly idiopathic CGN and unusual plasma cell proliferation in this patient should raise the question of a novel glomerulopathy with overlapping clinical and morphologic features. Should ANCA develop later, there would still be unresolved questions: hyperglobulinemia and enlarged kidneys in the face of renal failure with no evidence of HIV, multiple myeloma, or amyloidosis.

Nocardia Infection Preceding Diagnosis of Lymphoma.

Jasmin Jerez-Marte, MD, Lampros Karageorge, MD, and Keith Burwell, DO. Carilion Health System, UVA Roanoke-Salem Program, Roanoke VA

Background: An 80-year-old white male presented to the Dermatology Clinic, complaining of a nonhealing ulcer in his left ring finger. The ulcer was initially treated with oral minocycline without improvement.

Methods and Results: A biopsy showed a neutrophilic infiltrate, and the patient was treated for possible Sweet syndrome. Local injection of steroids and later oral steroids were tried with marginal improvement. Three months later, the patient was admitted into the hospital with complains of anorexia, early satiety, weight loss, and generalized weakness; the patient reported that symptoms started at the same time he noticed the finger ulcer 3 months ago. On the physical examination, he appeared debilitated, vital signs were within normal limits, no lymphadenopathy was palpated, and diminished breath sounds were noted on the left lung base. In the skin examination, a 3 X 2-cm, stage II ulcer was found on the left fourth finger. The hospital workup showed a left-sided pleural effusion on chest radiography that turned out to be transudate, a gastric outlet obstruction with retroperitoneal nodes on CT. An EGD showed a 6-cm antral ulcer. Biopsies of the nodes and gastric ulcer confirmed the diagnosis of B-cell lymphoma. The lesion of the left finger was initially treated with topical tacrolimus, as it was possibly Pyoderma gangrenosum. That same week, laboratory results from previous skin cultures grew Nocardia species; this was confirmed by a new skin biopsy that stained positive for AFB and showed the Nocardia organisms. At this point, the patient was initiated on trimethopim sulfamethoxazole, and slow improvement of the lesion was noted.

Concusions: This case illustrates how a skin lesion can be the clear manifestation of an underlying systemic process. At least 60% of Nocardia infections are seen in inmunocompromised patients and can appear, as we see in this case, before the diagnosis of the underlying disease.

Transdermal Absorption of Magnesium.

C. Norman Shealy, MD, PhD. Hiolos University Graduate Seminary, Fair Grove, MO.

Background: Magnesium deficiency has been reported in up to 80% of women and 70% of men. In addition, virtually every known disease is associated with magnesium deficiency, including asthma, hypertension, cancer, diabetes, migraine, allergies, myocardial infarction, and depression.

Methods and Results: Oral magnesium is difficult to absorb, and our studies demonstrate that it takes 6 to 12 months for intracellular restoration. Intravenous magnesium chloride can restore intracellular levels within 2 weeks, and maintainance may then be done with oral supplements. Over the past 6 years, we have evaluated several transdermal magnesium preparations and demonstrated that intracellular levels of magnesium can be restored to the normal range within 4 to 6 weeks. An interesting beneficial side effect of the transdermal magnesium chloride is that DHEA levels rise an average of 60% with transdermal magnesium. We have not observed this effect with either intravenous or oral magnesium. Average intracellular magnesium levels and serum DHEA levels in 30 patients who received transdermal magnesium chloride were as follows:
           Before   After    Reference Intracellular

           (mEq/L)  (mEq/L)       (mEq/L)

Magnesium  31.4     41.2          33.9 to 41.9

           (pg/dL)  (pg/dL)       (pg/dL)

DHEA       200      325           150 to 1,200

Despite the laboratory DHEA reference levels, in hundreds of paients with a variety of illnesses, virtually all have been either truly deficient or in the lower two quartiles of the reference range.

Conclusions: Transdermal application of magnesium chloride is a convenient, inexpensive method for restoration of intracellular levels of magnesium, with potential benefit in many illnesses. An added benefit is increased DHEA.

IDD Therapy in Back Pain Treatment: A Clinical Trial Comparing Key Diseases of Low Back Pain.

Carlos Ganuza, MD, Norman Shealy, MD, PhD, FACS, and Nirman Koladia, MD.

Objectives: To evaluate IDD therapy in the management of back pain as well as in key back pain diseases including herniated nucleus pulposus (HNP), spinal canal stenosis (SCS), spondylosis (SPS), and degenerative disc disease (DDD).

Methods: Ninety-nine patients, between the ages of 16 and 80 years, of both genders and all ethnicities, with symptom of back pain for more than 1 week were evaluated. In selecting the patient population, we noted the age, gender, and disease of each patient. The pain outcome instrument we chose to evaluate back pain was the numerical pain scale from 0 to 10.

Results: The patient population had a mean age of 56.98 (SD = 16.37). The number of females was 76 (76.76%) and that of males was 23 (23.23%). Considering a difference of 4 points on the numerical pain scale to be improvement, we obtained 83% (? = 75 to 91%) results for back pain improvement. The result for HNP was 80% (n = 45,? = 68 to 92%), for SCS the result was 76% (n = 26,? = 59 to 93%), for SPS the result was 73% (n = 11,? = 46 to 100%), and for "other" disease including DDD the result was 76% (n = 34,? = 61 to 91%). ? represents the statistically predicted general population improvement rates, using the z statistic, standard deviation, and assuming a normal distribution for back pain improvement. The "other" category included a few patients who had "double" diagnosis from the HNP, SCS, and SPS. The analyses at different improvement cutoffs also correlated well with the cutoff at four points of difference. Different cutoffs we used included 2, 3, and 5 points of difference.

Conclusions: IDD therapy from this trial appears to have obtained extremely beneficial results to the back pain patient and should be considered as an important option for the management of back pain and conditions leading to back pain like HNP, SCS, SPS and other key diseases, especially before the patients are referred to surgery.

Initial Experience with Buprenorphine in Primary Care.

Ronald J. Dougherty, MD, FAAFP, ASAM. Tully Chemical Dependency Treatment Center, Tully, NY.

Background: Thirty patients had requested to be placed on a Buprenorphine regimen. Over the past 6 months, 30 patients were treated with Buprenorphine in the form of Suboxone. Three of the total dropped out AMA, one was incarcerated on an old bench warrant, and one went to a long-term residential program that prohibited Buprenorphine to be administered or taken at that facility.

Methods and Results: Of the remaining 25, 16 males and 9 females, 15 had a history of heroin dependence and 10 prescription drugs. Most often the opioids abused were hydrocodone and ocycontin. There has been an implication that the prescription opioids most often were being prescribed by primary care physicians, and none of the 10 who had become opioid-dependent on hydrocodone and oxycontin were being prescribed these agents by primary care physicians; in most instances, these were being prescribed by "pain clinics." After 6 months, those 25 who were continued on Buprenorphine did well with regard to craving and analgesia on taking 1 to 4 2 mg/0.5 tablet per day. One with severe chronic pain dropped out and decided to be prescribed methadone for analgesia. Of the remaining patients, four for whom 2 mg/0.5 Suboxone was not significant to control their craving, were eventually escalated up to 8 mg Buprenorphine per day, with good control of pain and good control of drug craving.

Conclusions: There still remains a great gap in convincing primary care physicians that they may prescribe this medication for their opioid-dependent patients. There is a misconception on the part of primary care physicians that they must offer the patients counseling themselves. They need to be made aware that they can prescribe the medication but refer the patients for additional care and treatment to recognized agencies within their community. There still remains a limited number of pharmacies who carry Buprenorphine. In many of the chain pharmacies, "corporate headquarters" tells them that they may not stock this medication. When able, physicians are limited to only 30 patients. A better job must be done of promoting this agent to be used in primary care by practicing physicians.

Ecstasy May Cause Agony or Death.

Ronald J. Dougherty, MD, FAAFP, ASAM. Tully Chemical Dependency Treatment Center, Tully, NY.

Background: There has been a 300% increase in the use of the so-called "club drugs." These include GHB, which has contributed to some recent fatalities and to the arrest and conviction of young males, usually. In addition, Rophynal, the date rape drug, appears to be leveling off as far as reported fatalities. In many instances, the alleged date rape drug overdose, which leads to the person going to the ER, turns out not to be Rophynal, but rather other benzodiazepines or other substances.

Methods and Results: MDMA (methylenedioxymethamphetamine), otherwise known as Ecstasy or XTC, has had explosive use and abuse among teenagers and young adults. MDMA, which is both a hallucinogen and a stimulant, not uncommonly can cause adverse effects on serotonin, causing anxiety, depression, paranoia, confusion, hallucinations, and sleep disturbance. In addition, physical adverse effects can include cardiac arrhythmia, dehydration, hypertension, renal failure, and death. Some MDMA, consumers die of malignant hyperthermia when the drug's effects are intensified by dancing in hot, smokey clubs and the consumer fails to consume enough water to protect their kidneys and brain. Long-term use of MDMA has been reported to cause damage to the hippocampus. There have been many reported side effects from taking what has been marketed as "MDMA." These side effects include GI upset, seizures, cardiac eurithmia, and menal failure. One hundred seven pills that were sold as "Ecstasy" were assayed using gas chromatography-mass spectroscopy. Sixty-three percent of the pills contained some MDMA or an analogue, and 29% contained identifiable drugs but no MDMA or analogue. The most common drug identified other than MDMA was the cough suppressant dextromethorphan (the "DM" in many over-the-counter cough mixtures), which was identified in 21% of pills. The amount of dextromethorphan found in the pills was higher than the usual therapeutic dose of 15 to 30 mg taken up to four times daily (the recommended maximum dose is 90 mg/d in adults). Other drugs found in the pills included caffeine, ephedrine, pseudoephedrine, and salicylates. The authors note that high doses of dextromethorphan may cause lethargy, hyperexcitability, tachycardia, and other problems, and dextromethorphan may cause drug interactions, either with MDMA or with other drugs that are substrates for cyto-chrome P450 isoenzyme 2D6.

Conclusions: Evaluation of these pills confirms the old adage that "on the street there is no such thing as truth in packaging."

Patent Foramen Ovale, a Rare Source of Infective Endocarditis.

Farhan Aslam, MD, and A. Mirza, MD. Geisinger Medical Center, Danville, PA.

Background: Patent foramen ovale is present in one fifth of the adult population. It is not considered as a potential source of infective endocarditis, so antibiotic prophylaxis is not routinely recommended. A case of infective endocarditis with patent foramen ovale ia described as the source of infective vegetation and persistent bacteremia.

Case Information: A 71-year-old female with a history of type II diabetes and coronary artery disease was transferred to our tertiary care center with fever and mental status change. Five days before transfer, she was admitted to a local hospital with fever, delirium, and decreased urine output and treated empirically with cefepime. Subsequently, blood cultures grew methicillin-sensitive Staphylococcus aureus, and she was started on oxacillin. Investigations failed to reveal the source of infection and despite antibiotic therapy, the patient continued to be febrile; this prompted transfer to our center. At the time of admission, the patient was febrile (39[degrees]C) and slightly confused. Physical examination was unremarkable. A transesophageal echocardiogram was obtained that revealed a large mass with an adherent clot measuring 3 to 5 cm in right atrium and 2 cm in left atrium, stretching through the patent foramen ovale. Repeat blood culture also grew methicillin-sensitive S aureus, and she was continued on oxacillin. Her fever and confusion resolved with continued antibiotic therapy.

Conclusions: Patent foramen ovale is present in 15 to 20% of the population and is usually asymptomatic. It can allow right-to-left shunt only because of the flap, which covers it from the left side and acts as a valve. It can rarely act as a site of infective endocarditis; however, prophylactic antibiotic therapy is not usually warranted. Our patient demonstrated that patent foramen ovale should be considered as a source of infective endocarditis. Whether the patient with patent foramen ovale needs antibiotic prophylaxis is still a subject of debate.

Chronic Aortic Thrombosis: A Delayed Complication of Retained Para-aortic Bullet.

Ankur Sheth, Gerald T, Arbour, Jr, Ruby Kochar, and Vikas Khurana. LSU Health Science Center and Overton Brooks VA Medical Center, Shreveport, LA.

Background: Three primary influences predispose to thrombus formation: blood hypercoagulability, endothelial damage, and stasis or turbulence of blood flow. Ulcerated atherosclerotic plaques and vessel wall aneurysms can predispose to blood stasis or turbulence. Haemostasis, atherogenesis, and thrombosis are the processes that occur in flowing blood, and hence it is important to consider flow behavior of blood (haemorheology) in genesis of thrombosis. This report describes an unusual case of a bullet compressing the aorta leading to thombosis.

Case Report: A 48-year-old male with a history of a gunshot wound to the back 23 years earlier presented with bilateral leg weakness and cold lower extremities. Examination revealed decreased femoral and pedal pulses and cool lower extremities without neurological deficits. CT revealed a bullet lodged adjacent to the aorta at the level of the third thoracic vertebra with an intraluminal filling defect suggestive of chronic aortic thrombosis. Ultrasound examination revealed aortic thrombosis with absent flow to the infrarenal abdominal aorta and collateral circulation to the external iliacs and common femoral arteries.

Discussion: This patient had chronic aortic thrombosis in association with a bullet impinging on the aorta. It was postulated that the bullet changed flow dynamics and caused turbulence, leading to intimal damage and chronic thrombosis. The presence of collateral circulation around the area suggests that this developed over a period of time. Turbulent blood flow contributes to thrombosis by causing endothelial injury and forming countercurrents and pockets of blood stasis. Stasis disrupts laminar flow and brings platelets into contact with the endothelium, and it retards the inflow of the clotting factor inhibitors, thus promoting endothelial cell activation.

Conclusions: Removal of projectiles lodged close to major vessels should be considered to prevent long-term complications of vascular thrombosis.

Case Report: Nailing the Diagnosis of Acute Retroviral Syndrome (ARS).

Jennifer L. Gonzales, MD, Barry Trachtenberg, MSIV, and Anshu Bhatla, MD. UTHSCSA-RAHC, Harlingen, TX.

Background: Despite the specialization of HIV medicine, primary care

physicians have a critical role in the recognition of ARS. This mononucleosis-like syndrome occurs 2 to 6 weeks after exposure to HIV and is symptomatic in 50 to 70% of patients. A case in which the clinical clues suggested HIV is presented, but the diagnosis was delayed because of misinterpretation of laboratory tests.

Methods and Results: A 20-year-old male presented with fever, weight loss, and diarrhea. He was homosexual and admitted to unprotected sex with a known HIV-positive partner. On physical examination, the patient had fever and splenomegaly. His physicians were concerned about HIV, but the HIV ELISA was negative, and they pursued other diagnoses. He ultimately was discharged with a diagnosis of mononucleosis because of a positive heterophile test. He was readmitted several months later with fever, diarrhea, fatigue, odynophagia, and lymphadenopathy. The patient again had a positive heterophile test and negative HIV ELISA, but an HIV viral load of 750,000 copies/mL confirmed the diagnosis.

Conclusions: It was suspected that this patient had ARS at first presentation, illustrating the difficulty in making this diagnosis. The physicians documented that HIV was likely, but failed to order the correct test. Although ELISA is greater than 99% sensitive in seroconverted patients, it takes almost 3 months after exposure to seroconvert, up to 1 year on rare occasions. Depending only on the ELISA will often lead to a false reading. A PCR viral load (100% sensitive, 94.4% specific) does not have a window period. Also, other entities such as EBV can be difficult to diagnose in HIV. There have been reports of false-positivies or reactivation of the heterophile test in patients with ARS. Primary care physicians and specialists cared for this patient. Their failure to pursue the diagnosis beyond the ELISA underscores the need for directed education in this particular aspect of HIV disease.

Brain Abscess Complicating Otitis Media: A Spark Spreads Like Wildfire.

Harsha Gadadhar, MD, R. Alay, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga, TN.

Objectives: To recognize benefits of early MRI with gadolinium to diagnose complications.

Case: A 42-year-old male presented with a day of confusion, bizarre behavior, and speech abnormalities. Four days prior, he was treated for an ear infection. He had uncontrolled diabetes. He was febrile, tachycardic, and tachypneic. Examination was intubated non-responsive. The left tympanic membrane was not visualized due to discharge. Laboratory tests showed elevated WBC with left shift. MRI of the brain with gadolinium showed a 5 X 2.5 X 2.5-cm left temporal abscess, intraventricular rupture, and no herniation. Empiric intravenous third-generation cephalosporin and metronidazole was started, followed by craniotomy, abscess drainage, ventricular lavage, myringotomy, and middle ear lavage with antibiotic instillation. Vancomycin was added. Abscess culture grew streptococcus. After 3 weeks of hospitalization, the patient was discharged on intravenous antibiotics, antiseizure medications, and speech therapy.

Conclusions: Temporal lobe brain abscesses are complications of otitis media or sinusitis. Intraventricular rupture of brain abscess has a mortality rate of 80%. It is important to obtain MRI with gadolinium if brain abscess is suspected because MRI allows better differentiation of abscess from neoplasm, better definition of the abscess capsule, and detection of edema, ventriculitis, and rupture. Suggested empiric antibiotics are parenteral third-generation cephalosporins and metronidazole for 4 to 6 weeks. Vancomycin is added if neurosurgical procedure is performed. In abscess rupture, early craniotomy with drainage, ventricular lavage, and intrathecal antibiotic installations are indicated. Myringotomy and middle ear and mastoid lavage with antibiotic instillation is indicated for otitis media. All cases require seizure prophylaxis. This case serves to remind clinicians that even commonly encountered infections such as otitis media are not without complications.

New-Onset Heart Failure with Arrhythmia, Diabetes Mellitus, and Liver Disease: Hemochromatosis Not to Be Forgotten.

Scott Russell Beach, MD, Gerald Arbour, MD, Adrian Sequeira, MD, Ray Smith, MD, and Jian Huang, MD. Louisiana State University Medical Center at Shreveport, Shreveport, LA.

Background: Hemochromatosis is a genetic disorder of iron storage that results in excessive iron deposition in parenchymal cells with resultant tissue damage and impaired organ functions, especially the liver, pancreas, heart, gonads, and joints. Delayed diagnosis results in poor clinical outcome. This is a case of hemochromatosis in a patient presenting with new-onset CHF, liver function abnormalities, and diabetes.

Methods and Results: A 44-year-old male with a negative medical history was admitted for increased dyspnea on exertion for 3 weeks. His initial physical examination was significant for bibasilar lung crackles and lower extremity edema. Laboratory data showed B-type natriuretic peptide of 1,130 pg/mL, glucose of 331 mg/dL, AST of 218 U/L, and ALT of 146 U/L. Electrocardiography revealed atrial fibrillation, and his echocardiogram showed dilated cardiomyopathy with an ejection fraction of 15%. He was treated for CHF with minimal symptomatic relief. Hemochromatosis was considered later, when he had right upper quadrant abdominal pain and his bronze skin color was noted. The diagnosis was confirmed by a transferrin saturation of greater than 65%. Phlebotomy could not be initiated because the patient had cardiogenic shock and died. Clinical manifestations of hemochromatosis include weakness, abdominal pain, hepatomeagly, cardiac arrhythmias, CHF, diabetes, skin hyperpigmentation, and jaundice. The gene involved in the most common form of hemochromatosis is HFE. A homozygous G to A point mutation in this gene causes a cysteine to tyrosine substitution at position 282 (C282Y). This mutation may impair transferrin receptor-mediated uptake of transferrin-bound iron into the intestinal epithelium, thus interfering with the negative feedback to downregulate the iron transporter DMT1.

Conclusions: This case demonstrates the importance of early intervention and underscores the need to include hemochromatosis in the differential diagnosis of new-onset CHF, especially with concomitant cardiac arrhythmias, liver function abnormalities, and diabetes mellitus.

Determinants and Duration of Viral Shedding and Transmission of Human Parainfluenza Virus 3 Infection Among Allogenic Peripheral Stem Cell Transplant Patients.

Z.Y Aliyu, M.A. Bordner, D.K. Henderson, and J.A. Barrett. National Institues of Health, Bethesda, MD.

Background: Parainfluenza virus (PIV) infections may be significant causes of morbidity and mortality in patients undergoing stem cell transplantation. It has been suggested that the acquisition of hPIV3 infections seems to be independent of immunosuppression or transplant type and is driven primarily by patient exposure to the virus during periods of heightened community-wide or nosocomial activity.

Methods and Results: The incubation period for hPIV 3 is 1 to 3 days, and the duration of infectivity/viral shedding in nontransplant patients is 1 to 2 weeks. Data regarding the duration of infectivity/viral shedding and possible predictors of prolong infectivity in peripheral blood stem cell transplant patients (PBSCT) is limited. Of 56 allogenic PBSCT patients seen at our institution, 11 (6 inpatients and 5 outpatients) were positive for hPIV 3 during a 6-week period, compared with two positive cases recorded throughout the rest of the year. The inpatient attack rate was 11%. These patients were all placed on respiratory isolation and followed with weekly nasopharygeal swab/wash (NPW). The median time to conversion from positive to negative hPIV 3 NPW was 2.5 weeks, (median, 2.0; range, 1 to 6 weeks). The longest duration of viral shedding (6 weeks) was in the only haplo-identical SCT patient, who is also the index case. No differences in duration of viral shedding was noted for conditioning regimen (ablative vs nonablative), days after transplant (<15 or > 15 days), cysclosporine levels (100 to 200 vs 201 to 400 ng/L), absolute neutophil counts, absolute lymphocyte counts, CMV reactivation and coexisting peri-hPIV 3 infections evidenced by positive blood, urine, or sputum cultures. Most patients developed a brief flu-like illness without major respiratory complications. No deaths were recorded. No case of hPIV 3 was recorded among patients with aplastic anemia receiving ATG immunosuppression during the outbreak.

Conclusions: Our study demonstrates that although uncomplicated hPIV infection in allogenic PBSCT patients has limited morbidity, prolonged duration of viral shedding in this group may contribute to recurrent cycles of epidemics or prolong outbreaks and establish an environmental (community/nosocomial) contamination or "ping-pong" transmission from patients to asymptomatic healthcare workers or family members and back. Our study also emphasizes a universal policy for strict attention to infection control practices and weekly surveillance NPW until patients are asymptomatic and NPW negative are negative.

Efficacy of Budesonide in Acute Intestinal Graft Versus Host Disease.

Zakari Y Aliyu, MD, MPH. National Institutes of Health, Bethesda, MD.

Background: Acute intestinal graft vesus host disease (AIGVHD) represents one of the most daunting challenges after allogeneic transplantation. High-dose systemic corticosteroid is the first choice in abating the significant morbidity and mortality associated with AIGVHD after allogeneic bone stem cell transplantation (APBSCT). The systemic side effects of such therapy are often severe. Oral budesonide, a topically active glucocorticoid with limited systemic toxicity, has been used successfully in patients with inflammatory bowel disease. There are few reports of similar success in patients with AIGVHD.

Methods: This was a retrospective study of 14 patients with AIGVHD greater than or equal to grade II after APBSCT (9 myleoablative and 5 nonmyeloablative regimen). These patients received pulsed dose methylprednisolone of 500 mg IV QD for 3 days, followed by corticosteroids taper and additionally budesonide 9 mg/day divided into three doses. These patients were compared with a control group of 12 patients treated with high-dose steroids followed with a taper without budesonide. Both groups received similar prophylactic antibiotic and antifungal therapy and additional therapy with daclizumab and infliximab after 6 days of nonresponse to corticosteroids. The two groups were compared for total days and dose of corticosteroids use and improvement in clinical symptoms including abdominal cramps, frequency, and quantity of diarrhea.

Results: Patients treated with budesonide had a faster resolution of symptoms and required a shorter duration of systemic corticosteroid use (mean, 9.2 days vs 12.4 days, P < 0.05). The total dose of corticosteroid use was lower in the budesonide group (525 mg lower). No differences in acute infectious or metabolic complications were noted during the hospital stay in the two groups.

Conclusions: Budesonide appears to be an effective adjunctive therapy in AIGVHD with important steroid-sparing effects that may limit the toxicity of the latter. Additional prospective studies are needed to clarify its role and define appropriate regimes regarding time to initiation, dose, and duration of treatment with budesonide.

Two Interesting Faces of Immune Thrombocytopenic Purpura: Venous Thromboembolism and Helicobacter pylori.

Nirupama Mitikiri, MD. St Agnes Healthcare, Baltimore, MD.

Background: Immune thrombocytopenic purpura (ITP) is an acquired disorder of unclear cause. It is typically a chronic disease in adults. Spontaneous remission occurs only in 5% of patients. Corticosteroid treatment and splenectomy have been considered therapies of choice, but 20 to 30% of patients are refractory to both the therapies. Venous Thromboembolism is a very rare complication of ITP. Helicobacter pylori is a ubiquitous Gram-positive bacterium involved in the pathogenesis of gastric and duodenal ulcers. Its involvement has also been suggested in various autoimmune diseases such as megaloblastic anemia, Sjogren syndrome, and immune thyroiditis. Recently, H pylori has been associated with ITP.

Case Report: A 59-year-old white female went to her doctor's office for rash on both her legs. She was found to have petechiae by her physician, and laboratory results were positive for a platelet count of 4,000/[micro]L, with a normal hematocrit and white cell count. She had sinusitis 2 weeks prior and was started on ciprofloxacin. She had no epistaxis, hemoptysis, hematuria, or melena. Her medical history was significant for hypothyroidism secondary to radioactive iodine therapy for thyrotoxicosis, hypertension, diabetes, and hypercholesterolemia. She had cholecystectomy and a C-section in the past. She had no known drug allergies. There was family history of leukemia in her mother, and father had died of some hematologic disorder. She had no fever or weight loss. On examination, she had petechiae in all extremities. She was admitted to the hospital for further workup and started on intravenous Decadron. There was no evidence of hemolysis or renal failure. The diagnosis made was ITP. Her platelets initially responded to steroids, so she was discharged on oral prednisone. She had two relapses, which responded to intravenous immunoglobulin and enhanced-dose intravenous steroids. She also had Cushingoid features. The patient then had splenectomy but relapsed. She had an upper GI endoscopy with a biopsy positive for H pylori, and the platelet count improved transiently after 2 weeks of treatment. At this point, she presented with pulmonary embolism, a very rare course of the disease.

Conclusions: ITP is a common acquired bleeding disorder. An estimated annual incidence of ITP among adults is about 32 per million per year, using a platelet count cutoff of 50,000/[micro]L; 72% of the patients are female. Both genetic and environmental factors have been implicated in the cause. The pathogenesis of ITP is presumed to be related to platelet destruction and/or inhibition of platelet production via specific autoantibodies. The clinical manifestations of ITP are only those related to excessive bleeding caused by thrombocytopenia. Intracranial hemorrhage, a potentially fatal bleeding complication, is uncommon. Children typically present with an acute, sudden onset of ITP, which is usually associated with a history of infection in the several weeks preceding the illness. There is no gold standard test that can establish the diagnosis of ITP. The diagnostic criterion is isolated thrombocytopenia with no clinically apparent associated conditions. The interesting course of this disease is venous thromboembolism, which occurs only in 1 to 5% of patients. The cause varies from postsplenectomy state with increased platelet aggregability to antiphospholipid antibodies, protein C deficiency that become prominent after splenectomy. Up to now, there exist no recommendations for the duration and intensity of prophylactic anticoagulation after splenectomy. Also, use of intravenous immunoglobulin causing increased blood viscosity has been implicated. The other unusual presentation is association with H pylori. A molecular mimicry mechanism has been suggested as the possible mechanism for H pylori-associated ITP. Cytokines and chemokines produced in the gastric mucosa in response to H pylori infection may play a role in immune response in ITP. Clinically, age at onset of ITP is noted to be higher in H pylori-positive patients. H pylori is positive in more than 60% of patients with ITP, and about half of them respond to treatment. Although the implication of H pylori in the pathogenesis of ITP is not established, the data acquired to date still prompt us to consider the investigation and eradication of H pylori in these patients as a simple, inexpensive tool in early management of the chronic disease, avoiding the toxicity of prednisone and other immunosuppressants and the discomfort and complications of splenectomy.

Section on Oncology

Case Report: Right Breast Primary Extranodal Marginal Zone B-cell Lymphoma.

Melissa Joyner, MD, Join Y. Luh, MD, Terence Herman, MD, and Demetrio Mamani, MD. Department of Radiation Oncology and Division of Medical Oncology, Department of Internal Medicine, University of Texas Health Science Center at San Antonio. TX.

Background: Extranodal, primary breast lymphoma is a rare entity that often presents as localized disease. It accounts for only 1.7 to 2.2% of all extranodal lymphomas. At least 9.5% of such presentations are B-cell. Adult patients will usually have either marginal zone B-cell lymphomas or large B-cell lymphomas.

Case Presentation: This report describes a case of a primary, extranodal marginal zone B-cell lymphoma in a 61-year-old Hispanic female that was diagnosed with a core needle biopsy. Screening mammography revealed a nonpalpable, 1.2-cm irregular right breast mass. Prior mammograms from 2000 and 2002 were negative for any lesion. Physical examination revealed no axillary lymphadenopathy and no evidence of other sites of disease. The patient's history was significant for multinodular goiter and osteoarthritis without any history of cancer in first-degree relatives.

Methods and Results: The patient subsequently underwent complete staging, including CT of the chest, abdomen, and pelvis, as well as bilateral bone marrow biopsies with no evidence of metastatic disease. Morphological and immunohistochemical stain analysis confirmed the diagnosis of extranodal marginal zone B-cell lymphoma, stage IE. The patient was treated with tangential radiation therapy to the right breast for a total dose of 3,600 cGy in 20 fractions of 180 cGy per day over a 4-week period. The patient tolerated the radiation treatments well, with grade 2 to 3 skin erythema noted. At 1-month follow-up, the patient was doing well, with complete resolution of skin toxicity.

Conclusions: Lymphocytes are present in normal breast tissue, but extranodal breast lymphomas, either as a primary or secondary lymphoma are rare. The relationship with mucosa associated lymphoid tissue (MALT) and B-cell lineage and how these relate to the underlying cause of this malignancy remain an open area for further research.

Large Granular Lymphocytic Leukemia Versus Gamma Delta Hepatosplenic T-Cell Lymphoma: A Clinical Challenge.

Seema Hag, MD, and Sohail Saghier, MBBS. The University of Oklahoma College of Medicine, Department of Internal Medicne, Tulsa, OK.

Background: This report describes an interesting case that challenged the ability to distinguish between large granular lymphocytic leukemia (LGL) and gamma delta hepatosplenic T-cell lymphoma (HSTCL).

Methods and Results: LGL is a rare leukemia with a median age of onset at 55 years, having characteristic morphology, multiple autoimmune disorders, and indolent clinical course in females. HSTCL is an uncommon aggressive variant of non-Hodgkin lymphoma found in young males.

Case Presentation: A 53-year-old female with a 3-year history of pancytopenia, recurrent upper respiratory tract infections, fatigue, arthritis, and SLE presented with worsening cytopenia. A CT scan of the chest/abdomen/pelvis revealed hepatosplenomegaly with minimal lymphadenopathy. A peripheral blood smear showed pancytopenia with a minor population of large granular lymphocytes (reported CBC: RBC, 3.2/L; Hb1, 1 g/dL; platelets, 86 X [10.sup.9]/L; WBC, 1.0; neutrophils, 0.1; lymphocytes, 80). The patient had an IgM and IgG monoclonal gammopathy. Bone marrow biopsy revealed 40 to 50% cellularity with involvement by a T-cell lymphoproliferative disorder of TCR-gamma/delta immunophenotype positive for CD2, CD3, CD5dim, and CD7dim and negative for CD4, CD8, CD16, CD25, and CD56, with variable CD57 expression. Molecular studies for a T-cell receptor gene rearrangement showed no evidence of a T-cell clonal population. The cytogenetics profile was normal. Since the patient had features of both LGL and HSTCL, the case was referred to M.D. Anderson Cancer Centre for a second opinion. The patient was ultimately diagnosed with LGL. She was treated with cyclosporine for 8 months. The patient responded well, and her pancytopenia resolved.

Conclusions: This case highlights the clinical spectrum of LGL in the presence of an unusual immunophenotype. Our patient was CD8-negative and CD3-positve. CD8 negativity is present in HSTCL, yet our patient was presumed to have LGL on the basis of age, gender, typical signs and symptoms, and the presence of an autoimmune disorder. In addition, the CT scan findings of mild hepatosplenomegaly with lymphadenopathy and IgM/IgG monoclonal gammopathy supported the diagnosis of LGL, which is observed in 20% and 8% of the patients with LGL, repectively. A female patient with an indolent clinical course and 72% lymphocytes in the peripheral blood also argued against the features of HSTCL. The fact that the patient responded to LGL-specific treatment also suggested that this diagnosis was indeed correct.

Acquired Pure Megakaryocytic Aplasia in a Patient with IgA Deficiency: A Rare Association.

Seema Haq, MD, and Sadaf Saghier, MBBS. The University of Oklahoma College of Medicine, Tulsa, OK, and DOW Medical College, Karachi, Pakistan.

Background: Acquired pure megakaryocytic aplasia (APMA) is a rare disorder characterized by severe thrombocytopenia and markedly decreased or absent megakaryocytes in the bone marrow. Patients may have additional hematologic abnormalities. This report describes an interesting case of APMA in a patient with IgA deficiency. This unusual association has not been found in the literature.

Case Presentation: A 54-year-old female with a history of IgA deficiency presented with cough and hemoptysis for 2 weeks. She had no pain, fever, chills, melena, or any history of similar episode. There was no history of recent viral infection, alcohol use, medications, or exposure to toxins. Physical examination revealed petechiae of the extremities but was otherwise unremarkable. Laboratory investigations revealed pancytopenia. Serum chemistries, LDH, vitamin [B.sub.12], folate, PT/INR, PTT, fibrinogen, liver function tests, creatinine, and iron studies were all within normal limits. Further workup showed negative Coombs test, ANA, antiplatelet antibodies, parvovirus, and heavy metal screen. Peripheral blood smear and bone marrow biopsy revealed pancytopenia, with reduced number of megakaryocytes without any evidence of myelodysplastic or myeloproliferative changes consistent with APMA. The patient was then treated with antithymocyte globulin and cyclosporine for 7 months, and her hematological abnormalities resolved.

Discussion: The most likely pathogenetic mechanism responsible for APMA is immune suppression of megakaryocytic development and platelet production. Patients with IgA deficiency may develop antibodies directed against self-antigens, and there is a fair possibility that in our patient these antibodies might be responsible for induction of megakaryocytic aplasia. Our findings could not be related to cytostatic drug therapy. The possibility of the involvement of unknown viral infections cannot be excluded. The immune-mediated process is supported by clinical observations of efficacy of immunosuppressive treatment resulting in a dramatic response.

Conclusions: This case highlights the fact that APMA can occur in patients with IgA deficiency, and intensive immunosuppression is required to induce rapid remission.

The Anti-Apoptotic Mcl-1 Gene Expression Is Regulated by Ap-1 Transcription Factor and Its Expression Is Downregulated by Curcumin in Cancer Cells.

B.K. Nayak, C.A. Galindo, M.L. Meltz, and T.S. Herman. The University of Texas Health Science Center at San Antonio, Department of Radiation Oncology, San Antonio, TX.

Background: The anti-apoptotic Mcl-1 gene plays an important role in cell survival, differentiation, and apoptosis. The elevated expression of Mcl-1 plays an important role in development of various malignancies. The objective of the study was to determine the regulation of Mcl-1 expression by AP-1 transcription factor and to examine the effect of the AP-1 inhibitor curcumin on Mcl-1 expression.

Methods: The study was performed in human hematopoietic cells including 244B lymphoblastoid and Jurkat T-lymphoma cells. Cells were treated with 12-O-tetradecanoylphorbol acetate (TPA, 40 nM), or curcumin (50 [micro]M), or TPA (40 nM) plus curcumin (50 [micro]M). The AP-1 binding to Mcl-1 gene promoter was examined using electrophoretic mobility shift assay. Mcl-1 expression was examined using RNase protection assay and Western blot analysis.

Results: There was an induction of Mcl-1 expression in conjunction with the induction of fos and jun transcription factors in response to TPA. The simultaneous induction of Mcl-1 and fos/jun factors has led to our hypothesis that Mcl-1 might be an AP-1 target gene. Analysis of the Mcl-1 gene promoter indicated one consensus AP-1 binding site, TGACTCA at -1605/-1599. Binding of AP-1 complex to this site on Mcl-1 promoter was observed in control and TPA-treated cells. The AP-1 complex was supershifted in the presence of Jun B and c-fos antibody, indicating the presence of fos/jun factors in the AP-1 complex. Further, there was no AP-1 binding observed on the mutated AP-1 oligo, indicating specificity of AP-1 binding. The binding of AP-1 complex to the Mcl-1 promoter and the basal as well as TPA-induced Mcl-1 expression were inhibited in the presence of curcumin.

Conclusions: The study shows that the Mcl-1 gene is an AP-1-responsive gene and the Mcl-1 expression is inhibited by curcumin. This implicates that curcumin or other potential AP-1 inhibitor(s) might be used in specific therapeutic regimens to treat cancers overexpressing Mcl-1.

Pelvic Pain and Weight Loss in a Female with Primary Squamous Cell Carcinoma of the Rectum.

Join Y. Luh, MD, Samuel J. Wang, MD, PhD, Melisa Boersma, MS, MD, Russell Higgins, MD, Sridhar Beeram, MD, Morton Kahlenberg, MD, and Charles R. Thomas, Jr, MD. Departments of Radiation Oncology and Pathology, Division of Medical Oncology, Department of Internal Medicine, Department of Surgery, Division of Surgical Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX.

Background: Although adenocarcinomas of the rectum are common malignancies, the incidence of squamous cell carcinoma of the colon and rectum has been reported to be 0.25 to 0.1 per 1,000 colorectal carcinomas. This report describes a case of a patient with squamous cell carcinoma of the lower third of the rectum who underwent primary chemoradiation.

Case: A 39-year-old female began having constipation in May 2004. Over the next few months, she had a 20-pound weight loss and increased pelvic and rectal pain. She finally sought medical attention on October 21, 2004, in which a physical examination revealed a thin, white female with a large tender mass palpated at the posterior wall of the midrectum. A CT of the abdomen and pelvis revealed the presence of a 3.4 X 4.3-cm round rectal soft tissue mass.

Methods and Results: She underwent colonoscopy, which revealed a 4-cm rectal mass 5 cm from the anal verge. Biopsy revealed invasive moderately differentiated squamous cell carcinoma. She had no history of anoreceptive intercourse; however, the tumor cells stained positive for a cocktail of high-risk HPV genotypes by in situ hybridization. She was evaluated by radiation and medical oncology and clinically staged as stage 1 (T2 N0 M0). She subsequently received a total of 5,380 cGy of radiation followed by 5-fluorouracil and mitomycin-C. She reported feeling better on follow-up 2 months later, despite residual fatigue. She is to follow up with surgical oncology for a flexible sigmoidoscopy and biopsy, where she will be evaluated for response to therapy. Several mechanisms have been proposed to explain the pathogenesis of rectal squamous cell carcinoma. Multidirectional differentiation arising from poorly differentiated tumors, proliferation of uncommitted basal cells into malignant squamous cells, chronic irritation from inflammatory bowel disease, radiation, or HPV causing squamous metaplasia of glandular epithelium and squamous differentiation of adenomas and adenocarcinomas have all been proposed to explain the origin of these tumors. Some have argued that squamous cell carcinoma of the rectum represents metastatic disease of unknown primary.

Conclusions: Squamous cell carcinomas of the rectum are very rare malignancies with a mysterious pathogenesis. Although surgery has been the mainstay of treatment, chemoradiation may have an important role in noninvasive treatment of such patients with early stage disease.

Primary Intracranial Leiomyosarcoma: A Case Report.

Sakeer Hussain, Chip M. McDonald, and Gary V. Burton. Fiest Wieller Cancer Center, LSUHSC-S, Shreveport, LA.

Background: Involvement of intracranial structures with primary soft tissue sarcoma is rare. This report describes a patient with primary leiomyosarcoma involving the skull and dura.

Methods and Results: The patient, a 26-year-old male, presented with a 3-month history of an enlarging painless parieto-occipital mass. History was negative for smoking and drug use. Physical examination was normal, with the exception of a palpable, firm, nontender, 5-cm parieto-occipital mass. CBC and metabolic panel were normal. CT scan of the head demonstrated a large vascular soft tissue mass invading the right parietal bone and dura mater with displacement of the brain parenchyma. A stealth assisted craniotomy with cranioplasty and gross microsurgical resection of the tumor was performed for the clinical diagnosis of osteoblastic meningioma. Pathology revealed a soft tissue tumor involving both bone and dura. Immunostains were positive for smooth muscle actin and negative for epithelial membrane antigen. Margins of resection were negative. Pathology was interpreted as malignant spindle cell neoplasm consistent with high grade leiomyosarcoma with myxoid and epitheloid areas. CT scans of the chest, abdomen, and pelvis were negative for metastasis. The patient received 6.0 Gy of adjunctive radiotherapy to the region. Five months after therapy, the patient had right hip pain. MRI revealed heterogeneous marrow replacement in the right ischium with extraosseous soft tissue extension. CT scan showed multiple lung and liver lesions. MRI of the brain revealed tumor recurrence in the parietal-occipital extradural space. Fine-needle aspiration of a lung lesion confirmed recurrent leiomyosarcoma.

Conclusions: Primary intracranial tumors of mesodermal origin are rare and the majority are rhabdomyosarcomas in pediatric patients. Three cases of primary leimyosarcomas involving intracranial structures have been reported. These tumors can simulate meningiomas. Resection of the tumor is often difficult, and postoperative radiation and chemotherapy may be considered. Prognosis, despite complete resection and adjunctive therapy, is poor.

Guillain-Barre Syndrome in a Patient with Non-Hodgkin's Lymphoma.

CAPT. Jessica F. Powers, USAF, and CAPT. Colleen Gross, USAF. Wilford Hall Medical Center, Lackland AFB, TX.

Background: Guillain-Barre Syndrome (GBS) is an inflammatory demyelinating symmetrical polyneuropathy involving peripheral and cranial nerves. It is characterized by areflexia and an ascending, predominantly motor, neuropathy. Patients with lymphoma often have neurologic abnormalities, and a broad differential includes metastatic disease, treatment side effects, and paraneoplastic syndromes. GBS is reported in patients with Hodgkin's lymphoma but is rarely seen with non-Hodgkin's lymphoma.

Case: A 53-year-old female with stage IIIA diffuse large B-cell lymphoma, currently cycle 2, day 8 of cytoxan, adriamycin, vincristine, prednisone, and rituximab (CHOP-R), presented with progressive, painless lower extremity weakness.

Methods and Results: Physical examination revealed areflexia and decreased motor strength, weakest in her distal lower extremities. Cranial nerves were normal, and sensory examination revealed mildly decreased sensation in her distal lower extremities. She was in no respiratory distress. Laboratory studies ruled out lymphomatous meningitis, muscle breakdown, liver disease, uremia, HIV, diabetes mellitus, vitamin [B.sub.12] deficiency, multiple myeloma, and hypothyroidism. Cerebrospinal fluid analysis showed a normal protein, glucose, and cell count with negative cultures and negative cytology. Spinal MRI ruled out metastatic spinal disease and compressive lesions. Head CT was normal. Nerve conduction studies suggested a severe, symmetrical, length-dependent, sensorimotor, demyelinating polyneuropathy. She was treated with intravenous immunoglobulin 2 g/kg over 2 days and showed minimal to no clinical improvement. She then received plasma exchange with a significant increase in strength. She continues to regain neurologic function and is continuing CHOP-R chemotherapy.

Conclusions: Non-Hodgkin's lymphoma complicated by GBS has rarely been reported. Our patient displayed many of the classic features of GBS and improved only after initiation of GBS-targeted therapy. This case highlights the importance of considering possibilities other than drug toxicity in chemotherapy-treated patients with neurologic abnormalities.

Late Recurrence of Ewing Sarcoma in a 26-Year-Old Woman.

Henrik Illum, MD, and Gary V. Burton, MD. Department of Medicine, Feist Weiller Cancer Center, Louisiana State University Health Sciences Center, Shreveport, LA.

Background: Late recurrence of childhood tumors, such as Ewing sarcoma (ES), represent a difficult clinical problem. Determination of whether the recurrence represents a true recurrence or a second primary is difficult. This report describes a patient with a late recurrence of ES and reviews the literature relative the frequency and clinical management.

Methods: A 26-year-old female presented with a 3-week history of lumbar back pain and lower extremity paresis. Imaging studies showed a 5-cm, soft tissue tumor involving the pancreatic head and invading the L2 vertebra with spinal cord compression. Pathology and immunostains were consistent with ES. Fluorescence in situ hybridization for EWSR rearrangement was positive. Positron emission tomography revealed no evidence of metastatic disease. The medical history was significant for a stage IA ES involving the right hand diagnosed at age 13. That tumor was surgically removed and treated with radiotherapy only. The patient remained disease free and was lost to follow up at age 14.

Results: Previous reviews of large patient populations report that most ES recurrences were distant (47.9%); 35.2% were local and 16.9% were both. The median time to recurrence was 1.2 to 1.9 years (range, 0.6 to 11.9 years); 20% of recurrences occurred after 5 years. The reported longest time to recurrence was 17.1 years. Recurrence within 2 years of initial diagnosis carried a less favorable prognosis than later recurrence. Some studies reported cure rates for late relapses (after 5 years) similar to de novo disease.

Conclusions: Our patient represents the second longest reported time to recurrence for ES. It is not possible to determine if our patient's tumor represents a recurrence or a new primary ES. Her current tumor can, however, be expected to respond to treatment as de novo disease.

Oral Cancer in Patients Treated for Early Stage Breast Cancer: A Report of Two Cases and Review of the Literature.

Gang Ye and Gary Von Burton. Feist-Weiller Cancer Center, LSUHSC, Shreveport, LA.

Background: Early diagnosis and combined modality of treatment have significantly improved the survival of breast cancer. Most of these survivors will die of causes other than breast cancer, among which are second primary malignancies (SPM). A better understanding of the risk and pattern of SPM may lead to the improvement of surveillance and prevention strategies.

Case Report: Two rare cases of squamous cell carcinoma of oral cavity as SPM in patients treated for breast cancer are reported. The patients were white females who were diagnosed early stages (stages I and II, respectively) at middle age. They developed oral cancer after relatively long-term (6 and 7 years, respectively) remission of breast cancer. Both patients had undergone reserved surgery followed by adjuvant radiation treatment and adriamycin-based chemotherapy as the initial treatment for the breast cancer. One of them had also received tamoxifen for 5 years, as her cancer tissue was positive for hormone receptors. Neither of the cases had any other recognizable risk factors for oral cancers. The oral cancer in both patients was treated by surgical resection. The patients continue following up in the clinic and their breast cancer and oral cancer remain in remission.

Conclusions: The incidence of SPM and the possible association between SPM and initial treatment of breast cancer are discussed with a review of the literature. Prevention including behavioral and lifestyle modification remains the goal of efforts to reduce the overall incidence of oral cancer; yet, the recognition of potential development of SPM in breast cancer survivors warrants the cautious screening in these patients, which should include a careful examine of mouth cavity during a regular following check-up. The adjuvant treatment with chemotherapy, radiation, and hormone modifiers proves to decrease the recurrent or metastatic diseases of breast cancer and prolong disease free survival, and thus the benefits by far outweigh the probably slightly increased risks of developing SPM. Nonetheless, it is important for physicians to discuss with the patients about this low yet significant risk.

A Young Female with Severe Acute Renal Failure: An Unusual Presentation of Multiple Myeloma.

Michele Scott, MD, Mike Makdesi, MD, and Mukta Panda MD. University of Tennessee, Chattanooga, TN.

Objectives: To discuss an unusual presentation of myeloma and review the pathophysiology.

Case: A 42-year-old black female presented with weakness, nausea, and vomiting for 3 weeks. While in the ER she became unresponsive requiring resuscitation. Initial laboratory values showed H/H 5.3 g/dL/15.4%, potassium 9.8 mmol/L, BUN 223 mg/dL1, Cr 47.2 mg/dL, total protein 9.3 g/dL, albumin 3.8 g/dL. and Ca 12.6 mg/dL. Abdominal CT was normal. SPEP and UPEP revealed monoclonal spike identified as a free kappa light chain. Kidney biopsy showed a mixed picture of light chain and IgA nephropathy. Bone marrow biopsy revealed a hypercellular marrow with atypical plasma cells infiltrates expressing monoclonal kappa and CD56 estimated to be 16 to 30% of the marrow. Bone survey showed no lytic lesions. She was undergoing treatment with pulsed-dose steroids and thalidomide.

Conclusions: Multiple myeloma is a malignancy of plasma cells and overproduction of monoclonal immunoglobulin or free kappa or lambda chains Median age is 69 years, with increased risk in blacks. Common clinical features are back pain, fatigue, frequent infections, bone pain, and renal failure. Laboratory abnormalities might show azotemia, hypercalcemia, elevated total protein, low albumin, and anemia. X-rays can reveal punched out lytic bone lesions and osteopenia. The minimal criteria for diagnosis are greater than 10% plasma cells in bone marrow biopsy plus one of the following: monoclonal protein spike in serum or urine or lytic bone lesions. The myeloid cells secrete osteoclast activating factor, which leads to lytic bone lesions and hypercalcemia. Renal failure is secondary to direct toxic effects of the light chains on the renal tubular cells or from hypercalcemia. Treatment involves pain control, adequate hydration, chemotherapy if necessary, and treatment of the complications of the disease such as hypercalcemia with bisphosphonates. This was a very challenging case of multiple myeloma. Our patient was young and had an atypical presentation with fulminate disease and severe acute renal failure with a short prodrome.

Section on Ophthalmology

*An In Vitro Model of Treating Acute Postoperative Endophthalmitis with Combination of Vancomycin and Ceftazidime in a Single Syringe.

CAPT Robert Lyons, MD, USAF, MC, FS, and MAJ R. Gary Lane, MD, USAF, MC, FS. Ophthalmology Department, Wilford Hall Medical Center. San Antonio, TX.

Objectives: To quantify the difference in mean inhibitory concentrations of vancomycin and ceftazidime when combined together in a single syringe or injected separately.

Methods: Using standard laboratory techniques, minimum inhibitory concentrations (MIC) were obtained by using vancomycin and ceftazidime against the bacteria that most commonly cause acute postoperative endophthalmitis. Comparisons were made between vancomycin and ceftazidime in combination when injected separately into the same MIC well, simulating the current model of treatment, and when mixed in a single syringe prior to instillation in the MIC well.

Results: There was no difference in the MIC of vancomycin and ceftazidime when combined together in a single syringe versus injected separately. These results were consistent for all bacteria tested, which included S aureus, S epidermidis, S pneumoniae, and H influenzae. When combined into a single syringe at intravitreal concentrations, vancomycin and ceftazidime did not precipitate. Vancomycin and ceftazidime mixed in the same syringe was easily injected through a 25-gauge needle.

Conclusions: These findings suggest no antagonistic effect when mixing vancomycin and ceftazidime in a single syringe for the treatment of acute postoperative endophthalmitis. When compared with the current two-syringe method, the single syringe method offers less risk with no decrease in efficacy for the treatment of acute postoperative endophthalmitis.

Section on Pathology

Angiomyolipoma: A Report of Five Cases and Review of the Literature.

Cesar V. Reyes, MD, and Peter C. Roumeliotis, MD. Department of Pathology and Medicine, Morris Hospital, Morris, IL.

Background: Angiomyolipoma is an uncommon soft tissue tumor that is usually defined by triphasic features of mature adipose tissue, mixed thick-walled blood vessels, and benign smooth muscle and is confirmed with a melanocytic marker positivity. Microscopically, it is sometimes mistaken for a sarcomatoid carcinoma. The smooth muscle component is greatly variable, spindle to epithelioid, and often perivascular. The latter location is the basis of the favored histogenesis from perivascular epithelioid cells. Half of the tumors occur sporadically whereas the other half are associated with tuberous sclerosis complex, which is supported by chromosomal abnormalities. Its clinical behavior is almost generally benign, although rare instances of spread in the regional lymph nodes and inferior vena cava at the time of diagnosis have been reported.

Methods and Results: This report describes five cases of angiomyolipoma encountered in a small 82-bed tertiary care hospital in a 5-year period. The patient ages ranged from 47 to 83 years (mean, 67). The sex distribution was two males and three females. The lesion involves the left kidney in three cases, right kidney (one), and liver (one). Three cases were asymptomatic; one patient complained of microhematuria, and one presented with acute hemorrhagic rupture of a huge left kidney tumor. The renal lesions (four) were adequately resected, and the liver lesion was diagnosed via a computer tomographic scan-guided core-needle aspiration biopsy.

Conclusions: No recurrence was observed in 3- to 5-year follow-up after nephrectomy (four). None also showed evidence of metastasis and tuberous sclerosis complex.

Alveolar Soft Part Sarcoma of the Lower Extremity.

Tara N. Evans, MD, and Elliot Carter, MD. University of South Alabama, Mobile, AL.

Background: Alveolar soft part sarcoma is a rare soft tissue tumor of uncertain origin. Generally slow-growing but unmistakably malignant, alveolar soft part sarcoma tends to occur in the lower extremity of adolescents and young adults. Disseminated disease is common, with lung, bone, and brain being the most frequent sites of metastasis. The prognosis of these lesions is poor, with survival rates of 60 to 67% at 5 years and 15% at 20 years. Therapeutic options of chemotherapy and radiotherapy show little efficacy.

Methods and Results: This report describes the case of a 54-year-old black male who presented with a 2-week history of left leg pain. At that time, imaging studies revealed a left leg soft tissue mass just below the popliteal fossa and multiple bilateral lung lesions, suggestive of metastatic neoplasm. The patient was lost to follow-up for 5 months but eventually returned complaining of severe left leg pain, hemoptysis, diplopia, and headache. Imaging studies of the brain showed a sellar mass with bony destruction. A fine-needle aspiration and biopsy of the left lower extremity mass yielded uniform clusters of cells and single cells with large nuclei and single prominent nucleoli. Histologically, a biopsy of the mass showed nests of large polygonal cells with abundant eosinophilic cytoplasm, round regular nuclei, and prominent nucleoli. The nests of cells were bordered by small vascular channels, and a PAS stain highlighted intracytoplasmic rhomboid crystals. These crystals, a feature diagnostic of alveolar soft part sarcoma, were also identified by ultrastructural analysis.

Conclusions: The patient had subsequent development of a large lesion of the humerus compatible with metastatic sarcoma.

Hurthle Cell Neoplasm: Predicting Biological Behavior.

Robert L. West, MD. Department of Pathology and Laboratory Medicine, the Brody School of Medicine, East Carolina University, Greenville, NC.

Background: A case of Hurthle cell neoplasm was diagnosed in 1994. The neoplasm measured 2.5 cm in greatest dimension but had no other morphologic criteria, either gross or microscopic, to suggest it would behave in a malignant fashion. In 2004, the patient presented with a mass in the neck, thought to be an enlarged lymph node. The mass was excised and was metastatic Hurthle cell carcinoma in skeletal muscle.

Methods and Results: The difficulty in predicting biologic behavior of Hurthle cell neoplasm is well known. Most of these neoplasms are encapsulated, and demonstrating capsular or vascular invasion are two major morphologic criteria of malignant behavior. Some authors have concluded that size is a strong indicator of biologic behavior. More recently, investigators have attempted to use selected immuno stains, Ki67 and Cyclin DI in distinguishing benign from malignant neoplasms.

Conclusions: Determining prognosis is difficult and controversial. Variables adversely affecting prognosis are older age, tumor size, male gender, external beam radiation therapy, and chemotherapy, according to some investigators.

Parotid Lyphangioma: A Limited Diagnosis with Fine-Needle Aspiration Cytology

A. Arcot, J. Finley, and K. Hewan-Lowe. Brody School of Medicine at East Carolina University. Greenville, NC.

Background: Cysts within the parotid gland comprise a heterogenous group of lesions. These include lymphangioma, Warthin tumor, benign lymphoepithelial lesions, branchial cleft cysts, cystic pleomorphic adenoma, and cystic low-grade mucoepidermoid carcinoma. Of these entities, lymphangioma is an uncommon lesion in adults. Fine-needle aspiration (FNA) cytology is an excellent first step in the investigation of cystic parotid lesions. However, the FNA diagnosis of an uncommon cystic lesion such as a lymphangioma is limited.

Methods: A 58-year-old, HIV-negative male presented with a cystic lesion in the left parotid gland. FNA yielded 15 mL of clear fluid. Three months later, the lesion recurred. A multilocular, 3.5-cm cyst was resected from the superficial lobe of the parotid gland.

Results: FNA yielded only benign lymphocytes and proteinaceous debris. The surgical resection showed a multilocular cyst having a flattened cell lining that was immunopositive for CD31 and CD34. In the cyst wall, multiple lymphoid aggregates were present as well as connective tissue and smooth muscle bundles.

Results: A lymphocyte-rich lesion such as a lymphangioma would be expected to yield an aspirate consisting of lymphocytes. The flattened cell lining is rarely seen. Other lymphocyte-rich lesions, such as benign lymphoepithelial lesions, Warthin tumor, branchial cleft cysts, and mucoepidermoid carcinomas are distinctive because of their signature epithelial cell components. However, the absence of an epithelial component does not exclude these entities and may represent sampling error. Therefore, a definitive diagnosis of lymphangioma requires excision of the cyst.

Conclusions: Although FNA cytology is perceived as an excellent first step in the diagnosis of many cystic lesions of the parotid gland, it has limited utility in the diagnosis of lymphangioma. The diagnosis is suggested in aspirates yielding clear fluid and containing only lymphocytes and stromal fragments.

*Epstein-Barr Virus Studies and Clinical Outcome in Hodgkin Lymphoma and Hodgkin Lymphoma-Like Posttransplant Lymphoproliferative Disorder.

S. Chikkamuniyappa, M.C. Kinney, and A. Ehsan. Utah Health Science Center, San Antonio, TX.

Background: Hodgkin lymphoma and Hodgkin lymphoma-like posttransplant lymphoproliferative disorder (HL-PTLD and HL-like PTLD, respectively) have been reported in allograft recipients. Morphologic patterns and EBV status (BZLF-1, serology, viral load) have not been studied in detail to determine if they are useful in distinguishing these PTLDs from EBV+ de novo classic Hodgkin lymphoma (EBV + dHL) and in predicting their treatment/outcome. HL-PTLD/HL-like PTLD was compared with cases of EBV + dHL and EBV-negative de novo classic Hodgkin lymphoma (EBV-dHL), using immunohistochemistry (IHC) and EBV studies.

Methods: Tissue biopsies (HIV negative adult patients) were evaluated from 7 HL-PTLD and HL-like PTLD (all recipients were seropositive for EBV at the time of transplant), 23 EBV + dHL, and 11 EBV-dHL cases. The following IHC stains were performed: CD45RB, CD3, CD20, CD15, CD30, CD43, CD45RO, BZLF-1, and EBER-1. EBV serology and EBV plasma viral load by real-time PCR (TAQMAN assay EBV W1/W2 primers) were performed on pretreatment blood samples.

Results: Discriminating profiles were seen in the following:
            HL-like       PTLD           EBV + dHL     EBV-dHL
HL-PTLD     (n = 3)       (n = 4)        (n = 23)      (n = 11)

CD20+       3             4              20            1
CD15+       3             4              12            5
CD30+       3             4              23            11
EBER-1      Large cells   Large and      Large cells   Negative
                            small cells
BZLF-1      0             4              0             0
EBV         Not elevated  High VCA,      Not elevated  Not
  Serology                  EA (> 4-                     elevated
EBV viral   < 500 cp/mL   39,725 cp/mL   < 500 cp/mL   < 500 cp/mL

VCA, viral capsid antigen; EA, early antigen; cp, copies.

Two subgroups were identified among PTLD cases: (1) HL-PTLD presented later (mean, 7 years after transplant) with nodal disease did not respond to reduced immunosuppression (RI) and required cytotoxic chemotherapy (RX). This group was similar to EBV + dHL, immunophenotypically. (2) HL-like PTLD presented earlier (mean, 2 years) with extranodal disease, two patients responded to RI plus antiviral therapy and two required RX.

Conclusions: Hodgkin lymphoma arising as PTLD can be heterogeneous. Morphology, IHC, and EBV studies are useful in predicting response to withdrawal of immunosuppression and clinical outcome. CD20 is more common in HL-PTLD, HL-like PTLD, and EBV + dHL, suggesting targeted monoclonal anti-CD20 therapy warrants further investigation.

Papillary Carcinoma Presenting in the Thyroglossal Duct Cyst.

Vinita Mathur, MD, and Robert L. West, MD. Department of Pathology and Laboratory Medicine, the Brody School of Medicine, East Carolina University, Greenville, NC.

Background: Thyroglossal duct cyst carcinoma is a rare entity. This report describes two patients with papillary carcinoma in a thyroglossal duct cyst. The first patient was an adult and was previously reported. The second patient was 11 years of age.

Methods and Results: The adult patient was initially treated by surgery alone in 1992 and subsequently was seen in 1997 for unrelated reasons with no recurrence. The pediatric patient had local spread into adjacent skeletal muscle and declined further surgery. Papillary carcinoma in a thyroglossal duct cyst was diagnosed in less than 2% of thyroglossal duct cysts. Including our two cases, only 226 cases have been reported in the English language literature to date. Histologically, the most common type of carcinoma found in these malignant thyroglossal duct cysts is papillary carcinoma. Other types include squamous cell carcinoma, mixed papillary and follicular carcinoma, and anaplastic carcinoma. No clear consensus exists regarding the treatment of these patients after excision of the cysts. Most commonly, a Sistrunk procedure is performed in which the middle one third of the hyoid bone and the thyroglossal duct are excised. An alternative is to perform a total thyroidectomy after the Sistrunk procedure. Postoperative radioactive iodine therapy has also been offered.

Conclusions: The prognosis was found to be essentially the same in patients treated by a Sistrunk procedure alone compared with patients with a Sistrunk procedure and total thyroidectomy. Risk stratification based on histologic type, extent of the neoplasm, and metastasis appears to be the best approach to determine who would benefit from more aggressive treatment.

Littoral Cell Angioma: Unique, Multifocal Splenic Tumors.

M. Richardson, S. Thomas, K. Hewan-Lowe, L. Dobbs, Jr., and J. Finley. Brody School of Medicine, East Carolina University, Greenville, NC.

Background: Littoral cell angiomas are distinctive splenic tumors that present with signs of hypersplenism and splenomegaly or may be discovered during evaluation for coexisting clinical conditions. Radiographic studies show splenic masses, for which the differential diagnoses include lymphoma, metastatic carcinoma, and hemangioma. The diagnosis of a littoral cell angioma is usually made after splenectomy.

Clinical Features: Three patients, respective ages 49, 57, and 76 years, underwent splenectomy. One patient had splenomegaly that was secondary to myelofibrosis. The other two patients had symptomatic cholelithiasis. Radiographic studies, performed on the patients with symptomatic cholelithiasis, showed multiple hypodense lesions in spleens of normal size.

Results: The spleens weighed 250, 298, and 1,802 grams and contained firm, tan nodules 0.3 to 3 cm in size. Microscopic examination showed slit-like and cavernous vascular spaces with plump lining cells showing enlarged hyperchromatic nuclei, abundant clear cytoplasm, and focal hemophagocytosis. These cells were immunopositive for CD31, Factor VIII-RAg, and CD68, and negative for CD34. The vascular spaces contained sloughed lining cells, macrophages, and blood.

Discussion: Histologically, a littoral cell angioma must be distinguished from a hemangioma and an angiosarcoma. The lining cells in the littoral cell angioma are plump, unlike those in a hemangioma, and simulate those of a low grade angiosarcoma. However, neither cytologic atypia nor mitotic activity is present. The immunophenotype of the littoral cell angioma (CD31+/CD34-/CD68+/Factor VIII-RAg+) is a key factor in the diagnosis of this tumor and correlates, with the dual differentiation of the littoral cells in the spleen.

Conclusions: Littoral cell angiomas are unique vascular tumors of the spleen. Hypersplenism or coexisting clinical conditions lead to their discovery. Histopathologic examination is required to establish a definitive diagnosis of littoral cell angioma and exclude other splenic neoplasms or conditions.

Papillary Fibroelastoma: A Common, Benign Cardiac Tumor.

A. Dash, K. Hewan-Lowe, and J. Finley. Brody School of Medicine, East Carolina University, Greenville, NC.

Background: Papillary fibroelastomas (PFs) account for 8% of all cardiac tumors and are not as common as myxomas, the most common benign cardiac tumor. Although the valvular surface is the predominant location, PFs can arise at other locations on the endocardium. Many asymptomatic PFs are an incidental finding at autopsy. Mobile PFs are associated with clinical symptoms. Currently, transesophageal echocardiography and cardiac surgery for the treatment of coronary artery and valvular diseases are instrumental in the discovery of asymptomatic PFs.

Clinical Features: Five patients, age range 50 to 78 years, who underwent cardiac surgery, were found to have endocardial tumors. Two tumors were associated with stenotic valves, two tumors were associated with a normal valve, and one tumor was located on the endocardial surface of the right atrium. The coexistent clinical findings were coronary artery disease, valvular stenosis, thromboembolic phenomenon, and presumptive bacterial endocarditis. Preoperative diagnosis of the tumors on the normal valves was the result of transesophageal echocardiography.

Results: Each cardiac tumor was a papillary, myxoid tumor that resembled a sea anemonone. The elongated, branching papillary fronds had a core of eosinophilic, compact connective tissue that was rich in elastic fibers. A layer of endothelial cells lined the surfaces of the papillae. The subendothelial regions were myxoid and contained rare spindle cells.

Discussion: The underlying cause of PFs is controversial. Association with stenotic valves would support the theory that these lesions are a reactive process. On the other hand, the presence of PFs on normal valves suggest that they are true neoplasms.

Conclusions: With the advent of transesophageal echocardiography and an increase in cardiac surgery for valvular and vascular diseases, cardiac papillary fibroelastomas have become a more common surgical disease and are less often incidental tumors found at autopsy.

Idiopathic Infantile Arterial Calcification: A Case Report with Energy-Dispersive X-Ray Microanalysis.

Kressida T. Cain, MD, Andrea G. Kahn, MD, Judy A.C. King, MD, PhD, and Elizabeth A. Manci, MD. Department of Pathology, University of South Alabama, Mobile, AL.

Background: Idiopathic infantile arterial calcification (IIAC) is a rare disease of unknown cause affecting children in the neonatal or early infancy period of life. IIAC is inherited as an autosomal recessive disease with a poor prognosis and usually diagnosed at autopsy.

Methods and Results: A 28-week gestational age fetus was born to a primigravid mother after a pregnancy complicated by intrauterine demise, polyhydramnios, and hydrops fetalis. Autopsy examination revealed ascites, pleural effusions, and diffuse calcification of the intima and/or media associated with minimal arteritis of the aorta, coronary arteries, great vessels, pulmonary arteries, and medium to large vessels of the pancreas. Arteritis involving the pulmonary arteries was moderate to severe. Fibrous intimal thickening was noted in the affected vessels. Both kidneys had concentric calcifications in tubules, glomerular tufts, and Bowman capsules. Cardiomegaly and coarctation of the aorta were present. No additional morphologic findings were identified. Fibroblast culture for karyotyping failed to grow. Selected sections of lung and kidney containing calcified areas were further analyzed by scanning electron microscopy and energy-dispersive x-ray microanalysis revealing the presence of calcium and phosphorus.

Conclusions: This study shows that the calcifications in IIAC are not limited to blood vessels but may also be seen in renal tubules and Bowman capsule. Although most reports of IIAC in the literature are autopsy cases, a few cases have been detected antemortem by ultrasound. The antenatal diagnosis can be achieved by serial ultrasonographic examinations, which may be useful for early diagnosis in future pregnancies of affected families.

Section on Pediatrics and Adolescent Medicine

*Lung Function in Young Children with Recurrent Wheeze and Cough: Relationship to Bronchoscopic and Bronchoalveolar Lavage Fluid (BALF) Findings.

John Saito, MD, William T. Harris, MD, Jonathan Gelfond, Terry L. Noah, MD, Margaret W. Leigh, MD, Robin Johnson, RRT, and Stephanie D. Davis, MD. Division of Pulmonology, Department of Pediatrics and Department of Biostatistics, University of North Carolina, Chapel Hill, NC.

Objectives: Identification of the cause and assessment of the severity of airway disease in infants with recurrent wheeze and/or cough is difficult in the clinical setting. The specific aims of this study were to (1) generate hypotheses about the usefulness of infant pulmonary function tests (IPFT), obtained using plethysmography and the raised-volume rapid thoracoabdominal compression (RVRTC) technique, in predicting abnormalities in anatomy, inflammation, or infection, and (2) describe the anatomic, microbiologic, and physiologic findings of this population.

Methods and Results: A prospective, descriptive study was performed of IPFT in 23 infants under 3 years of age who received clinically indicated flexible bronchoscopy (FB) for recurrent wheeze and/or cough. Retrospective data on 108 infants who underwent FB over the same time period but who did not have IPFT were also reviewed. As a whole, males in this population were 2.6 times more likely than females to undergo FB. Mean z scores (n = 22) were -1.26, -2.21, 2.43, and 2.03 for forced expiratory volume at 0.5 seconds (FE[V.sub.0.5]), flows between 25 and 75% of forced vital capacity (FE[F.sub.25-75]), functional residual capacity (FRC) and the ratio of residual volume divided by total lung capacity (RV/TLC), respectively. Younger and shorter infants had FE[F.sub.25-75] z score values that were profoundly depressed (P = 0.005). FRC was significantly elevated in the presence of: (1) airway inflammation (P = 0.04), (2) visible bronchitis (P = 0.01), and (3) lower airway abnormality (P = 0.04). There was no significant association between the other IPFT variables and the four covariates of airway inflammation, positive bacterial culture, lower airway abnormality, and visible bronchitis. In the retrospective population, visible bronchitis (56%), lower airway abnormalities (44%), neutrophilic inflammation (61%), and positive bacterial cultures (62%) were identified.

Conclusions: IPFT parameters obtained using plethysmography and the RVRTC techniques are useful in identifying severity of airflow obstruction and hyperinflation in this population. In general, lung function changes were not useful in predicting abnormalities in anatomy, inflammation, or infection as identified by FB. The shorter infants with severe airflow limitation may have relatively small airways, leading to difficulty in clearing mucus and predisposing to chronic lower airway infection.

*Prevalence of Chlamydia Among Active Duty Male Soldiers Reporting to a Troop Medical Clinic for Routine Health Care at a Military Installation in Central Texas.

Jeffery P. Greene, MD, and Elisabeth Stafford, MD. Division of Adolescent Medicine, Department of Pediatrics, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX.

Objectives: To determine the prevalence of Chlamydia among active duty males receiving routine health care and measure risk factors associated with sexually transmitted infections (STI) in a high-risk population.

Methods: Male soldiers between the ages of 18 and 25 years, reporting to sick call for routine care between November 2004 and March 2005, were asked to volunteer for STI screening. All male soldiers who reported to sick call were given educational information regarding Chlamydia trachomatis and were allowed the opportunity to participate in the study. Conversely, they had the option to not participate in the study. The estimated prevalence of Chlamydia was determined by using the Transcriptase Mediated Amplification (TMA) urine-based test. Names and contact phone numbers were provided to ensure proper follow-up and treatment of those whose test results were positive. Risk factor assessment was ascertained by questionnaire. Subjects who tested positive for Chlamydia were treated with azithromycin, 1 gram in a single dose. Samples that tested positive were compared with the total number of samples tested to determine a prevalence rate.

Results: A total of 138 male soldiers were screened for Chlamydia. The majority of soldiers who participated in the study reported to sick call for evaluation of an unspecified injury, 31.9% (95% CI: 0.241 to 0.397). The estimated prevalence of Chlamydia was 8.0% (95% CI: 0.035 to 0.125). The majority of soldiers screened and soldiers who tested positive for disease were asymptomatic, 97.1% (95% CI: 0.925 to 0.991) and 72.7% (95% CI: 0.428 to 0.905), respectively. Overall, 42.8% (95% CI: 0.345 to 0.510) of respondents attested to using barrier protection during their last sexual encounter. Of those who screened positive for Chlamydia, 63.6% (95% CI: 0.352 to 0.848) did not use a condom during their last encounter. Those who tested positive for disease more commonly presented with concerns about STI. However, 36.4% (95% CI: 0.152 to 0.648) of those with Chlamydia reported to sick call primarily for musculoskeletal injuries. No subjects who tested positive for disease had been treated for an STI in the past (95% CI: 0.039 to 0.305).

Conclusions: The prevalence of Chlamydia in this high-risk population of active duty male soldiers is within the range of previous studies. Providers must continue to educate and screen for Chlamydia. This study's aim is to incorporate risk assessment for sexually transmitted infections in the evaluation of male soldiers in order to initiate routine testing.

Streptococcus pyogenes Disseminated Infection and Necrotizing Fasciitis Presenting as Acute Polyathralgia.

Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Background: Streptococcus pyogenes causes respiratory tract and skin infections but can also cause a wide variety of invasive systemic infections.

Methods and Results: A 10 year-old male had a complaint of fever and joint pain for 2 days. He told his mother that he had knee pain that was attributed to minor trauma. He then complained of pain to migrating to his shoulders, elbows, and feet. His medical history was significant for atopic dermatitis and ADHD. His medication were amphetamine/dextroamphetamine and sertraline. He had a temperature of 38.6[degrees]C, blood pressure of 145/64 mm Hg, heart rate of 136/minute, and respiratory rate 32/minute. His pulse oximetry on room air was 85%. His examination showed ecchymosis to his left upper thigh and swelling to both lower extremities. His left knee was tender, warm, and with pain on range of motion. His right knee and both elbows were warm with mild pain on range of motion. Otherwise, his examination was unremarkable. His WBC count was 9,600/[mm.sup.3] with 17% neutrophils and 34% bands; hemoglobin was 12.3 g/dl and platelets were 179,000/[mm.sup.3]. His electrolytes, liver function tests, lactate, and urinalysis were normal. His knee was aspirated, and fluid analysis showed WBC count of 15,440/[mm.sup.3] with 85% neutrophils. Cultures were negative. He was hospitalized and on the following day required intubation for respiratory failure. A CT scan of the abdomen and lower extremities showed extensive soft tissue stranding of the muscles consistent with necrotizing fasciitis. His left hip and right knee were aspirated for persistent fever and this time cultures grew out group A Streptococcus. He was started on clindamycin. He had a long hospital course but was discharged 1 month later to the children's rehabilitation center.

Conclusions: S pyogenes has reemerged as an important cause of toxic shock syndrome (TSS) and life-threatening skin and soft tissue infections. Necrotizing fasciitis is an acute, rapidly progressive, severe infection of the subcutaneous tissue. The infection starts as an erythematous swelling with severe pain that progresses to a bluish and dusky with bullae, which becomes frank gangrene by day 4 to 5. Progression leads to streptococcal toxic shock syndrome, which is characterized by hypotension and multiple organ failure. Treatment of these severe infections includes appropriate antibiotics and surgical debridement.

Acute Headache in Children Presenting to a Pediatric Emergency Department

Antonio E. Muniz, MD, Sam Bartle, MD, Chris Woleben, MD, Robin L. Foster, MD, and Steve Liner. MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Objectives: Headache is a common presenting complaint to emergency departments. Although the overwhelming majority of these headaches are benign and self-limited disorders; however, a headache can be the initial symptom of life-threatening disorders. Few data exists regarding acute headache in children. Therefore it is important for physicians to have a rational approach to the initial evaluation of a child or adolescent who presents to the emergency department with headache. The purpose of this study is investigate the epidemiology and diagnostic procedures in children presenting with a headache.

Methods: This was a prospective evaluation of consecutive children less than 18 years old who presented to a pediatric emergency department with the chief complaint of headache. No patients were excluded.

Results: There were 275 children, with 140 (51%) males. The mean age was 9.8 [+ or -] 4.4 (95% CI, 9.2, 10.3), with a range of 1 to 17 years. There were 190 (69%) blacks, 72 (26.1%) whites, 8 (2.9%) Hispanics, and 5 (1.8%) other race. There were 80 (29.0%) children with fever. The location of the headache was bifrontal in 111 (40.3%), diffuse in 103 (37.4%), localized in 49 917.8%), posterior in 9 (3.2%), and bitemporal in 3 (1%). Only 8 (2.9%) had an aura. Diagnostic test included CBC count, 72 (26.1%); basic metabolic profile, 41 (14.9%); urinalysis, 8 (2.9%); urine pregnancy test, 1 (0.36%); rapid streptococcal antigen, 12 (4.3%); CXR, 2 (1.09%); CT scan of the head, 95 (34.5%); and lumbar puncture, 6 (2.1%). A neurologic consult was obtained in 4 (1.4%). The diagnosis included viral syndrome (26.9%); nonspecific, 61 (22.1%); migraine, 33 (12%); contusion, 32 (11%); ventriculoperitoneal (VP) shunt malfunction, 20 (7.2%); streptococcal pharyngitis, 15 (5.4%); otitis media (2.9%); rhinitis, 6 (2.1%); sinusitis, 6 (2.1%); meningitis, 6 (2.1%); tension headache, 2 (.07%); UTI, 2 (0.7%); pneumonia, 2 (0.7%); dental infection, 2 (0.7%); tumor, 1; subarachnoid hemorrhage, 1; atlantoaxial rotary subluxation, 1; Rocky Mountain spotted fever, 1; and CO poisoning, 1. Posterior location of the headache and the presence of a VP shunt were associated with serious underlying diasease.

Conclusions: Headaches are a common presentation to an emergency department. Viral syndrome, nonspecific, migraine, contusions, VP shunt malfunction, and streptococcus pharyngitis account for the majority of the cases. CT scan showed new abnormalities in a minority of patients and should be reserved for those with significant head trauma and to exclude VP shunt malfunction.

Pulmonary Embolism in an Adolescent.

Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Background: Pulmonary embolism (PE) in children is an uncommon event; however, when they do occur, thry are associated with significant morbidity and mortality and must be considered in children with risk factor for a PE.

Methods and Results: A 16-year-old male had a complaint of fever, cough, increased work of breathing, and nasal congestion for 1 week. His medical history was significant for a severe head injury with a comatose state from a motor vehicle accident. His medication included baclofen, methylphenidate, and bisacodyl. He had a temperature of 38.6[degrees]C, blood pressure of 145/64 mm Hg, heart rate of 136/minute, and respiratory rate of 32/minute. His pulse oximetry on room air was 85%. His HEENT examination showed dry mucosa membranes. His neck was supple without adenopathy. His lung examination was normal. His cardiac examination showed tachycardia without gallops or murmurs. His abdominal examination was normal. His neurologic examination was unchanged for aphasia. His WBC count was 15,600/[mm.sup.3], with 52% neutrophils; hemoglobin was 14.5 g/dL and platelets were 134,000/[mm.sup.3]. Electrolytes showed a sodium of 182 mEq/L and BUN of 32 mg/dL and creatinine of 0.9 mg/dL. Urine analysis was normal. Chest radiograph was normal. The 12-lead ECG showed sinus tachycardia with no abnormalities. A CT scan of the chest showed multiple defects in the right upper and middle lobe, consistent with multilobar pulmonary embolism. He was started on heparin and given intravenous fluid hydration. He was hospitalized in the PICU. Peripheral lower extremity Doppler did not show a deep venous thrombosis. He was started on warfarin and the hypoxia resolved. He was discharged to a pediatric rehabilitation center.

Conclusions: Pulmonary embolism is a rare event in children and is probably underdiagnosed. For the same reason, much of the information pertaining to diagnosis and management has been derived from adult practice. The most common risk factors in children include presence of central venous catheter, recent surgery, immobilization, cardiomyopathy, sickle cell disease, trauma, neoplasma, hyperalimentation, dehydration, and inherited disorders of coagulation. Symptoms in children include pleuritic chest pains, dyspnea, cough, and a feeling of apprehension. Physical findings include tachypnea, fever, and diaphoresis. Diagnosis can be made by either a V/Q scan or CT scan, and rarely pulmonary angiography is required. Treatment includes anticoagulants and fibrinolytic therapy in patients with severe PE and hemodynamic instability.

Ischemic Electrocardiographic Changes from Severe Heat Stroke in an Adolescent.

Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Background: Heat stroke can result in significant diffuse tissue derangement in the body. The heart can equally be affected and lead to ischemia and infarction. Early recognition of this complication and aggressive therapy is required for a good outcome.

Methods and Results: A 15-year-old male collapsed after playing football in a hot summer day. He had a week pulse and was extremely diaphoretic and started vomiting. Intravenous fluids were initiated and he was transported to the ED. He had no chest pains, dyspnea, or abdominal pain. PMH was unremarkable. He took no medications and reported no of tobacco, alcohol, or illicit drugs. There was no family heart disease. Temperature was 37.9[degrees]C, blood pressure was 88/25 mm Hg, heart rate was 155/minute, and respiratory rate was 26/minute. Pulse oximetry was 98% on room air. He was in moderate distress. His examination showed tachycardia and diaphoresis. His 12-lead ECG showed ST with ST-segment depression in leads [V.sub.2]-[V.sub.6], I, II, aVF, and ST-segment elevation in aVR. He was given aspirin and enoxaparin. A 2D echocardiogram showed hyperkinesis and normal wall motion. After 60 mL/kg of intravenous fluids, his vital signs normalized. His electrolytes, liver function tests, and complete blood count were normal. He was admitted to the PICU. His troponin was 2.7 ng/mL, which normalized over the next day. He did well and was discharged in stable condition.

Conclusions: Heat stroke can lead to morbidity and mortality. Tissue damage during heatstroke is believed to result from uncoupling during oxidative phosphorylation. Acute hepatic failure, ARDS, renal failure, DIC, coagulopathy, and decerebrate convulsions are among the fatal complications. It is important to realize that heart damage can occur from heat stroke, and appropriate diagnostic and therapeutic measures should be instituted.

A 22-Month-Old with an Overdose of Racing Fuel.

Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Virginia Commonwealth University Medical Center, Richmond, VA.

Background: Fuel contains different compounds that may cause respiratory and CNS depression if accidentally ingested by children. Racing fuel is made up of methanol, which can cause serious morbidity and mortality if taken in sufficient amounts.

Methods and Results: A 22-month-old male accidentally ingested an unknown amount of top fuel used in racing cars. This contains methanol and nitromethane. He was given some milk to drink and salt water as instructed per the bottle. He then began to cough but there was no vomiting. On arrival to the ED he was more lethargic. His medical history was unremarkable. He took no medications. He had a temperature of 37.2[degrees]C, heart rate of 100/minute, and respiratory rate of 24/minute. His physical examination was unremarkable except for lethargy. His WBC count was 8,400/[mm.sup.3], with 76% neutrophils; hemoglobin was 12 g/dL and platelets were 312,000/[mm.sup.3]. His electrolytes were normal. His methanol level was 430 mg/L. The patient was hospitalized and started on fomepizole (4-MP), 50 mg/kg per dose every hour, and was also given folic acid. Serial monitoring of electrolytes did not reveal any acidosis. Ophthalmologic examination did not reveal any abnormalities. He did well and was discharged on the following day, when his methanol level was near normal.

Conclusions: Methanol is found in cleaning materials, solvents, varnishes, antifreeze, windshield washer fluid, and certain types of fuels, including fuel used in racing cars. Methanol is potentially toxic in amounts as small as a single mouthful. When metabolized by hepatic alcohol and aldehyde dehydrogenase, methanol forms formaldehyde and formic acid, both of which are toxic. The eyes, CNS, and GI tract are affected. Formic acid inhibits cytochrome oxidase, and degradation of formic acid is folate dependent. Patients may present with headache, vertigo, confusion, nausea, vomiting, abdominal pain, and blindness. Laboratory abnormalities include hypoglycemia, increased serum osmolal gap, severe anion gap metabolic acidosis, and anemia. Treatment is indicated if levels are greater than 20 mg/dL and may include alcohol infusion, administration of fomepizole, or hemodialysis.

A Newborn with Beal Syndrome.

L.T. Leslye Green, MD, and LCDR David Lesser, MD. Naval Hospital, Pensacola FL.

Background: This report describes a newborn with multiple connective tissue abnormalities. Careful examination of the infant and a detailed history of his mother indicated Beal syndrome (congenital contractural arachnodactyly) affected both.

Methods and Results: A viable term male infant was delivered via C-section for arrest of labor to a healthy, 30-year-old G1P0. The parents had no known history of familial birth defects. Pregnancy history was marked only by a false-positive triple-screen for Trisomy-21; amniocentesis revealed a normal karyotype. After delivery, it was noted the infant could not extend either elbow past 90 degrees. The mother stated she had a similar limitation. Further examination of the infant also revealed a crumpled helix of the ear, ulnar deviation of the fingers, campylodactyly, and hyperflexible ankles that could be dorsiflexed to the shin. Cross-referencing these anomalies with the index in Smiths Recognizable Patterns of Human Malformations indicated Beal syndrome as the likely cause.

Further questioning revealed that the mother also had hyperflexible wrists and ankles and several dislocations of both patella in childhood. She never had any diagnosis or treatment for her condition.

Conclusions: Beals and Hecht first reported this condition in 1971 and included the original Marfan report in the same entity. This autosomal dominant trait is linked to a mutation that encodes for fibrillin. Unlike Marfan syndrome, ocular and cardiovascular complications rarely occur. The most serious sequlae can be severe kyphoscoliosis, requiring bracing in childhood. Early physical therapy aimed at stretching the affected contractures can return normal ranges of motion. Surgical release of tendons or realignment of affected patella is sometimes advocated. A careful examination of newborn deformities and extensive history taking from parents can reveal previously unknown genetic traits. Thus, initiating early screening and intervention can positively affect a child's future.

Neck Pain to Craniectomy: Near-Fatal Intracranial Hemorrhage Secondary to Venous Thrombosis in a 16-Year-Old Woman on Transdermal Contraception.

Ganesh D. Kini, MD, PhD, Susan A. Lee, DO, Amoreena R. Howell, BS, R. Allen Blackwood, MD, and Jeri L. Lantz, MD. Department of Internal Medicine, University of Virginia Roanoke-Salem Program, Roanoke, VA.

Background: A 16-year-old white woman presented to the ED with photophobia and neck pain, originally presumed to be due to cervical strain. She subsequently had altered mental status. CT scan of head showed cerebral intraparenchymal bleed and neurological status worsened. An emergency life-saving left parietal craniectomy was performed. The patient subsequently developed extensive thromboses of the major vessels of both upper and lower extremities. Further review of cerebral angiography showed probably left transverse sinus, sigmoid sinus, and internal jugular venous thromboses.

Methods and Results: Investigation into history revealed that the patient was sexually active, had recently been on transdermal contraception, and was a known smoker. She was found to be heterogeneous for the Factor V Leiden mutation and had hyperhomocysteinemia. Anticoagulation was held until 10 days after surgery to avoid cerebral rebleeding. The patient continued to improve neurologically. After the 10-day period, the patient was started on therapeutic intravenous heparin drip to keep PTT at approximately 45 and 3 days later was started on coumadin. She continued to make significant progress and was discharged from acute care to rehabilitation services 18 days after admission. In rehabilitation, she demonstrated significant neurological improvement while still having visual problems, mixed aphasia, anomia, and poor auditory comprehension. Follow-up 1 month later revealed an ambulatory patient, independently performing ADLs, awaiting replacement of the skullcap.

Conclusions: Factor V Leiden mutation is the most commonly inherited coagulopathy, accounting for 40 to 50% of VTE. The risk of VTE among those with Factor V Leiden mutation and on OCP was reported to be increased more that 30-fold compared with women with either risk factor. However, an estimated 1,000,000 people would need to be screened to prevent 1 death from DVT/PE, making such screen inefficient. Further studies may shed light on the risk of patients with this mutation and on estrogen-containing transdermal contraceptives.

Section on Psychiatry

*Boarding Home Placement in Patients with Schizophrenia: Predictor of Better Prognosis.

Robert G. Bota, MD, J. Stuart Munro, MD, and Kemal Sagduyu, MD. University of Missouri, Kansas City, MO.

Objectives: To determine if boarding home placement of patients with schizophrenia decreases the need for acute inpatient treatment, during and after the placement.

Methods: Data were collected from the medical records of the 74 patients initially diagnosed with schizophrenia in our hospital from July 2001 to June 2002. The progress of these patients was then tracked until February 2005. Data gathered were analyzed using the Statistical Package for Social Sciences (SPSS) software for standard deviation, correlations, paired sample test, and t test two-tailed analysis.

Results: From this patient cohort, 35 had no boarding home (BH) placement and used our inpatient services with a frequency of 1.1 days per month on average. Another 20 patients were placed in a BH after an average period of 10 months without placement in a BH. During the pre-BH period, they needed more acute inpatient care (3.3 vs 1.1 days/mo) than patients who did not receive BH services (P < 0.0003). After BH placement, these 20 patients spent an average of 14 months in a BH, requiring only 0.34 days per month inpatient treatment. On discharge from BH, for the next 11 months, they needed only 0.22 days per month of inpatient services. This rate of hospitalization was less than that of the same patients before BH placement (P = 0.0003) and patients who were not placed in BH (P < 0.001). The remaining patients were lost at follow-up, mainly as result of their travel pattern.

Conclusions: Referral to BH was done as result of frequent need for acute inpatient stabilization. BH placement resulted in a persistent decrease in the need for inpatient hospitalization.

*Protective Effect of Pharmacological Treatment in Early Schizophrenia.

Robert G. Bota, MD, J. Stuart Munro, MD, and Kemal Sagduyu, MD. Western Missouri Mental Health Center, Kansas City, MO.

Background: Many patients present for assessment in the prodromal phase of schizophrenia. It is difficult to identify patients "at risk" for schizophrenia, and there are no guidelines to what interventions might influence the prognosis when prodromal symptoms are identified.

Objectives: To determine what benefits may be derived from use of antipsychotic medication during the prodromal period.

Methods: Data were collected from the medical records of patients who were given a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) schizophrenia diagnosis in a state hospital over a 2-year period. Their progress was then tracked over a 3-year period. Analysis was made of common characteristics of patients for the first presentation before the diagnosis of schizophrenia, at the time of diagnosis with schizophrenia, and during the follow-up presentation.

Results: Of 24 patients diagnosed with schizophrenia, 10 had already presented with prodromal symptoms, referred by their families. Of those patients, 70% received treatment and 30% were discharged without medication. The patients treated during the prodromal period had significantly less hospitalization days (18 days) than patients evaluated for the first time at the time of schizophrenia diagnosis (27.14 days) and than patients who presented with prodromal symptoms but were not started on medication (69 days) over a 3-year period. The average length of treatment was 7 months before the schizophrenia diagnosis. The patients had reported a prodromal period spanning to 39 months. Behavior changes were reported approximately 16 months later, and bizarre behaviors were reported approximately 5 months before the initial diagnosis.

Conclusions: Antipsychotic medication prescribed during prodromal period appears to have a protective effect. Having an early presentation did not predict prognosis. Early treatment with antipsychotics may not stop the progression to schizophrenia, but it might diminish the severity of the illness as it develops.

Safe, Effective Nonpharmaceutical Treatment of Depression.

C. Norman Shealy, MD, PhD, Fair Grove, MO.

Background: Antidepressant drugs are the second largest group of prescribed pharmaceuticals. The best such drugs are reported to be effective in 42% of patients. Some 20% of Americans are on antidepressant drugs in any given year, and it is widely suggested that at least another 20% of people "need" such drugs. Over the past 30 years, the author treated more than 30,00 patients with a nondrug approach that has been far more effective and has no complications. This latter is increasingly of interest, as there is widespread debate about the complications of antidepressant drugs in adolescents and in adults. For several decades, this approach was part of a more comprehensive treatment protocol, with smaller stuies of the individual components.

Methods and Results: More than ninety percent of the patients treated had failed to respond to one or several antidepressant drugs. Most had unipolar depression, with a few who had bipolar depression. Several thousand patients were evaluated with an MMPI as well as the usual screening tool, the Zung Test for Depression. Beginning in Februaly 2004, an additional 200 patients were treated who had unipolar depression, as measured by a Zung score of 50 or above as well as an MMPI well above the 60th percentile on the depression scale. The treatment consisted of application of the Liss Cranial Electrical Stimulator, 60 minutes each morning. This FDA-approved device puts out 15,000 pulses per second, modified 15 and 500 HZ, at 1 to 2 millamps. It has been proven to increase both serum and CSF levels of serotonin and beta endophin. Used alone, it has been effective in 50% of depressed patients. Since anxiety is virtually always a component of depression, a photostimulator of blue, red, or mixed blue/red light, with a frequency of 1 to 7 Hz, was used. Ninety percent of individauals report feeling deeply relaxed within 10 minutes. By using the combination of the Liss and the photostimulator, 84% of the patients significantly improved in their depression scores on both the Zung and MMPI. Patients are also advised to use transdermal magnesium lotion and to do a home study program for self-regulation. Most reported that they followed the entire recommended program.

Conclusions: Earlier work with 30,000 depressed patients has now been simplified to allow a simple approach requiring only 3 visits, with instruction for home application of the Liss CES and a photostimulator. Eighty-four percent of 200 pateints treated with this protocol achieved significant improvement in depression as measured by the MMPI and Zung. Three hopsitals are now using this approach for the successfuol outpatient treatment of depression. All physiciands are encouraged to consider this approach, which is twice as effective as the best antidepressant, without the complications of pharmaceuticals.

The Physician as Patient.

Jeffrey P. Tuttle, MD. University of Kentucky, College of Medicine, Department of Psychiatry, Lexington, KY.

Background: Diagnosing and treating physician-patients offers unique challenges that undermine the defenses physicians rely on when confronted with difficult diagnoses. Standard physician-patient relationships exist within a framework of extreme information imbalance, which physicians use to control the nature of the relationship and the direction of patient care.

Methods and Results: In the traditional physician-patient relationship, the physician-provided paternalistic care and treatment recommendations were frequently accepted without question. This differs considerably from the postmodern physician, who educates the patient on a multitude of diagnostic and therapeutic options and allows the patient a certain degree of autonomy when selecting the direction of care. Although patients theoretically determine their own treatment, based on the information provided by their physician, the vast amount of information required to make such decisions prevents most patients from doing so without significant guidance from their physician. Physicians therefore are often in control of the relationship and guide their patient accordingly. This control may be used as a means to avoid discussing difficult diagnoses or prognoses and a method for physicians to distance themselves from emotionally demanding encounters.

Conclusions: When working with physician-patients, who are frequently knowledgeable about their own diagnoses, this advantage is compromised. Subsequently, the physician-patient relationship becomes vulnerable to fear and anxiety on behalf of the treating physician who must operate within a restricted environment. This anxiety is evident through the numerous psychological defense mechanisms, including intellectualization, humor, and avoidance, used to regain control of the relationship. Physicians need to be cognizant of these issues when caring for colleagues and make efforts to protect the relationship from the aforementioned complications.

Distinguishing Seizures Versus Pseudoseizures: Role of Prolactin.

Supriya Mannepalli, MD, and Mukta Panda, MD. University of Tennessee College of Medicine, Chattanooga Unit, Chattanooga, TN.

Objectives: Discuss the role of serum prolactin level in distinguishing pseudoseizures from seizures and to discuss the advantage of serum prolactin over video EEG monitoring.

Methods and Results: A 38-year-old male police officer with a history of seizure disorder presented with multiple tonic-clonic seizures for 1 day. Seizures witnessed in the ER included spasms of the body, arching of the head, and labored breathing. The postictal patient appeared lethargic. He had a history of right sided stroke 1 year ago with residual weakness. Home medications included lamotrigine and paroxetine. Physical examination was negative except for weakness of the right upper extremity. Laboratory data were normal, with a serum prolactin level of 22 ng/mL (n < 20 ng/mL). The EEG showed diffuse slowing consistent with sedative use. CT and MRI of the head revealed no acute changes. Seizures continued despite therapeutic phenytoin levels. Phenobarbitol was started eventually. Psychiatric evaluation revealed that the patient had role models for seizures as a police officer, positive family, and financial stressors. The patient was diagnosed with conversion disorder with pseudoseizures.

Conclusions: Serum prolactin is useful in distinguishing pseudoseizures from seizures. The postictal prolactin response correlates with type of seizures and postictal duration. Usually prolactin level is elevated 5 to 10 times normal postictally. The sensitivity and specificity for epileptic seizures in children were 64% and 98% when levels were obtained within 100 minutes postictally. Another study concluded that prolactin has 60% overall accuracy in diagnosis of seizures in adults. Minimal elevations can be observed in stress. Though there are specific clinical differences between seizures and pseudoseizures, checking prolactin is affordable and widely available compared with video EEG monitoring, which is the gold standard. Video EEG monitoring is costly, time consuming, and is not always readily available as was in our case.

Quetiapine in Huntington Disease.

John P. Hendrick, MD. Mountain Home VAMC, Mountain Home, TN.

Background: Treatment of Huntington disease (HD) is palliative and limited to reducing choreiform movements and behavioral disturbances.

Methods and Results: The use of the atypical antipsychotic quetiapine to treat a patient with HD with severe paranoia and significant choreiform movements is reported. Quetiapine effectively controlled the patient's paranoia and has noticeably improved his functioning. The patient required periodic increases in quetiapine as the symptoms of HD worsened, reaching a maintenance dosage of 600 to 1,200 mg, depending on symptomatology. This treatment strategy has resulted in the patient's family being able to maintain him at home for more than 11 years since diagnosis.

Conclusions: The use of atypical (or second-generation) antipsychotics in neurodegenerative disease is reviewed.

Insight Preservation in Early Schizophrenia Predicts Better Prognosis.

Robert G. Bota, MD, Stuart Munro, MD, and Kemal Sagduyu, MD. Western Missouri Mental Health Center, Kansas City, MO.

Background: Schizophrenia is characterized by diminished insight, which fluctuates with disease progression. Insight deterioration in the prodrome of schizophrenia is poorly understood. Despite pharmacological treatment, including early interventions, there is a high risk of relapse and need of acute care in schizophrenic patients.

Objectives: To determine if insight deterioration occurs during the prodrome and if insight preservation early in the illness predicts a better prognosis.

Methods: Data were collected retrospectively from the records of 24 patients initially diagnosed with schizophrenia during a 2-year period. Patients' progress was then tracked over a 3-year period. Insight was determined by a physician's subjective evaluation, patient interest, and participation in treatment planning and patient accuracy in reporting behaviors and symptoms when compared with reports from collaterals.

Results: Ten patients of 24 were given a (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) DSM-IV-TR schizophrenia diagnosis. Twelve of the 24 were evaluated at least once after the initial diagnosis. Eight patients were determined to have insight regarding the developing illness. Insight preservation correlated with less need for emergency visits and fewer hospitalization days (P < 0.005). It also was associated with more depressive and anxious mood. Patients and family members described early, ego-dystonic perceptual disturbances, followed by diminished insight. Willingness to get treatment significantly correlated (t test) with decreased need for hospitalization, less medication for agitation, and more participation in group therapy.

Conclusions: Most patients maintain insight during the perceptual disturbance phase. Insight diminishes as the early delusional phase sets in. Higher levels of preserved insight correlate with less need for acute treatment. Further research in this area is warranted for determining if early insight oriented interventions in the prodromal phase can improve the prognosis of schizophrenia.

Section on Radiology

Practical Approach to the Imaging of Liver Masses.

Michael C. Doherty, MD, Joseph F. Navoy, MD, and W.M. Flowers, Jr. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Liver masses are a very common occurrence in abdominal imaging. There is increasing utilization of magnetic resonance imaging (MR), computed tomagraphy (CT), and ultrasound (US), and this increases the number of masses found and also the number that are discovered incidentally. The radiologist has a preeminent role in the detection and characterization of these lesions.

Methods and Results: Noninvasive diagnoses can be made in the majority of masses by imaging alone. Common benign lesions of the liver are hemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma (HCA). Common malignant lesions are hepatocellular carcinoma (HCC) and metastatic disease. Thirty-seven percent of oncology patients have liver metastases, second only to regional lymph nodes. The majority of metastases are hypovascular. Hypervascular metastases are seen with breast, neuroendocrine, thyroid, and renal tumors and from melanoma and sarcomas. For evaluation of liver masses, the pattern of enhancement with MR and CT, and the clinical history are keys to diagnosis. Breath-hold imaging has significantly improved and changed the way liver MR is done and interpreted. Previously, MR focused on the signal intensity of [T.sub.2]-weighted images. Currently dynamic gadolinium enhanced [T.sub.1]-weighted gradient-echo sequences are the mainstay for diagnosis. The proper CT technique is important to maximize detection and characterization of liver lesions. A multiphasic scan must be performed with noncontrast, arterial, portal venous, and delayed phase scans. Intravenous contrast should be delivered through a power injector. Ultrasound is a good screening technique. It is also a problem solver for hypodense lesions found on routine CT (cyst vs solid vs hemangioma).

Conclusions: The main strength of US is the ability to characterize cysts. With proper utilization and interpretation of US, CT, and MR imaging studies, the majority of liver masses can now be diagnosed noninvasively without need for biopsy.

Imaging of Renal Masses.

Michael C. Doherty, MD, Joseph F. Navoy, MD, and W.M. Flowers, Jr. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: There are several imaging modalities available for the evaluation of renal masses. These include intravenous pyelography (IVP), ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and angiography.

Methods and Results: CT is considered the gold standard for the evaluation of renal masses. MRI is used when there is a history of allergy to contrast media or renal insufficiency. US is a good screening procedure and is excellent for the evaluation of simple cysts. The differential diagnosis of renal masses includes simple or complex cyst; the most common renal mass; renal cell carcinoma (RCC), the most common primary malignancy; angiomyolipoma (AML), a hamartoma composed of smooth muscle, fat, and arteries; oncocytoma, a benign renal lesion with a characteristic but nondiagnostic central scar; multilocular cystic nephroma (MLCN), a benign, well-encapsulated, multilocular noninfiltrating renal tumor; renal abscess, which can present as a thick walled, complex cystic mass; renal metastasis, usually presenting as a single or multiple small solid mass(es); and lymphoma, derived almost exclusively from systemic disease. Cross-sectional imaging is accurate for the detection and diagnosis of masses greater than 1 cm in size. Lesions less than 1 cm are too small to characterize. Simple cysts are accurately diagnosed and require no further evaluation. The Bosniak classification is useful for the management of complicated cysts. Most RCC are accurately diagnosed and staged by imaging. They should be surgically removed. A solid mass containing fat is usually an AML.

Conclusions: Management is based on the size of the lesion. If an abscess is suspected, percutaneous aspiration is used for diagnosis. If metastatic disease or lymphoma is suspected, percutaneous biopsy is used for diagnosis if necessary. Oncocytoma and MLCN require surgical excision for accurate diagnosis and to exclude RCC.

Imaging of Pancreatitis.

Michael C. Doherty, MD, Joseph F. Navoy, MD, and W.M. Flowers, Jr. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: The goals of imaging in pancreatitis are to confirm or establish the diagnosis, assess for severity and complications, and to determine the cause.

Methods and Results: Acute pancreatitis (AP) is an acute inflammatory process of the pancreas with variable involvement of the peripancreatic tissues and/or remote organs. The diagnosis is usually established by elevation of pancreatic enzymes. Forty-five percent of cases of AP are secondary to gallstones, 35% to alcohol, and 20% are idiopathic. Chronic pancreatitis (CP) is characterized by progressive and irreversible damage with alterations in pancreatic function and morphology. There is a mixture of fibrosis, acinar cell destruction, and ductal distortion. Sixty to seventy percent of cases of CP are secondary to alcohol abuse. CT is the gold standard for demonstrating complications and for determining the severity of the disease. Ultrasound (US) is excellent to assess for gallstones. Magnetic resonance cholangiopancreatography (MRCP) is an emerging technique for evaluation of the pancreaticobiliary tree. Imaging findings with US in AP are hypoechoic parenchyma, inhomogeneous echotexture, and diffuse or focal enlargement. US and CT may be normal in mild cases. CT may show pancreatic enlargement or peripancreatic inflammation and may show the presence of complications. These include acute fluid collections (pancreatic juice, hemorrhage, edema, and necrotic tissue); pseudocyst or hemorrhagic pseudocyst; gastric outlet, biliary or duodenal obstruction; pancreatic abscess; pseudoaneurysm; and portal, superior mesenteric, and splenic vein thrombosis. CP must be differentiated from pancreatic cancer. Pancreatic and biliary ductal dilitation suggests neoplasm. Pancreatic duct dilitation with beading suggests CP.

Conclusions: Imaging in AP is used to confirm the diagnosis, establish the severity, demonstrate complications, and determine underlying cause. Imaging in CP is used to detect morphologic changes in the pancreas and to help establish the diagnosis.

Magnetic Resonance Imaging Appearance of Liposarcoma.

Nancy Lawhon, MD, FACR, and W. Mel Flowers, Jr., MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Liposarcoma is the most common soft tissue sarcoma, accounting for approximately 17% of all soft tissue sarcomas. Most liposarcomas have well-defined and mostly lobulated margins. The well-differentiated liposarcomas are composed of mainly fat with septa or nodules. This report describes a case of this entity, with emphasis on the magnetic resonance imaging findings.

Methods and Results: A 31-year-old white female presented with an enlarging hard, nontender mass in the posterior calf. There was no history of trauma. Plain radiographs of the involved area showed a radiolucent mass that contained calcification. On [T.sub.1] MRI images, there was a well-defined lesion with heterogeneous signal, but with most of the mass appearing to be fat. On the [T.sub.2], fat saturation images the majority of the signal was suppressed within this mass. Pathological diagnosis was liposarcoma. Plain films and CT are superior to MRI in detailing cortical bone erosion and tumor calcification. MRI is useful in soft tissue analysis and then particular, in this case, depicting the fatty nature of a mass. Chest radiograph may be used as an initial screening for pulmonary metastatic disease; however, definitive pulmonary metastases are better evaluated by chest CT. The diagnostic procedure of choice for liposarcoma is open biopsy. In large and deep tumors, diagnosis and treatment may involve open incisional biopsy followed by definitive resection. The presence of lipoblasts is the key finding in this diagnosis. Well-differentiated liposarcomas usually contain a predominance of mature fat cells with relatively few widely scattered lipoblasts.

Conclusions: A misdiagnosis of lipoma can result from inadequate sampling. The well-differentiated type and most myxoid types of liposarcoma have a favorable prognosis, with 100% and 88% 5-year survival, respectively. Round cell and poorly differentiated types have a poor prognosis; each has a 5-year survival of about 50%.

Multimodality Evaluation of Enchondromas.

Nancy Lawhon, MD, FACR, and W. Mel Flowers, Jr., MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Enchondromas are usually solitary benign lesions, consisting of ectopic hyaline cartilage deposits in intramedullary bone. The lesions replace normal bone with mineralized or unmineralized hyaline cartilage. This report describes a case of this entity, with emphasis on the multimodality radiographic imaging findings.

Methods and Results: A 45-year-old white female presented with nonspecific knee pain. She was referred for MRI because of a questionable lesion of the lateral femoral condyle cortex, but this area was normal. Plain knee films were obtained and featured only subtle chondral calcifications in the proximal tibial lesion. The CT demonstrated the tumor and confirmed the chondral calcifications. There was avid uptake in the lesion on bone scan. On MRI coronal [T.sub.1] images, there was a metadiaphyseal well-circumscribed lesion with signal isointense to muscle centrally within the marrow of the tibia. STIR imaging showed lobulated borders of the lesion with high signal intensity reflecting the high fluid content of hyaline cartilage. There was peripheral enhancement of the lesion with gadolinium. The remainder of the MRI was normal. In this patient with knee pain a low-grade chondrosarcoma needed to be excluded. The patient had a biopsy and enchondroma was confirmed. MRI findings may be useful in distinguishing enchondromas in the long bones from bone infarcts. Bone infarcts show low signal intensity in the marrow on [T.sub.1] with surrounding high signal serpiginous outline around the lesion on [T.sub.2]. In bone infarcts there is a central zone of necrosis in the chronic stage. Central hyperintensity on [T.sub.2]-weighted images is more consistent with an acute infarct. There may be very mild gadolinium enhancement, particularly around the rim of the lesion, with gadolinium enhancement.

Conclusions: In the setting of pain with no other abnormal findings, MRI can differentiate between bone infarct and enchondromas usually, but chondrosarcoma versus enchondroma must be differentiated with biopsy.

Magnetic Resonance Findings in Adamantinoma.

Nancy Lawhon, MD, FACR, and W. Mel Flowers, Jr., MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Adamantinomas are extremely rare, locally aggressive and/or malignant lesions composed of epithelial-like cells in a dense fibrous stroma. They most commonly occur in the second through the fifth decades, with no gender preference. The most common location is in long tubular bones and approximately 85% occur in the tibia. This report describes a case of this entity with emphasis on the radiographic findings, especially the findings on magnetic resonance imaging.

Methods and Results: A 31-year-old presented with a painful left lower extremity mass. Anterior-posterior and lateral radiographs of the left tibia and fibula revealed an aggressive distal diaphyseal lytic lesion of the tibia there was cortical destruction and a questionable skip lesion just proximal to the large mass in the tibia. Multiplanar, multi-echo MRI with gadolinium showed a destructive bone lesion with a large soft tissue component and confirmed the suspected skip lesion proximally. The patient had aggressive surgical resection with a pathologic diagnosis of adamantinoma. Six months after surgery, a PA and lateral chest radiograph showed multiple pulmonary metastatic nodules.

Conclusions: In general, adamantinomas have a varied radiographic appearance but usually present as expansile, multilocular, lytic lesions without periostitis. The principle differential diagnostic dilemma is fibrous dysplasia. Differential diagnosis also includes osteosarcoma, telangiectic osteosarcoma, lymphoma, and metastatic disease. Tumor recurrence is frequent with inadequate therapy.

Magnetic Resonance Imaging Findings in Necrotizing Fasciitis.

Nancy Lawhon, MD, FACR, and W. Mel. Flowers, Jr., MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Necrotizing fasciitis (NF) is a relatively rare, rapidly progressive infection characterized by extensive necrosis of subcutaneous and fascial tissue. This report describes a case of this entity with emphasis on the magnetic resonance imaging (MRI) findings.

Methods and Results: A 34-year-old female with an insect bite in her groin presented with rapidly progressive swelling, pain, and inflammation of her legs. MRI showed cellulitis and bright [T.sub.2] signal defining the fascia of upper thigh consistent with fasciitis. Additional sequences revealed a right labial abscess and contrast enhancement of the subcutaneous and deep fascial tissues. The diagnosis of NF was made on radiological grounds. This disorder is associated with beta-hemolytic streptococci, but this causes only a minority of the cases. Most are caused by other bacteria or different streptococcal serotypes. Organisms spread from the subcutaneous tissue along the superficial and deep fascial planes, facilitated by bacterial enzymes and toxins. This deep infection causes vascular occlusion, ischemia, and tissue necrosis. Superficial nerves are damaged, producing the characteristic localized anesthesia. Septicemia ensues with systemic toxicity.

Conclusions: The mortality rate is greater than 70% if not recognized and appropriately treated. Standard radiographs are of little value unless gas-forming organisms produce free air. CT may be more sensitive than plain radiography in demonstrating subcutaneous air. [T.sub.2]-weighted MRIs may show well-defined regions of high signal intensity in the deep tissues. More importantly, MRI delineation of the extent of NF may be useful in directing rapid surgical debridement. Early clinical recognition of NF may be difficult and clinical differentiation between this entity and cellulitis may be impossible. Cellulitis involves infection of only subcutaneous fatty tissue and can usually be treated adequately with antibiotics. NF requires early surgical intervention in addition to antibiotics. Early fasciotomy and debridement in NF have been associated with improved survival compared with delayed surgical exploration.

Renal Lesions Too Small to Classify by CT: Outcome Study Based on Follow-up for 18 to 62 Months (38 Mean) by Multiphasic Helical CT or Laparoscopy.

E.K. Lang, B. Gayle, R. Macchia, R. Charafeddine, L. Meyers, E. Castle, and R. Thomas. Tulane University Health Sciences Center, Department of Radiology, New Orleans, LA, SUNY, Brooklyn, NY, and Tulane University Health Sciences Center, Department of Biostatistics and Department of Urology, New Orleans, LA.

Objectives: To establish significance, possibility, and cause of "renal lesions too small to classify by CT" by follow-up multiphasic helical CT, laparoscopy, biopsy, or surgery.

Methods: Four hundred sixty-five "renal lesions too small to classify by CT" and with follow-up studies for 18 to 62 months (38 mean) at three university medical centers were analyzed in this retrospective study. Seventy-two lesions featured a lower than parenchymal density on preenhancement CT, 3939 lake of enhancement on postenhancement CTs. The lesions ranged in size from 0.4 to 1.0 cm (7 mm mean), were hypovascular, and lacked enhancement. Outcome was based on multiphasic helical CT (n = 440), laparoscopy (n = 19), biopsy (n = 4), and surgery (n = 2).

Results: Three hundred thirty-five of these lesions were no longer identifiable on follow-up examinations. However, 58 of these had been treated for urinary tract infections. Sixty-nine lesions had increased to greater than 1 cm in diameter and exhibited CT criteria of cysts. Fifty-one had increased in size with CT findings consistent with medullary necrosis, renal abscess, or calyceal diverticula. Follow-up CTs suggested renal infarcts in four. Four enlarging lesions proved to be metastatic neoplasms; two others were angiomyolipomas.

Conclusions: Less than 1% of the lesions were malignant neoplasms; however, 51 (11%) were caused by inflammatory disease prone to progress to medullary necrosis, renal abscesses, or calyceal diverticular if left untreated. Fifty-eight (12.5%) of the lesions were no longer identifiable, possibly due to treatment of coexisting urinary infections. Two hundred seventy-seven lesions (60%) disappeared without treatment, probably due to normalization of a temporary ischemic process.

Radiological Signs of Sickle Cell Disease.

W. Mel Flowers, Jr., MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Patients with sickle cell disease (SCD) have painful vaso-occlusive crises that produce striking radiological findings. These are demonstrated in this presentation.

Methods and Results: SCD is a genetically determined disorder of the red blood cells. The sickled cells do not circulate well. If deoxygenated, the hemoglobin polymerizes, leading to anemia, tissue oxygen starvation, and infarction. Infants and young children are especially susceptible to bacterial infections that can kill in as little as 9 hours from onset of fever. Narrowed or blocked small blood vessels in the brain can lead to serious, life-threatening strokes, primarily in children. They may have cerebral blood velocities that are 3 to 4 times normal, primarily the consequence of luminal narrowing. These can be demonstrated by transcranial Doppler ultrasound. Radiologically, the patient with an acute chest syndrome (ACS) presents with parenchymal lung infiltrates caused by in situ nonembolic microvascular occlusion by sickled erythrocytes, atelectasis, infection, thromboembolism, and fat embolism from bone marrow necrosis. Even though the ACS usually is self-limited, it can present with or progress to respiratory failure, with noncardiogenic pulmonary edema and severe hypoxemia. Bones show (1) bone marrow hyperplasia, with increased trabeculation of the medullary cavities with distortion and growth disturbance in the skull, vertebrae, and long bones; (2) hematogenous bacterial infection that results in osteomyelitis and septic arthritis; and (3) bone infarction with collapse of vertebral end plates, resulting in the so-called "fish" vertebra, H vertebra, or Lincoln log sign. The humeral and femoral heads may show sclerosis or collapse, and long bone diaphyses may show the bone within a bone sign. Other findings include gallstones, autospleenectomy, and a dense liver from hemochromatosis.

Conclusions: Sickle cell disease produces imaging abnormalities in many organs and systems. These characteristic changes result in radiological patterns that can be highly specific. Detailed knowledge of these multimodality findings can improve diagnostic results.

*Bioactive Coils for Endovascular Occlusion of Cerebral Aneurysms: Is There a Difference?

Andy Brown, MD, and Razvan Buciuc, MD. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Object and Background: The authors performed a review of the literature supplemented by personal experience to assess the practical advantages and disadvantages of using bioactive coils for endovascular occlusion of cerebral aneurysms. Since its inception, endovascular occlusion of cerebral aneurysms has primarily been accomplished with platinum coils. While the success rate of this technique approaches or exceeds that of surgical intervention, continued aneurysm growth, recanalization, and potential rehemorrhage remain inherent problems. Recently, to improve long-term clinical outcomes of endovascular coils, various bioactive polymer coatings have been applied to the coil structure. Collectively these coils have been termed bioactive secondary to the endothelial response evoked following endovascular deployment. Early histological evaluations of aneurysms occluded with hydrogel-coated coils report additional advantages due to expansion of this polymer at intravascular pH.

Methods: The authors compiled initial and 6-month follow-up results from endovascular aneurysm occlusions performed with hydrogel polymer-coated coils at their institution after July 2004. At the time this report was written, a total of six patients had undergone endovascular aneurysm occlusions primarily utilizing hydrocoils. Using Medline and PubMed databases, the authors performed a review of the literature to supplement personal data regarding bioactive coils.

Conclusions: The first bioactive hydrogel-coated coil was placed in 2001 and thus the literature presenting short-term clinical outcomes is sparse. Bioactive coils induce a local inflammatory response causing more rapid scarring and endothelialization. Additionally, hydrogel expands to varying degrees according to the coil diameter, improving its filling volume. Initial clinical results and early pathological specimens provide supportive evidence that bioactive coils are safe and more effective in aneurysm filling and post-placement vascular healing than conventional coils. Thus, the use of bioactive coils may increase the single procedure endovascular occlusion rate.

Radiological Signs of Sarcoidosis.

W. Mel Flowers, Jr, MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: This presentation demonstrates the radiological findings and their clinical correlations in sarcoidosis. Sardoidosis is a systemic disease of unknown cause, characterized by the development of noncaseating granulomas and fibrosis. Mediastinal and hilar adenopathy occurs in about 85% of cases and lung involvement in about 20%.

Methods and Results: The chest x-ray staging system follows: Stage 0, normal; Stage 1, 50% of patients have bilateral hilar adenopathy; Stage 2, 25% of patients have bilateral hilar adenopathy and pulmonary infiltrates; Stage 3, 15% of patients have pulmonary infiltrates only; Stage 4, 5% of patients have pulmonary fibrosis and chronic respiratory impairment. End-stage disease is characterized by marked traction bronchiectasis, bullae formation, fibrotic granulomas with extensive calcification, cavitation or cyst formation, and intracavitary fungus balls. The granulomatous process involves the gastric antrum leading to irregular nonspecific narrowing. Sarcoidosis causes hypercalcemia and nephrocalcinosis. There are multiple calcifications of the kidneys and enlarged retroperitoneal lymph nodes. Sarcoidosis has a predeliction for cranial nerves and the base of the brain. Aseptic meningitis and diabetes insipidus may occur. Bone abnormalities include generalized osteopenia, decrease in cortical thickness, striations of the cortex, punched out cystic lesions centrally or eccentrically located, and a coarsened, reticulated, or lacework trabecular pattern. The hand is the predominant site of skeletal sarcoidosis. There are multiple sites of bone destruction involving the phalanges. The larger areas involve the cortex. There are punched out lesions and a well-defined "lace-like" destruction. Up to 85% of patients will have spontaneous improvement (6 months to 1 year).

Conclusions: Oral corticosteroids are indicated in patients with severe ocular, neurologic, or cardiac presentations, malignant hypercalcemia, and symptomatic or progressive pulmonary fibrosis. Methotrexate is used in patients who are refractory to steroids or cannot tolerate the side effects. Knowledge of the radiographic findings in sarcoidosis will lead to improved patient treatment.

Clinical and Radiological Signs of Hyperparathyroidism.

W. Mel Flowers, Jr, MD, FACR. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: This presentation addresses the radiology of hyperparathyroidism and reviews the clinical, anatomical, embryological, and physiological presentations. In the 1930s and 1940s, virtually all primary hyperparathyroidism presented as osteitis fibrosa cystica. The radiographic findings were so characteristic that chemical analysis was needed only for confirmation. Osteitis fibrosa cystica is a descriptive term applied to the striking bone changes due to excessive parathyroid hormone. These changes include subperiosteal resorption of bone, affecting the following structures: diaphyses of the phalanges, phalangeal tufts, lamina dura, clavicular tip, clavicular surface at the coroclavicular ligament attachment, symphysis pubis, and sacroililac joints. Abnormalities also include cysts, brown tumors, pathological fractures, and gross deformities. Both generalized decreased bone density and osteosclerosis may occur. Other findings include salt and pepper skull, chondrocalcinosis, nephrolithiasis, and rugger jersey spine. Presently, the diagnosis is usually made by biochemical analysis. Patients with primary hyperparathyroidism and striking bone findings are now few and far between. Radiographs are not essential for the diagnosis, but radiographic abnormalities are still found incidentally. For example, renal patients may have radiographic signs on their routine chest films.

Methods and Results: Hyperparathyroidism is caused by excessive and incompletely regulated secretion of parathyroid hormone from one or more parathyroid glands. Three basic types have been described: primary, secondary, and tertiary. There are three different pathological conditions that cause primary hyperparathyroidism: parathyroid hyperplasia, parathyroid adenoma (often localized with nuclear medicine studies), and parathyroid carcinoma. Secondary hyperparathyroidism is caused by a reactive production of parathyroid hormone and is seen in renal disease. Also, congenital hyperparathyroidism has been reported as a secondary fetal response to maternal hypoparathyroidism. In tertiary hyperparathyroidism, the overactive parathyroid glands of patients with renal disease can become autonomous.

Conclusions: Knowledge of the embryology, anatomy, and radiological characteristics of the parathyroid glands is essential in the diagnosis and treatment of patients with parathyroid disease.

Radiological Signs of Blastomycosis.

W. Mel Flowers, Jr, MD, FACR, George Benashvili, MD, Jonathan Fratkin, MD, and Stanley W. Chapman, MD. Departments of Radiology, Pathology, and the Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS.

Background: This presentation demonstrates the radiological findings and their clinical correlations in blastomycosis. This disease is caused by inhalation of mold spores of blastomyces dermatitidis. These convert to yeasts and invade the lungs, occasionally spreading hematogenously to the skin and other tissues. The lungs are the primary site of involvement and pulmonary disease is present in over 90% of patients. Occasionally the chest film is normal. Lung abnormalities may include pulmonary infiltrates, hilar mass, cavitation, atelectasis, and miliary disease. The skin is the most frequent site of spread from the lungs and can be involved in more than 75% of patients with systemic disease. Bone is the second most frequent site of spread from the lungs and occurs in about 25% of these patients. Osseous sites affected include the vertebrae, long bones, ribs, carpus and tarsus. Characteristic radiographic features are osteomyelitis, osteolysis, periostitis, cortical erosions and joint destruction. Central nervous system (CNS) blastomycosis is a secondary infection and occurs in about 4% of patients with the disease. In HIV-infected patients, CNS involvement is 35%. There are three different presentations in the central nervous system: acute or chronic meningitis, single or multiple cerebral abscesses, and granulomatous mass lesions. Rare sites of involvement include the eye, paranasal sinuses, pericardium peritoneum, spleen, liver, adrenal gland, and thyroid.

Methods and Results: The definitive diagnosis is made by culture. Diagnosis is almost as certain if direct examination of sputum, pus, or urine specimens reveals characteristic thick-walled, unencapsulated yeasts that are 8 to 15 [micro]m or more in diameter and form broad-based buds. Untreated blastomycosis is usually slowly progressive and ultimately fatal. Oral itraconazole is used for mild-to-moderate blastomycosis IV amphotericin B is the treatment of choice for those with severe, life-threatening infections and is usually effective.

Conclusions: Knowledge of the features of this disease will improve radiological diagnosis.

Sonolucent Renal Abnormalities in Children.

Joseph F. Navoy, MD, Michael C. Doherty, MD, and W.M. Flowers, Jr., MD. Department of Radiology, University of Mississippi Medical Center, Jackson, MS.

Background: Ultrasound is a safe, noninvasive, portable, readily available, and inexpensive mainstay for evaluation of the kidneys in children. Sonolucent renal abnormalities include posterior urethral valves (PUV), uretero-pelvic junction (UPJ) obstruction, ureteral duplication, primary megaureter, prune belly syndrome, vesicoureteral reflux, and renal cystic disease.

Methods and Results: Findings in PUV are bilateral hydroureteronephrosis with parenchymal thinning, thick-walled bladder, and dilated prostatic urethra. In severe cases of PUV, cystic dysplasia may be present. Findings in UPJ obstruction include multiple cystic structures of uniform size, communication between the cysts, moderate-sized or large renal pelvis, and absence of ureteral dilatation. Findings of ureteral duplication are dilated upper pole collecting system with a thin rim of parenchyma and cystic dysplasia in severe cases. The draining ureter is dilated and tortuous, and there is a ureterocele in the bladder base. Signs in primary megaureter are fusiform dilatation of the ureter proximal to the tapered distal extravesical segment. With increasing severity, the proximal ureter and pelvocalyceal system dilate. In extreme cases there is parenchymal thinning. Findings in the neonate with autosomal recessive polycystic kidney disease (ARPCKD) are bilateral enlarged echogenic kidneys, often with a sonolucent rim. Occasionally there are discrete macroscopic cysts. In multicystic dysplastic kidney (MCDK), findings include anechoic masses of variable size and random distribution. There is no connection between the cysts and no identifiable renal pelvis. Absent or dysplastic renal parenchyma: Rarely there may be a solitary cyst. Multilocular cystic nephroma (MLCN) findings are well-defined multiple cysts separated by echogenic septa. If cysts are small and contain mucoid material they may appear to be solid.

Conclusions: Ultrasound is the preferred initial modality to evaluate kidneys in neonates and children. A variety of sonolucent abnormalities can be evaluated.

On the Diagnostic Fringes.

Ramesh Patel, MD, and Asmita Roy, Bsc. University of Mississippi Medical Center, Jackson, MS.

Background: Uncommon manifestations of common disease entities as well as diseases with very low incidence pose diagnostic challanges both clinically and on radiologic studies. These cases can be seen as being on the diagnostic fringes.

Methods and Results: In these cases, familiarity with a wide spectrum of presentation sharpens ones skills of clinical and radiological diagnostic skills. Radiologic features of a number of these cases, including in utero abnormalities, are illustrated and discussed.

Conclusions: The clinical presentations and the pathways of diagnosis are corelated with the radiologic studies.

Fibrosing Mediastinitis.

Ramesh Patel, MD, and Narayan Sundram, AB. University of Mississippi Medical Center, Jackson, MS, and Vanderbilt University, Nashville, TN.

Background: Fibrosing mediastinitis is an uncommon condition with poorly understood etiology and pathophysiology. The basic pathology is progressive fibrosis within the mediastinum. The cardiovascular, respiratory and nervous structures in the mediastinum can be affected resulting in functional compromise of these structures to a variable extent.

Methods and Results: In some of the cases the cardiovascular and respiratory changes can be irreversible and not be amenable to either medical or surgical treatment, leading to death. Diagnosis of this condition is made by radiologic studies such as plain radiography, CT, and magnetic resonance scans.

Conclusions: Clinical signs and symptomology as well as the spectrum of radiologic abnormalities in the illustrated cases are discussed.

Tumoral Calcinosis.

Ramesh Patel, MD, and Henry Giles, MD. University of Mississippi Medical Center, Jackson, MS.

Background: Tumoral calcinosis is a relatively rare condition most frequently seen in people of African descent. It is not a neoplasic disease despite its presentation as juxtaarticular masses which can be quite large. The most frequent age group is second decade. Although many of the patients are asymptomatic the masses can show progressive growth. The masses can be painful if the contiguous nerves are involved. Occasionally the overlying skin can ulcerate with extrusion of chalky fluid from the underlying mass. The masses are composed of calcific debris enclosed within saccular fibrous capsules. The most common site of involvement is the joint. It can also occur around shoulder, elbow and ankle joint. Typically, it is not seen around the knee joint.

Methods and Results: Radiologic studies such as plain radiographs, CT, radionuclide bone scans, and magnetic resonance imaging help to make the specific diagnosis and define the extent of the disease. Total exterpitation is the only definitive therapy. Recurrence can occur after incomplete resection. Hence, radiologic studies should define the entire extent of involvement prior to surgery. The underlying bones are not involved. Visuilization of fluid/fluid levels on the radiologic studies is supposed to indicate metabolically active process within the masses.

Conclusions: Cases with various radiologic studies and signs are discussed.

Section on Surgery

*Off-Pump CABG/MAZE for the Treatment of Coinciding Coronary Artery Disease and Atrial Fibrillation.

Manuel Caceres, MD, and G. Phillip Schoettle, Jr., MD. University of Tennessee HSC at Memphis, TN.

Background: The Cox-Maze III procedure is the gold standard treatment for atrial fibrillation (AF). Less cumbersome and invasive techniques have been utilized with variable failure rates. Coronary artery disease (CAD) requiring operative intervention is occasionally seen in patients with AF. Off-pump techniques using radiofrequency ablation (RFA) have been proposed as an alternative in this setting.

Methods: Twelve patients with concomitant AF and CAD underwent off-pump coronary artery bypass (OPCAB) by a single surgeon. Modified Maze procedure using a bipolar epicardial RFA device and resection of the left atrial appendage was also performed. Male to female ratio was 11/1 and the average age was 67 years old.

Results: Sinus rhythm (SR) was evident in 11/12 (92%) patients at the end of the intervention and in 7/12 (59%) patients by discharge. After a follow-up of 4 to 12 months, 7/12 (59%) patients remained in SR. The average left atrial size by 2D-echocardiography in patients remaining in SR and those with persistent AF was 37 vs 48 mm, respectively. RFA added 15 minutes to the length of the procedure, and no RFA-related intraoperative or postoperative complications were seen.

Conclusions: Epicardial RFA is a safe and useful adjunct for the management of AF and CAD when OPCAB is entertained. Similar to on-pump procedures, smaller atrial size seems to portend a favorable outcome. This is the first series reporting outcome of combined RFA and OPCAB. Larger series are needed to determine which patients benefit the most from this procedure.

*Laparoscopic Cholecystectomy in the Elderly: Increased Complications and Conversions to Laparotomy.

David S. Kauvar, MD, Brandon D. Brown, MD, Anthony Braswell, MD, and Michael Harnisch, MD. Brooke Army Medical Center, Department of General Surgery, San Antonio, TX.

Background: The incidence of gallstones increases with age and as the proportion of the population 65 years of age and older continues to grow, increased demand for laparoscopic cholecystectomy (LC) in the geriatric population is likely. LC has advantages over open cholecystectomy, but comparative evaluation of the procedure in elderly patients is lacking.

Methods: A 2-year retrospective review of patients undergoing LC was performed. Demographic information, diagnosis, operation performed, and operative complications were recorded. Patients were placed into two groups: age 65 years or greater and less than 65 years of age. Primary outcome measures were rates of complication and conversion to laparotomy.

Results: Three hundred fifteen patients underwent LC in the study period, and 59 (19%) were 65 years of age or older. The older age group experienced higher rates of conversion to an open procedure (22% vs 2.7%, P < 0.05), and operative complications (17% vs 3.1%, P < 0.05). In addition, elderly patients had longer operative times (108 [+ or -] 55 vs 83 [+ or -] 34 minutes, P < 0.05). Acute cholecystitis was the operative diagnosis in a greater proportion of patients in the older age group (31% vs 16%, P < 0.05), and elderly patients were more likely to have had prior upper abdominal surgery (8.5% vs 1.6%, P < 0.05).

Conclusions: LC in the geriatric population carries with it increased risk for conversion to laparotomy and operative complications compared with LC in younger patients. This probably is due to the increased acuity of gallbladder disease in this population. Surgeons should bear these issues in mind in the care of these patients.

*Rapamycin Inhibits Free Radical-Induced Cytotoxicity in Human Vascular Smooth Muscle Cells.

Charles E. Wall, Jr, MD, Zhongbiao Wang, MD, PhD, Walter H. Newman, PhD, Martin L. Dalton, MD, Department of Surgery and Division of Basic Sciences, Mercer University School of Medicine, Macon, GA.

Objectives: Restenosis of successfully angioplastied coronary vessels has been reported to occur at a rate of 30 to 40%. Histologic studies in both human and animal models suggest that proliferation and migration of smooth muscle cells cause neointimal thickening and play a predominant role in the restenosis process. Inflammatory cells and their products may be responsible for the production of oxygen free radicals, which have been shown to stimulate vascular smooth muscle cell proliferation and apoptosis. Coronary stents impregnated with rapamycin have been shown to reduce neointimal hyperplasia in human coronary arteries. The purpose of this study was to determine if rapamycin could inhibit the production of H202 by vascular smooth muscle cells.

Methods: Vascular smooth muscle cells were isolated from the endothelium of harvested human saphenous vein (HSV). The cells were then allowed to proliferate in culture medium. A 72-well plate was used to assess cell viability when exposed to H202 alone and when exposed to H202 plus varying concentration of rapamycin.

Results: Cells exposed to H202 alone underwent cell death. Cells exposed to H202 plus rapamycin showed increased viability in comparision to H202 alone.

Conclusions: VSMC proliferation and apoptosis are two important components of coronary restenosis after balloon angioplasty and stenting. The apoptotic effects of H202 combined with the VSMC proliferative effect of the hydroxyl radical plays a role in neointimal hyperplasia. Rapamycin eluting stents disrupt this process by altering cell death caused by H202 and reducing neointimal hyperplasia.

Section on Urology

*Contemporary Management of Upper Tract Nephrolithiasis: Role of Laparoscopic Intervention.

Scott V. Burgess, MD, Jeffrey P. Bejma, MD, Sanjeev Gupta, MD, Erik P. Castle, MD, and Raju Thomas, MD, MHA, FACSB.

Background: Treatment of upper tract kidney stones can be accomplished by several different techniques. Laparoscopic ureterolithotomy and pyelolithotomy are both treatment options for patients with large impacted calculi. Refinements in laparoscopic techniques have allowed renal pelvic, proximal ureteral and even calyceal diverticular stones to be removed during a single operative setting. These techniques may provide higher stone-free rates after a single operation compared to percutaneous treatments without increasing morbidity.

Materials and Methods: Since the inception of urologic laparoscopy in the mid-1990s, 25 ureterolithotomy, four pyelolithotomy, seven pyeloplasty with renal pelvic stone removal, and two laparoscopic nephrolithotomies for calyceal diverticular stones have been performed at our institution. We retrospectively reviewed the following patient parameters: stone size, operative time, length of stay, stone-free rates, and perioperative complications.

Results: In the ureterolithotomy group, 75% of the stones are in the proximal ureter or at the ureteropelvic junction. Stone size, operative time, length of hospital stay, and stone-free rate are presented below.
                    Stone size     OR time        LOS        Stone-free
Procedure           (cm)           (min)          (days)     rate

Lap                 1.6 (0.9-2.3)  170 (85-260)   1.2 (1-4)  100%
  (n = 25)
Lap                 2.2 (1.5-3.0)  202 (156-220)  1.3 (1-2)  100%
  (n = 4)
Lap pyeloplasty     0.7 (.2-2.0)   243 (170-310)  1           85%
  with stone
  (n = 7)
Lap                 3.3 (2.6-4.0)  158 (139-178)  1.5 (1-2)  100%
  (n = 2)

One ureterolithotomy was complicated by prolonged urinary drainage secondary to a migrated ureteral stent and one patient required conversion for open pyeloplasty.

Conclusions: Large upper tract stones are often difficult to treat. This report describes successful laparoscopic management of ureteral, renal pelvic, and calyceal diverticular stones with excellent stone clearance rates and acceptable morbidity.

Positive Surgical Margins in Robotic Radical Prostatectomies: Impact of Learning Curve on Oncologic Outcomes.

F. Atug, E.P. Castle, S.V. Burgess, R. Davis, and R. Thomas. Department of Urology, Tulane University Health Sciences Center, New Orleans, LA.

Objectives: Robotic-assisted prostatectomy (RAP) continues to generate excitement within the urological community. Positive surgical margins after radical prostatectomy is a known risk factor for disease recurrence and may lead to adjuvant treatment. The goal of this study was to assess the incidence of positive surgical margins in our series of RAP and to evaluate the effect of the learning curve on margin positivity rate.

Methods: Between 2003 and 2005, 90 consecutive RAPs were performed and retrospectively reviewed. The patients were divided into three groups, based on timeline of surgery. The incidence and location of positive surgical margins were compared between the groups (Table 1). Additional variables evaluated included preoperative PSA, preoperative Gleason score, and final pathologic stage.

Results: The margin positive rates were 46.6%, 26.6%, and 13.3% for the first, second, and third groups, respectively (Table 1). Patient demographics and preoperative staging variables were evenly distributed amongst all three groups.

Conclusions: This study illustrates that experience gained with time led to a decrease in the incidence of positive margins. It is not thought that a selection bias affected the results, as patient variables were comparable within the study groups. On further analysis, the negative surgical margin rate increased from 53.4% to 73.4% in group 2 and to 86.7% in group 3, although the Gleason scores were higher in groups 2 and 3. Clearly, a significant learning curve is associated with robotic radical prostatectomy and can affect the oncologic outcome in patients undergoing this procedure.
Table 1

                        Group 1     Group 2     Group 3

Patients (n)            30          30          30
Age                     56.3        59.5        60.37
Patients with positive  14 (46.6%)   8 (26.6%)   4 (13.3%)
  surgical margins
Patients with negative  10 (53.4%)  12 (73.4%)  18 (86.7%)
  surgical margins
Positive margin
Bladder neck             4           3           1
Apex                     6           5           3
Other                    6           2           1
PSA                      7.25        6.14        6.24
Gleason score
  ? 6                   27          21          18
  3 + 4                  2           5           9
  4 + 3                  1           3           2
  8 to 10                0           1           1
Pathological stage
  pT2                   24          26          25
  pT3                    5           2           4
  pT4                    1           2           1

There may have been more than one location for each patient with a
positive margin.

Microscopic Hematuria and Pelvic Congestion Syndrome: A Late Sequela of Cirrhosis.

Erich K. Lang, MD, Raju Thomas, MD, Erik P. Castle, MD, Wayne J.G. Hellstrom, MD, M. Brammer, and S. Joshi. Tulane University Health Sciences Center, New Orleans, LA.

Objective: To investigate the relationship of hematuria and peliv congestion syndrome to collateral flow and pressure-related changes in the left renal vein as a consequence of cirrhosis and deomonstrated on dynamic helical CT.

Materials and Methods: Forty patients (29 male, 11 female), age 38 to 73 years, with the diagnosis of cirrhosis presented with microscopic hematuria (n = 32), pelvic congestion syndromes (n = 8), and varicoceles (n = 2) were included. Patients were studied by multiphasic helical CT pre-enhancement, late areterial-early cortico-medullary, parenchymal and excretory phase sequences, 1.25 to 3.8 mm collimation.

Results: Advance cirrhosis, hepatitis C (n = 14), alchoholism or nutritional (n = 26) was confirmed in all 40 patients. The early corticomedullary and parenchymal phase CT demonstrated huge splenorenal shunts in all patients. In 17 of 18 patients, elevated left renal vein pressure was confirmed by left renal vein catheterization. Eight of the female patients showed massive dilation of the ovarian vein communicating to dilated pelvic veins and causing a pelvic congestion syndrome, two male patients demonstrated left varicoceles, a consequence of retrograde flow in the dilated left gonadal vein.

Conclusions: Massive splenorenal anastomoses to the left renal vein causes elevation of left renal vein pressure and probably are responsible for microscopic hematuria. Retrograde flow frim the left renal vein into the gonadal and ovarian veins cause pelvic vein congestive syndrome in the female and varicoceles in the male.

Dapoxetine for the Treatment of Men with Premature Ejaculation (PE): Dose-Finding Analysis.

Wayne Hellstrom, MD, Stanley Althof, PhD, Marc Gittelman, MD, Christopher Steidle, MD, Kai-Fai Ho, PhD, Sherron Kell, MD, and Anders Nilsson-Neijber, MD. Department of Urology, Tulane University Health Sciences Center, New Orleans, LA. Department of Urology, School of Medicine, Case Western Reserve University, Cleveland, OH, South Florida Medical Research, Aventura, FL, Northeast Indiana Research, LLC, Fort Wayne, IN, and ALZA Corporation, Mountain View, CA.

Objectives: Dapoxetine is the first medication developed specifically for PE, the most common male sexual dysfunction. Two phase II clinical trials have investigated the efficacy and tolerability of 20, 40, 60, and 100 mg dapoxetine. The objective of the current analysis was to determine the appropriate prn doses of dapoxetine to evaluate for further study in large-scale phase III clinical trials.

Methods: Both double-blinded, multicenter, randomized, placebo-controlled, three-period crossover phase II studies enrolled men with PE, based on DSM-IV-TR criteria and intravaginal ejaculatory latency time (IELT). Study details are shown in the Table. Subjects were instructed to take study drug before anticipated sexual intercourse (1 to 3 hours prior in study 1 and 1 to 2 hours prior in study 2) and to attempt sexual intercourse approximately twice weekly. The primary end point was IELT, measured with a stopwatch held by the female partner. Groups were compared using a mixed-effects ANOVA analysis.

Results: Randomized subjects (128/157) completed study 1 (dapoxetine, 20 mg and 40 mg) and randomized subjects (130/166) completed Study 2 (dapoxetine, 60 mg and 100 mg). All four doses demonstrated statistically significant improvements in IELT over placebo (Table). The most commonly reported adverse events (AEs) were nausea, diarrhea, dizziness, and headache. The incidence of some AEs, including nausea, diarrhea, dizziness headache, insomnia, and nervousness appeared to be dose related. Overall, prn administration of dapoxetine 60 mg was better tolerated than dapoxetine 100 mg.

Conclusions: Although statistically significant, between-group effect sizes suggested that the magnitude of effect with the 20-mg dose appeared small. Discontinuation due to AEs in study 2 occurred almost exclusively in the 100-mg group. Based on the results of these two studies, dapoxetine doses of 30 mg (half of the highest dose with acceptable tolerability) and 60 mg were chosen for further investigation in phase III efficacy and safety studies.
                         Study 1                Study 2

Age range                18-60 years            18-65 years
IELT for inclusion       <2 min estimated       <2 min with stopwatch
Treatment period         4 weeks per treatment  2 weeks per treatment
Washout period           none                   72 hours
Dapoxetine dose
  (n per group)
  (n = 145)              20 mg
  (n = 141)              40 mg
  (n = 142)              Placebo
  (n = 144)              60 mg
  (n = 155)              100 mg
  (n = 145)              Placebo
Mean baseline IELT    1.34      1.34      1.34  1.01      1.01  1.01
Mean ? from baseline
  IELT, min           1.38 (a)  1.97 (b)  0.88  1.95 (b)  2.23  1.06
Discontinuation due   0         2         0     0         9     1
  to AE

(a) P = 0.042 vs placebo; (b) P < 0.0001 vs placebo.

Effects of Alpha-Blockers on Ejaculatory Function in Normal Subjects.

Wayne Hellstrom, MD, William Smith, MD, and Suresh Sikka, PhD. Tulane University Health Sciences Center, Department of Urology, Section of Andrology, New Orleans, LA.

Objectives: Patients treated with tamsulosin (TAM), an [alpha]-adrenergic receptor blocker with preferential binding to [alpha]1A and [alpha]1D subtypes have a higher incidence of ejaculatory dysfunction (EjD) than with other [alpha]-blockers. The nature and mechanisms of EjD with TAM are not understood. TAM blockade of peripheral [alpha]-receptors may be linked to retrograde ejaculation (RE) due to bladder neck relaxation and/or reduced seminal contraction and sperm progression; TAM blockade at central sites (eg, serotonergic) may be linked to anejaculation. By contrast, alfuzosin (ALF) does not cross the blood-brain barrier in animal models, and EjD with ALF is rare. The current study explores the mechanism of EjD with TAM and examines if these are locally or centrally mediated effects.

Methods: Healthy adult males received 5 days of TAM 0.8 mg once daily (OD), ALF 10 mg OD, and placebo (PB) in a randomized, three-way, double-blinded crossover with a 10-day washout between treatments. Primary end points were changed from baseline on day 5 of each treatment period in ejaculate volume and postejaculate sperm concentration (urine sperm concentration) as a measure of RE. Comparisons were conducted in the intent-to-treat (ITT) population using mixed-effect analyses of covariance (P < 0.05).

Results: ITT volunteers (n = 57) were young (mean: 25 [+ or -] 4.4 years), primarily black (77%) males. Mean ejaculate volume was significantly decreased from baseline with TAM (-2.4 mL; 95% CI [0.0, +0.6]) vs ALF (+0.3 mL, 95% CI [-2.8, -2.1]) or PB (+0.4 mL, 95% CI [+0.1, +0.8]) (Ps < 0.0001). Mean urine sperm concentration showed no significant change from baseline for TAM (1.7 X 106; 95% CI [0.0, 3.4]) or ALF (1.2 X 106; 95% CI [0.0, 3.4]) vs PB (1.4 X 106; 95% CI [-0.3, +3.1]). Of the 48 men who completed the study, 43 (90%) had a clinically significant decrease in semen volume with TAM compared with 10 (21%) and six (13%) on ALF and PB, respectively. Anejaculation was observed in 17 subjects (35%) with TAM compared with 0% on both PB and ALF. Both ALF and TAM were well tolerated. Dizziness was the most frequently reported adverse event with ALF and TAM (11% and 14%, respectively).

Conclusions: Most volunteers on TAM had reduced ejaculation, and one of three had anejaculation; however, few had increased postejaculate sperm in their urine indicative of retrograde ejaculation. Conversely, the incidence of EjD with ALF appeared similar to PB. Further research is needed to identify mechanisms of EjD with TAM, eg, serotonergic central effects.

Cost-Analysis of Radical Retropubic, Perineal, and Robotic Laparoscopic Prostatectomy: A Single Institutional Analysis.

Scott V. Burgess, MD, Michael Woods, MD, Erik P. Castle, MD, Raju Thomas, MD, and Rodney Davis, MD. Center for Minimally Invasive Urologic Surgery, Tulane University Health Sciences Center, New Orleans, LA.

Background: Several prostatectomy techniques are available for treatment for organ-confined prostate cancer. Minimally invasive techniques, such as advancements in laparoscopic instrumentation and robotics, have led to shorter hospital stays, reduction in patient pain, and a quicker return to normal activity. The goal of this study was to determine the operative costs, hospital costs, and duration of hospitalization for patients undergoing radical retropubic (RRP), radical perineal (RPP), and robotic prostatectomy.

Methods: A retrospective chart and financial review was undertaken examining all patients who underwent RRP, RPP, or robotic prostatectomy during the last 18 months. Total operative costs and hospital charges were derived from actual patient bills, knowing fully well the disjoint between billed charges, actual costs, and reimbursement. Operative time, estimated blood loss, and length of stay were also compared between the three groups, performed at one hospital by one surgical team.

Results: Over the last 18 months, consecutive 16 RRP, 16 RPP, and 39 robotic prostatectomies were analyzed for this study. Operative costs, hospital charges, estimated blood loss, operative time, and length of hospitalization are presented below.
                 OR          of stay               OR
Procedure        time (min)  (days)   EBL (cc)     charges ($)

Robotic             301       1.3         416         26,870
  prostatectomy  (192-679)            (110-2,000)  (17,367-50,890)
Perineal            196       1           780         16,320
  prostatectomy  (105-337)            (200-1,000)  (10,940-29,380)
Retropubic          202       1.7       1,015         16,522
  prostatectomy  (142-348)   (1-3)    (300-2,000)  (13,000-26,810)

                 Non-OR           hospital
Precedure        charges ($)      charge ($)

Robotic             14,889           42,996
  prostatectomy  (9,671-43,041)   (25,281-81,263)
Perineal            13,451           29,771
  prostatectomy  (8,091-23,983)   (19,917-41,463)
Retropubic          14,663           31,518
  prostatectomy  (10,075-25,669)  (25,670-40,495)

Conclusions: Radical prostatectomy remains the standard of care for clinically localized prostate cancer. Robotic-assisted prostatectomy is associated with substantially higher operative and hospital charges. Perineal prostatectomy, in experienced hands, remains the most cost-effective procedure, with shorter operative times, less blood loss, and a shorter hospital stay. There appears to be no significant difference in the non-OR charges between the three treatment groups.

Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction: Comparing DaVinci Robotic to Classic Laparoscopic Pyeloplasty.

Scott V Burgess, MD, Michael Woods, MD, Erik P. Castle, MD, Freddy Mendez-Torres, MD, and Raju Thomas, MD. New Orleans, LA.

Background: Laparoscopic pyeloplasty is a minimally invasive method to treat ureteropelvic junction obstruction (UPJO), although this procedure is not widely available due to its technically demanding nature. The introduction of the daVinci Robotic System may allow this procedure to be performed at more centers. This study compared their most recent 20 patients who underwent laparoscopic robotic pyeloplasty with patients who underwent classical laparoscopic pyeloplasty.

Materials and Methods: From Feburary through October 2004, 20 patients underwent laparoscopic pyeloplasty with the daVinci Robotic system for UPJO. All patients underwent Anderson-Hynes dismembered pyeloplasty, with seven patients requiring renal pelvic tailoring. Three patients underwent redo-pyeloplasty after failed open pyeloplasty. Three transperitoneal ports were placed for the robot. An umbilical port and two additional ports were placed 8 cm from the umbilicus, 30 cranially and caudally from an axis between the umbilicus and UPJ. A fourth port was placed in a subxyphoid location for retraction, suction, and dissection by the bedside surgeon. A ureteral stent and JP drain was placed in all cases.

Results: All cases were completed laparoscopically. Sixty percent of robotic patients had a crossing vessel at the UPJO. The average blood loss was 52 and 95 mL for the robotic and classical laparoscopic groups, respectively. Mean operative time was 230 minutes (180 to 310) for the latest 20 robotic cases, dropping to 210 minutes (180 to 240) in the last five cases. The classic laparoscopic group presented a mean operative time of 273 minutes, even after 25 cases. There were no operative or postoperative complications in either group. The average hospital stay was 1.1 days (1 to 3) for the robotic group and 1.4 days (1 to 3) in the classic group. All patients were evaluated by comparing pre- and postoperative renal scans and/or urograms.

Conclusions: Laparoscopic pyeloplasty is becoming the treatment choice for UPJO, but intracorporeal laparoscopic suturing and tissue handling remain a challenge to nonexperienced laparoscopic surgeons. The seven degrees of motion of the daVinci robotic system greatly enhances the precision in dissection and suturing of the UPJ. This has led to decreased operative times, even in patients who require extensive pelvic tailoring or have had previous endopyelotomy or open pyeloplasty. The reduced learning curve associated with robotics should foster widespread dissemination of this minimally invasive technique.

*This abstract was one of 25 selected for oral presentation in SMA's Physicians-in-Training Competition.
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Title Annotation:Oral Presentation Abstracts
Publication:Southern Medical Journal
Date:Oct 1, 2005
Previous Article:Braxter P. Irby, Jr., MD: incoming president of SMA.
Next Article:Abstracts of scientific posters.

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