312 Absorption Greinwald
of Topical Cocaine in Rhinologic Procedures. JH, Holter MR. Laryngoscope 106:1223, 1996
This prospective study evaluated intranasal absorption of cocaine solution. Twelve patients with an average age of 30.4 years were used. All patients were undergoing septoplasty or endoscopic nasal sinus surgery except two, who underwent maxillectomies. All patients were screened preoperaatively for cocaine metabolites and found to be negative. Standard cotton pledgets soaked with a 4% cocaine solution were used to pack the patient’s nares bilaterally before surgery. Three patients had nasopharyngeal packs soaked with same solution packed and left for the entire procedure. Once the cotton pledgets and nasopharyngeal packs were removed, they were frozen and sent for quantitative analysis of cocaine. Blood was drawn from patients 45 minutes after cotton pledgets were placed. The results showed an average 102 mg of cocaine was recovered from the pledgets and an average of 2.61 mg from the nasopharyngeal packs. The average plasma level obtained from the patients was 63 ng/dL. The authors concluded a significant amount of cocaine remained on the cotton pledget, (102 mg of a possible 160 mg). The nasopharyngeal packs yielded a smaller amount, 2.61 mg. The overall intranasal absorption of a 4% cocaine solution was 36.4%. Age, sex, and type of anesthesia were not found to influence absorption. Their opinion was that the intranasal cotton pledgets played the most significant role in determining amount of cocaine absorbed, siting studies that show direct application of cocaine solution to nasal mucosa results in plasma levels four to five times higher than their study showed.R. HOLLOWAY Reprint requests to CDR John Greinnnnwald, Jr, USNR, Department of Otolaryngology-Head and Neck Surgery, UIHC, 200 Hawkins Dr, Iowa City, IA 52242. Application of Magnetic Resonance Neurography in the Evaluation of Patients with Peripheral Nerve Pathology. Filler AG, Kliot M, Howe FA, et al. J Neurosurg 85:299, 1996 Unlike images of damaged bone and blood vessels, direct images of nerves have not been available to the clinical diagnostician in the past. The advent of magnetic resonance (MR) neurography now makes it possible to learn how such images can improve neurological diagnosis and management. New diffusion-based MR protocols have achieved dramatic increases in clarity of nerve imaging, but one technique requires strong magnetic field gradients not generally available for clinical MR imaging. The other technique, T,-based neurography, uses standard clinical MR equipment modified with custom-built, high resolution, phased-array coils and special post-processing techniques. In this report, the authors evaluate whether direct nerve imaging with MR neurography could be used to make clinically important diagnostic distinctions in 148 patients that cannot be readily accomplished using conventional diagnostic techniques. Longitudinal and cross-sectional fascicular images readily distinguished perineural from intraneural masses, and lesions from cysts, thus improving the predictability of resection and the need for intraoperative electrophysiological monitoring. Fascicle patterns and longitudinal anatomy helped identify nerves and improved the safety of the procedures. In trauma cases, MR neurography identified nerve discontinuity preoperatively, verifying the need for surgical repair (including the mandibular nerve). Focal nerve compressions (including carpal tunnel) could also be localized precisely, allowing for smaller
targeted surgical exposures. The authors show that direct nerve imaging can add useful diagnostic information in situations where physical examination, electrodiagnostic tests, and existing imaging techniques are inconclusive. Future enhancements and refinements of the technique of neurography will improve selectivity and increase the clinical utility of the images.-R.E. ALEXANDER Reprint requests to Dr Filler: Division of Neurosurgery, University of California at Los Angeles Medical Center, CHS 74-140, 10833 Le Conte Ave, Los Angeles, CA 900956901. Immunohistochemical Localization of BCL-2 in Ameloblastoma. Arai J, Abiko Y, Ohuchi T, et al. Jpn J Oral Maxillofac Surg 42:797, 1996 This study was undertaken to examine if the expression of BCL-2 is involved in the development of ameloblastomas, because the BCL gene product has been shown to block apoptosis and to contribute to tumorigenesis. The materials consisted of surgical specimens of 20 histologically confirmed amelobastomas. The specimens were subjected to immunohistochemical examinations using anti-BCL-2 and antiPCNA antibodies and the TUNEL method to identify DNA fragmentation in situ. BCL-2 was observed in all undecalcified specimens. The localization was most conspicuous in the cytoplasm and nuclear membrane of cylindric or basaloid cells adjacent to the stroma. There was no difference in the expression among the subtypes (follicular, acanthomatous, plexiform and mixed) of the tumor. It was also positive in lymphocytes in the stroma. PCNA was positive in peripheral cells of tumor nests. The pattern of its localization was more or less similar to that of BCL-2, but the positive reaction to PCNA was found more often than that of BCL-2. In the TUNEL method, DNA fragmentation was observed in tumor cells showing squamous metaplasia and keratinization. The results indicate that the BCL-2 gene product may be involved in the development of ameloblastoma by blocking apoptosis of cells at the peripheral layer of tumor nests--T. NAKAJIMA Reprint requests to Dr Arai: Department of Oral Pathology, School of Dentistry, Health Science University of Hokkaido, 1757, Kanazawa, Toubetsucho, Ishikarigun, Hokkaido 061-02, Japan. Peripheral Ameloblastoma: Report of a Case With Malignant Aspect. Califano L, Maremonti P, Boscaino A, et al. Brit J Oral Maxi110 Surg 34:240, 1996 Peripheral ameloblastoma is a rare odontogenic tumor with some characteristics similar to the central ameloblastoma. It differs in that it originates form the mucosa. Clinically the lesion is exophytic ranging from 0.5 to 4.0 cm in diameter. These behave in a slow, benign way and recurrence is uncommon. This case reports of a peripheral ameloblastoma with a high malignancy histological freature. This case reviews a 47-year-old man with a 3 cm, painful mass on the canine area of the left maxilla. After surgical resection of the left maxilla a histological examination showed islands and nests of tumor cells with a trabecular architectural growth pattern. The neoplasia showed continuity with the basal cell layer of the surface epithelium. Some tumor islands showed atypical palisading arrangement. There was also high mitotic index and evident perineural infiltration. Peripheral ameloblastomas behavior is usually benign; in the literature there are only 3 cases of malignant peripheral ameloblastoma and only one case with metastasis. There are less than 100 cases of central malignant ameloblastomas. Rare
metastases are usually described in the regional nodes, lungs, liver, and kidney. A suggested classification to classify central malignant ameloblastomas are based on four features 1) primary and metastatic growth, 2) metastasis exhibiting a less-differentiated pattern than the primary tumor. 3) primary and metastatic growth exhibiting dedifferentiation, and 4) ameloblastomas with anaplastic transformation and metastatic disease not present or histologically proven. Histologic malignancy criteria of ameloblastic carcinoma are the following: infiltrating growth, cytologic atypia, high mitotic index, and perineural infiltration. In this case this lesion was considered a peripheral ameloblastic carcinoma. As a consequence the surgeon and pathologist should consider the existence of these rare cases in the management of these ameloblastic lesions.-J.A. ELLIS.Jr Reprint
to Dr Califano:
Maxillary Alveolar Cleft Repair in Dogs Using Recombinant Human Bone Morphogenetic Protein-Z and a Polyruer Carrier. Mayer M, Hollinger J, Ron E, et al. Plast Reconstr Surg 98:247, 1996 The accepted treatment for the correction of osseous defects is autogenous grafting, which has about 80% success. However, donor site morbidity is a continued subject of concern. This study was conducted in an attempt to identify a possible alternative to autografts for correction of osseous defects. Recombinant human bone morphogenetic protein-Z (BMP-Z) delivered in poly lactide-co-glycolide (PLG) and autogenous blood was compared with PLG and autogenous blood without BMP-Z, as well as autograft and untreated controls for quantity of bone replacement in surgical maxillary alveolar wounds in dogs. Twenty-four foxhounds were divided evenly between 2 and 4 months time periods and among the four treatment groups. Dogs were prepared by removal of two of the three incisors bilaterally and a 1 cm defect in bone was created from crest to nasal floor. Nasal mucosa was then sutured to oral mucosa and a stent was placed. Five months were allowed for healing, followed by repair with one of the four materials. Iliac crest was used for corticocancellous autograft; 1.1 mL autogenous blood and 200 mg of rh BMP-Z were mixed and added to 400 mg of PLG particles. At 2 or 4 months post-repair dogs were killed and the site of repair was surgically exposed for photographs. The graft sites and recipient beds were recovered and placed in 70% ethanol. Radiographs of the tissue were made and ranked according to bone bridging and density. Histologic sections were then made to examine cell and stroma detail. Clinically all specimens were well healed. Radiographic examination did not show differences among treatment and time including some of the untreated defects that had bone bridging. At 2 months the autograft had substantial bone whereas the other three groups had bone and fibrous tissue mixture. At 4 months the untreated group was unchanged from 2 months. The PLG, blood, and rh BMP-Z groups had bony trabecular bridges and the autograft had thick trabecular bridges. The following three conclusions were drawn: 1) At 2 months the autograft defects had more bone than with other treatment; 2) By 4 months PLG, blood, and rh BMP appeared equivalent to autograft; and 3) the cleft wound was not adequate as a model because some untreated defects progressed to bony repair. An improved wound model is required to draw substantial conclusions. PLG was a good vehicle because no giant cell reaction occurred and it was resolved by 2 months.-PAUL L. WOLF
Reprints requests to Dr Hollinger: Department of Surgery, Anatomy, and Cell Biology, Division of Plastic and Reconstructive Surgery, Oregon Health Sciences University, Portland, OR 97229.
Coronary Heart Disease in Women; Gender Differences and Effects of Menopause. Villablanca AC. Postgrad Med 100:191, 1996 Cardiovascular disease (especially coronary heart disease, [CHD]) is the leading cause of death in women in the United States today. The mortality rate in women-about 500,000 per year-exceeds that of men. Cardiovascular disease accounts for 37% of the deaths in all women and over 50% of the deaths in post-menopausal women. Morbidity is also higher in women than men, because the women tend to be older and sicker at the time of diagnosis. Some heart disease are entirely gender-specific, such as postpartum cardiomyopathy, toxemia, pre-eclampsia, and others. Others are more common in women than men, including mitral valve prolapse, coronary vasospasm angina, and chest pain precipitated by panic attacks and anxiety. Unfortunately, most women hardly consider CHD a health concern, which has tragic consequences. The clinical manifestations of CHD in women is different from that in men. Women are twice as likely to present with angina and less likely to present with sudden death or infarction. Women are more likely to have heart failure and cardiogenic shock, and will present with an acute infarction at least 5 hours later than men. Women have a higher mortality rate than men during hospitalization, 6 weeks later, and 1 year postinfarction. Black women have the highest mortality rate (48%). Fewer noninvasive diagnostic tests are performed on women than men. Women are referred for bypass surgery at about half the rate of men. Women at the age of 55 years have the same cardiac risk as men at 4.5 years, a 10 year lag. Blood pressures reach higher levels in women than in men and 70% of women over 6.5 years of age are hypertensive. Women smokers who take oral contraceptives have a 20-fold increase in risk for myocardial infarction because of enhanced thrombosis. Use of oral contraceptives has no impact on cardiovascular risk in nonsmokers. Women have higher high-density lipoprotein (HDL) levels than men until menopause, then HDL levels drop, but still remain higher than men. However, the threshold for low HDL is 10 mg/dL lower than for men. The presence of elevated very-low-density lipoproteins are a greater independent risk factor for women than men. A number of new studies are underway to address unanswered questions about CHD in women. National Institutes of Health is sponsoring the Women’s Health Initiative Clinical Trial, which will be the largest study ever conducted in women. It will involve 1,400 patients at each of 45 national centers and will be ongoing over the next 10 to 15 years. Other large studies are the Hormone Estrogen Replacement Study now going on with 340 postmenopausal participants, and the Angiographic Trial in Women, studying 450 patients with CHD at 5 centers. The latter will run for 3 years. The new data should lead to improved outcomes for women with CHD.-R.E. ALEXANDER Reprint requests to Dr Villablanca: Division of Cardiovascular cine, TB 172 Bioletti Way, University of California, Davis, of Medicine, Davis, CA 95616.
Primary Non-Hodgkin’s Lymphoma of the Salivary Glands. An Analysis of 22 Cases. Wolvius EB, van der Wal JE, van Diest PJ, et al. J Oral Path01 Med 25:177, 1996