Committal of a patient due to media influence? A case report.
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Adolescent↗
Biomedical subjects
P J Dean
Publications and source records attributed to P J Dean.
The role of Yersinia enterocolitica and Yersinia pseudotuberculosis in granulomatous appendicitis: a histologic and molecular study.
Granulomatous appendicitis is an enigmatic entity. Purported causes include Crohn's disease, foreign body reactions, sarcoidosis, and infectious agents; however, most cases remain idiopathic. Yersinia enterocolitica (YE) and Y. pseudotuberculosis (YP) have been implicated as causes of appendicitis, ileocolitis, and mesenteric adenitis. The authors examined the potential role of YE and YP in granulomatous appendicitis using histologic and molecular methods. Forty cases of granulomatous appendicitis were evaluated for histologic features including transmural inflammation, number and character of granulomas, and mucosal changes. Twort Gram, Grocott methenamine-silver (GMS), and Ziehl-Neelsen stains were evaluated, and polymerase chain reaction (PCR) analysis was performed to identify pathogenic YP and YE. Twenty-five percent (10 of 40) of the cases were positive for pathogenic Yersinia by PCR (four YE, four YP, and two with both species). Prominent histologic features included epithelioid granulomas with lymphoid cuffing, transmural inflammation with lymphoid aggregates, mucosal ulceration, and cryptitis. One Yersinia-positive case contained mural Gram-negative bacilli; fungal and acid-fast bacilli stains were all negative. Except for one culture-negative case, serologies and cultures were not done or results were unavailable. Two Yersinia-positive patients were diagnosed subsequently with Crohn's disease, suggesting a possible relationship between the two entities. No other patients developed significant sequelae. YE and YP are important causes of granulomatous appendicitis, and Yersinia infection may mimic Crohn's disease. No histologic features distinguish reliably between Yersinia species, or between Yersinia-positive and Yersinia-negative cases. Because special stains and cultures are often not diagnostic, PCR analysis is an excellent technique for the diagnosis of Yersinia.
Adolescent↗
Hepatitis C infection among survivors of childhood cancer.
Preliminary reports have suggested that survivors of childhood cancer and aplastic anemia who are infected with the hepatitis C virus (HCV) have a low risk for progression to significant liver disease. Among our surviving patients who were transfused between 1961 and March 1992, 77 (6.6% of surviving patients tested thus far) have evidence of HCV infection, whereas 4 surviving patients who were transfused after March 1992 are HCV-infected. One patient chronically infected with HCV died of liver failure, and 2 patients died of hepatocellular carcinoma. To characterize the risk for these and other complications, 65 patients are enrolled in a longitudinal study of HCV infection, of whom 58 (89.2%) had circulating HCV RNA at the time of protocol enrollment, with genotypes 1A and 1B most commonly isolated. Most enrolled patients have few or no symptoms, carry out normal activities, and have normal liver function. To date, 35 patients have undergone liver biopsy for abnormal liver function since the diagnosis of primary malignancy; central pathology review shows 28 (80%) have chronic active hepatitis, 25 (71%) have fibrosis, and 3 (9%) have cirrhosis. These preliminary data suggest that though most survivors of childhood cancer who are infected with HCV are clinically well, some are at risk for clinically significant liver disease. Identification of other HCV-infected patients and prospective monitoring of this cohort are ongoing to determine the risk for, and to identify factors associated with the progression of, liver disease.
Adult↗
Low prevalence of human papillomavirus infection in esophageal squamous cell carcinomas from North America: analysis by a highly sensitive and specific polymerase chain reaction-based approach.
Several studies have documented the frequent occurrence of human papillomavirus (HPV) DNA in esophageal squamous cell carcinomas (ESCC) in patients from geographic regions where the incidence of this type of cancer is high, such as parts of China. However, the prevalence of HPV infection in ESCC in patients from low incidence geographic regions, such as North America, remains controversial. Therefore, this study evaluates the prevalence of HPV in ESCC in patients from North America, a region where the population is considered at low risk for the development of this neoplasm. ESCCs in 51 patients from three North American cities were analyzed for the presence of HPV DNA by a highly sensitive and specific polymerase chain reaction (PCR) method. Tumor DNA was extracted from formalin-fixed, paraffin-embedded tissue specimens and assayed by PCR using an L1 HPV consensus sequence primer, as well as HPV 16 and HPV 18 E7 region primers. The use of consensus primers to the L1 region allows for detection of most known HPV types and many novel HPV types. Appropriately sized reaction products were analyzed by restriction fragment length polymorphism (RFLP) to confirm the presence and type of HPV, and to exclude products produced by amplification of human DNA sequences. After complete analysis, only one case (2%) of ESCC was HPV DNA positive. This case was independently confirmed using L1 and E7 consensus primers as HPV type 16 and was the only case that tested positive with either assay. These results show that, in contrast to geographic regions where ESCC is prevalent, HPV infection occurs infrequently in association with ESCC in patients from North America.
Adult↗
Alcohol misuse in clinical forensic medicine.
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Journal Article↗
Diverticular disease-associated chronic colitis.
A clinical syndrome of chronic colitis unique to the sigmoid colon harboring diverticular was recently reported; its histopathological appearance has not been fully elucidated. In this study, the authors analyzed the clinical and pathological features of 23 patients (age range, 38-87 years; median age, 72 years) with diverticular disease-associated chronic colitis. Nineteen presented with hematochezia; four had abdominal pain. Colonoscopic visualization of the mucosa showed patchy or confluent granularity and friability affecting the sigmoid colon encompassing diverticular ostia. Colonic mucosae proximal and distal to the sigmoid were endoscopically normal. Mucosal biopsy specimens showed features of idiopathic inflammatory bowel disease that included plasmacellular and eosinophilic expansion of the lamina propria (100%), neutrophilic cryptitis (100%) with crypt abscesses (61%), basal lymphoid aggregates (100%), distorted crypt architecture (87%), basal plasmacytosis (61%), surface epithelial sloughing (61%), focal Paneth cell metaplasia (48%), and granulomatous cryptitis (26%). Concomitant rectal biopsies obtained in five patients demonstrated histologically normal mucosa. Fourteen patients treated with high-fiber diet or antibiotics or both improved clinically, as did nine patients administered sulfasalazine or 5-aminosalicylic acid. Five patients underwent sigmoid colonic resection, three for stricture with obstruction and two for chronic blood loss anemia. Among a control population of 23 age- and gender-matched patients with diverticular disease without luminal surface mucosal abnormality, none required resection during the same follow-up period. By Fisher's exact test, a statistically significant difference in outcome for patients with and without colitis was detected (p = 0.049). In addition, three patients developed ulcerative proctosigmoiditis 6, 9, and 17 months after the onset of diverticular disease-associted colitis. The data indicate that diverticular disease-associated chronic sigmoid colitis expresses morphological features traditionally reserved for idiopathic inflammatory bowel disease. Its clinical and endoscopic profiles permit distinction from Crohn's disease and ulcerative colitis. Patients with chronic colitis in conjunction with diverticula are at increased risk for sigmoid colonic resection. Diverticular disease-associated chronic colitis may also precede the onset of conventional ulcerative proctosigmoiditis in some cases.
Adult↗
Scleroderma and the watermelon stomach.
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Adult↗
The escape theory of suicide in college students: testing a model that includes perfectionism.
A model of the escape theory of suicide was tested, using the following measures: the Life Experiences Survey, the Socially Prescribed Perfectionism subscale, the Self-Rating Depression Scale, the Hopelessness Scale, the Reasons for Living Inventory, and the Scale for Suicide Ideation. College students (N = 114) completed all of these measures, and results were correlated. LISREL path analysis failed to validate the proposed model. All proposed paths were significant, except for the reciprocal path proposed between negative life events and socially prescribed perfectionism. Two residual paths were also significant: from socially prescribed perfectionism to suicide ideation, and from hopelessness to suicide ideation. A revised model constructed from these significant paths had a good overall fit, which suggests that an interactional model is more appropriate than a linear one.
Adolescent↗
Impact of the Crohn's-like lymphoid reaction on staging of right-sided colon cancer: results of multivariate analysis.
The presence of lymphoid aggregates within the muscularis propria or pericolic fibroadipose tissue apposing invasive colorectal carcinoma, termed the Crohn's-like lymphoid reaction, has been related to improved patient length of survival according to univariate statistical analysis. We tested the Crohn's-like lymphoid reaction as an indicator of prognosis in a multivariate statistical analysis of 344 resected right-sided colonic cancers. Improved 5-year survival in univariate analysis was associated with low tumor grade, regular tubule configuration, expanding tumor growth pattern, prominent peritumoral lymphocytic infiltration, absence of tumoral invasion of extramural veins, all levels of intramural and extramural invasion short of widespread local tumor permeation, conspicuous Crohn's-like lymphoid reaction, and absence of both nodal metastasis and nodal-independent tumor nodules in pericolic fat. By the Cox proportional hazard model using the stepwise method, depth of tumor invasion, lymph node metastasis, Crohn's-like lymphoid reaction, and metastatic tumor nodules in pericolic fat retained independent prognostic significance. Combining the four variables to formulate pathological prognostic categories yielded a highly favorable prognostic group-92% 5-year survival and 95% confidence limits (88% to 96%)--encompassing 53% of the study population. It included all Dukes' stage A carcinomas, 66% of Dukes' stage B adenocarcinomas, and 11% of Dukes' stage C cancers. Lymph node metastases coupled with intramural and extramural extent of tumor invasion are the cornerstones of colorectal cancer staging. Addition of other variables improves prognostication for the cecum and ascending colon. From this study the Crohn's-like lymphoid reaction and metastatic tumor nodules in pericolic fat emerge as significant independent indicators of prognosis for right-sided colon cancer. Complex correlations of both indicators with nonselected variables were observed.
Adenocarcinoma↗
Reversible ischemic colitis in young women. Association with oral contraceptive use.
Ischemic colitis, a condition of middle-aged to elderly patients, occurs uncommonly in younger persons. In this study, we describe the clinical and pathological features of 18 young adults (mean age, 29 years; age range, 17-39 years) with spontaneous ischemic colitis, 17 of whom were women. All presented with abrupt onset of severe, cramping abdominal pain followed by hematochezia. Colonoscopic visualization of the mucosa showed segmental hyperemia, friability, and erosion affecting the distal transverse colon (three cases), splenic flexure (three cases), descending colon (five cases), and sigmoid (seven cases). Mucosal biopsy documented superficial ischemic necrosis in seven patients; 11 patients had full-thickness mucosal necrosis with regeneration. Colonic mucosa proximal and distal to the ischemic segment was endoscopically normal in all patients and histologically normal in the eight patients in whom biopsies were obtained. All patients recovered with supportive care. Median duration of illness was 2.1 days (range, 1-4 days). Ten women (59%) were using low-dose estrogenic oral contraceptive agents, compared with the 1988 national average of 18.5% oral contraceptive users among females aged 15 to 44 years. The calculated odds ratio yielded a greater than sixfold relative risk for the occurrence of ischemic colitis among oral contraceptive users. In addition, four women not currently on hormonal contraceptive therapy had a past history of oral contraceptive use; the three remaining women were taking estrogen as replacement therapy after oophorectomy. In one patient, documented reversible ischemic colitis recurred on resumption of oral contraceptive use; four women reported symptoms and signs of recurrent ischemia but did not seek further medical evaluation. Our data indicate that transient colonic ischemia represents a form of acute segmental colitis in young adults; before the 5th decade of life, spontaneous ischemic colitis is a disorder found almost exclusively in women and is associated with the clinical use of exogenous estrogenic agents.
Adolescent↗
From Dukes through Jass: pathological prognostic indicators in rectal cancer.
In the recently described Jass staging system for resected adenocarcinoma of the rectum, peritumoral lymphocytic infiltration and tumor growth pattern are introduced as significant indicators of prognosis in conjunction with depth of tumor invasion and lymph node metastasis. The authors of this study have tested the applicability of the Jass system by reviewing 348 resected rectal cancers for 12 pathological variables, including two newly recognized features, namely the Crohn's-like lymphoid reaction and metastatic tumor nodules in pericolic fat. By univariate analysis improved 5-year survival rate was associated with tubular-type adenocarcinoma, low tumor grade, retention of tubule configuration and nuclear polarity, expanding tumor growth pattern, prominent peritumoral lymphocytic infiltration, absence of extramural vein invasion by tumor, all levels of intramural and extramural invasion short of widespread local tumor dissemination, a Crohn's-like lymphoid reaction pattern, and absence of both nodal metastasis and tumor nodules in perirectal fat. By Cox stepwise proportional hazards analysis, depth of tumor invasion, lymph node metastasis, Crohn's-like lymphoid reaction, and extramural venous invasion retained independent prognostic significance. Peritumoral lymphocytic infiltration and tumor growth pattern of the Jass staging system failed to compete successfully with other variables in the proportional hazards model, in part because of their correlation with the model's selected variables. Both intramural and extramural extent of tumor invasion coupled with lymph node metastasis form the cornerstones of rectal cancer staging. However, other factors do refine prognostication. From this study the Crohn's-like lymphoid reaction emerges as a significant new independent indicator of prognosis for survival from rectal cancer. Although the Crohn's-like lymphoid reaction and extramural vein invasion took precedence as staging variables in this study, a complex interrelationship with other parameters was observed.
Adenocarcinoma↗
Prevalence of HIV risk factors for individuals examined in clinical forensic medicine.
OBJECTIVE: to identify the prevalence of high-risk factors for infection with Human Immunodeficiency Virus (HIV) in individuals examined in clinical forensic medical practice and to determine opinions and attitudes about HIV in this patient group. DESIGN: Anonymised questionnaire completed by consecutive individuals seen in clinical forensic medical practice. SETTING: Police stations in London attended by Group IV forensic medical examiners. SUBJECTS: 518 individuals examined in police stations (including prisoners and suspects, those detained in police custody, police officers and victims of crime). RESULTS: 164 (31.7%) individuals did not respond to the questionnaire because of: 1) refusal (12.6%) 2) inability because of drugs and/or alcohol (11.4%) 3) mental illness/disorder (4.2%) or 4) language difficulties (3.5%). 28.4% of the respondents were in at least one of the 'high-risk' categories for HIV infection. 26.5% were intravenous drug misusers; 15% were prostitutes; 9.8% (or their sexual partners) had lived in Central or East Africa since 1977; 5.9% were male homosexuals and 0.5% were haemophiliacs. 5.1% were infected with HIV or had Acquired Immunodeficiency Syndrome (AIDS). Only 28.8% of individuals always used condoms in short-term sexual relationships. 44.4% of respondents believed that everyone should be tested for HIV. CONCLUSION: Over one-quarter of the respondents were in higher-risk groups for infection with HIV. Almost one-third could or would not respond. It is concluded that it is not possible to identify by questionnaire, individuals at higher risk of HIV infection in forensic medical practice. This reinforces the necessity of observing good clinical practice to reduce contamination risks in this work environment. It is clear that education about risks for HIV infection is still much needed.
Journal Article↗
Assault and injury in clinical forensic medical practice.
A prospective study was undertaken of 150 individuals in police custody, seen by a Forensic Medical Examiner (FME) for documentation of alleged assault and associated injuries. Ninety-six per cent consented to participate in the study of whom 86% were male. The mean age was 29.8 years. Most assaults (35%) were said to be unprovoked, 26% of injuries were alleged to have occurred at the time of arrest, 17% as a result of domestic incidents and 8% due to driving incidents. Twenty-nine per cent of examinees were victims of assault, 21% complained of alleged police assault and 20% were police officers injured during arrests. There was no significant difference between the mean ages of victims and assailants, and no significant difference in the proportions of each group under the influence of alcohol. Those individuals alleging police assault were all male, and significantly more likely to be unemployed and single. Victims of assault were significantly more likely to be female. Weapons were used in only 15% of cases. The head was the most common site of injury. Twenty-three per cent of the study population required hospital assessment. The study has characterized the different groups of individuals requiring medical assessment for assault and injury in police custody. The findings in this study population differ from similar studies undertaken in alternative settings.
Adolescent↗
Drug misusers in police custody: a prospective survey.
Approximately 11% of individuals seen by forensic medical examiners in police custody in London are drug misusers. This prospective survey using an anonymized structured questionnaire attempted to define some of the characteristics of this selected group of drug misusers. The study was undertaken in Metropolitan Police Service stations (London, UK) within the area covered by Group IV Forensic Medical Examiners. One hundred and fifty consecutive drug misusers in police custody were assessed. Of these individuals 77% used heroin; 30% used both heroin and cocaine regularly; 72% were injecting drugs; 32% were being prescribed drugs (e.g. methadone) by general practitioners or drug agencies. Those individuals prescribed drugs spent a similar amount per day on illicit drugs as those who were not (100.30 pounds versus 106 pounds). Four per cent of individuals were HIV-positive; 25.7% were hepatitis-B positive. Only 9.7% were aware that prophylaxis for hepatitis-B was possible. Seventy-four per cent had served previous prison sentences and of those 82% had used class A controlled drugs whilst serving the sentence. It is concluded that drug misusers seen in police custody tend to be recidivists. It seems that some clear means of identifying and ensuring referral and attendance at an appropriate agency may be the only way to break the cycle of drug misuse, prison and further drug misuse in this highly (self) selected group of patients.
Adolescent↗
Primary autoimmune cholangitis. An alternative to antimitochondrial antibody-negative primary biliary cirrhosis.
The authors report the clinical and liver biopsy features of nine patients with primary autoimmune cholangitis, a unique form of chronic nonsuppurative destructive cholangitis associated with high-titer serum antinuclear antibodies, including eight women and one man; their median age was 51 years. All patients showed cholestatic hepatic enzyme profiles (median gamma glutamyl transferase and alkaline phosphatase, 800 U/L and 700 U/L, respectively). The median antinuclear antibody titer was 1:1,280 (range, 1:640-1:2,560). All patients' sera were negative for antimitochondrial antibodies; six were also nonreactive for anti-M2 mitochondrial autoantigens. Liver biopsies showed marked paucity of interlobular bile ducts (median percentage of portal tracts containing bile ducts, 11%; range, 0-50%). Granulomatous cholangitis was present in two cases; five livers showed the pattern of bile ductular proliferative piecemeal necrosis. Seven patients were treated with prednisone and azathioprine without clinical benefit. During follow-up of 1 to 5 years, disease has progressed in seven patients, including four who have developed other autoimmune conditions. Although clinically, biochemically, and histopathologically comparable to primary biliary cirrhosis, autoimmune cholangitis abdicates antimitochondrial antibodies in favor of antinuclear antibodies. It represents a distinctive subset of antimitochondrial antibody-negative adult ductopenic disorders, for which conventional immunosuppressive therapy does not appear warranted.
Adult↗
Idiopathic granulomatous appendicitis, or Crohn's disease of the appendix revisited.
Idiopathic granulomatous appendicitis has been categorized as primary Crohn's disease of the appendix based on its pathologic features, although the clinical course of this condition simulates acute appendicitis. In this study we report the clinical and pathologic features of 10 cases of idiopathic granulomatous appendicitis and compare the histopathology to 14 appendices inflamed by Crohn's disease. The patients comprised six women and four men with an age range of 15 to 48 years (mean, 29 years). Six patients had acute onset of right lower quadrant abdominal pain while in three patients the presentation was subacute; one patient was asymptomatic. Focal neutrophilic infiltration of crypts with crypt abscesses, mucosal erosion and ulceration, fissures, transmural lymphoid aggregates, and mural fibrosis were comparable in idiopathic granulomatous appendicitis and Crohn's disease affecting the appendix. Fistulization occurred more commonly in Crohn's disease. Idiopathic granulomatous appendicitis contained 19.7 granulomas per tissue section (range, 2.75 to 71.0) compared with 0.3 granulomas per tissue section (range, 0 to 3.0) for appendices affected by Crohn's disease. No patient with granulomatous appendicitis treated by simple appendectomy had recurrence of disease at mean follow-up of 4.5 years. Our morphologic data support the clinical contention that idiopathic granulomatous appendicitis is nosologically distinct from Crohn's disease. Ironically, the presence of numerous granulomas is the histopathologic feature distinguishing idiopathic granulomatous appendicitis from Crohn's disease.
Adolescent↗
DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis.
The objective of the present study was to determine whether abnormal epithelial DNA content (aneuploidy) in colonic biopsy specimens from ulcerative colitis (UC) patients correlated with and predicted histological progression to dysplasia. Aneuploidy was absent in 20 low-cancer risk patients. In 81 high-cancer risk patients aneuploidy correlated significantly with the severity of histological abnormality (negative, indefinite, dysplasia, or cancer). Statistically our data suggest that many more biopsy specimens than are usually taken are needed to detect focal dysplastic lesions. Prospective study of 25 high risk patients without dysplasia revealed 5 with aneuploidy, all of whom progressed to dysplasia in 1-2.5 years, whereas 19 patients without aneuploidy did not progress to either aneuploidy or dysplasia within 2-9 years. Our data indicate that aneuploidy in mucosal biopsy specimens correlates with histological grade and identifies a subset of patients without dysplasia who are more likely to develop it. It was concluded that more frequent and extensive colonoscopic surveillance of this minority subset of high risk patients and less frequent surveillance in the remaining majority may reduce cost and detect more curable lesions.
Adolescent↗