ECTOPIC PREGNANCY—Early Diagnosis,Clinical Errors and Conservative Operation

This report of eight years'' experience with extrauterine pregnancy by a single gynecologist is an exposition of how the diagnosis was made or why it was missed.Of 26 diagnoses of ectopic pregnancy, five were false (20 per cent); and in three cases (10 per cent) the diagnosis was not made promptly—a total error of 30 per cent.Ectopic pregnancy will be discovered earlier if obstetric patients are always examined shortly after missing the first menstrual period.A palpable adnexal mass was present in 19 of 21 ectopic pregnancies (90 per cent). A mass was palpable in only one of five cases erroneously diagnosed as ectopic pregnancy (20 per cent).Decidual casts were passed by four patients, two of whom did not have ectopic pregnancy.If two gynecologists do not agree on the question of extrauterine pregnancy, a third opinion should be sought or culdoscopy employed.Enucleation of the conceptus and salvage of the oviduct is advocated.     

PSYCHIATRIC UNITS IN GENERAL HOSPITALS—Problems in Development and Efficient Operation

An adequate 25-bed psychiatric unit can be housed in a wing of a general hospital. Even more important than physical facilities are competent personnel, to be headed by a chief psychiatrist and a psychiatric nurse supervisor, for the unit. Incorporating teaching facilities into the unit helps to integrate psychiatry into the other disciplines of medicine in a continuing educational program.Having psychiatric units in general hospitals enables many voluntary patients to be treated in early stages of the disorder, with a high proportion of recoveries.Medicolegal aspects and the lack of adequate coverage of mental disorders by voluntary prepayment health plans are serious problems in the economy of a unit. Improved hospital administration, expanded training programs, educational work by local mental health societies and modification of laws on malpractice and commitment will go far to help solve these problems.     

Alzheimer’s Disease Susceptibility Genes APOE and TOMM40, and Hippocampal Volumes in the Lothian Birth Cohort 1936

The APOE ε and TOMM40 rs10524523 (‘523’) variable length poly-T repeat gene loci have been significantly and independently associated with Alzheimer’s disease (AD) related phenotypes such as age of clinical onset. Hippocampal atrophy has been significantly associated with memory impairment, a characteristic of AD. The current study aimed to test for independent effects of APOE ε and TOMM40 ‘523’ genotypes on hippocampal volumes as assessed by brain structural MRI in a relatively large sample of community-dwelling older adults. As part of a longitudinal study of cognitive ageing, participants in the Lothian Birth Cohort 1936 underwent genotyping for APOE ε2/ε3/ε4 status and TOMM40 ‘523’ poly-T repeat length, and detailed structural brain MRI at a mean age of 72.7 years (standard deviation = 0.7, N range = 624 to 636). No significant effects of APOE ε or TOMM40 523 genotype were found on hippocampal volumes when analysed raw, or when adjusted for either intracranial or total brain tissue volumes. In summary, in a large community-dwelling sample of older adults, we found no effects of APOE ε or TOMM40 523 genotypes on hippocampal volumes. This is discrepant with some previous reports of significant association between APOE and left/right hippocampal volumes, and instead echoes other reports that found no association. Previous significant findings may partly reflect type 1 error. Future studies should carefully consider: 1) their specific techniques in adjusting for brain size; 2) assessing more detailed sub-divisions of the hippocampal formation; and 3) testing whether significant APOE-hippocampal associations are independent of generalised brain atrophy.     

POISON CONTROL—Operation of an Information Center in a Rural and Agricultural Community

The Fresno Community Hospital Poison Control Center has been in operation for about three years, under the sole directorship of the pathologist. All expenses are paid by the hospital. It has served a definite need in the community. As an agricultural and more or less rural community, it shows more poison cases having to do with plants, insecticides, kerosene and fertilizers than do urban communities.     

CARCINOMA OF THE AMPULLA OF VATER—Whipple Operation and Ten-Year Arrest in Three Cases

For their value as factors in the evaluation of pancreatoduodenectomy for carcinoma of the ampulla of Vater, the late results in three cases in which the Whipple operation was performed for this lesion are presented. At the time of the report, the time that had elapsed since operation was 12 years in one case, 11 in another and 10 in the third. After this article was written, one patient died of carcinoma of the body of the pancreas, but whether the lesion was a recurrence, a metastatic growth, or a second primary lesion could not be determined. There was no evidence of recurrence or metastasis in two of the patients. This report is based upon observation in recent surgical care of two of the patients and upon direct information of the other patient.     

Dissecting the Gene Dose-Effects of the APOE ε4 and ε2 Alleles on Hippocampal Volumes in Aging and Alzheimer’s Disease

Objective

To investigate whether there is a specific dose-dependent effect of the Apolipoprotein E (APOE) ε4 and ε2 alleles on hippocampal volume, across the cognitive spectrum, from normal aging to Alzheimer’s Disease (AD).

Materials and Methods

We analyzed MR and genetic data on 662 patients from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database–198 cognitively normal controls (CN), 321 mild-cognitive impairment (MCI) subjects, and 143 AD subjects–looking for dose-dependent effects of the ε4 and ε2 alleles on hippocampal volumes. Volumes were measured using a fully-automated algorithm applied to high resolution T1-weighted MR images. Statistical analysis consisted of a multivariate regression with repeated-measures model.

Results

There was a dose-dependent effect of the ε4 allele on hippocampal volume in AD (p = 0.04) and MCI (p = 0.02)–in both cases, each allele accounted for loss of >150 mm³ (approximately 4%) of hippocampal volume below the mean volume for AD and MCI subjects with no such alleles (Cohen’s d = −0.16 and −0.19 for AD and MCI, respectively). There was also a dose-dependent, main effect of the ε2 allele (p<0.0001), suggestive of a moderate protective effect on hippocampal volume–an approximately 20% per allele volume increase as compared to CN with no ε2 alleles (Cohen’s d = 0.23).

Conclusion

Though no effect of ε4 was seen in CN subjects, our findings confirm and extend prior data on the opposing effects of the APOE ε4 and ε2 alleles on hippocampal morphology across the spectrum of cognitive aging.     

RECURRENT PILONIDAL CYST AND SINUS—A Plan of Preoperative Preparation,Operation and Postoperative Care

Evaluation ten years following radical excision and primary closure of recurrent pilonidal cysts led to the conclusion that the method of preoperative and postoperative care and the surgical technique employed gave satisfactory results. In 50 patients operated upon, the duration of symptoms varied from ten days to six years. Primary healing was achieved in all but one case in which there was slight skin overlapping. Thirty-three of the 50 patients were located for appraisal at the end of ten years. Three had had recurrences.The procedure involved eradication of acute infection preoperatively, wide, en bloc radical excision, with primary closure reattaching flaps centrally to the presacral fascia, and drainage of the depths of the wound.     

ROC Volumes – Should They Be Used?

Invited comment on Alonzo, T.A. and Nakas, C.T. (2007). Comparison of ROC umbrella volumes with an application to the assessment of lung cancer diagnostic markers. Biometrical Journal 49, 654-664. Issues remain as to the appropriateness of volumes as summary measures of accuracy when distinguishing between multiple disease classes and when comparing accuracy of tests.     

Canadian-trained Physicians in United States Internships and Residencies: “Operation Retrieval” and Report of Statistics, 1966-1968

In response to a shortage of medical teachers and scientists, A.C.M.C. began “Operation Retrieval” in 1967 in an effort to contact and to survey graduates of Canadian medical schools who are interns and residents in the United States. This paper describes the publications produced for these graduates, and the concerns of graduates as discovered by on-site visits to Los Angeles, Boston and New York. These concerns centre around difficulties in communication with Canada. This paper also gives a statistical report on the numbers of graduates who are interns and residents in the United States, and the locations, fields of specialization and years of graduation of residents. The decreasing numbers are believed to reflect improving Canadian facilities as well as difficulties associated with the American military draft.