Diligent Search Research Articles

Schwannomas: a pitfall in the diagnosis of pleomorphic adenomas on fine-needle aspiration cytology.

Fine-needle aspiration cytology (FNAC) is being employed with increasing frequency for the preoperative diagnostic workup of salivary gland lesions. Although most cases show morphologic features very characteristic of specific entities, few lesions, both benign and malignant, can cause problems in interpretation. We report four cases initially diagnosed on FNA as spindle-cell tumors, possibly benign nerve sheath tumors (BNST) in the salivary gland region. These cases were later diagnosed on histologic examination as schwannoma (two cases) and as pleomorphic adenoma (two cases). Review of the cytomorphology of these four cases enabled the correct diagnosis of pleomorphic adenoma in the two cases misinterpreted as BNST. Benign peripheral nerve sheath tumors should always be considered in the differential diagnosis of pleomorphic adenoma. A diligent search for epithelial elements is recommended prior to diagnosing BNST in the head and neck region.

Ocular manifestations in children born after in vitro fertilization.

To report the ocular abnormalities found in children born after in vitro fertilization. Forty-seven children (25 girls and 22 boys) born after an in vitro fertilization pregnancy (mean +/- SD birth weight, 2335 +/- 817 g; range, 924-4300 g) and referred for ophthalmic evaluation were included in the study. All underwent a thorough ocular examination. Obstetric history was gathered following a detailed questionnaire with the mothers. Of 70 eyes among nonverbal children, visual acuity was "normal for age" in 60 (86%), "fair" in 4 (6%), and "poor" in 6 (9%). Visual acuity in 24 eyes in verbal children ranged from 6/6 to no light perception, with 4 (17%) having poor vision. Cycloplegic refraction disclosed an emmetropia in 22 (27%), hypermetropia in 47 (57%), and myopia in 13 (16%) of the eyes. Anisometropia of more than 1.0 diopters was found in 8 children. Major ocular malformations were observed in 12 (26%) of the 47 children. These malformations included Coats disease, congenital cataract, congenital glaucoma, hypoplastic optic nerve head, idiopathic optic atrophy, coloboma with microphthalmos, and retinoblastoma. Ocular anomalies were frequently observed in this cohort of offspring born after in vitro fertilization. A diligent and prospective prenatal search for such malformations should unveil the real prevalence of ocular malformations in children born after in vitro fertilization.

The process of developing a research questionnaire to measure attitudes to shared learning

This article discusses the process by which a questionnaire was developed specifically to measure attitude to shared learning. Over a three-year period the attitude questionnaire was developed and tested using pre-registration students who were engaged in a shared learning programme. These pre-registration students were from three professional groups, namely occupational therapy (OT), diagnostic radiography (DR), and therapeutic radiography (TR). While the study hypothesis was that shared learning would improve attitudes over the three-year period, the focus of this article is to discuss the process by which the research instrument was developed. The rationale for focusing on the process is a simple one. After a diligent literature search it was clear that there were no attitude questionnaires specific to attitude measurement in relation to shared learning. Thus without an already validated attitude to a shared learning questionnaire, it became imperative to create systematically a credible attitude measure of shared learning. The process centred on understanding how monadic scales are constructed and used to measure attitudes and perceptions of participants. Amongst a number of processes to be followed was the need also to check the reliability of the developed questionnaire. This was done using the Cronbach alpha coefficient. A Cronbach alpha coefficient of 0.7 was set as a minimum reliability requirement, which was duly satisfied. The outcome of this process was that it very useful to learn how to produce a suitable instrument to measure attitude to shared learning and to add in a small way to the range of attitude questionnaires available.

Peritonitis of undetermined aetiology following laparoscopic surgery

We present an unusual case of peritonitis of undetermined aetiology following a simple laparoscopic surgical procedure. This patient presented with a clinical picture similar to bowel injury after laparoscopic surgery. However, no trauma to the bowel could be found despite a diligent search. Instead, purulent turbid material was seen in the peritoneal cavity with no evidence of faecal material. The patient responded very well to antibiotic treatment, without any long-term sequelae. The value of prophylactic antibiotics in laparoscopic surgery is discussed.

Chest pain of esophageal origin

Patients with unexplained chest pain remain a difficult and perplexing challenge for the gastroenterologist. Despite exclusion of a cardiac origin many patients remain disabled by pain. In these, a diligent search for an esophageal cause-gastroesophageal reflux disease, motility abnormalities, or esophageal hypersensitivity using all available diagnostic (therapeutic) tools-results in a positive outcome. Appropriate use of a diagnostic trial of therapy, ambulatory pH monitoring and/or esophageal manometry, necessitates understanding of the respective benefits. The recent literature examines the value of a short course of high-dose proton pump inhibitors in establishing a diagnosis of gastroesophageal reflux disease-associated chest pain, the use of tricyclic antidepressants, and behavioral therapy in the management of these difficult patients with nonreflux, noncardiac chest pain.

Improving the imaging diagnosis of cervical spine injury in the very elderly: implications of the epidemiology of injury

Purpose: To enumerate host and vector factors that affect each phase of cervical spine injury (CSI) among the elderly, and to attribute specific pathoanatomic characteristics of CSI to host and/or vector factors. Methods: Structured review of English literature references selected from MEDLINE keyword search using PUBMED and OVID search engines. Only articles addressing the role of “aging” or being “elderly” (using a variety of definitions) in CSI were included. The following information was abstracted: journal; year of publication; authors' specialty or departmental affiliation; study design; inclusion and exclusion criteria; year(s) of data collection; number of CSI vs. controls; summary findings, including rate estimates, obvious study weaknesses. Results: Seven of 13 articles were medical-record-based case series, most derived from institutional trauma registries. Four were population-based surveys. One was an assessment of Medicare claims data for all-cause trauma and one a review paper. Blunt-force CSI was most commonly related to domestic falls, then to vehicular-pedestrian collisions and finally to vehicular crashes. More than two-thirds of fractures involved CO-C3, especially in individuals with cervical spondylosis and/or osteoporosis. In 15 to 40 % of CO-C3 fractures there is a delay in diagnosis. An adult forme fruste of SCIWORA (spinal cord injury without radiographic abnormality) was a relatively common cause of central and anterior cord syndromes in the absence of observable fractures or dislocations. Conclusions: The epidemiology of CSI in elderly patients should inform triage and imaging decisions. Since most CSI diagnostic errors involve the upper cervical spine, additional attention to the radiographic anatomy of the craniocervical junction and diligent search for abnormalities in this region are warranted.

Epithelial cells and other cytologic features of pseudomyxoma peritonei in patients with ovarian and/or appendiceal mucinous neoplasms: a study of 12 patients including 5 men.

Pseudomyxoma peritonei (PP) is a rare condition. Cytologic evaluation of peritoneal fluid often is an initial diagnostic test for possible ovarian and/or appendiceal primary tumors. Previous studies suggest that patients with PP who have epithelial cells (ECs) in their peritoneal fluid usually have a less favorable prognosis than patients with acellular PP. To the authors' knowledge, few reports of PP in the cytologic literature cite the presence of ECs. Twelve cases of PP diagnosed by cytologic examination at the University of Texas M. D. Anderson Cancer Center over 15 years were identified. In all cases, primary tumors were confirmed histologically. All available cytologic smears and cell block sections were reviewed for cytomorphology, with particular attention given to the presence of ECs. A correlation between the presence of ECs and patient outcome also was sought (median follow-up, 26 months). Two patients had ovarian neoplasms, six patients (one female and five males) had appendiceal neoplasms, and four patients had synchronous ovarian and appendiceal tumors. Cytologic features included mucin pools (12 of 12 patients), ECs (11 of 12 patients), mesothelial or mesothelial-like cells (10 of 12 patients), histiocytes (11 of 12 patients), and fibroblast-like or spindle cells (6 of 12 patients). ECs were columnar with mucinous features in the majority of cases, and the number of ECs in each case was variable, ranging from 1+ (rare) to 3+ (many). Of the 11 patients with available follow-up data, 6 had recurrent disease, 4 had persistent disease, and 1 patient with acellular PP was alive without clinical evidence of disease after 24 months of follow-up. Unlike previous PP cytology reports, the current study frequently identified ECs (92%). Because of the potential prognostic implication of ECs in patients with PP, a diligent search for ECs is warranted. Indication of the presence or absence of ECs in the cytology report may be useful when PP is diagnosed.

Capital Budgeting, the Hold-up Problem, and Information System Design

In this article, we explore the connection between information system design and incentives for project search. The choice of an information system affects the level of managerial slack that is generated during project implementation. Whether slack is beneficial or costly to an organization has been the subject of debate. In our model of the hold-up problem in capital budgeting, there are both costs and benefits to having managerial slack. The cost of slack is the consumption of perquisites by the manager. The benefit of slack is that it can serve as a motivational tool. The possibility of increasing his slack may encourage a self-interested manager to conduct a more diligent search for a profitable project. To trade off the costs and benefits of slack in our model, an optimal information system sometimes incorporates coarse information, late information, and a mix of monitored and self-reported information. These features are familiar to accountants. Accounting incorporates both verified (monitored) and unverified (self-reported) information and provides information that is aggregated (coarse) and historical (late).

Tonsillectomy in diagnosis of the unknown primary tumor of the head and neck

Objectives: The purpose of this study was to discuss the experience of one tumor registry with performing tonsillectomy in the diagnostic approach to unknown head and neck primary tumors. It also describes the importance of including tonsillectomy in this evaluation algorithm. Study Design: A retrospective chart review was done of 68 patients with either tonsillar or unknown primary squamous cell carcinoma culled from 829 patients seen from 1956 to 1996 at the head and neck tumor registry at the Naval Medical Center San Diego. Methods: Records from the head and neck tumor registry, radiation oncology service, and pathology department were reviewed with attention to presenting symptom, initial examination, diagnostic studies performed, and type and result of biopsies performed. Results: Thirty-four patients sought treatment for a neck lymph node metastasis of squamous cell carcinoma without an identifiable primary tumor site. Six of these (18%) had the primary site diagnosed by performing tonsillectomy ipsilateral to the presenting neck mass. Six of 14 T1 tonsillar carcinomas in this series had the primary site identified by tonsillectomy. Conclusions: Despite a diligent search, a primary tumor site may not be found in the head and neck cancer patient. The tonsil may harbor an occult squamous cell carcinoma. The patient benefits from identification of the initial tumor site because postoperative irradiation ports may be reduced and because surveillance for recurrence may be improved. For these reasons, tonsillectomy should be performed ipsilateral to the presenting cervical metastasis if no other primary tumor site is identified. (Otolaryngol Head Neck Surg 2000;122:52-5.)

Chest pain of esophageal origin

The treatment of patients with unexplained chest pain is difficult and challenging. After a cardiac etiology has been ruled out, a diligent search for an esophageal etiology-gastroesophageal reflux disease, motility abnormalities, or esophageal hypersensitivity-should be undertaken with judicious use of a diagnostic (therapeutic) trial of therapy, ambulatory pH monitoring, or esophageal manometry. The recent literature discusses the use of high-dose omeprazole in diagnosing and treating chest pain associated with gastroesophageal reflux disease, correlates abnormal ambulatory pH monitoring with response to omeprazole, and provides additional insights into the pathogenesis of esophageal chest pain.

Business Software Alliance: Industry protector or bully?

The Business Software Alliance (BSA) comprises a number of leading software companies including Adobe Systems, Autodesk, Lotus, Microsoft, Novell and the Santa Cruz Operation. The BSA has been actively pursuing corporate overuse of its members' software in the UK since 1991, and has achieved many high profile successes against leading companies. Using Anton Piller Search and Seize Orders, representatives of the BSA and their lawyers arrive unannounced at the premises concerned and carry out a diligent search of the hard disks of all the company's PCs. If the search reveals unlicensed copies of software on the hard disks (and this is usually identified by the serial numbers of the software), the infringers have generally been required to pay damages and costs and, in some cases, make abject public apologies.

Delayed metastases in skin cancer of the head and neck: the case of the "known primary".

Regional metastases from head and neck cutaneous tumors are uncommon, and most present within 2 years from initial diagnosis. Occasionally such metastases may manifest at a later date, increasing the possibility of being derived from a second noncutaneous primary cancer of the head and neck region. The authors studied the course of disease in patients treated for cutaneous neoplasms manifesting with delayed regional metastases. They evaluated patients treated for cutaneous neoplasms with regional metastases presenting more than 3 years from initial treatment. There were 10 cases of squamous cell carcinoma, one case of basal cell carcinoma, and one case of basosquamous carcinoma. Mean duration from initial diagnosis to presenting neck metastases was 4 years 2 months. Mean overall follow-up is 2 years 5 months, and 3 years for patients alive without disease. Four patients died of unrelated causes and 3 patients died of their disease. Five patients are alive and free of disease. A diligent search for a second primary must always be carried out when neck metastases appear. Yet, delayed regional metastases appearing more than 3 years after resection of skin neoplasms is not uncommon and are usually associated with the primary skin cancer. Prolonged follow-up is essential, even in T1 patients. Patients with regional recurrence should be treated aggressively.

Research Not Foreign to Two-Year Colleges

Why is research a word not usually found in the two-year college vocabulary? At a 2YC3 conference held in New York in 1995, it appeared that undergraduate research in two-year colleges tended to be a very regional and limited undertaking. Webster defines research as: 1. Careful or diligent search; 2. Studious inquiry or examination; and 3. The collecting of information about a particular subject. These are things performed in our laboratories, so why not do them in a formal setting, making the students more aware that they are performing research? The challenge is to develop an investigative spirit in ourselves and thus in our students. This does not mean that we have to be inventing new procedures or making profound discoveries. Instructors, however, hesitate to implement a research program, claiming a lack of equipment, time, interest, training, or support. By sharing my experience, I hope it will make it easier for you to overcome some of these obstacles and enjoy the experiences of student research.

Patterns of Injury in Belted and Unbelted Individuals Presenting to a Trauma Center After Motor Vehicle Crash: Seat Belt Syndrome Revisited

Study Objective: Investigators have described a “seat belt syndrome” consisting variously of injuries to the lumbar or cervical spine, abdominal contents, or all 3. In this study we sought to identify these and any other patterns of injury associated with seat belt use in patients who presented to a trauma center after a motor vehicle crash. Methods: The charts of all patients involved in motor vehicle crashes who presented as trauma alerts to the study institution between January 1, 1991, and December 31, 1993, were retrospectively reviewed for data regarding belt use and 35 specific injuries in 7 body regions. We calculated the positive likelihood ratio of injury between belted and unbelted patients, along with 95% confidence intervals. Results: We identified 1,124 patients involved in motor vehicle crashes. Of these subjects, 376 were belted and 544 unbelted; in 204 belt status was unknown. Belted patients were more likely to have sustained sternal fracture than were unbelted patients (4% versus .7%; positive likelihood ratio, 1.97; 95% confidence interval, 1.09 to 3.29) but were less likely to have sustained head injury (30.6% versus 46.0%; positive likelihood ratio, .67; 95% confidence interval, .53 to .83). We noted no statistically significant differences in the rates of other specific injuries, including cervical and lumbar fractures and the need for abdominal surgery. Conclusion: Severe injuries of all types occur in both belted and unbelted individuals involved in motor vehicle crashes who present to a typical trauma center. With the exception of sternal fractures, injuries previously associated with the seat belt syndrome occurred in similar proportions of belted and unbelted patients. Head injuries were less frequent. Seat belt use cannot serve as a discriminator for specific injury. A diligent search of all body regions is indicated in both belted and unbelted patients. [Porter RS, Zhao N: Patterns of injury in belted and unbelted individuals presenting to a trauma center after motor vehicle crash: Seat belt syndrome revisited. Ann Emerg Med October 1998;32:418-424.]

Traumatic Basilar Aneurysm after Endoscopic Third Ventriculostomy: Case Report

In reply: It is usually possible through a computerized search of the literature to determine what has and has not been published. Davis' report on measuring syrinx pressures was not heralded by the title of his article(1) and lacked a Key Words list, thereby eluding a diligent and exhaustive literature search. We apologize for the oversight. Davis is correct that the treatment of choice for syringomyelia is to correct the cause when possible. However, his recommendations regarding the use of valved and valveless shunts are highly speculative, and the readers are advised to regard them with caution. There is much to be learned about the pathophysiology of intramedullary pressure in syringomyelia. We agree with Tator (2), who encourages neurosurgeons to measure syrinx pressures at the time of surgery as a means to better understand the relationship of intramedullary pressure and clinical outcome. Thomas H. Milhorat Anthony L. Capocelli, Jr. Rene M. Kotzen Brooklyn, New York

The Apparently Isolated Choroid Plexus Cyst: Importance of Minor Abnormalities in Predicting the Risk for Aneuploidy

Objectives: To assess the risk of aneuploidy in cases of isolated choroid plexus cysts (CPCs) and to compare the risk when associated with minor or major anomalies. Methods: All fetuses with CPCs and known karyotype were identified. CPCs were categorized as ‘isolated’ or associated with minor or major sonographic anomalies. Preexisting risk factors for aneuploidy were compared between groups. The frequency of aneuploidy was compared between fetuses with isolated CPCs and those with CPCs associated with minor or major anomalies. Continuous and categorical variables were analyzed using one-way analysis of variance or chi-square as appropriate with p < 0.05 considered significant. Results: One hundred and forty-nine fetuses with CPCs diagnosed at a mean gestational age of 19 weeks were identified. No significant differences in the frequency of preexisting risk factors for aneuploidy were identified between groups. Eighteen of 149 (12%) fetuses with CPCs had other sonographic anomalies; in 10 they were minor, and 2 of the 10 had abnormal karyotypes. Four of 8 fetuses with major anomalies were aneuploid. All 131 fetuses with isolated CPCs had normal karyotypes, and all aneuploid fetuses had additional anomalies. Conclusions: The overall rate of aneuploidy in patients with CPCs was 4% with no abnormal karyotypes among isolated CPCs. The presence of even minor sonographic abnormalities substantially increased the risk of aneuploidy. Isolated CPCs identified sonographically may not place the patient at risk of aneuploidy, but should prompt a diligent search for other minor or major anomalies. The finding of any other anomaly warrants consideration for karyotypic evaluation.

All is not lost even though your policies are—proving the existence and terms of missing insurance policies

Court rulings over the past decade in insurer/policyholder disputes have established that liability policies dating back to the 1960s and earlier can provide millions of dollars in coverage to policyholders with environmental liabilities. Many policyholders, however, are unable to locate their old policies and find that their insurers and brokers cannot either. Policyholders who have destroyed or lost their policies will need to reconstruct their coverage from secondary evidence. If they wind up in court, the policyholders have the burden of proof and must show that (1) they conducted a diligent search for the policies but could not locate them; (2) the policies did, in fact, exist; and (3) the key coverage terms in the lost policies are, in fact, as claimed by the policyholders. A survey of reported cases reveals that courts have differed widely over the nature and extent of secondary evidence sufficient to prove the existence of a lost policy. The reported cases underscore the importance of convincing the reviewing court to apply the “preponderance of the evidence” standard of proof on this issue, rather than the “clear and convincing” standard. Regarding policy exclusions, courts have uniformly held that once a policyholder proves the existence of the policy and the key terms of coverage, the insurer then has the burden of proving the existence and wording of exclusions in the policy.

Skin and serum reactivity among humans to histoplasmin in the vicinity of a natural focus of Histoplasma capsulatum var. duboisii.

The epidemiology of histoplasmosis duboisii (African histoplasmosis) is not well understood. The present study was carried out to investigate the prevalence of skin sensitivity and to determine by immunodiffusion the presence of antibodies among humans to histoplasmin around a recently discovered natural focus of Histoplasma capsulatum var. duboisii in a bat cave in Ogbunike in the Anambra State of Nigeria. Out of the 40 subjects, all young adults aged 18-30 years, comprising cave guides, traders and farmers examined in the immediate vicinity of the cave, 14 (35.0%) gave a positive skin test. In another population of the same age group, comprising 620 persons, viz. traders, farmers, palm oil workers and some patients attending rural clinics, examined in other nearby areas in Anambra State, 55 (8.8%) reacted positively to histoplasmin. In the immunodiffusion tests, 2 (2.08%) of the 96 school children and 17 (9.4%) of the 181 young adults, including farmers, palm oil workers and traders tested amongst the population around the cave, demonstrated precipitating antibodies to histoplasmin in their sera. Only 5 (0.79%) of the 630 adults of the same age group with similar occupations examined from other areas in Anambra State had precipitating antibodies. Out of another 50 subjects examined, viz.; wood workers, traders, farmers, and school teachers in Nsukka in the Enugu State, two (4.0%) demonstrated antibodies. It is suggested that asymptomatic infections due to the duboisii variety of H. capsulatum may be common in the human population around the cave. A diligent search with the help of local hospitals and public health officials may reveal clinical cases of histoplasmosis duboisii with cutaneous and systemic lesions.

Mitochondrial abnormalities in oculopharyngeal muscular dystrophy

This report describes a 56-yr-old man with a dominantly inherited disorder affecting four generations and characterized by bilateral ptosis and dysphagia. Muscle biopsy showed only minor light microscopic abnormalities but electron microscopy revealed fibres containing paracrystalline mitochondrial inclusions. Southern analysis of mitochondrial DNA obtained from muscle did not reveal mitochondrial gene deletions. An extensive search eventually identified the characteristic intranuclear filaments of oculopharyngeal muscular dystrophy (OPMD). Abnormal mitochondria are non-specific epiphenomena in OPMD but a potential source of confusion with a late-onset mitochondrial cytopathy. This case further emphasizes the necessity for a diligent search for the diagnostic intranuclear filaments when oculopharyngeal muscular dystrophy is suspected clinically.

Defending the True Faith: Kirk, State, and Catholic Missioners In Scotland, 1653-1755

DANIEL SZECHI* In March, 1708, Scottish Privy Council was meeting daily in emergency session in a frantic attempt to put kingdom in a defensible state before Franco-Jacobite invasion poised to strike from Dunkirk could arrive in Scotland. While examining reports from officers and magistrates from all over country, their deliberations suddenly focused on threat of a Roman Catholic uprising in support of James Francis Edward Stuart, Old Pretender, and as Lord Grange reported in a letter to his brother Earl of Mar, This occasioned severalls of Council to complain that notwithstanding many complaints there has been made of encrease of Popery and swarming of priests openly and avowedly in many places of north and Galloway and Nithsdale, that yet nothing was effectually done to restrain them.' Strangely, government does not seem to have heeded complaints even in aftermath of abortive invasion of 1708, for six years later author of an anonymous, but strikingly similarly worded, condescendance, written in response to General Assembly of Kirk's representations to government regarding the of poperie, was warning Scotland's rulers that Kirk was in danger of being overwhelmed by Catholic tide. In Highlands in 1714, author lamented: In paroch of Lochaber priests swarm like locusts, running from house to house, gaining multitudes to their anti-Christian idolatry, baptizeing and marrying. In presbytery of Abemethie priests keep publick meetings, visite, preach, declare people marrYed and say Mass without fear of laws.2 Nor was writer a voice in wilderness. A special committee of commission of General Assembly begged for immediate action by Court of Police in 1718, arguing that it was evident from last accounts that disease grows and will encresce if some stop be not put to progress of it.3 In 1720 another memorial writer declared that, such a height have and Jacobites now arrived at in [the] Duke [of] Gordon's countries, that Protestant friends to government are in hazard of their lives, and he cited cases of two converts to Kirk who were assaulted by mobs of papists and in one case at least forced to flee area.' Even in aftermath of suppression of '45, another memorialist felt moved to complain to Duke of Newcastle that in consequence of efforts of Catholic priests throughout Scotland, is prevailing dayly5 The nighannual petition of General Assembly of Kirk after 1688, that a diligent search be made for popish priests, eloquently attests that memorialists' concern was generally shared by ministers throughout Scotland.6 Moreover, underpinning professed anxiety of ministers and elders about apparent success of missionary efforts of Catholic Church, there was apparently solid cause for concern. Since 1650's Congregation de Propaganda Fide in Rome had been funding a sustained effort to re-establish a permanent Catholic presence in Scotland. The Scots Colleges in Paris and Rome annually turned out dedicated young Scotsmen devoted to this missionary effort. Between 1653 and 1753 their efforts produced an eightfold increase in number of secular priests operating in Scotland. The Jesuits, Dominicans, Benedictines, Franciscans, and even Cistercians briskly seconded their efforts by sending over substantial numbers of additional mission priests. The number of professed Catholics nearly tripled between 1690's and 1750's. Prima facie, it would appear that Kirk was on defensive and encreasce of popery was a reality. And yet, with perfect hindsight, we of course know that Protestantism in Scotland was never in any danger from Catholic mission effort. The eightfold increase in secular priests on mission in Scotland conceals a leap from an insignificant five priests in 1653 to a puny forty in 1753. …