Washington University Medical Center Research Articles

Current management of patients with invasive cervical carcinoma.

After the logic of evidence-based medicine, there are several conclusions to be reached from these recent prospective, randomized phase III clinical trials. Patients with stages IB2 and IIA cervical carcinoma, although technically manageable, should be treated with external pelvic irradiation and brachytherapy and weekly (cisplatin 40 mg/m2 x 6 wk), if it is suspected that the likelihood of positive lymph nodes or margins requiring adjuvant treatment after radical surgery would be significant. In those patients in whom the risks of either positive margins or lymph nodes are low, either radical surgery or radiation are equally efficacious options. A recent report that surveyed the Surveillance, Epidemiology, and End Results program database suggested that there may be a survival advantage for surgical intent-to-treat patients compared with the radiation intent-to-treat patients for tumors 4 cm or smaller in patients with stage IB and IIA cervical cancers. Certainly, toxicity criteria for these patients in terms of long-term problems need to be further examined. For those patients who undergo a radical hysterectomy and lymph node dissection, postoperative irradiation is indicated if high-risk factors such as large tumor size, lymph vascular space invasion, and deep stromal invasion are identified. Patients who are found to have positive lymph nodes, positive parametrial invasion, or positive margins at the time of hysterectomy should receive postoperative irradiation with chemotherapy. All other patients with more advanced clinical stages of cervical carcinoma should be treated with external pelvic irradiation, brachytherapy, and concurrent chemotherapy. Based on the results of the randomized studies, there appears to be no role for either hydroxyurea or fluorouracil. The chemotherapy agent of choice, at present, is cisplatin administered concurrently with irradiation at a dose of 40 mg/m2 weekly for 6 weeks. Concurrent chemotherapy should be avoided in patients with a poor performance status and other severe comorbidities, and these patients should be treated with irradiation alone. Further refinement of treatment for those patients who require combined chemo/radiation versus those with comorbidities such that combination chemotherapy is actually too toxic must be defined.

Posterior fossa meningiomas: surgical experience in 161 cases

BACKGROUND We report the clinical, radiological, and surgical findings of patients with posterior fossa meningiomas surgically treated at our institution over the last 6 years. METHODS We reviewed 161 consecutive cases of posterior fossa meningiomas operated on between April 1993 and April 1999 at The George Washington University Medical Center. RESULTS There were 128 female and 33 male patients (mean age 47 years, range of 10–81 years). Meningiomas were classified as petroclival (110 cases), foramen magnum (21 cases), cerebellar hemispheric, lateral tentorial (14 cases), cerebellopontine angle (9 cases), and jugular foramen (7 cases). Mean tumor equivalent diameter (TED) = (D1×D2×DE) 1/3 was 3.1 cm (range of 0.53–8.95). Head pain (50% of cases) and disturbance of gait (44%) were the most common presenting symptoms, and cranial neuropathies the most common neurological signs on admission. Mean preoperative performance status (Karnofsky scale) was 80.2 (range 40–100). Surgical approaches to these tumors included partial labyrinthectomy petrous apicectomy, fronto-temporal/fronto-temporal orbitozygomatic osteotomy, retrosigmoidal, extreme lateral, transpetrosal, and combined. In 38 cases a staged procedure was performed. Gross-total resection was achieved in 57% of patients, and subtotal/partial in 43%. Surgical mortality was 2.5% and complications were encountered in 41% of patients. Postoperative CSF leak occurred in 22 cases (13.6%). The mean follow-up was 19 months, ranging from 0.2 to 63.6, and the mean performance status of patients with a follow-up of at least 12 months was 77 (range of 40–100). Recurrence or progression of disease was found in 13.7% of cases (follow-up 2 years or more). CONCLUSION Our experience suggests that although posterior fossa meningiomas represent a continuing challenge for contemporary neurosurgeons, such tumors may be completely or subtotally removed with low rate of mortality and acceptable morbidity, allowing most of these patients to achieve a good outcome in a long-term follow-up.

EFFECT OF OXYGENIZED WATER ON PERCENT OXYGEN SATURATION AND PERFORMANCE DURING EXERCISE

EFFECT OF OXYGENIZED WATER ON PERCENT OXYGEN SATURATION AND PERFORMANCE DURING EXERCISE A. Jenkins, T. B. Waddell, M. Moreland, and B. Fernhall, FACSM. Exercise Science Programs, The George Washington University Medical Center, Washington DC, and Exercise Science Department, Syracuse University, Syr

On the Châtelperronian/Aurignacian Conundrum: One Culture, Multiple Human Morphologies?

Previous articleNext article No AccessDiscussion and CriticismOn the Châtelperronian/Aurignacian Conundrum: One Culture, Multiple Human Morphologies?JeromeE.Dobson and GlennW.GeelhoedJeromeE.DobsonOak Ridge National Laboratory, Oak Ridge, Tenn. 37831/Office of the Dean, George Washington University Medical Center, Washington, D.C. 20037, U.S.A. ([email protected]). 8 viii 00 Search for more articles by this author and GlennW.GeelhoedOak Ridge National Laboratory, Oak Ridge, Tenn. 37831/Office of the Dean, George Washington University Medical Center, Washington, D.C. 20037, U.S.A. ([email protected]). 8 viii 00 Search for more articles by this author Oak Ridge National Laboratory, Oak Ridge, Tenn. 37831/Office of the Dean, George Washington University Medical Center, Washington, D.C. 20037, U.S.A. ([email protected]). 8 viii 00PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by Current Anthropology Volume 42, Number 1February 2001 Sponsored by the Wenner-Gren Foundation for Anthropological Research Article DOIhttps://doi.org/10.1086/318438 Views: 65Total views on this site Citations: 3Citations are reported from Crossref PDF download Crossref reports the following articles citing this article:Susan J. Crockford Thyroid rhythm phenotypes and hominid evolution: a new paradigm implicates pulsatile hormone secretion in speciation and adaptation changes, Comparative Biochemistry and Physiology Part A: Molecular & Integrative Physiology 135, no.11 (May 2003): 105–129.https://doi.org/10.1016/S1095-6433(02)00259-3Susan J. Crockford Commentary: Thyroid Hormone in Neandertal Evolution: a Natural or a Pathological Role?, Geographical Review 92, no.11 (Nov 2019): 73–88.https://doi.org/10.1111/j.1931-0846.2002.tb00135.xJerome E. Dobson Comment in Reply: an Interdisciplinary Discourse on the Role of Iodine in Human Evolution, Geographical Review 92, no.11 (Nov 2019): 97–103.https://doi.org/10.1111/j.1931-0846.2002.tb00138.x

Autosomal dominant inheritance of prostate cancer: a confirmatory study

Objectives. To confirm, in a study of a large, independent cohort of families with prostate cancer, the findings of three segregation analyses that have suggested the existence of an inherited form of prostate cancer with an autosomal dominant inheritance mode. Methods. Between January 1991 and December 1993, 1199 pedigrees were ascertained through single, unrelated, prostate cancer probands who presented for radical prostatectomy at the Division of Urologic Surgery, Washington University Medical Center in St. Louis, Missouri. Maximum likelihood segregation analysis was used to test specifically for mendelian inheritance of prostate cancer. Results. Segregation analyses revealed that the familial aggregation of prostate cancer can be best explained by the autosomal dominant inheritance of a rare (q = 0.0037) high-risk allele. According to the best-fitting autosomal dominant model, 97% of all carriers will be affected by 85 years of age compared with 10% of noncarriers. Furthermore, the autosomal dominant model predicts that the high-risk allele accounts for a large proportion (65%) of all patients diagnosed with prostate cancer before 56 years of age. However, of all prostate cancer cases, a relatively small proportion is inherited (8% by 85 years old). Conclusions. These results are in agreement with earlier reports of segregation analyses of prostate cancer and strengthen the evidence that prostate cancer is inherited in a mendelian fashion within a subset of families.

Syphilitic aortitis is dying but not dead

Catheterization and Cardiovascular InterventionsVolume 52, Issue 2 p. 240-241 Editorial Comment Syphilitic aortitis is dying but not dead Tsung O. Cheng MD, Tsung O. Cheng MD The George Washington University Medical Center, Washington, D.CSearch for more papers by this author Tsung O. Cheng MD, Tsung O. Cheng MD The George Washington University Medical Center, Washington, D.CSearch for more papers by this author First published: 30 January 2001 https://doi.org/10.1002/1522-726X(200102)52:2<240::AID-CCD1058>3.0.CO;2-FCitations: 6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume52, Issue2February 2001Pages 240-241 SCAI Member Sign in RelatedInformation

Clinical significance of microsatellite instability in endometrial carcinoma.

The purpose of this study was to compare the clinical characteristics of endometrial carcinomas with and without microsatellite instability (MSI). The authors prospectively acquired DNA from patients with endometrial carcinomas at Washington University Medical Center. Tumors were assigned MSI (+) status when two or more of five microsatellite repeat markers revealed novel bands in tumor DNA not present in the corresponding normal DNA. Clinical characteristics and survival data of patients with and without MSI were abstracted from patient charts. Statistical significance was calculated with the chi-square test, and survival was assessed with Kaplan-Meier methods. The authors found 65 of 70 (93%) patients with MSI (+) tumors to be of white race, whereas only 124 of 159 (78%) patients with MSI (-) tumors were white (P = 0.012). Advanced disease (International Federation of Gynecology and Obstetrics Stage III-IV) was observed in 9 of 70 (13%) MSI (+) patients and 44 of 159 (28%) MSI (-) patients (P = 0.017). In addition, aggressive histologic subtypes were observed less frequently in MSI (+) tumors (6/70 [8%]) than in MSI (-) tumors (30 of 159 [19%]) (P = 0.034). Race and stage were shown by multivariate analysis to be different in MSI (+) and MSI (-) patients. Recurrence and overall survival were similar in the two groups. Patients with MSI (+) tumors were more likely to be of white race and to present with early stage disease. Further investigation is needed to explain why patients with MSI (+) tumors have similar survival to patients with MSI (-) tumors, despite presenting at earlier stages, being of white race, and being less likely to be associated with virulent histologic subtypes.

Expanding the kidney donor pool: Ethical and medical considerations

year later, proteinuria developed. She had an uncomplicated pregnancy in 1990. Five years later, arterial hypertension required treatment with enalapril. Her serum creatinine then was 1.2 mg/dL. The serum creatinine rose to 1.3 mg/dL two years ago and to 1.5 mg/dL last year. Earlier this year, a 24-hour urine collection contained 810 mg protein; the serum creatinine was 1.6 mg/dL and the creatinine clearance was 31 mL/min/ 1.73 m 2 . Her urine sediment was benign. A further increase in her blood pressure necessitated treatment with lisinopril, 10 mg each morning, and amlodipine, 5 mg each night. She says that she has no regrets about her decision to donate despite the outcome. Five years ago, her husband’s brother developed renal failure; with her encouragement, her husband donated a kidney. Her husband, now age 44, is in good health and has normal blood pressure, normal serum creatinine, and no proteinuria.

Review of the Bethesda System atlas does not improve reproducibility or accuracy in the classification of atypical squamous cells of undetermined significance smears

The Bethesda System (TBS) and its accompanying atlas were developed to promote uniform diagnosis and reporting of cervical and vaginal cytology, especially with respect to borderline abnormal smears. The authors assessed whether group study of TBS atlas improves the reproducibility and accuracy of the cytopathologic diagnosis of equivocal Papanicolaou smears. One hundred "atypical" smears were divided into pretest and posttest sets containing equal numbers of negative, atypical squamous cells of undetermined significance (ASCUS), and squamous intraepithelial lesion (SIL) diagnoses based on a five-member panel review. Two comparable teams of four pathologists from George Washington University Medical Center (Washington, DC) and Kaiser Permanente (Portland, OR), each comprised of two more experienced cytopathologists and two less experienced pathologists, independently reviewed the 50 pretest slides and classified the slides according to TBS as negative, ASCUS, or SIL. The teams then conducted group study sessions using TBS atlas. After the review, the pathologists independently classified the 50 posttest slides in a similar manner. Pretest, pair-wise interobserver agreement ranged from 30% to 66% compared with 34-62% for posttest agreement. Absolute percent agreement of reviewers' diagnoses with a previously developed consensus diagnosis based on opinions of a five-expert panel (cytopathologic certainty scale) ranged from 44% to 62% for the pretest set and from 40% to 60% for the posttest set. Comparison of the detection of oncogenic human papilloma virus (HPV) DNA by hybrid capture tube test with smears classified as negative, ASCUS, or SIL revealed that seven of eight reviewers did not demonstrate a stronger association between HPV detection and cytologic diagnosis in the posttest set. Review of TBS atlas by itself does not appear to improve the reproducibility or accuracy of cytologic diagnoses. The lack of improvement was similar among the pathologists involved regardless of experience level or whether they had a close working relation. Cancer (Cancer Cytopathol)

Early interventions for children at risk

The George Washington University Medical Center, Department of Psychiatry, Washington, DC, USA The George Washington University Medical Center, Department of Psychiatry, 2150 Pennsylvania Avenue, NW, Washington, DC 20037, USA

Metals and disorders of cell accumulation: modulation of apoptosis and cell proliferation.

*Inorganic Carcinogenesis Section, Laboratory of Comparative Carcinogenesis, National Cancer Institute at National Institute of Environmental Health Sciences, 111 Alexander Drive, P.O. Box 12233, MD F0-09, Research Triangle Park, North Carolina; †College of Optometry and Department of Biology and Biochemistry, University of Houston, Houston, Texas; ‡Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky; §Department of Pharmacology, Molecular and Cellular Oncology Program, The George Washington University Medical Center, Washington, D.C.; and ¶Institute of Chemical Toxicology, Wayne State University, Detroit, Michigan

The Collected Reports from SUPPORT and HELP: An Annotated Bibliography of Manuscripts in print as of December 31, 1999, and SUPPORT Prognostic Formulas

Journal of the American Geriatrics SocietyVolume 48, Issue S1 p. S222-S233 The Collected Reports from SUPPORT and HELP: An Annotated Bibliography of Manuscripts in print as of December 31, 1999, and SUPPORT Prognostic Formulas Nancy Freeborne MPH PA-C, Corresponding Author Nancy Freeborne MPH PA-CThe Physician Assistant Program, The George Washington University Medical Center, 2175 K St NW, Suite 820, Washington DC 20037.Search for more papers by this author Nancy Freeborne MPH PA-C, Corresponding Author Nancy Freeborne MPH PA-CThe Physician Assistant Program, The George Washington University Medical Center, 2175 K St NW, Suite 820, Washington DC 20037.Search for more papers by this author First published: 27 April 2015 https://doi.org/10.1111/j.1532-5415.2000.tb03136.xCitations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume48, IssueS1May 2000Pages S222-S233 RelatedInformation

Stage I (t1 N0 M0) squamous cell carcinoma of the laryngeal glottis: Therapeutic results and voice preservation

Background The therapeutic outcomes for voice preservation in Stage I (T1 N0 M0) glottic carcinoma, treated with conservation surgery, radiation therapy, and endoscopic resection, are controversial. Methods A retrospective tumor registry retrieval of data on patients treated with curative intent at Washington University Medical Center–Barnes Hospital between January 1971 and December 1990 for the surgical group, January 1971 to December 1985 for the low-dose radiation group, and January 1986 to January 1995 for the high-dose radiation group, was performed. Results The 659 patients with Stage I (T1 N0 M0) glottic carcinoma treated with curative intent were subdivided into four groups: (1) 90 patients received low-dose radiation (mean dose 58 Gy, range 55–65 Gy, daily fractionation 1.5–1.8 Gy); (2) 104 patients received high-dose radiation (mean dose 66.5 Gy, range 65–70 Gy, daily fractionation 2–2.25 Gy); (3) 404 patients underwent conservation surgery; and (4) 61 patients had endoscopic resection. T1A (85%) and T1B (15%) disease was equally distributed among the groups. The anterior commissure was involved in 38 patients in the radiation therapy groups and 56 patients in the surgical groups. The overall local control was 89%. The overall local salvage was 84%. The overall unaided laryngeal voice preservation was 90%. The overall 5-year disease specific and actuarial survival rates were 95% and 81%, respectively. Prevalence of 2% regional metastases, 1.2% distant metastases, and 14% second primary malignancies were documented. The cure rate was 69% for regional metastases, 13% for distant metastases, and 44% for second primary malignancies. There were 5 complication deaths (0.1%), and 38 (6%) patients died of intercurrent disease. The use and dose of tobacco products was significantly increased in patients who died of intercurrent disease (p = 0.004) or developed second primary malignancies (p = 0.024). No significant difference was observed among the four therapeutic groups in the 5-year cause-specific survival rate (p, 0.68). Actuarial survival was significantly decreased in the low-dose radiation therapy group as compared with the other three therapeutic groups (p = 0.04). Initial local control was poorer for the endoscopic (77%) and low-dose radiation (78%) groups as compared with the high-dose radiation (89%) and conservation surgery (92%) groups (p = 0.02) but significant differences were not found for ultimate local control following salvage treatment. Unaided laryngeal voice preservation was similar for high-dose radiation (89%), conservation surgery (93%) and endoscopic resection (90%), but significantly poorer for low-dose radiation (80%; p = 0.02). T1B disease (N = 94) had similar local control and voice preservation with conservation surgery (87%) and high-dose radiation (88%) but lower results with low-dose radiation and endoscopic resections (67% unaided laryngeal voice preservation; p = 0.02). Conclusion (1)The four therapeutic groups achieved similar rates of disease specific survival and ultimate local control. (2) Low-dose radiation was associated with significantly lower overall actuarial survival and unaided laryngeal voice preservation. (3) Endoscopic resection was associated with a significantly lower initial local control rate, but following salvage therapy achieved equivalent results to the other treatment methods. (4) Patients with (T1 N0 M0) glottic carcinoma had similar survival, local control, and unaided laryngeal voice preservation rates with high-dose radiation, conservation surgery, and endoscopic resections, but not with low-dose radiation therapy. © 1999 John Wiley & Sons, Inc. Head Neck 21: 707–717, 1999.

Impact of two ambulatory care training programs on smoking-cessation activities.

Tobacco use causes significant morbidity and mortality. Resident physicians at the George Washington University Medical Center are trained to counsel patients to stop smoking. I retrospectively reviewed charts of 300 patients treated by resident physicians in the Department of Medicine (200) and the Department of Health Care Sciences (100). In the 200 patients cared for by resident physicians in the traditional internal medicine training program, a smoking history was obtained in 93 (47%). Forty-seven patients (51%) smoked, and 7 smokers (15%) were counseled to stop smoking. In 100 patients cared for by resident physicians in the primary care internal medicine training program, a smoking history was obtained in 94 patients (94%). Twenty-three patients (24%) smoked, and 11 (48%) were counseled to stop smoking. Resident physicians in the primary care training program obtained more smoking histories and counseled more patients to stop smoking. Further study is necessary to evaluate strategies that can be used in residency training to encourage smoking-cessation counseling.

Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective?

The elderly have prevalence rates and clinical features of gastroesophageal reflux disease (GERD) similar to those in younger individuals, but the role of laparoscopic antireflux surgery (LARS) in the elderly has not been clearly established. The purpose of this study was to determine if the results of LARS in the elderly are comparable with those in younger patients. All patients undergoing LARS for GERD at the Washington University Medical Center were entered prospectively into a computerized database. Between May 1992 and June 1998, 339 patients underwent LARS and were divided into two groups based on age: nonelderly (ages, 18-64 years; n = 303) and elderly (age, >/=65 years; n = 36). Data were expressed as mean +/- standard deviation (SD) and statistical analysis was performed. Elderly patients had a higher American Society of Anesthesiology (ASA) score (2.3 +/- 1.5) and a longer hospital stay (2.1 +/- 0.2 days) than the younger group (ASA, 1.9 +/- 0.5; hospital stay, 1.6 +/- 0.9 days; p < 0.001). Operation times averaged 154 +/- 68 min in the elderly compared with 134 +/- 49 min in the nonelderly (p = NS). Grade I complications occurred significantly more frequently in the elderly (13.9%) than in the nonelderly (2.6%), but the incidence of grade II complications was similar between the groups (elderly 2.8% vs nonelderly 2.7%). There were no grade III complications in either group, but there was one death in the nonelderly group. At follow-up ranging to 81 months (median, 27 months), the two groups had similar low incidences of heartburn and dysphagia. Anatomic failures of LARS developed in 19 nonelderly patients (6.2%) compared with 2 elderly patients (5.5%; p = NS). As shown in this study, LARS is safe and effective in elderly patients with GERD. Age older than 65 years should not be a contraindication to laparoscopic antireflux surgery in properly selected patients.

Depth-Psychological Under-standing: The Methodologic Grounding of Clinical Interpretations.

Clinical Professor of Psychiatry and the Behavioral Sciences; George Washington University Medical Center; Washington, DC

Academic health centers can bridge the gulf between medicine and public health.

The authors review why the gulf between clinical medicine and public health has existed since the first schools of public health were established in 1916. They emphasize that academic health centers (AHCs) have the potential to bring together these two perspectives--as well as the health services perspective--to clarify what they offer and to find creative ways to build upon their combined strengths. The authors describe institutional approaches that can be taken to narrow the gulf, with examples from the initiatives of this type that are under way at The George Washington University Medical Center in Washington, D.C. For example, the authors state and discuss in detail that an AHC's medical, public health, and health services institutions should be physically and institutionally close; that collaboration between them requires well-structured interaction; that institutional structures are needed to ensure cooperation when internal competition is likely; and that collaboration is fostered by new opportunities and the potential for new resources. The authors conclude by stating that the future will require that the health education and prevention perspective of public health, the treatment perspective of medicine, and the financial and management perspective of health services be developed and integrated into the work of AHCs, and give examples of specific activities that would be possible with such integration.

Plastic surgical workforce: too many or too few?

From the Division of Plastic Surgery, The George Washington University Medical Center, Washington, DC.

Silver Amplification for Electron Microscopy: An Overview.

The Center for Microscopy and Image Analysis, The George Washington University Medical Center, Washington, DC, U.S.A.

Immunogold Labeling for Transmission Electron Microscopy: Exploring New Frontiers.

Department of Veterinary Morphophysiology/Neurobiology Research Group, Università degli Studi di Torino, Torino, Italy (A.M.); The Center for Microscopy and Image Analysis, The George Washington University Medical Center, Washington, DC, U.S.A. (R.R.); Institute of Pathological Anatomy, General Hospital, Salzburg, Austria (W.M.).