Faculty Bibliography

The hallmark presentation of combat trauma-nightmares, waking hallucinations, intrusive traumatic memories, and extreme affective reactions to environmental triggers-may best be conceptualized as part of an adaptive mechanism intended to protect the individual against a repetition of trauma. Combat veterans continuously must cope with the extreme affects that combat induced. Fear, rage, guilt, and grief predominate. Their mental and emotional life is complicated by a conscience split between war zone and civilian morality and by the special group dynamics of combat. Optimal clinical understanding of combat-related trauma, whether in a psychoanalytic or general mental health setting, requires an awareness of the interaction of the personal dynamics of each individual with the specific characteristics of their combat situation

Neoplasms of histiocytes and dendritic cells are rare, and their phenotypic and biological definition is incomplete. Seeking to identify antigens detectable in paraffin-embedded sections that might allow a more complete, rational immunophenotypic classification of histiocytic/dendritic cell neoplasms, the International Lymphoma Study Group (ILSG) stained 61 tumours of suspected histiocytic/dendritic cell type with a panel of 15 antibodies including those reactive with histiocytes (CD68, lysozyme (LYS)), Langerhans cells (CD1a), follicular dendritic cells (FDC: CD21, CD35) and S100 protein. This analysis revealed that 57 cases (93%) fit into four major immunophenotypic groups (one histiocytic and three dendritic cell types) utilizing six markers: CD68, LYS, CD1a, S100, CD21, and CD35. The four (7%) unclassified cases were further classifiable into the above four groups using additional morphological and ultrastructural features. The four groups then included: (i) histiocytic sarcoma (n=18) with the following phenotype: CD68 (100%), LYS (94%), CD1a (0%), S100 (33%), CD21/35 (0%). The median age was 46 years. Presentation was predominantly extranodal (72%) with high mortality (58% dead of disease (DOD)). Three had systemic involvement consistent with 'malignant histiocytosis'; (ii) Langerhans cell tumour (LCT) (n=26) which expressed: CD68 (96%), LYS (42%), CD1a (100%), S100 (100%), CD21/35 (0%). There were two morphological variants: cytologically typical (n=17) designated LCT; and cytologically malignant (n=9) designated Langerhans cell sarcoma (LCS). The LCS were often not easily recognized morphologically as LC-derived, but were diagnosed based on CD1a staining. LCT and LCS differed in median age (33 versus 41 years), male:female ratio (3.7:1 versus 1:2), and death rate (31% versus 50% DOD). Four LCT patients had systemic involvement typical of Letterer-Siwe disease; (iii) follicular dendritic cell tumour/sarcoma (FDCT) (n=13) which expressed: CD68 (54%), LYS (8%), CD1a (0%), S100 (16%), FDC markers CD21/35 (100%), EMA (40%). These patients were adults (median age 65 years) with predominantly localized nodal disease (75%) and low mortality (9% DOD); (iv) interdigitating dendritic cell tumour/sarcoma (IDCT) (n=4) which expressed: CD68 (50%), LYS (25%), CD1a (0%), S100 (100%), CD21/35 (0%). The patients were adults (median 71 years) with localized nodal disease (75%) without mortality (0% DOD). In conclusion, definitive immunophenotypic classification of histiocytic and accessory cell neoplasms into four categories was possible in 93% of the cases using six antigens detected in paraffin-embedded sections. Exceptional cases (7%) were resolvable when added morphological and ultrastructural features were considered. We propose a classification combining immunophenotype and morphology with five categories, including Langerhans cell sarcoma. This simplified scheme is practical for everyday diagnostic use and should provide a framework for additional investigation of these unusual neoplasms.

Freud's concept that the dream protects sleep is first applied to a clinical vignette involving combat veterans and then re-examined. Although conceived in the context of the topographical model, it is more compatible with the structural model. The mind produces a believed hallucination mimicking gratification of impulses that would lead to awakening. It is hypothesized that the dream develops in the neonate during the arousal of the REM state to protect sleep from burgeoning object-directed impulses. The clinical vignette suggests that traumatic dreams can use past trauma to insure current vigilance. Traumatic memories may symbolize fantasy complexes in dreams

In two children with left coronary artery to right ventricle fistula, nuclear magnetic resonance imaging provided high-quality images of the course of the dilated coronary artery and its termination in the right ventricular apex. The advantages of this noninvasive multiplanar imaging technique for visualization of coronary fistulae and dilated coronary arteries are described. This report represents the first description of coronary artery fistula by nuclear magnetic resonance imaging.

Monoclonal antibodies OKT11 (gamma 1) and OKT11A (gamma 2) are described and appear to have similar binding specificities. They bind, in immunofluorescence, with greater than 95% of infant thymocytes, staining both cortical and medullary cells, 65-80% of blood lymphocytes and selectively stain the T cell-dependent paracortical areas of tonsil. A small proportion (9-12%) of bone marrow lymphocytes stain, but this population excludes the terminal transferase-positive cells. Both the gamma 1 and gamma 2 antibodies stain the surface membrane Ig-negative lymphocytes in blood and tonsil and are to block sheep E rosette formation (to normal or leukemic T cells). In contrast, other monoclonal anti-T reagents tested (OKT1, OKT3, OKT4, OKT6, OKT8, OKT9, OKT10) did not block E rosette formation. E rosette formation and OKT11 bindings are coincident on T-ALL cell lines and both are trypsin-sensitive. In a series of 145 leukemias and 26 leukemic cell lines investigated, only leukemias with a T cell phenotype including E rosette positivity were reactive with OKT11 and OKT11A. OKT11A binds to a polypeptide of approximately 50 000 molecular weight on thymic lymphocytes. This structure may carry the recognition site for sheep erythrocytes. These antibodies provide additional useful markers for T cell analysis and are of potential therapeutic value.

Five hundred celiac angiograms were reviewed to evaluate the frequency of clinically significant variations in the origin of the left gastric artery. In 13 of 500 cases, the left gastric artery arose anomalously most often as a direct branch of the aorta; in 14 of 500 cases, the left gastric artery primarily supplied the liver with only minor contributions to the stomach. An aberrant origin of the left gastric artery necessarily influences the angiographic diagnosis and therapy of gastrointestinal hemorrhage

Evaluation of 19 patients with a history of renal trauma revealed three angiographic features helper in the diagnosis of posttraumatic renal scarring: (1) a cup-shaped renal contour defect characterized by smooth margins, infolding of the renal cortex, and extension of the calyces to the edge of the defect; (2) occlusion of an extra- or intrarenal artery associated with a distal avascular zone of infarction; and (3) a grossly heterogeneous nephrogram characterized by scattered islands of renal tissue separated by broad or narrow avascular scars. Limited pathologic correlation suggests that the cup-shaped contour defect reflects subcapsular hemorrhage and that the mottled, heterogeneous nephrogram reflects a shattered kidney