Biostatistical Basis of Elective Node DissectionFORTNER, JOSEPH G.; WOODRUFF, JAMES ; SCHOTTENFELD, DAVID ; MACLEAN, BARBARA
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During the years 1954 through 1964, 259 individuals with primary malignant melanoma had an elective node dissection. Microscopic metastases were found in 15% of these patients. The presence of only a microscopic focus of involvement gave a 10-year cure rate of 67%; metastasis larger than a microscopic focus in a single node, 50%; and more than one node, 15%. One hundred forty-five individuals were treated by wide excision alone with 18% subsequently requiring a therapeutic lymphadenectomy with a ten-year cure of only 6%.
Variations in Adrenocortical Responsiveness During Severe Bacterial InfectionsSIBBALD, WILLIAM J.; SHORT, ALLISTIR ; COHEN, MARGO P.; WILSON, ROBERT F.
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Plasma cortisol levels and their response to .25 mg synthetic A.C.T.H. (CortrosynR) were studied in 26 septic patients. Four (15.4%) of these patients appeared to have greatly increased adrenocortical activity with plasma cortisol levels averaging 65.4 ± 14.8 μg/dl (normal = 8–18 μg/dl. All four of these patients were agonal and died within five days. Seventeen (65.4%) of these 26 patients appeared to have an appropriate adrenocortical response to severe infection in that their plasma cortisol levels increased (averaging 19.2 ± 6.0 μg/dl) following synthetic A.C.T.H. The remaining five patients, who constituted 19.2% of the 26 patients studied, appeared to have some impairment of adrenocortical function. In spite of severe bacterial infections and no history to support Addison's disease, their plasma cortisol levels (averaging 13.8 ± 3.3 μg/dl) were not increased above normal and their response to CortrosynRwas much less than would be expected; the increase in plasma cortisol levels in these patients following the synthetic A.C.T.H. averaged 1.1 ± 3.6 μg/dl. It is reemphasized that patients with severe sepsis who are not responding adequately to standard therapy should be suspected of having adrenocortical insufficiency and treated accordingly.
Malignant Tumors in Choledochal CystsTSUCHIYA, RYOICHI ; HARADA, NOBORU ; ITO, TOSHIYA ; FURUKAWA, MASATO ; YOSHIHIRO, ITUO ; KUSANO, TOSHIHUMI ; UCHIMURA, MASAYUKI
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Between 1960 and 1975, 17 patients with congenital cystic dilatation of the common bile duct (choledochal cyst) were treated and three were associated with malignant tumors in the cysts and one was with carcinoma of the gallbladder. Preoperative diagnosis of adenocarcinoma in the choledochal cyst was established in one patient by cytologic examination of the bile which was obtained during the procedure of endo-scopic pancreaticocholangraphy (EPCG) and percutaneous transhepatic cholangiography (PTC). Definitive treatment of the choledochal cysts associated with malignant tumors in the biliary tract was accomplished by excision of the cysts with tumors and choledochojejunostomy in two patients, by cystoduodenostomy following external drainage in one and by cholecystectomy with resection of invaded transverse colon in one with cancer of the gallbladder. Successful excision of choledochal cysts in 11 patients including three cases associated with malignant tumors in the biliary tract during the last 15 year period is the basis of this report.
When Should the Third Renal Transplant Rejection Episode be Treated?MATAS, ARTHUR J.; SIMMONS, RICHARD L.; KJELLSTRAND, CARL M.; FRYD, DAVID S.; NAJARIAN, JOHN S.
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Recent reports cite better survival when repeatedly rejecting renal allografts are removed and patients returned to hemo-dialysis. However, the criteria for graft removal remain undefined; although some reports recommend removing all kidneys undergoing a third rejection. In our series (1968–1973) of 316 patients with technically successful first grafts followed 21/2–8 years, graft survival was inversely related to the number of rejection episodes. One hundred per cent of kidneys without rejection are currently functioning or functioned at the time of death compared to 90% with one rejection, 67.4% with two and 21% with three. However, 40% of kidneys having three rejection episodes functioned longer than one year after treatment of the third rejection episode. In an attempt to determine the predictability of one year graft survival or failure following treatment of the third rejection, a formula was developed that correctly predicted in 33 of 38 (87%) patients, The formula was based on information available prior to treatment of the third rejection episode, and represents an index of baseline renal function (serum creatinine after second rejection episode) and two indices of the severity of rejection episodes (serum creatinine change between the first and second rejection episodes; rapidity of sequential rejection). Following its derivation, the formula was applied to a second group (1974) of 19 patients having had three rejection episodes. The formula correctly predicted one year allograft survival or failure following treatment of the third rejection episode in 68% of these patients. A striking finding of our review was a significant difference in current patient survival between those having no rejection episodes (89%) and those having one or more rejection episodes (65%) (p < .00001). There was no significantly greater long-term curtailment in survival if more than one rejection eipsode was treated. Patients having one rejection eipsode seemed to die from varying causes and at varying time periods. Patients dying after two or more rejection episodes had an increased incidence of deaths due to bacterial infection.
Cardiac Depression in BacteremiaPOSTEL, JOHN ; SCHLOERB, PAUL R.
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Hemodynamic and respiratory effects of a 5-hr IV infusion of Ps. aeruginosaat a dose of 108organisms per ml per minute were studied in 6 dogs. Four dogs served as controls. Gramnegative bacteremia, with 70,000 ± 1,800 organisms per ml of blood, caused a 50% reduction of cardiac output at three hrs. Peripheral vascular resistance increased significantly, but mean heart rate fell below control levels. Decline in mean systemic blood pressure from 150 ± 5 mm Hg to 88 ± 6 mm Hg was accompanied by a significant increase in pulmonary arterial wedge pressure with normal right atrial and pulmonary arterial pressures. Pulmonary vascular resistance also remained unchanged. With progression of the low output state and development of hypothermia, arteriovenous oxygen difference (A-V DO2) fell significantly. Despite a decline in functional residual capacity, venoarterial admixture diminished in the face of reduced pulmonary capillary perfusion, normal arterial Po2values, decline in body temperature and finally very narrow A-V DO2. Histologically, ventricular myocardium revealed severe interstitial edema. It is concluded that myocardial dysfunction may occur early during gram-negative bacteremia, and formation of myocardial edema appears to be a significant contributing factor in myocardial failure.
Fungus Infections After Liver TransplantationSCHRÖTER, GERHARD P. J.; HOELSCHER, MANFRED ; PUTNAM, CHARLES W.; PORTER, KENDRICK A.; STARZL, THOMAS E.
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The problem of fungus infections after liver transplantation was studied. In 100 consecutive recipients of orthotopic liver homografts there were 10 and 8 examples, respectively, of localized and disseminated infections caused by Candida species. Candidemia was demonstrated in 8 of these 18 patients. One patient who had a localized Candida infection also had disseminated cryptococcosis. An additional 31 patients were infested in that Candida could be cultured from sites where it is not normally found, such as the blood (8 examples), urine (8), ascitic fluid (8), and wounds (22). This exorbitant incidence of monilial infections and infestations was associated with a high frequency of complications involving the homograft as well as the hosts' gastrointestinal tract during the post-transplantation period. The yeasts found in blood, urine, ascitic fluid and elsewhere were thought to have originated from the gut. Ten of the 100 patients had aspergillosis which was localized in 7 instances and disseminated in 3. The lung was the most frequently affected organ. The fungus infections played a contributory role in the downhill course of our patients but in the event of death more fundamental and more frequent causes of failure were technical complications involving the homografts, difficulties in controlling rejection with reasonable immunosuppressive doses and bacterial sepsis. Suggestions have been made for the better control of fungal infections in liver recipients.
Current Management of MelanomaSEIGLER, H. F.; FETTER, B. F.
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EVEN THOUGH CARSWELL first used the term melanoma in a treatise in the early part of the 19th century, Hippocrates is credited with the first recorded clinical observation of cutaneous melanoma. During the seventeenth century several reports appeared in the literature referring to the “fatal black tumor.‘’ In 1806 both Laennec and Dupuytren published on melanosis; however, it was not until 1864 that Sir James Paget stated that cancer could develop in a mole. In 1892 Hutchinson published his Archives of Surgeryin which he carefully described the senile freckle which we now call Hutchinson's melanotic freckle. A decade ago Clark2formulated the classification utilized throughout the world today. He described three separate types: 1) melanoma, Hutchinson's melanotic freckle type (lentigo maligna melanoma), 2) melanoma, invasive with adjacent intraepidermal component of superficial spreading type (superficial spreading melanoma), 3) melanoma, invasive, without adjacent intraepidermal component (nodular melanoma).
Surgical Treatment of Pulmonary AspergillomaSOLTANZADEH, HOOSHANG ; WYCHULIS, ADAM R.; SADR, FARROKH ; BOLANOWSKI, PAUL J.; NEVILLE, WILLIAM E.
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Fourteen patients with aspergilloma (fungus ball) were reviewed. Hemoptysis was the major symptom (93%). Chest roentgenograms disclosed a “fungus ball” in every patient, and the mycelia of Aspergillus fumigatus were recovered from all resected specimens. One of three patients treated by pneumonectomy died post-operatively. A lobectomy was performed in ten patients, and segmental resection in one without mortality or significant morbidity. There has been no evidence of recurrence in a follow up of six months to ten years. On the basis of this experience and a review of the literature, excision of a solitary “fungus ball” is recommended when the diagnosis is made. Non-surgical therapy should be reserved for patients whose general medical status or pulmonary reserve prohibit resection.
Palmar Hyperhidrosis and its Surgical TreatmentADAR, RAPHAEL ; KURCHIN, ALEXANDER ; ZWEIG, AMIKAM ; MOZES, MARK
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One hundred patients with primary palmar hyperhidrosis (HH) underwent bilateral upper dorsal sympathectomy (UDS) by the supraclavicular approach. Pre-operative epidemio-logical and clinical data are described. The immediate and late results, as well as the complications and side-effects are detailed. Follow-up was completed on 93 patients between four and 50 months after the operation (average 18 months). Of 93 patients, 91 had drying of the hands. In 58% some moisture returned to the hands but in no case did the hyperhidrotic state recur. Subjective patient evaluation was excellent or good in 83 patients (89%) and only one patient (a technical failure) was completely dissatisfied. Reasons for some degree of dissatisfaction with the operation were mainly compensatory HH in non-denervated areas, and Horner's syndrome. Compensatory HH usually decreased with passage of time and, permanent Horner's syndrome occurred in 8% of patients (4% of procedures). Technical failure can be avoided by use of frozen section examination intraoperatively. For severe cases of palmar HH that cause social, professional and emotional embarassment, bilateral simultaneous UDS by the supraclavic-ular approach is the procedure of choice: Morbidity is small, and almost all patients enjoy improved quality of life after the operation.
Treatment of Peptic Ulcer Disease in the Renal Transplant PatientOWENS, MILTON L.; PASSARO, EDWARD ; WILSON, SAMUEL E.; GORDON, H. EARL
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This study reviews previous reports of peptic ulcer disease in kidney transplant recipients and includes our own experience. Between 1968–1976, 12 transplant centers reported on gastrointestinal complications occurring in 1853 renal transplant recipients. Among these are 52 patients in whom peptic ulcers developed before transplantation and 72 patients in whom peptic ulcers developed after transplantation. Included are 21 patients with peptic ulcer from 115 renal transplant recipients at VA Wadsworth Hospital. Patients who were operated upon for peptic ulcer before transplant were compared to patients with peptic ulcer before transplant but who were not operated upon. Ulcer recurrence was significantly lower in the operated group p < .0003. Following transplantation 59 of 68 patients with peptic ulcer disease presented with bleeding or perforation. Mortality was high: 31 deaths in 72 patients (43%). Symptoms usually occurred early, 74% in 6 months, but 19% occurred after one year. The mortality from duodenal, gastric, combined gastric and duodenal and recurrent ulcers did not differ significantly. Elective surgery is indicated for peptic ulcer when demonstrated before or after kidney transplantation.