Retrospective study of the skin-sparing mastectomy in breast reconstruction.

The final appearance of the reconstructed breast is greatly dependent on the relative amounts of skin and breast tissue excised at the time of the mastectomy and on the exact location of the skin incision. A complete mastectomy may be performed using modified skin incisions to avoid the sacrifice of unnecessary breast skin. The type of skin-sparing incision used varies based on the exact location of the tumor and the size of the breast, but it always includes the nipple-areola complex and the biopsy site. The presence of local recurrence, distant disease, or death was determined in 50 consecutive patients who had skin-sparing mastectomies and immediate breast reconstruction between 1985 and 1991 to ascertain the safety of the procedure. The period of follow-up ranged from 23 to 121 months, with a mean of 57 months and a median of 51.5 months. There was no local recurrence, active distant disease was present in five patients, two patients died of distant disease, and there were two unrelated deaths.

HIV seropositivity in a burn center's population.

HIV infection in a patient with burn injuries complicates the care of both the patient and the treating burn team. In the patient, HIV slows wound healing and increases the complications seen with burns. For the treating team, HIV is a hazard that infects the large volume of bodily fluids to which the burn team is potentially exposed. At Saint Francis Memorial Hospital, a team of plastic surgeons, infectious disease specialists, medical internists, psychiatrists, social workers, and nurses was established for the care of patients with burn injuries who have HIV. To ascertain the baseline need for this specialized care, we interviewed 103 consecutive patients admitted to the Bothin Burn Center. Those found to be positive by history (3 of 103) were excluded from HIV testing. Of the remaining 100 consecutive patients, all consented to HIV testing. None of these patients, even those with known risk factors, was found to have undiagnosed HIV positivity. We conclude the occult incidence in the population tested is lower than expected, and continued testing is warranted.

Management of pulmonary blastoma in children.

Pulmonary blastoma is a rare neoplasm, accounting for 0.5 per cent of all primary malignant pulmonary tumors. The clinical features, radiologic findings, and management of five children with pulmonary blastoma are described. The female/male ratio was 4:1. Mean age at presentation was 34 months, with a mean duration of symptoms of 1.8 months. Fever and cough were the most common symptoms. Opacification of the right lung field with mediastinal shift to the left was the predominant roentgenologic feature. The tumor involved the right chest in all patients. Thoracotomy was performed in all patients to establish the diagnosis. Two patients underwent complete resection at the initial operation, an incomplete resection was performed in one patient. Delayed complete resection was performed in another patient. All the patients received combination chemotherapy and one patient also received radiotherapy for primary disease. Two patients with histologic and immunohistochemical evidence of striated muscle differentiation were treated as rhabdomyosarcomas. Both these patients have survived for 24 and 67 months after diagnosis. The tumor recurred in three patients. Recurrence was treated with a combination of surgery, chemotherapy, and radiotherapy. Overall disease-free survival rate was 40 per cent. Long-term follow-up and additional patients are required to provide prognostic information.

Studies on the pharmacokinetics and pharmacodynamics of recombinant hirudin (rHV2-Lys 47) after intravenous and subcutaneous administration in dogs.

In recent years, the pharmacological and biochemical characterization of hirudins has taken a major upswing due to the availability of this natural polypeptide in recombinant form. Despite this, the current knowledge on the pharmacokinetics and pharmacodynamics of recombinant hirudin (rH) appears to be incomplete. The present study was designed to investigate the relationship between plasma concentrations of rH with corresponding antithrombin responses after intravenous (i.v.) and subcutaneous (s.c.) administration in dogs. Four male, Mongrel dogs were each injected with an i.v. (bolus) dose (1 mg/kg) of one specific variant of rH, i.e. rH with a lysine residue in position 47 (rHV2-Lys 47). The dogs were injected with a s.c. dose (1 mg/kg) of rHV2-Lys 47 after one week. After each dose, blood was collected at different time intervals, plasma separated and stored at -70 degrees C. Plasma concentrations of rHV2-Lys 47 were determined using an enzyme-linked immunosorbent assay (ELISA) method and pharmacokinetic parameters were determined using standard non-compartmental methods. The ex vivo antithrombin activity of the drug was measured using activated partial thromboplastin time (APTT), calcium-thrombin time (Ca++TT) and a chromogenic anti-IIa assay. The results from this study indicate that the pharmacokinetic behavior of rHV2-Lys 47 is strongly influenced by the route of administration. In all three functional assays used, a significant correlation was obtained after i.v. administration between plasma concentrations and corresponding responses over the time period of the study when compared to s.c. administration. The results are indicative of a probable structural and functional modification of this rH variant after s.c. administration which may be responsible for the altered pharmacokinetics and pharmacodynamics after s.c. dosing.

Alteration of pharmacokinetics and pharmacodynamics of recombinant hirudin (rHV2-Lys 47) after repeated intravenous administration in dogs.

Native hirudin is a heterogenous polypeptide obtained from the medicinal leech, Hirudo medicinalis. Recent advances in molecular biological techniques have led to the availability of large amounts of hirudin in the recombinant form. Recombinant hirudins (rH) are currently being investigated for potential use in the prophylaxis and treatment of deep venous thrombosis (DVT), in disseminated intravascular coagulation (DIC) and during cardiovascular bypass surgery. In this study, one specific variant of rH with a lysine residue in position 47 (rHV2-Lys 47) was administered in dogs in a multiple dose regimen of 2 mg/kg (i.v. bolus) for three weeks with a dosing interval of one week. After each dose, blood samples were collected at regular time intervals, plasma separated and stored at -4 degrees C. Concentrations of rHV2-Lys 47 in each sample were determined using an enzyme-linked immunosorbent assay (ELISA). Ex vivo antithrombin responses measured included activated partial thromboplastin time (APTT), calcium-thrombin time (Ca++TT-10 NIH units/ml) and a chromogenic anti-IIa assay. It was the purpose of this study to detect any sensitization or desensitization of antithrombin responses when rHV2-Lys 47 is used in a repeated fashion such as would be expected in the prophylaxis of DVT. The results indicated that there was no attenuation in the responses; however, there was a sensitization of response as measured by the Ca++TT (10 NIH units/ml). These findings could have major implications in the clinical use of rH where this drug is expected to be used in a multiple dose regimen.

Simplified perioperative management in vertical banded gastroplasty.

Vertical Banded Gastroplasty (VBG) is the most commonly performed weight loss operation in the United States and is of proven adjunctive benefit in the treatment of morbid obesity. In an attempt to reduce the hospital related complications associated with morbidly obese patients we simplified the perioperative management of 244 patients undergoing VBG. Our goals were early feeding, early ambulation and a short hospital stay. Neither nasogastric tube nor Foley catheter was used after surgery. Mean postoperative stay was 3.24 +/- 0.8. Forty-one patients (16.8%) developed significant complications. Only two of these had a nosocomial complication (0.8%). The remaining 39 patients had technical complications not related to the protocol of simplified perioperative care. Short hospital stay and simplified perioperative management are feasible and safe for the large majority of patients undergoing VBG and may, in fact, significantly decrease the nosocomial morbidity common to this type of patients.

Thymic carcinoid.

Carcinoid of the thymus is a rare neoplasm. Differentiation from thymoma is important because they have entirely different prognosis. A patient in whom a 19 x 18 x 12 cm carcinoid tumor of the thymus was surgically removed is presented. The tumor metastasized to peritracheal and internal mammary nodes, and invaded the SVC, pleura, lung, and pericardium. This is apparently the largest reported tumor of its kind. Prior to induction of anesthesia cardiopulmonary bypass and rigid bronchoscopy were readily available. Awake intubation was utilized. Even though long-term prognosis is poor, an aggressive surgical approach and adjuvant radiotherapy may achieve extended survival with excellent quality of life. Central aspects of the disease as well as pivotal therapeutic points are discussed.

A physico-chemical approach to the study of the binding interaction between S-adenosyl-L-methionine and polyanions: binding constants and nature of the interaction with sodium poly(styrene sulfonate).

The interaction between S-adenosyl-L-methionine (AdoMet) and sodium poly(styrene sulfonate) NaPSS) was studied by means of ultrafiltration and ultraviolet absorption spectroscopy at several pH values and sodium sulfate concentrations. The results obtained are interpreted mainly in terms of electrostatic interactions and permit the evaluation of the binding constants under different experimental conditions. Furthermore, ultraviolet absorption spectroscopy data show a specific short-range interaction between the aromatic electronic system of AdoMet and the NaPSS aromatic ring. The results indicate that the binding strength is greatly affected by the AdoMet positive charge on the adenine ring. The other positive charges on both the sulfonic pole and the amino acidic group of AdoMet contribute only weakly to the binding to the polyanionic matrix, thus assuring some stability of AdoMet even at physiological pH.

The amylase profile: a discriminant in biliary and pancreatic disease.

Serial serum amylase determinations were made in 85 consecutive patients who presented with an initially elevated value. In 35 patients (Group A), the clinical findings were consistent with biliary tract disease. All underwent cholecystectomy for documented cholelithiasis within a week of diagnosis, and 23 percent had choledocholithiasis as well. Fifty patients (Group B) presented with a first episode of acute alcoholic pancreatitis. An amylase profile, consisting of initial and final values and the daily rate of change, was significantly different between the two groups. The initial serum amylase value was higher in Group A patients and decreased more rapidly to a lower value than in Group B patients. We conclude that both the initial value and pattern of serum amylase decay distinguish the hyperamylasemia of biliary tract disease from that of alcoholic pancreatitis.

Stricture of the common bile duct from chronic pancreatitis.

Early diagnosis and treatment of stricture of the common bile duct from chronic pancreatitis are essential as the life-threatening complications of biliary cirrhosis and acute cholangitis can occur even in the absence of clinical jaundice. In a series of 40 patients with longstanding chronic pancreatitis and stricture of the common bile duct, findings included chronic pain in 26 patients, jaundice in 17 patients, secondary biliary cirrhosis in six patients and acute cholangitis in six patients. Persistent elevation of the alkaline phosphatase level was the most sensitive laboratory indicator of occult obstruction of the biliary tract. The diagnostic long tapered stenosis of the distal common bile duct was delineated by percutaneous transhepatic cholangiography in 21 of 22 patients and endoscopic retrograde cholangiopancreatography in eight of 11 patients. Operative decompression of the biliary tract included 32 biliary-enteric bypasses, three sphincteroplasty procedures and three emergency tube drainages. There was one postoperative death and seven other patients had postoperative complications. Sphincteroplasty failed to relieve the obstruction in two patients and two patients with biliary-enteric bypass had late anastomotic strictures develop which required reoperation. Only seven patients were free of pain at follow-up study which ranged from 0.5 to 15.0 years. Clinical suspicion based upon persistent hyperaklalinphosphatemia, diagnosis by cholangiography and decompression of the biliary tract by choledochoenterostomy can reliably avert the lethal complications of stricture of the common bile duct caused by chronic pancreatitis.

Intraperitoneal nutritional support: initial results in a canine model.

To evaluate the capacity of the peritoneal membrane to efficiently absorb complex nutritional solutions, five adult mongrel dogs were prepared with peritoneal and intravenous catheters. In duplicate studies each dog's peritoneal catheter was rapidly infused with 1 liter of fluid containing 1.25% glucose, 5% fat emulsion, 2.5% mixed amino acids, and 20 ml of standard electrolyte additive solution. Plasma and peritoneal fluid nutrient and electrolyte concentrations and osmolarities were measured initially, 1/2 hr, and hourly for 5 hr after infusion. Mean peritoneal fluid volume increase was 56 +/- 45 ml at 5 hr (P less than 0.05). Plasma osmolarity remained unchanged as peritoneal fluid osmolarity rapidly declined to plasma level over the initial 2 hr. Peritoneal fluid concentrations of glucose, triglycerides, and amino acids all fell precipitously during the first hour (P less than 0.01) while plasma concentrations rose in reciprocal fashion (P less than 0.01). Maximal rises above basal plasma concentrations all occurred at 1/2 hr and amounted to 42.7% for glucose, 39.7% for triglycerides, and 113.2% for amino acids. Levels returned to normal or near normal by 5 hr. Net absorption of glucose was 91.7% of the total glucose load after 5 hr of intraperitoneal dwell time. Triglyceride absorption was 65.1% and amino acid absorption was 91.9%. Greater than 75% of total nutrient absorption occurred during the initial hour of dwell. It is estimated that both nonprotein energy and nitrogen requirements could be met with two to three intraperitoneal nutrient solution exchanges per day. Thus, provision of total nutritional needs may be possible with an intraperitoneal support system.

Mesenteric cysts and intra-abdominal cystic lymphangiomas.

Although mesenteric cysts and intra-abdominal cystic lymphangiomas are uncommon and clinically confusing lesions, histologic and ultrastructural evidence suggests that they are pathologically distinct. Differentiation of these lesions is important since lymphangiomas may follow a proliferative and invasive course. Of 28 cases documented at laparotomy, histologically eight patients (29%) had cystic lymphangiomas and 20 patients (71%) had mesenteric cysts. Lymphangioma was found to be exclusively a disease of childhood and young adulthood (mean age, 10 years); mesenteric cyst was found in all age groups (mean age, 44 years), and two thirds of these patients were over 40 years old. Patients with lymphangiomas more frequently were male (75% vs 30%), symptomatic (88% vs 35%), and had ascites (50% vs 0%) and larger lesions (mean, 8.8 vs 4.7 cm) when compared with patients with mesenteric cysts. Complete excision was possible in all but four patients, with no operative deaths and a postoperative complication rate of 7%. After a mean follow-up period of four years, there were no recurrences among 16 patients who had undergone complete excision.

In vitro synthesis of pig pancreas ribonuclease.

From studies on the in vitro synthesis of the heavily glycosylated pig pancreas ribonuclease (molecular weight of the protein moiety is 13 786, on the basis of the amino acid composition), the following points emerge: (1) the enzyme is synthesized as a precursor having an apparent molecular weight about 7000 higher than that of the mature non-glycosylated protein; (2) the mRNA coding for the enzyme protein consists of about 950 nucleotides.