Letter to an ethicist: resuscitative interventions.

Few issues raise more questions for physicians than the resuscitation of seriously ill patients. In the following exchange of letters, Dr. John Quinlan discusses two difficult cases involving patient resuscitation, while Dr. William Cook responds by referring to the Joint Statement on Resuscitative Interventions that was approved last year by the CMA and several other health care organizations.

Molecular detection of prostate epithelial cells from the surgical field and peripheral circulation during radical prostatectomy.

PURPOSE: Prostate cancer progression despite organ confined pathological assessment has been reported in a variable number of men after radical retropubic prostatectomy. To study this phenomenon, we used the prostate specific antigen (PSA) reverse transcriptase-polymerase chain reaction assay. MATERIALS AND METHODS: We prospectively assayed the peripheral venous blood before, during and after surgical manipulation as well as the intraoperative field blood for PSA reverse transcriptase-polymerase chain reaction-positive cells in 22 men undergoing radical retropubic prostatectomy. RESULTS: PSA reverse transcriptase-polymerase chain reaction-positive cells were identified in 20 of the 22 operative field samples (91%) and 4 of 16 (25%) had evidence of intraoperative hematogenous dissemination (p = 0.046). No significant association was identified among Gleason score, pathological stage and the PSA reverse transcriptase-polymerase chain reaction result. CONCLUSIONS: Our results suggest that tumor cell spillage and less frequently hematogenous dissemination may be associated with operative manipulation of the prostate during radical retropubic prostatectomy and may potentially represent mechanisms of failure after radical retropubic prostatectomy.

Retroperitoneal pulmonary sequestration: a rare congenital anomaly in a 71-year-old man.

The suprarenal fossa is a clinically silent area of the body where nonfunctioning, indolent lesions may pass unnoticed. We report on a 71-year-old man with muscle invasive transitional cell carcinoma of the bladder who was found on staging abdominopelvic computerized tomography to have a 5 x 6 cm. left periaortic suprarenal mass. Serum analysis for a hormonally or vasoactive tumor was unrevealing. Fine needle aspiration was also nondiagnostic. An extrathoracic pulmonary sequestration was found at surgical exploration. Pulmonary sequestration rarely occurs in an extrathoracic location, is usually diagnosed in the first decade of life and to our knowledge has never been reported in this location in a patient of this age.

Pyelovenous lymphatic migration of transitional cell carcinoma following flexible ureterorenoscopy.

Ureterorenoscopy has enhanced the diagnosis and treatment of upper urinary tract disorders. However, the irrigation necessary for visualization and distention of the lumen may increase renal pelvic pressure, resulting in pyelovenous lymphatic backflow. We report a case of renal pelvic transitional cell carcinoma that may have migrated to submucosal venous and lymphatic spaces during flexible ureterorenoscopy.

Bilateral transpedicular decompression and Harrington rod stabilization in the management of severe thoracolumbar burst fractures.

Fifty-eight patients with severe thoracolumbar burst fractures were treated with bilateral transpedicular decompression, Harrington rod instrumentation, and spine fusion. Spinal realignment and stabilization was achieved by contoured dual Harrington distraction rods supplemented by segmental sublaminal wiring. Posterior element fractures were noted in 25 patients, 9 of whom had associated dural tears. Computed tomography was performed to assess the cross-sectional area of the spinal canal before surgery and after decompression. Patients at initial evaluation averaged greater than 67% spinal canal compromise. After surgery, successful decompression was accomplished in 57 patients. One patient required staged, anterior thoracoabdominal decompression and fibula strut grafting. At follow-up (average, 43 months; range, 25-70 months), neurologic improvement was found in 77% of the patients who initially presented with neurologic deficits. Thirty-four of 40 patients with incomplete paraplegia improved one or more subgroups on the Frankel scale. A solid fusion was attained in all 58 patients. No patient had a significant residual kyphotic deformity. Single-stage bilateral transpedicular decompression and dual Harrington rod instrumentation reliably provides decompression of the spinal canal and restores spinal alignment. The procedure allows early mobilization and provides an environment for solid fusion and maximum neurologic return.

Fetal posterior urethral valve syndrome: a prospective application of antenatal prognostic criteria.

A case of posterior urethral valve syndrome is presented. Four weeks after a normal 24-week ultrasound examination, diminished amniotic fluid, megacystis, and renal hyperechogenicity were observed. A repeat ultrasound examination at 30 weeks' gestation identified oligohydramnios and increased renal echogenicity. These findings prompted the performance of a percutaneous cystocentesis to assess fetal renal function indirectly. The specimen was evaluated for osmolality and sodium and chloride concentrations. The urine electrolyte concentrations (sodium 115 mEq/L; chloride 93 mEq/L) and the osmolality (230 mOsm/L) were elevated, suggesting impaired renal function and a poor prognosis. Despite these findings, aggressive management was used, including administration of antenatal corticosteroids and elective preterm delivery. A percutaneous cystocentesis was required during the infant's initial resuscitation, followed by a difficult urethral catheterization. Ultimately, a vesicostomy performed on day 4 of life was associated with prompt return of renal function (serum creatinine 0.7 mg/dL at the time of discharge). At 6 months of age, normal renal function has been documented and the vesicostomy has been closed. This case demonstrates the potential limitations of available prognostic criteria in evaluating fetal urinary obstruction and residual renal function. In selected cases (when the onset of obstruction is documented in the third trimester), refinement of these prognostic criteria may be indicated. Similar cases may be best managed by preterm delivery and prompt postnatal decompression.

Occupational exposure limits for carcinogens--variant approaches by different countries.

The differences in treatment of occupational exposure limits for carcinogens by 24 countries is described along with a discussion of the American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit values (TLV) treatment, the similar treatment of the new Occupational Safety and Health Administration (OSHA) standard, and the treatment by provinces of Canada. The unique listing by the Federal Republic of Germany of so-called technical guiding concentrations of a group of carcinogens is discussed with the note that Austria used this same system. Publications on justification for establishing occupational exposure limits for certain carcinogens are discussed also.

Massive retroperitoneal hemorrhage owing to a ruptured adrenal cyst.

We report a rare case of massive retroperitoneal hemorrhage owing to rupture of an adrenal cyst after blunt abdominal trauma. A large retroperitoneal hematoma was evacuated and subtotal adrenalectomy was performed. Convalescence was uneventful. Histology revealed an endothelial-lined adrenal cyst suggesting a vascular or lymphatic etiology.

Segmental neurofibromatosis.

Of the various forms of neurofibromatosis, the best known are peripheral neurofibromatosis (von Recklinghausen's disease) and central neurofibromatosis. There is a rare form called segmental neurofibromatosis, in which the cutaneous and neural changes are limited to one sector of the body and with which there is usually no family history of neurofibromatosis. We report four patients with this disorder and stress the value of repetitive, limited excision of peripheral nerve tumors in their management.

Self-report of depressive symptoms in low back pain patients.

Two studies designed to examine the self-report of depressive symptoms in low back pain patients are presented. Symptoms of depression were assessed with the Beck Depression Inventory. In the first study, a sample (N = 134) of patients who presented for neurosurgical evaluation were evaluated. In the second study, a subgroup of patients found to have lumbar disc protrusion were compared to a subgroup with few or no positive physical findings at the time of physical examination. If the cut-off scores recommended by Beck were used, patients in both studies would be classified as mildly depressed. Both studies found that patients were significantly more likely to report somatic than cognitive symptoms of depression. Patients with multiple physical findings or a disc abnormality at the time of operation were not found to be more likely to report somatic symptoms than patients with few physical findings.

The rheumatoid hand and preventive surgery.

Preventive surgery in rheumatoid arthritis of the hand is aimed at avoiding or at least delaying deformity and disability and at alleviating symptoms, especially pain. This can be successfully accomplished only in the disease's early phases. The family physician is in a position to assess his rheumatoid patients and to develop a good sense of the disease's progression. He can therefore make timely referrals to a hand surgeon, before major deformity and disability are present and the optimum time for preventive surgery has passed. The common surgical procedures-including excision of rheumatoid nodules; release of nerve entrapments; tenosynovectomy; synovectomy, and resection and reconstruction of the ulnar head-are discussed, as are their indications.

Utilization of medical services after short-term psychiatric therapy in a prepaid health plan setting.

Utilization of medical services in Group Health Association of Washington, D.C., was analyzed for patients referred in 1970 for short-term psychiatric therapy under benefits but who had no therapy or referral for at least the 12 preceding months. A matched comparison group and family members were also studied. Medical visits were analyzed in three time periods: the 12 months preceding referral, the next 4 months when therapy was likely to be received, and a final 12 months. Compared with controls, the Index Cases did not show a significant reduction of "offset" in utilization of outpatient medical services after referral, but they did decreases days of medical hospitalization significantly. When Index Cases were divided into low and high users of psychiatric therapy, the former showed a decline, the latter an increase in medical visits, and the difference between them was significant. The before-after change in utilization among other family members was similar to that for index and control subjects. The findings suggest the need to identify the types of patient and the clinical settings which are most likely to maximize the offset effect of brief psychotherapy. Medical care programs should be tailored to meet the different psychotherapy. Medical care programs should be tailored to meet the different psychiatric needs of these and other patients in an effective and efficient manner.