A multicenter, randomized, double-blind trial of somatostatin in the management of acute hemorrhage from esophageal varices.

A prospective, randomized, placebo-controlled, double-blind, multicenter clinical trial of intravenous somatostatin (Stilamin; Serono Laboratories, Inc., Randolph, MA) was performed in 102 patients with actively bleeding esophageal varices from August, 1985, to November, 1986. Patients had major hemorrhage indicated by hematemesis or melena and evidence of significant blood loss. For entry, patients had to have endoscopic demonstration of active bleeding from esophageal varices or stigmata of recent hemorrhage and bright red blood in the gastric aspirate with no other source of bleeding found. Randomized patients received identical-appearing somatostatin or placebo for a 30-hr study period. Those given somatostatin received a 250-micrograms bolus and a 250-micrograms per hr infusion with repeat bolus and doubling of the infusion if the bleeding was not controlled. In retrospect, 18 patients could not be evaluated. Of the 84 evaluable patients, 48 received somatostatin and 36 placebo. They were comparable in age, gender, severity of liver disease and history of variceal bleeding. Transfusion requirements were similar in both groups. Bleeding stopped for 12 consecutive hr during 30 hr of the study period in 31 (65%) of the somatostatin group vs. 30 (83%) of the placebo group (p = 0.06). The median time to cessation of bleeding was 2 hr in the placebo group and 3 hr in the somatostatin group. Deaths following the study period were nine (25%) in the placebo group and 15 (31%) in the somatostatin group. Within the limitations of the present study, we conclude that somatostatin was ineffective in the management of active bleeding of esophageal varices.

Knodt rod distraction lumbar fusion.

Ninety-nine cases of Knodt rod fusions have been followed for an average of 18 months postoperatively. These patients were all severely incapacitated with pain for an average of 5.3 years prior to surgery. They all had a thorough preoperative work-up including myelogram, EMG and extensive conservative care. The procedure performed was an extensive bilateral laminectomy of the L5 vertebra with foramenotomy and a posterior lateral intertransverse fusion with the use of Knodt rods between the L4-5 and S1 levels. There was an overall average improvement after surgery in 70.35% of the cases. When the consideration of psychological problems and industrial cases were eliminated, the overall improvement was 80.38%. There were no major complications except that in five patients the Knodt rods were removed from between one week and one year postoperatively. Knodt rod fusions have results reported in the literature of frequent complications and very poor success rates. They can be a very good adjunct to the spine surgeon's armamentarium. In patients with long-range back pain who plan to return to heavy labor, the Knodt rods can give a surprisingly high rate of success.

A history of orthopedics in San Francisco and the West.

The unique development of early medical specialization in the West can be traced to California's geography and economic development. Such early specialization produced men with orthopedic inclinations. Early orthopedists founded the first medical school and the first modern teaching hospital, helped to found Stanford's Lane Medical Library and made the first use of x-rays in the West. In addition many of these orthopedists were prominent in the political and social activities of the time.

Total hip replacement as a salvage in traumatic lesions about the hip.

One hundred and eight total hip replacements have been accomplished in an attempt to salvage a problem caused by trauma. Many times, patients with traumatic arthritic problems have a quick transition from a normal existence to a severe disability. They may not have had the ability physically or mentally to handle this disability seen in patients with rheumatoid disease or idiopathic osteoarthritis. It has been shown that these patients with total joint replacement can be rehabilitated to almost a normal degree of function. Complications occur, but with careful planning and execution, they can be held to a minimum. In the long run, a high incidence of degenerative disease is seen in these problems. The primary procedure should not be done so as to jeopardize a secondary reconstruction.