Natural compounds in anti-leukaemic therapy: a review.

Human leukemia results from multiple mutations that lead to abnormalities in the expressions and functions of genes that maintain the delicate balance between proliferation, differentiation and apoptosis. Continued research on the molecular aspects of leukemia cells has resulted in the developments of several potentially useful therapeutic agents. Discovery of new cellular and/or molecular pathways enabling innate or acquired resistance of cancers to current chemotherapeutics to be overcome is therefore of crucial importance if one wants to efficiently combat those cancers associated with dismal prognoses. In this concern, natural compounds are regarded as new chemical entities for the development of drugs against various pharmacological targets, including cancer, and, above all, leukemia.

Management of lower extremity arterial trauma.

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Urgent lobectomy and pneumonectomy.

A small number of trauma patients with penetrating thoracic trauma will require formal pulmonary resections to repair severe injuries or control massive haemorrhage. Although previous reports on this subject have addressed the management of these injuries in battle conditions, civilian experience with this type of chest injury is limited. In a 3-year period, 259 patients underwent urgent thoracotomies for penetrating thoracic trauma. We retrospectively reviewed 43 patients who underwent lobectomies or pneumonectomies to control bleeding (93%) or bronchial injuries (7%). Handguns were the aetiologic agent in 41 patients (95%). The most common complication, pneumonia, was seen in 21 patients (87%). Fifteen patients (62%) developed respiratory failure. The complications of wound infection, post-operative haemorrhage and empyema were seen in equal frequency in four patients (16%). Two patients (8%) developed bronchopleural fistulas. Nine pneumonectomies and 34 lobectomies were performed with mortality rates of 66% and 38%, respectively (overall mortality, 44%). Ten (53%) deaths occurred in the operating room, late deaths (2-15 days) were secondary to sepsis and multiple organ dysfunction syndrome (MODS). Currently, the management of patients with devastating thoracic injuries to the thoracic cavity is divided into two stages. First, initial resuscitation with rapid surgery to control major bleeding, cardiac tamponade, tracheal disruptions and potentially lethal air embolism is indicated. Once the life-threatening conditions have been resolved, definitive surgical procedures are performed to repair injuries to any of the thoracic structures.

Characteristics of trauma centers and trauma surgeons.

We surveyed directors of trauma at 408 trauma centers (as indicated by the state chairmen of the American College of Surgeons' Committee on Trauma [ACSCOT]). Of the 408 trauma directors 290 (71%) responded with information relative to their hospitals and the 1537 general surgeons taking trauma call. Altogether, 75% of the surgeons worked on an identified trauma service, 80% belonged to a cadre of surgeons identified as expert, 52% were viewed as full time, 25% provided in-house staff coverage, and 76% had completed an ATLS course. Six percent of the entire group were 60 to 73 years old and demonstrated a commitment to trauma equal to that of their younger cohorts. As a group, the older surgeons took less call, but when community or the institutional call needs were identified, the older surgeons met the challenge.

Laparoscopic evaluation of tangential abdominal gunshot wounds.

The use of laparoscopy in abdominal trauma has been proposed for several decades; however, it has not been widely used. With the advent of laparoscopic cholecystectomy, general surgeons are realizing the potential of this technique. This should result in an expanded role for laparoscopy, including the evaluation of abdominal trauma. We present a series in which laparoscopy was used in the evaluation of tangential gunshot wounds to the abdomen. Laparoscopy enabled us to demonstrate whether the missile had violated the peritoneal cavity and to avoid laparotomy in cases without peritoneal penetration.

Melanosis coli: a case report in a trauma patient and review of the literature.

Melanosis Coli (MC) is a benign pigmentation disorder of the colon occasionally diagnosed at endoscopy. The authors report a case of M. coli in a patient with a gunshot to the abdomen, in whom the entity produced an interesting clinical picture, and a review of the literature on this condition.

Whipple procedure for trauma: is duct ligation a safe alternative to pancreaticojejunostomy?

The use of pancreatic duct ligation (DL) during a Whipple procedure for trauma has been reported but not analyzed. We reviewed 13 cases of DL and compared the results with that reported for the Whipple procedure for trauma with pancreaticojejunostomy (PJ). The mortality rate of DL was 53.8%. Pancreatitis occurred in three cases (23.1%) and caused one death. Pancreatic fistulae occurred in 50% of patients surviving two or more days after DL. No long-term survivor developed overt diabetes mellitus. Malabsorption occurred in 50% of the long-term survivors of DL. When the DL and PJ groups were compared no statistically significant difference could be found in either mortality or pancreatic morbidity. The 46.2% survival rate for DL warrants its consideration as a technique available to trauma surgeons when faced with an unstable patient unable to tolerate further operative therapy.

The use of segmental anatomy for an operative classification of liver injuries.

There is no universally accepted standard classification for liver injuries, and thus accurate comparison of reports on the subject is impossible. Most published reports on liver trauma suggest that both morbidity and mortality have a linear correlation with not only the amount of liver parenchyma injured but also with the magnitude of the surgical intervention. The exceptions are retrohepatic vein injuries, which have a mortality independent of associated parenchymal injury but should be integrated in any classification of liver injury. The classification proposed is based on the segmental anatomy of the liver (as defined by Couinaud): Grade I--Injuries requiring no operative intervention, or any injury that requires operative intervention limited to a segment or less. Grade II--Any injury that requires operative intervention involving two or more segments. Grade III--Any injury with an associated juxta- or retrohepatic vein injury. We reviewed all patients with isolated liver injuries during the past 5 years and prospectively reviewed all patients for the 6-month period from January to June 1988 and applied this classification. Sixty-nine patients had grade I injuries, with one death (1%); thirteen patients had grade II injuries, with six deaths (46%); and 13 patients had grade III injuries with nine deaths (69%). Postoperative morbidity was 7% for grade I, 57% for grade II, and 50% for grade III. This study supports the conclusion that morbidity and mortality from liver injury are directly related to the volume of parenchyma involved, and that segmental anatomy can be applied to define this volume. Mortality from retrohepatic vein injuries is independent of associated parenchymal injury. We believe that this proposed classification will provide a simple, reproducible, and accurate means for reporting and comparing liver injuries.

The use of serum amylase and lipase in evaluating and managing blunt abdominal trauma.

In order to determine the usefulness of serum amylase and lipase in the initial evaluation and subsequent management of blunt abdominal trauma (BAT) patients, we collected serum amylase and lipase on 85 consecutive BAT patients at admission, hospital day 1, hospital day 3, and hospital day 7. Only one patient had a pancreatic injury. A total of 45 patients (53%) had at least one enzyme abnormality during the study. There was no correlation between amylase or lipase values and age, sex, type of injury, diagnostic tests, operation, and outcome. In a control group of nonabdominal-trauma patients with admit studies only, all enzyme values were normal. We conclude that serum amylase and lipase are randomly elevated in patients with nonpancreatic-BAT both initially and during subsequent hospitalization and are not useful clinical tools in these patients.

A new technique for exposure of injuries at the confluence of the retrohepatic veins and the retrohepatic vena cava.

Because of difficulties in rapid exposure and control, injuries of the retrohepatic veins and retrohepatic vena cava continue to have mortality rates approaching 100%. Current strategies include shunt and finger fracture techniques, with controversy continuing over the optimal approach. We describe a new technique which involves mobilization of the liver by transecting the superhepatic vena cava, and affords a posterior approach to these injuries. Cadaveric dissection and clinical experience are described.

Retrohepatic vein injuries: experience with 20 cases.

The mortality for injury of the retrohepatic veins is reported to vary from 50 to 100%. The use of hepatic bypass techniques, introduced in the 1960's, has not significantly decreased this mortality. We reviewed our experience with liver injuries over a 5-year period from 1982 to 1987 to determine our results with these particular injuries. Twenty patients had retrohepatic vein injuries. There were 11 patients with penetrating trauma and nine with blunt trauma. A total of 15 patients died, for a mortality rate of 75%. Fourteen patients died intraoperatively from exsanguination and one postoperatively from sepsis. A shunt was used in an attempt to bypass the injury in ten patients, with nine deaths. In the ten remaining patients who were not shunted, there were six deaths. Thus, in ten shunted patients the mortality was 90% and in ten non-shunted patients, 60%. Our review supports other studies reporting a lower mortality by direct exposure and repair of retrohepatic vein injuries. Although total vascular occlusion of the liver may not be well tolerated in hypotensive patients, rapid application of the above approach resulted in better patient survival than the use of shunts.

Preoperative screening for HIV infection. A balanced view for the practicing surgeon.

Routine preoperative screening for human immunodeficiency virus (HIV) infection is becoming increasingly prevalent. Reasons in favor of routine screening include the following: (1) Knowledge of HIV status may allow the surgeon to decrease risk of infection. (2) The patient may benefit, because HIV infection may alter the risk-benefit ratio of a procedure. (3) Knowledge of HIV status will not affect how the patient is treated. Arguments against routine screening include the following: (1) Since the risk during individual procedures is low, it is unlikely that knowledge of HIV status can actually reduce risk. (2) Patient care may be negatively affected. (3) There is a possibility of false-positive results. (4) The accepted ethical standards of autonomy, confidentiality, and informed consent are not always adhered to. We explore these issues in detail. Recent work has framed the risk of surgeons and defined the reliability of diagnostic screening tests. All of these factors must be weighed before a surgeon can decide for or against a policy of routine preoperative screening.

Splenomegaly as a cause of fecal incontinence. A new problem in an old disease.

Eight patients with fecal incontinence were seen. All eight patients had massive splenomegaly secondary to myelofibrosis and myeloid metaplasia. Six of the eight patients underwent splenectomy for hypersplenism. Five of the six had total improvement of the fecal incontinence. One died two weeks postoperatively and could not be evaluated. In our opinion, the fecal incontinence was related to the splenomegaly. The possible mechanism is discussed. If absolutely necessary for control of fecal incontinence in this situation, splenectomy should be considered.

Portal hypertension. A fifteen year perspective.

Two hundred six consecutive patients were followed from 5 to 15 years after a distal splenorenal shunt operation. Nonalcoholic patients demonstrated nearly twice the survival rate when compared with alcoholic patients. The mean duration of life for the surviving nonalcoholics was 10 years and for the alcoholics, 9 years. We predict that approximately a third of the nonalcoholics will enjoy long-term survival. The operative mortality rate was similar in both groups, being about 4 percent. The risk of liver cancer was highest in the male alcoholics, and long-term survival was greater for women in both the alcoholic and nonalcoholic groups.

Effect of a clerkship on students' attitudes toward practice problems and preventive care.

The authors compared the attitudes of men and women junior medical students at one medical school before and after completing the surgery clerkship. The attitudes surveyed pertained to the students' confidence in dealing with problems in the doctor-patient relationship, concerns about future practice, and attitudes about preventive care. The women and men differed in only one career preference, with more women than men choosing obstetrics-gynecology. The class as a whole had more positive attitudes in all three areas after the clerkship. The men and women did not differ before or after the clerkship in their confidence in handling problems in the doctor-patient relationship. The women, however, had higher levels of concern than the men about preventive care after the clerkship. Although the men and women overall entered the clerkship with similar attitudes, the women left the surgical clerkship with more positive attitudes overall but also with more concerns about future practice than the men. Because of the demands made on students' time during the surgery clerkship, some women students may become concerned about conflicts that could arise from balancing career roles and homemaker roles, and they may need support at this time in dealing with these concerns.

Student attitudes about surgery in older patients before and after the surgical clerkship.

Although emphasis has been placed on including content on treating the elderly in the medical school curriculum, little attention has been given to whether content on surgical management of the elderly should be provided in the surgical clerkship. The purpose of this paper is to describe geriatric principles emphasized in a surgical clerkship and changes in attitudes of students. Junior students (N = 175) were tested on attitudes before and after the clerkship. Attitudes about treating the elderly and surgery in the elderly changed significantly and positively. Attitudes about emergency surgery in the elderly became more realistic, particularly in those selecting surgery as a career. This study differs from others that found that students became more negative about treating the elderly as they progressed through medical school. The surgical clerkship provides a different perspective of the older patient from that seen on medicine or in long-term care, in that the elderly are usually admitted and treated successfully in a short time. The fact that the surgical clerkship, in contrast to other medical school experiences, can positively influence attitudes about aging for all students, regardless of career choice, is encouraging and suggests that including content on surgical management of the elderly can help students become more favorable about treating older patients.

Resection of metachronous hepatocellular carcinomas.

We have described the rare case of a woman with no recognized predisposing factors for hepatocellular carcinoma in whom a second hepatic neoplasm was successfully resected nine years after a presumed "curative" partial hepatectomy. The importance of long-term measurements of available tumor markers as well as aggressive surgical management is emphasized.