MANAGEMENT OF NEPHROSIS—The Use of Long Continued Hormone Therapy

The course of nephrosis in 36 children was evaluated. Twelve of 24 who received no treatment or short-term courses of steroids died. Eleven of the 24 had been well for six months to five years at the time of this report.Twelve patients received steroids by schedule over extended periods. One died and eleven had been free of signs and symptoms of nephrosis for four to eighteen months at the time of report. In only two cases was therapy discontinued. It seems evident that these patients are experiencing a better state of well-being. Whether or not the prognosis is being altered for any single patient cannot be determined.     

The Kolff-Merrill artificial kidney; clinical application in acute renal insufficiency

Acute renal insufficiency is often called "lower nephron nephrosis." Its recognition, its prognostic significance, and its therapy by conservative measures are receiving increasing clinical emphasis. The mortality rate in this complicated syndrome still remains unduly high. One method of therapy of anuric patients whose lives are in jeopardy because of fulminating uremia or critical potassium intoxication is use of an artificial kidney to "purify" the blood stream by means of extracorporeal dialysis.The author describes clinical (and laboratory) experience with ten such dialyzed patients, eight of whom presented the classical picture of acute renal insufficiency. Four died, one from unrecognized coronary occlusion, another from antecedent, overwhelming peritonitis. Two other patients with chronic kidney disorders received no benefit from dialysis and died of renal disease. Good biochemical and clinical response was brought about in six cases of lower nephron nephrosis. Presumably, these six patients would have died had they not been subjected to artificial dialysis.     

Treatment of renal failure from diabetic nephropathy with cadaveric homograft

We report two patients with terminal renal failure secondary to diabetic nephropathy treated with cadaveric kidney transplantation. Neither of these patients had peripheral vascular disease or peripheral neuropathy. There was a proliferative diabetic retinopathy with hemorrhages and exudates in one patient and only background diabetic changes in the ocular fundi of the other; there have been no significant changes in visual acuity or retinopathy in either patient following the transplantation. Both have good kidney function after 8 and 15 months and are completely rehabilitated.The requirement for insulin decreased in both patients during the period of renal insufficiency and increased following transplantation; this seemed to be related to the large dose of steroids given because now that a maintenance level of steroids has been established, both patients require the same dosage of insulin as they did before the onset of renal insufficiency.     

Waldenstr?m's macroglobulinemia: review of 45 cases.

Of 168 patients with monoclonal IgM in the serum 45 (27%) had Waldenström''s macroglobulinemia. The mean age at diagnosis was 66 years. Generalized weakness, fatigue and bleeding manifestations were the usual chief complaints. Lymphadenopathy and hepatosplenomegaly were frequent. Moderate or severe anemia was noted in 29 patients, 9 had abnormal liver function, 8 had cold agglutinemia and 7 had cryoglobulinemia. Two patients had false-positive VDRL tests. The serum concentration of IgM usually exceeded 1000 mg/dl. Comparison of IgM values obtained by immunoquantitation and electrophoresis showed two types of discrepancy: readings were too high by immunoquantitation when IgM of low molecular weight was present, and readings were too low when, probably, IgM/IgG complexes were present or the serum was hyperviscous. Bence Jones protein was detected in 71% of the urine samples tested but the concentration was usually low, exceeding 200 mg/24 h in only nine instances. The mean survival time from the time of diagnosis for the 24 patients who died was 49.5 months and for the patients who are still alive, 43 months. Survival seemed to be related to the presence of azotemia, hypoalbuminemia and abnormal liver function.     

Adjuvant immunotherapy with levamisole in resectable lung cancer

Summary Levamisole (1.1–3.8 mg/kg daily) or a placebo was given in a randomized, double-blind study to 211 patients undergoing curative surgery for primary lung cancer. The treatment, in a fixed dose of one tablet (containing 50 mg or a placebo) t.i.d., was given for 3 days before the operation, and such 3-day courses were repeated every 2 weeks thereafter for 2 years.A significant reduction of the cancer mortality was observed at 18 and 21 months post surgery in the levamisole group. There was also a nonsignificant increase of the disease-free interval.In patients who had received more than 2 mg/kg (or more than 80 mg/m²) daily, the crude recurrence rates had been halved and the death rates reduced to one-third. No beneficial effect could be observed in the patients who had been given a lower dose. In the former, adequately dosed patients, the beneficial effect was more marked if the tumor had been more advanced at the time of surgery. In addition, the incidence of hematogenous secondaries was significantly reduced in the same group of patients.Professor Swierenga died in late 1977, shortly before completion of the work     

Domiciliary nebulisers in asthma: a district survey.

Fifty three patients who were found to be using a home nebuliser for asthma completed a questionnaire. The results showed some confusion about the criteria for recommending whether a patient should buy a nebuliser and for its correct use. Twelve patients had not received any instruction on the use of their nebuliser, and only 11 of those old enough used a peak flow meter in conjunction with it. Eight patients aged 7-15 were using inhaled sympathomimetic aerosols only at the time of buying a nebuliser as compared with most of the older patients, who were using regular oral steroids. Forty nine patients assessed their asthma as moderate to severe, but eight of these were not attending a hospital clinic. Several patients were using 20 mg salbutamol or more every day, and on occasion doses of up to 50 mg a day were reported. It is recommended that patients should be assessed before they buy a nebuliser and advice given on correct use by a district nebuliser service, organised either by respiratory function technicians or in physiotherapy departments for adults together with a paediatric health visitor for children.     

Correlation between lymphocyte-mediated auto-tumor reactivities and clinical course

Summary T-cell-enriched blood lymphocyte populations from 24 osteosarcoma and 22 soft-tissue sarcoma patients were assayed at the time of surgery for proliferative response to, and/or cytotoxic potential against autologous tumor cells. Tumor-free period and survival of the patients were correlated with the results obtained in the in vitro tests. The observation time was between 18 and 118 months (mean 62) for the osteosarcoma patients and between 18 and 72 (mean 42) for the patients with soft-tissue sarcoma. In both groups tumor-free period and survival were longer for those individuals who had auto-tumor reactivity. In the non-reactive group, all patients died within 3 years. Almost all patients had cytotoxicity against K562.     

Renal Transplantation: An Analysis of 33 Cases

Thirty-three patients with end-stage renal failure have had transplants over a three-year period, four patients receiving kidneys from siblings and the remainder cadaver organs. Twenty-seven kidneys survived with stable function for periods of six months to three years. Graft survival at one year was 85% and at two years 82%. One patient died and five were returned to dialysis. Complications included rejection episodes, technical problems, respiratory and wound infections, gastrointestinal disorders, and side effects of steroids.     

Treatment of Infected Pseudarthrosis of the Inferior Limb with Low-Frequency Pulsing Electromagnetic Fields: Report of 16 Cases

We report our experience in the treatment of infected pseudarthrosis of the inferior limb with pulsing electromagnetic fields (PEMFs) in 16 patients. The problems arising from the treatment of the infected pseudarthrosis, in which skin lesion, bone non-union and draining infection must be faced at the same time, will be discussed. Twelve patients healed in an average stimulation time of 5.6 months. The results of PEMFs stimulation were satisfactory because of the high percentage of success (75%), and the fact that a surgical operation was avoided in most of the patients. In the failed patients, PEMF stimulation had a positive effect on the local conditions of the pseudarthroses.     

Circulating immune complexes in patients with breast cancer.

In a retrospective study in women with breast cancer circulating immune complex levels were measured by radioimmunoprecipitation with 125I-Clq. Before operation all the patients showed plasma immune complex levels significantly higher than those in controls. Twelve months after mastectomy patients identified clinicopathologically as having a good prognosis had almost normal levels of immune complexes. By contrast, patients with detectable dissemination on diagnosis or those who died within 22 months after mastectomy had significantly raised plasma levels. The tumour-specific nature of the immune complexes detected remains to be shown and suggestions about the applicability of this test not only for prognosis but also for monitoring the course of malignant diseases need to be confirmed by further investigations.     

Role of hepatic arterial embolisation in the carcinoid syndrome.

Eighteen patients with severe symptoms of the carcinoid syndrome were assessed for hepatic embolisation. Four were too ill, and one had mild symptoms; thus 13 received a periembolisation regimen of cyproheptadine, fenclonine, aprotinin, methylprednisolone, tobramycin, flucloxacillin, and metronidazole. Embolisation was not performed in one patient with an occluded portal vein and was unsatisfactory in two others, in one because she was moribund and in the other because the hepatic artery had been ligated. Dramatic improvement in symptoms occurred in the nine patients in whom embolisation was successfully carried out, with abolition of flushing, severe abdominal pain, and wheeze and reduction in diarrhoea from 10.5 (SD 7.6) to 1.6 (0.9) stools/day. Urinary excretion of 5-hydroxyindole acetic acid fell from 1048 (716) to 289 (184) mumol/24 h (200 (137) to 55 (35) mg/24 h). Complications included one death from septicaemia, a hepatic abscess requiring surgical drainage, abdominal pain in three patients, pleural effusion in two, and transient encephalopathy in one. Relief of symptoms lasted for one to 24 months, and second embolisation in two patients produced further remissions of four to six months. Five patients died, one to 40 months after embolisation, in four cases because of metastases or heart failure. Hepatic embolisation is the treatment of choice for symptoms of the carcinoid syndrome resistant to medical treatment.     

Trimodality treatment in malignant pleural mesothelioma – Ordeal or real deal?

BackgroundManagement of MPM is complex and controversial as there is a paucity of good quality evidence. We report the toxicity and outcomes in patients who received trimodality treatment for non-metastatic MPM at our institution.Methods & materialsWe reviewed the electronic medical records of surgically managed MPM patients at our institution in the last decade. Dosimetric parameters of target volume and organs at risk were documented by the treatment planning workstation. SPSS was used for statistical analysis.ResultsBetween January 2008 and October 2018, 21 patients underwent surgery for MPM – all but 2 patients underwent extra-pleural pneumonectomy (EPP); epithelioid MPM was the most common histology. All patients, except 2, received neoadjuvant Pemetrexed/platinum doublet chemotherapy. Fourteen patients received adjuvant hemithoracic RT; ten patients were treated with a conformal technique at our institute and dosimetric data was available for analysis. Average time to start RT after surgery was 51 days (range 32–82 days). All patients were treated with a conformal technique using IMRT/VMAT to a dose of 45Gy in 25 fractions. Mean overall RT duration was 35 days (range 30–42 days). Grade I/II Pneumonitis was seen in 4 patients. One patient developed grade III acute lung toxicity unrelated to RT. At a median follow up of 25 months, 8 patients had died, of whom six died due to the disease and two died in the immediate post op period. Two-year DFS and OS were 58% and 73%, respectively.ConclusionIn spite of the extensive surgery and complex hemithoracic RT, we demonstrated excellent dosimetry, toxicity profile and favorable outcomes in non-metastatic MPM.     

Early autoimmune complications after thymomectomy in a patient with interstitial lung disease. Case report

Thymoma has been associated with a variety of autoimmune disorders. We report a case of myasthenia gravis and pancytopenia in a 53-year-old man with lymphoepithelial thymoma and interstitial lung disease. Preoperative examination revealed neither hematologic abnormality nor myasthenia gravis. The patient had enteritis prior to thymomectomy, sternal infection in the first month of operation, and urinary infection at the third month. About three months after thymomectomy, he required mechanical ventilation support due to myasthenia gravis-related respiratory failure. One month later, a rapidly progressing pancytopenia developed. The patient died within two weeks of overwhelming septicemia unresponsive to treatment with antibiotics and steroids. The possible onset of myasthenia gravis or pancytopenia after thymomectomy should be kept in mind during follow-up. Recurrent infections in the early stages of thymomectomy may suggest a lethal onset of pancytopenia.     

Scope of surgery for intracranial aneurysm in the elderly: a preliminary report.

Thirty-two elderly patients were reviewed six months to six years after intracranial surgery for subarachnoid haemorrhage. Out of 24 patients whose surgical outcome had been satisfactory, one had died from an unrelated illness and the remainder were well and leading normal lives. Eight patients had a poor outcome, which in some cases was due to factors other than age. In only three could a poor outcome be attributed to early surgery and advanced age. The results confirm that in at least three-quarters of patients aged 60-65 the risk of further haemorrhage can be removed by surgery without causing a major neurological deficit.     

单倍体相合造血干细胞移植联合脐带间充质干细胞输注治疗儿童重型再生障碍性贫血的临床观察及安全性分析

目的观察单倍体相合造血干细胞移植（hi-HSCT）联合脐带间充质干细胞（hUC-MSC）输注治疗儿童重型再生障碍性贫血（SAA）的临床效果及安全性。 方法整理海军总医院儿科2010年2月至2014年1月收治的11例接受hi-HSCT联合hUC-MSC输注治疗的SAA患儿的临床资料,进行回顾性分析。对其治疗情况、并发症发生情况及生存情况进行观察,总结该治疗方案的临床效果与安全性,以及治疗体会。 结果患儿全部获得造血重建,移植后1个月复查嵌合体均为70% ~ 100%供者嵌合。白细胞植入时间8 ~ 21 d,中位时间为12 d;血小板植入时间10 ~ 24 d,中位时间为15 d。11例患儿中,2例发生Ⅰ度急性移植物抗宿主病（GVHD）,1例发生Ⅲ度急性GVHD,均经相关治疗后好转;1例发生局限性慢性GVHD,经相关治疗后好转;2例发生广泛性慢性GVHD,发生率为18.18%。患儿移植期间均发生不同程度的恶心、呕吐、纳差和发热等症状,给予对症支持治疗后好转。8例（72.73%）发生口腔黏膜炎,2例（18.18%）发生肺部感染,9例（81.82%）发生病毒感染,2例（18.18%）发生腹泻,均经综合治疗后好转。11例患儿随访时间12 ~ 29个月,中位随访时间16个月,截止末次随访时1例因广泛性慢性GVHD接受持续治疗,2例接受免疫抑制剂减量治疗,其余4例均停用免疫抑制剂;1例患儿因家属自行停用环孢素A发生排异死亡。 结论hi-HSCT联合hUC-MSC输注治疗儿童SAA具有良好临床疗效,值得进一步关注。     

Ablative radioiodine therapy for hyperthyroidism: long term follow up study.

A total of 225 patients were treated for hyperthyroidism with 555 MBq (15 mCi) radioiodine to ablate the thyroid and induce early hypothyroidism. The efficacy of this treatment in eradicating hyperthyroidism and problems of follow up were assessed one to six years later from case records and questionnaires. Information was received from 197 out of 219 live patients (90%) and from 160 doctors concerning 207 patients (92%). Only three patients were not traced and six had died since treatment. The modal time to hypothyroidism was three months, and 64% of patients were hypothyroid at one year; 5.6% had failed to become euthyroid within one year. Ninety five per cent of patients had been seen by the doctor and 82% had had a thyroid test done within the past two years. Most doctors preferred patients to be returned to their care once thyroxine treatment was stabilised. An ablative dose of 131I is recommended as an effective means of treatment which has clear advantages over conventional methods. Good communications and effective follow up should ensure success.     

Combination Therapy for Myelomatosis

Twenty-eight patients with multiple myeloma have been treated with a quadruple chemotherapeutic regimen consisting of 1, 3 bis (2-chloroethyl)-1-nitrosourea (BCNU), cyclophosphamide, melphalan, and prednisolone. Nineteen new patients and nine who had escaped from previous single-agent therapy were included in the study. The results to date, on eight criteria of response, seem to be superior to those obtained from previous chemotherapeutic regimens. The study has been in progress for 18 months and only three patients have died. Only one who had not received previous therapy died, and she had complicating hyperparathyroidism, which almost certainly contributed to her death.     

Experience with 50 free TRAM flap breast reconstructions

The data from the first 50 patients undergoing free TRAM flap breast reconstruction in two units were examined. Average patient age was 42 years, and average weight was 62 kg. Forty percent of patients were chronic smokers, and 26 percent had low abdominal scars. Twelve percent exercised their abdominal muscles regularly. Eighteen percent had undergone radical mastectomy, whereas 76 percent had undergone modified radical mastectomy and 6 percent had undergone subcutaneous mastectomy. Postoperative radiotherapy had been given in 16 percent of patients, and 54 percent had received postoperative chemotherapy. The average time from mastectomy was 32 months, whereas six breasts were reconstructed immediately. Average operating time was 5.6 hours, and average blood loss was 2.4 units. Average hospital stay was 11.2 days. Complications included three total flap losses (6 percent) and two partial flap losses (4 percent). Abdominal hernia occurred in two patients (4 percent).     

Slow infusions of vinblastine in the treatment of adult idiopathic thrombocytopenic purpura: a report on 43 cases

Forty-three adult patients with idiopathic thrombocytopenic purpura (ITP) were treated by slow intravenous infusions of vinblastine. Nineteen had ITP of recent onset (i.e. of less than 6 months duration) and had contraindication to steroids (3 patients), refractoriness to steroids (6 patients) or to steroids and high dose intravenous immunoglobulins (IVIg, 10 patients). Of the 19 patients, 10 achieved complete response (CR), 2 achieved partial response (PR), 2 had minor response (MR) and the remaining 5 patients had no response (NR). Six of the complete responders remained in CR after 12 to 48 months, whereas all other responders relapsed within 3 months, in spite of maintenance therapy. Twenty-four patients had chronic ITP (i.e. of 6 months duration or more) and had showed no or only transient response to steroids and/or splenectomy, and in many of them, to other therapeutic approaches. Four achieved CR, 4 PR, 6 MR and 10 NR. All but 3 responses were shorter than 3 months, in spite of maintenance therapy. Most responses to slow infusions of vinblastine began after the first infusion. Main side effects included leukopenia in 9 patients (but with absolute neutropenia in only one) and peripheral neuropathy in 2 patients. Interval from diagnosis was the only prognostic factor of response to treatment. We conclude that slow infusions of vinblastine may be a useful approach in ITP of recent onset, when contraindication or refractoriness to steroids and/or IVIg exists. In our experience, this treatment has limited benefit in chronic ITP. In addition, it remains to be demonstrated that slow infusions of vinca alkaloids have any superiority over intravenous bolus injections of the same drugs.