Breast reconstruction with postmastectomy radiation therapy: current issues

Two recent trials have demonstrated superior locoregional control, disease-free survival, and overall survival in node-positive breast cancer patients with the addition of postmastectomy radiation therapy to mastectomy and chemotherapy. Based on these results, there has been an increased use of postmastectomy in patients with early-stage breast cancer. The inability to determine which patients will require postmastectomy radiation therapy has increased the complexity of planning for immediate breast reconstruction. There are two potential problems with performing an immediate breast reconstruction in a patient who will require postmastectomy radiation therapy. One problem is that postmastectomy radiation therapy can adversely affect the aesthetic outcome of an immediate breast reconstruction. Several studies have evaluated the outcomes of breast reconstructions that were performed before radiation therapy and have revealed a high incidence of complications and poor aesthetic outcomes. Furthermore, these studies have found that often an additional flap is required to restore breast shape and symmetry. The other potential problem is that an immediate breast reconstruction can interfere with the delivery of postmastectomy radiation therapy. During planning for immediate breast reconstruction, it is imperative to carefully review the stage of disease and the likelihood the patient will require postmastectomy radiation therapy. Unfortunately, the ability to detect and predict the presence or extent of axillary lymph node involvement is limited, and the need for postmastectomy radiation therapy is usually not known until after mastectomy. In all cases of decision making regarding possible postoperative radiation therapy and whether or not to perform immediate breast reconstruction, the situation should be discussed at a multidisciplinary conference or addressed among the various medical, surgical, and radiation teams, with active participation by the patient. Immediate breast reconstruction probably should be avoided in patients known to require postmastectomy radiation therapy and delayed until it is certain the therapy will be needed in patients who may require the therapy.     

SAFER GASTRECTOMY—100 Consecutive Cases Without Mortality

Duodenal stump disruption accompanied by fatal peritonitis is the complication most to be feared following gastrectomy and anastomosis by any one of the Billroth II modifications.While many explanations of this complication have been presented and many means devised to prevent it, by far the most frequent cause is distention of the proximal duodenum because of obstruction at the stoma due to kinks, angulations or postoperative edema.A supplemental report is made on a disintegrating T-tube designed to facilitate gastroenteric anastomosis, insure patency of the stoma and make impossible obstruction of the proximal loop.This report covers 100 consecutive instances in which the disintegrating tube was used and emphasizes the favorable postoperative course usually experienced by the patients.     

Safer gastrectomy; 100 consecutive cases without mortality

Duodenal stump disruption accompanied by fatal peritonitis is the complication most to be feared following gastrectomy and anastomosis by any one of the Billroth II modifications. While many explanations of this complication have been presented and many means devised to prevent it, by far the most frequent cause is distention of the proximal duodenum because of obstruction at the stoma due to kinks, angulations or postoperative edema.A supplemental report is made on a disintegrating T-tube designed to facilitate gastroenteric anastomosis, insure patency of the stoma and make impossible obstruction of the proximal loop. This report covers 100 consecutive instances in which the disintegrating tube was used and emphasizes the favorable postoperative course usually experienced by the patients.     

Recurrent urinary infections in girls: relation to enuresis

Maximum bladder capacities (MBC) have been studied in 89 girls receiving treatment for urinary infections at a time when the infection had been controlled. Fifty-six of the girls had been enuretic when first seen, 40 remained enuretic even when the infection had been cured. The MBC''s of the enuretic children were significantly smaller than those who were not or had not been enuretic. The enuresis and small bladder capacities were therefore not usually due to the urinary infection. It is concluded that in girls either enuresis predisposes towards the development of urinary infections, or that a common underlying pathology predisposes to both entities.     

Responses of plasma immunoreactive atrial natriuretic factor, aldosterone and urinary dopamine to salt-loading in a patient with severe idiopathic edema

A patient with severe idiopathic edema and long history of diuretic abuse had, in response to salt loading, an inability to increase urinary sodium excretion associated with a paradoxical response (decrease) of urinary dopamine excretion, a non suppressible aldosterone and non stimulable immunoreactive atrial natriuretic factor in plasma. These patterns distinguished this patient from those with a milder form of idiopathic edema who did not abuse diuretics and had, in comparison with controls, marginally decreased urinary sodium and dopamine responses but normal aldosterone suppressibility and ANF stimulability. Since the natriuretic action of ANF appears to be mediated by dopaminergic mechanisms, this severe natriuretic handicap may be due to a chronic diuretic abuse-induced combined ANF and dopamine deficiency.     

Clinical spectrum of invasive candidiasis in critically ill non-neutropenic patients

Invasive Candida spp. infections in non-neutropenic critically ill patients admitted to intensive care units can be classified as focal and systemic. Both types of infection usually occur after episodes of candidemia, although some focal infections may be of exogenous development, like those occurring after trauma or be device-related.The clinical spectrum of invasive Candida spp. infections includes focal urinary tract, abdominal, ocular, respiratory tract, renal and hepato-biliary infections, as well as systemic infections like candidemia and acute systemic candidiasis with multiorgan involvement after hematogenous seeding. Candida spp. isolates in "significant" samples, like synovial fluid, cerebrospinal fluid and blood cultures, represent true infection. However, the diagnosis of invasive infection based on "non-significant" samples, like surgical drains and digestive tract exudates, requires additional criteria. The total number of isolates from different sites, the presence of risk factors, the clinical host response, as well as severity of illness need to be taken into account for the diagnosis of invasive candidiasis. The clinical signs of systemic infection due to Candida spp. are completely non-specific and cannot be differentiated from bacterial peritonitis, urinary tract infection or bacteremia. These infections may be associated with signs of sepsis,severe sepsis, septic shock or multiorgan dysfunction. In the future clinical multicentre observational and interventional studies are necessary to reach agreement on clinical definitions and classification of invasive Candida spp. infections in critically ill non-immunocompromised patients.     

A clinical approach to common electrolyte problems: 2. Potassium imbalances.

A clinical approach to potassium imbalances is presented. Hypokalemia is rarely due solely to a reduced intake of potassium; instead, it usually results from a potassium flux into the cells or increased loss of the element, at times combined with a decreased intake. The clinician must seek the cause of the intracellular flux or the source of the gastrointestinal or renal loss. The causes of gastrointestinal losses are generally self evident. Renal potassium wasting, though, generally results from increased mineralocorticoid activity, an increased rate of urinary flow or of sodium delivery to the distal nephron, or both, hypomagnesemia or a combination of these factors. Hyperkalemia may be factitious, but usually it is caused by a flux of potassium from the cells or a decrease in the renal loss of potassium, the latter being mediated by a reduction in renal function, mineralocorticoid activity, or the rate of urinary flow or sodium delivery, or both. In both hypokalemia and hyperkalemia, treatment must be guided by the specific clinical circumstances.     

The role of primary bone grafting in complex craniomaxillofacial trauma

The role of craniofacial surgical techniques and immediate bone grafting in the management of complex craniofacial trauma has been reviewed. Four hundred and one patients with complex facial injuries have been treated. Two hundred and forty-one primary bone and cartilage grafts have been performed in 66 patients. Complex facial injuries should be managed by direct exposure, reduction, and fixation of all fractures utilizing interfragmentary wiring. Very comminuted or absent bone is replaced by immediate bone grafting, producing a stable skeleton without the need for external fixation devices. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O technique. Results of immediate bone grafting have been excellent, and complications are rare. All deformities should be corrected, whenever possible, during the initial operation. This one-stage reconstruction of even the most complex facial injuries will prevent severe postoperative traumatic deformity and disability that may be extremely difficult or impossible to correct secondarily.     

Protection of Renal Function During Surgery of the Abdominal Aorta

The operative and postoperative urinary output of 55 patients who underwent surgery for ruptured abdominal aortic aneurysms, unruptured abdominal aortic aneurysms, and aorto-iliac occlusive disease was recorded. There were five cases of postoperative anuria among 28 patients who received no free fluid in the immediate preoperative period. No case of anuria occurred in 27 patients who received either: (1) a water load of 5% dextrose in water or (2) 20% mannitol solution. The patients who received mannitol had a markedly greater operative and postoperative urinary output.Intravenous infusion of mannitol is recommended during the preoperative and operative period in patients with ruptured aneurysms of the abdominal aorta.     

Discovering topological motifs using a compact notation.

Discovering topological motifs or common topologies in one or more graphs is an important as well as an interesting problem. It had been classically viewed as the subgraph isomorphism problem. This problem and its various flavors are known to be NP-Complete. However, this does not minimize the importance of solving this problem accurately in application areas such as bioinformatics or even larger network studies. The explosion in the size of the output is usually caused by isomorphisms in the motif or graph: we present a method to handle this without sacrificing the correct answers. In this paper, we apply the natural notion of maximality, used extensively in strings, to graphs and present a simple three-step approach to solving this problem completely and exactly (without resorting to heuristics). We handle the natural combinatorial explosion due to isomorphisms inherent in the problem (which could result in output size being exponential in the input size) by the use of "compact location lists." In other words, instead of enumerating k elements out of n, we use the ((n)(k)) form in an implicit manner (k immediate neighbors of a vertex out of n possible immediate neighbors). This drastically reduces the size of the output without any loss of information. The algorithm we present is linear in terms of the size of the output encoded as compact lists.     

Massive scrotal edema as a complication of abdominoplasty

Massive scrotal edema is an unreported complication of abdominoplasty. This patient's postoperative decompensation of medial thigh and scrotal lymphatic return may well have been due to an occult lymphedema tarda or previously compromised lymphatics from the fibrosis of venous stasis disease and obesity.     

Islet-cell Carcinoma (Zollinger—Ellison Syndrome) with Fulminating Adrenocortical Hyperfunction and Hypokalemia

The production of ACTH-like material by tumours arising in non-endocrine tissue may initiate severe adrenocortical hyperfunction. The pathogenesis and clinical and laboratory features of Cushing''s syndrome associated with such tumours are characteristic. The autonomous production by the tumour of ACTH-like material cannot be suppressed by exogenous corticoids. The onset of clinical symptoms is rapid; muscle wasting, general weakness, thirst and peripheral edema predominate, and the classical signs of Cushing''s syndrome may be absent. High levels of plasma 17-hydroxycorticosteroids and urinary 17-hydroxycorticosteroids and 17-ketosteroids, usually with normal levels of urinary aldosterone, commonly occur. Hypokalemic alkalosis unresponsive to replacement therapy may cause death. In the case reported herein, the intriguing possibility exists that two hormone-like substances were produced by the primary growth and its metastases: one, ACTH-like, to account for the adrenal hyperplasia and Cushing''s syndrome; and another, gastrin-like, giving rise to the ulcerogenic diathesis.     

Protective Effect of Seleno-<Emphasis Type="SmallCaps">l</Emphasis>-Methionine on Cyclophosphamide-Induced Urinary Bladder Toxicity in Rats

Cyclophosphamide (CP) is a widely used antineoplastic drug, which could cause toxicity of the normal cells due to its toxic metabolites. Its urotoxicity may cause dose-limiting side effects like hemorrhagic cystitis. Overproduction of reactive oxygen species (ROS) during inflammation is one of the reasons of the urothelial injury. Selenoproteins play crucial roles in regulating ROS and redox status in nearly all tissues; therefore, in this study, the urotoxicity of CP and the possible protective effects of seleno-l-methionine (SLM) on urinary bladder of rats were investigated. Intraperitoneal (i.p.) administration of 50, 100, or 150 mg/kg CP induced cystitis, in a dose-dependent manner, as manifested by marked congestion, edema and extravasation in rat urinary bladder, a marked desquamative damage to the urothelium, severe inflammation in the lamina propria, focal erosions, and polymorphonuclear (PMN) leukocytes associated with occasional lymphocyte infiltration determined by macroscopic and histopathological examination. In rat urinary bladder tissue, a significant decrease in the endogenous antioxidant compound glutathione, and elevation of lipid peroxidation were also noted. Pretreatment with SLM (0.5 or 1 mg/kg) produced a significant decrease in the bladder edema and caused a marked decrease in vascular congestion and hemorrhage and a profound improvement in the histological structure. Moreover, SLM pretreatment decreased lipid peroxide significantly in urinary bladder tissue, and glutathione content was greatly restored. These results suggest that SLM offers protective effects against CP-induced urinary bladder toxicity and could be used as a protective agent against the drug toxicity.     

Rapid but not slow spinal cord compression elicits neurogenic pulmonary edema in the rat

The development of neurogenic pulmonary edema (NPE) can be elicited by an immediate epidural balloon compression of the thoracic spinal cord. To evaluate whether a slower balloon inflation could prevent NPE development, we examined the extent of NPE in animals lesioned with a rapid (5 microl - 5 microl - 5 microl) or slow rate (3 microl - 2 microl - 2 microl - 2 microl - 2 microl - 2 microl - 2 microl) of balloon inflation. These groups were compared with the NPE model (immediate inflation to 15 microl) and with healthy controls. Slow balloon inflation prevented NPE development, whereas the pulmonary index and histology revealed a massive pulmonary edema in the group with a rapid rate of balloon inflation. Pulmonary edema was preceded by a considerable decrease in heart rate during the inflation procedure. Moreover, rapid inflation of balloon in spinal channel to either 5 microl or 10 microl did not cause NPE. Thus, a slow rate of balloon inflation in the thoracic epidural space prevents the development of neurogenic pulmonary edema, most likely due to the better adaptation of the organism to acute circulatory changes (rapid elevation of systemic blood pressure accompanied by profound heart rate reduction) during the longer balloon inflation period. It should be noted that spinal cord transection at the same level did not cause neurogenic pulmonary edema.     

Candiduria: problems of diagnosis and therapy]

Candiduria is rather common. Yeasts could be detected in urine that was contaminated during collection of the specimens in patients with urinary bladder colonization or the upper urinary tract infection due either to retrograde spread of the pathogen from the urinary bladder or hematogenous dissemination from a distant infection focus. Most patients with candiduria are asymptomatic. The rate of complications is not known but appears to be low since candidemia rarely results from asymptomatic candiduria unless obstruction is present or instrumental examination of the urinary tract was performed. Unfortunately, there are no reliable diagnostic tests distinguishing fungal infection and colonization. Guidelines for antifungal therapy of candiduria, based almost entirely on fantastic reports and expert opinions, rather than on controlled clinical trials, were proposed by the Infectious Diseases Society of America. Until reliable methods for distinguishing infection from colonization are developed, further use of antifungal therapy is unlike to provide information for clinicians on the pathogenesis and effective treatment of candiduria.     

Diagnosis and management of meningococcal disease: the need for centralized care

Meningococcal infection remains a significant health problem in children, with a significant mortality and morbidity. Prompt recognition and aggressive early treatment are the only effective measures against invasive disease. This requires immediate administration of antibiotic therapy, and the recognition and treatment of patients who may have complications of meningococcal infection such as shock, raised intracranial pressure (ICP) or both. Encouragingly, its mortality has fallen in recent years. This is the result of several factors such as the centralization of care of seriously ill children in paediatric intensive care units (PICUs), the establishment of specialized mobile intensive care teams, the development of protocols for the treatment of meningococcal infection, and the dissemination by national bodies and charities of guidance about early recognition and management. We will review the pathophysiology and management of the different presentations of meningococcal disease and examine the possible role of adjunctive therapies.     

Therapeutic experience with netilmicin.

Netilmicin, a new aminoglycoside antibiotic, was used to treat 19 patients with urinary tract infection and 5 with systemic infection. The causal organisms were Escherichia coli (in 2), Klebsiella pneumoniae (in 4), Serratia marcescens (in 12) and Pseudomonas aeruginosa (in 7); 1 patient was infected with two of these organisms. All the isolates of causal organisms except one of Serratia were initially sensitive to netilmicin but many were resistant to other aminoglycosides. Sixteen of the urinary tract infections responded to netilmicin therapy, although relapse occurred in three patients. Two of the three patients with musculoskeletal infection responded to combined therapy with surgery and netilmicin; the other patient responded to the same regimen but with carbenicillin added. Netilmicin cured pneumonia in one patient but failed in the other patient with pneumonia, who had leukemia. Superinfection occurred in five patients with urinary tract infection. Adverse reactions to netilmicin were minor. Netilmicin may prove to be a useful agent, particularly for infections due to multiresistant Klebsiella or Serratia, or when prolonged aminoglycoside therapy is required.     

A rationale for administering leukocyte endogenous mediator to protein malnourished,hospitalized patients

Leukocyte endogenous mediator is a low molecular-weight protein synthesized by circulating monocytes and fixed macrophages of the reticuloendothelial system. Exogenous administration of leukocyte endogenous mediator to a well-nourished animal stimulates both specific and nonspecific immune function and replicates the protein metabolic response to infection, characterized by fever and increased amino acid oxidation, skeletal protein degradation and synthesis of “acute-phase” proteins. Leukocyte endogenous mediator administration also affords protection against semilethal doses of bacteremia in the well-nourished animal.In the protein-depleted host, synthesis or release of leukocyte endogenous mediator in response to infection appears to be reduced and the attenuated metabolic response may be attributed, in part, to a deficit in its production. However, nutritional repletion of the malnourished patient results in restoration of the capacity to produce leukocyte endogenous mediator usually within three to seven days, if adequate dietary protein is provided.Since protein malnutrition is associated with increased incidence and severity of bacterial infections, we postulate that the reduced synthesis and/or release of leukocyte endogenous mediator in protein malnutrition is detrimental. In those critically-ill, malnourished patients who cannot endogenously synthesize leukocyte endogenous mediator, and for clinical reasons cannot be repleted rapidly or are already infected and/or undergoing operative stress, exogenous administration of leukocyte endogenous mediator should be considered along with nutritional support. Administration of this protein to a seriously-ill malnourished individual should produce a metabolic profile of fever, increased urinary nitrogen excretion and falls in serum albumin concentrations that are generally considered pathologic. However, administration of leukocyte endogenous mediator over short periods of time should also provide the anabolic impetus for the augmented synthesis of proteins beneficial to recovery. In most cases, these countervailing forces of anabolism and catabolism should be of benefit to the host if the response to infection and injury is viewed as a physiologic redistribution of endogenous nutrients to meet the more critical and immediate needs of the stressed patient.     

Cobalt tumor of the thyroid gland

Diminutive kidney, hypoplasia or atrophic pyelonephritis, may be the cause of hypertension, lumbar or abdominal pain, obscure gastrointestinal symptoms or chronic urinary infection accompanied by chills and fever. A hypoplastic kidney is prone to infection and stone formation.Diagnosis includes meticulous x-ray examination and renal function studies employing the more accurate quantitative phenolsulfonphthalein test of each kidney. Nephrectomy is the treatment for unilateral disease causing symptoms; localized atrophic pyelonephritis is amenable to partial resection. Since urinary stasis invites infection, obstructing ureteral strictures should be dilated. Pyelectasis, secondary to ptosis, and ureteropelvic obstruction should be corrected by nephropexy or plastic repair. These conservative measures may prevent renal destruction.SIXTEEN PATIENTS WERE SUBJECTED TO NEPHRECTOMY: Six because of persistent pain and chronic infection and ten because of hypertension. The six with pain and chronic urinary infection were relieved. In six of the ten with hypertension, the disease recurred within six months to seven years.