Mesenteric ischemia secondary to cocaine abuse: case reports and literature review.

In summary, we report two cases of mesenteric ischemia following cocaine abuse in young women. In such cases it is always difficult to prove a direct causal relationship between the abuse of cocaine and mesenteric ischemia. Both our patients were relatively young (in their thirties) and did not have any history of atherosclerosis, and their urine toxicity screens were positive for the use of cocaine. Cocaine-related hospital visits are on the increase. Mesenteric ischemia should be considered in the differential diagnosis when evaluating a young patient with a history of cocaine abuse presenting with an acute abdomen.

Anterior cervical osteophytes: a rare cause of dysphagia.

Anterior cervical osteophyte is a rare cause of dysphagia usually occurring in the elderly. We report two cases in which the anterior cervical osteophytes impinged upon the esophagus, and we describe their surgical management. Initial investigation of a case of dysphagia should be directed to the common causes; however, in the elderly and in those with disorders of the cervical spine an anterior cervical osteophyte may be the cause of dysphagia.

The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot.

BACKGROUND: Melanoma of the foot is often discussed as an uncommon tumor which, when it occurs, presents in nonwhite races. STUDY DESIGN: The tumor registry of a 650 bed community teaching hospital and the Connecticut Tumor Registry were retrospectively reviewed for the nine-year period from July 1980 to July 1989. Patient age, race, sex, incidence of misdiagnosis, and delay until definitive therapy were recorded. Tumor location, size, staging, follow-up, recurrence, and disease-free survival rates were also recorded and correlated with initial disease, stage, and misdiagnosis or delay. RESULTS: Twenty-six cases were identified at Bridgeport Hospital, and 140 cases were identified in the Connecticut Tumor Registry. Significant delay in diagnosis occurred in 68 percent of the cases from the hospital and at least 16 percent of the cases in the state tumor registry. Regardless of stage, melanoma of the foot had a worse prognosis than melanoma of the thigh and lower leg. Delays in diagnosis had no demonstrable effect on clinical outcome. CONCLUSIONS: Melanoma of the foot is not as rare as commonly suspected, and constituted 3 percent of the 4,562 melanomas reported in the state tumor registry for the nine-year period. The majority were in fair-skinned individuals, and misdiagnosis was common. It is the inherent aggressiveness of the tumor rather than the delay in diagnosis that accounts for the poor clinical outcome.

Aggressive axillary evaluation and adjuvant therapy for nonpalpable carcinoma of the breast.

While quadrantectomy or lumpectomy with axillary node sampling and dissection, or both, has been shown to be an equivalent alternative to modified radical mastectomy, some surgeons have begun to omit axillary dissection altogether in patients with extremely small tumors, believing that the axilla is unlikely to be involved. In reviewing the incidence of axillary involvement with 69 nonpalpable primary tumors in one community for nine years, 20 per cent of patients with invasive carcinoma had axillary involvement. In a four year review of the Connecticut Tumor Registry, we identified 137 instances of quite small invasive carcinoma of the breast that were 1 millimeter or less. Sixteen per cent of these patients had axillary involvement. The survival of patients with nonpalpable primary tumors and axillary involvement was no different than patients with palpable primary tumors and axillary involvement. Regardless of how small the primary tumor, the incidence of axillary disease is significant and failure to evaluate the axilla will result in understaging and inappropriate decisions about adjuvant therapy.

Is routine preoperative hemodynamic evaluation of nonagenarians necessary?

An Incidence of co-morbid cardiac disease in the elderly surgical patient as high as 66% has been previously reported. Even in the absence of clinically significant cardiac disease, advanced age alone is often considered sufficient indication for Swan-Ganz placement, hemodynamic evaluation, adjustment of fluid states, and inotropic support. Yet data clearly documenting the need for this evaluation and therapy are difficult to obtain. All major general surgical and orthopedic operations in non-agenarians were reviewed in our institution from July 1, 1987 through December 31, 1988. Fifty-one procedures were performed on 46 patients. None of these patients had preoperative Swan-Ganz catheterization or hemodynamic evaluation. Eighteen general surgical, 30 orthopedic, 2 neurosurgical, and 1 gynecological procedures were performed. Forty-three were performed under general anesthesia, 7 under spinal anesthesia, and 1 with local anesthesia. Seven out of 51 patients (14%) experienced major complications, and 16 out of 51 (31%) experienced minor complications. Thirty-day mortality was 0%, and 6-month survival was 92%. Only one complication occurred within 48 hours of surgery that might possibly have been prevented with hemodynamic evaluation, adjustment of fluid status, inotropic support, and intensive care unit monitoring.

Hypothermia and acidosis worsen coagulopathy in the patient requiring massive transfusion.

Massive transfusion may cause abnormalities of electrolytes, clotting factors, pH, and temperature and may occur in a scenario of refractory coagulopathy and irreversible shock. Identification of correctable variables to improve survival is complicated by the interplay of this pathophysiology. Temperature may be an under-appreciated problem in the genesis of coagulopathy. In vitro studies have demonstrated that platelet function and vascular response are critically temperature-dependent. We reviewed the records of 45 trauma patients without head injury or co-morbid medical illness who required massive transfusions. The mean Injury Severity Score was 55 +/- 6, a mean of 22.5 +/- 5 units of blood was transfused, and mortality was 33%. Nonsurvivors were more likely to have had penetrating injury (88% versus 55%), received more transfusions (26.5 +/- 9 versus 18.6 +/- 1, p less than 0.05), had lower pH (pH 7.04 +/- 0.06 versus 7.18 +/- 0.02, p less than 0.05), had lower core temperature (31 +/- 1 degree C versus 34 +/- 1 degree C, p less than 0.01), and had a higher incidence of clinical coagulopathy (73% versus 23%). Severe hypothermia (temperature less than 34 degrees C) occurred in 80% of the nonsurvivors and in 36% of survivors. Patients who were hypothermic and acidotic developed clinically significant bleeding despite adequate blood, plasma, and platelet replacement. Avoidance or correction of hypothermia may be critical in preventing or correcting coagulopathy in the patient receiving massive transfusion.

Cyclosporine inhibits protein kinase C-dependent signals in human peripheral blood lymphocytes.

T helper lymphocyte activation is thought to occur when the T3T1 receptor is activated by antigen, and a calcium signal and stimulus to protein kinase C appear to be essential for interleukin-2 production and lymphocyte proliferation. Previous work from our lab has demonstrated that the calcium signal is unaffected by cyclosporine. In this report, a macrophage and T suppressor/cytotoxic-depleted population of human peripheral blood mononuclear cells is stimulated with Sepharose beads bound to OKT3 monoclonal antibody and Sepharose-OKT3 plus a phorbol ester (a stimulus to protein kinase C). Cyclosporine inhibits both the Sepharose/OKT3-mediated and Sepharose/OKT3/phorbol myristic acetate-mediated mitogenesis. Cyclosporine inhibits either protein kinase C or protein kinase C-dependent intracellular signals necessary for T helper activation and proliferation.

Specific but limited role of new imaging techniques in decision-making about intraabdominal abscesses.

Despite the very high accuracy rate of imaging studies (ultrasound, computed tomography, liver-lung-spleen scans and gallium-67 scans) in detecting intraabdominal abscesses, our experience with 80 recent cases indicate that these techniques have not significantly altered traditional methods of decision-making about when and where to drain such abscesses. In only 12.5 percent of cases were such decisions based on special imaging techniques alone, and most of these cases subphrenic abscesses were diagnosed late after surgery. In the remainder, physical examination and routine radiologic studies sufficed, with special imaging techniques primarily corroborating clinical evidence based on these methods. We conclude that the use of special imaging techniques alone in a search for the cause of fever early after abdominal surgery does not provide evidence upon which clinical decisions can be based unless there are already physical signs of an abscess.

Epidemiology of burns. The burn-prone patient.

Predisposition to burning was identified by history, by conversation with the family, or by physical examination. Factors that decreased the patient's ability to respond appropriately were considered as predisposing. A consecutive series of 155 hospitalized, burned, adult patients was reviewed. Approximately 50 per cent of the entire series showed predisposition to burning; among the more severe burns, this fraction was 57 percent. Among women, predisposition was more prominent in all categories than among men. Among women, those predisposed to burning had larger burns and a greater likelihood of dying. Alcoholism led the list of predisposing factors, with senility, psychiatric disorders, and neurological disease following in order. The patient's own home was usually the site of the burn in those predisposed, with the initial ignition being in the patient's hair or clothing, the mattress, bedclothes, or an overstuffed chair. All of the burns occurring in hospital or mental institution patients were among those predisposed to burning.