The relationship between surgery and medicine in palliative care.

Palliative care represents the beneficence of surgery and medicine. A unified approach toward symptom control in patients with advanced diseases by surgeons and physicians is essential. Proposals are put forward to develop relationships between surgery and medicine for palliative care, teaching, and research. A model for integrating surgical and medical services to deliver the best palliative care is presented in this article.

Palliative medical oncology.

Most advanced cancer patients remain incurable. They are carrying the tumor burden and the burden of symptoms as a result of physical, emotional, and spiritual distress. Modern medical oncology, sophisticated as it may appear in its endeavors to cure cancers, has historically failed to consider pain and symptom control as part of cancer care. Because of this, palliative medicine has emerged as the champion of pain and symptom control in advanced cancer patients. The reasons for medical oncology not embracing palliative care are analyzed and a model for palliative medical oncology is proposed.

The opioid-sparing effects of intravenous ketorolac as an adjuvant analgesic in cancer pain: application in bone metastases and the opioid bowel syndrome.

Side effects of morphine are common when given in titrated doses to control severe pain in advanced cancer. We report a case series of acutely ill cancer patients suffering from pain, complications of advanced disease, and opioid side effects. They were treated with intravenous (i.v.) ketorolac along with i.v. morphine using repeated dosing. Excellent pain relief with improvement in the opioid bowel syndrome was achieved. We found it possible to switch from IV ketorolac to oral ketorolac along with oral morphine for long-term pain control. Ketorolac can be well tolerated in high-dose, long-term use even in this frail patient population. An algorithm is presented for the suggested use of ketorolac as a morphine sparing agent. Potential methods for studying ketorolac further in this role are discussed.

The ailments of cancer registries: a proposal for remedial education.

A study on the ailments of cancer registries, manifested by inaccuracies in data collection and delays in data retrieval, is presented. The etiology is identified as the lack of educational foundation for physicians and medical students. The symptoms are caused by the distance between physicians and the cancer registry. Investigations were carried out by error analysis, problem identification, and comparative and contrast studies. Pathogenesis is described on the basis of lack of bondage between the medical record system and the cancer registry. Educational remedies starting from the patients, medical students, and physicians are prescribed. Newly designed data collection forms that can form a secure link between the hospital medical record and the cancer registry are presented. It is hoped that physicians will perceive the cancer registry not as a burden of paperwork, but as a valuable tool to study cancer, and see it as a reflection of their achievements in cancer control.

Clinical, genetic and fertility studies of Indians with beta S-globin gene and the influence of Hb S on Plasmodium falciparum malaria infection.

Clinical studies were carried out on mild Indian sickle cell anaemia in Malaysia, and genetic and fertility studies were carried out on 101 families with and without sickle-cell haemoglobin (Hb S). The Indian sickle cell anaemia patients reached adulthood, and pregnancies and deliveries were uneventful without blood transfusion. There was no foetal wastage and the number of children produced was not significantly different from that in families without Hb S. 28 Indian patients hospitalized with Plasmodium falciparum malaria infection were also examined for their beta S genotype. P. falciparum malaria infection occurred much more frequently in individuals without Hb S than in Hb S carriers.

Sickle cell anemia associated with alpha-thalassemia in Malaysian Indians.

The Indian rubber estate workers in Negri Sembilan, Malaysia, who originated from Orissa in India were found to have a high frequency of Hb S (Joishy SK, Hassan K: Clin Res 28:280, 1980). Unlike the usually severe clinical picture of sickle cell anemia seen in African and American blacks, the clinical picture of the disease in this population was mild and many have reached old age. We studied the leukocyte DNA of 12 patients with sickle cell anemia, ranging in age from 4 to 61 years and 30 sickle cell trait carriers, ranging in age from 7 to 63 years, for the presence of alpha-globin gene deletions by gene mapping according to Southern (Southern EM: J Mol Biol 98:503, 1975), using alpha- and zeta-globin gene probes obtained by nick translation of the alpha- and zeta-globin genes cloned into plasmid. All 12 sickle cell anemia patients were found to have alpha-thalassemia2 (alpha-thal2), either in the homozygous or heterozygous condition. Of the Hb S trait carriers, six did not have alpha-thal2 or alpha-thal1 and 24 had alpha-thal2 (15 heterozygous, 9 homozygous). Seven of these Hb S trait carriers with alpha-thal2 had an additional gene abnormality. Five of them had a fast-moving Eco RI fragment 5.6 kb long that hybridized with zeta-specific probe but not with alpha-specific probe. An unusual DNA pattern of a different type was further found in the other two. Bgl II restriction analysis showed that the alpha-thal2 was mostly of the rightward deletion alpha-thal1 genotype. None of the sickle cell anemia patients and Hb S trait carriers had deletion type alpha-thal1. The sickle cell anemia patients had very high levels of Hb F and low levels of Hb A2. The Hb S trait carriers with alpha-thal2 had relatively low levels of Hb S.

The contribution of red cell morphology to the diagnosis of beta-thalassemia trait.

The contribution of red cell morphology to the diagnosis of beta-thalassemia trait in a predominantly healthy population was analyzed. The smears from 59 beta-thalassemia trait subjects already identified by DEAE-cellulose microcolumn chromatography, 60 subjects with other forms of microcytosis, and 64 nonmicrocytic subjects were randomly selected and evaluated blind. The "experimental" morphologic criteria were the presence of both basophilic stippling and either microcytosis or target cells. The "control" morphologic criteria were the presence of both microcytosis and poikilocytosis. Although the sensitivity of both sets of criteria were only moderate (73%), the specificity and predictive value of the experimental criteria were very high (99% and 98% respectively).

Clinical and chemotherapeutic study of hepatocellular carcinoma in Malaysia: a comparison with African and American patients.

Twenty Malaysian patients with unresectable primary liver cell cancer were prospectively studied at the General Hospital, Kuala Lampur, and were compared for clinical features with an equal number each of African and American patients being studied by the Eastern Cooperative Oncology Group. The patients received intravenous 5-FU and oral MeCCNU which was used for the first time in an Asian country. Most of the Malaysian patients were Chinese, belonged to younger age groups, and presented with massive hepatomegaly, jaundice, and fever. Toxicity to MeCCNU invariably occurred in the form of leukopenia or thrombocytopenia, but none life threatening. Partial response was seen in 20% of Malaysians as compared to 16% in Americans and none in Africans. Malaysians achieved a median survival of 16 weeks compared to 28 weeks in Americans and only eight weeks in Africans. Malaysian Chinese patients were all HBc Ab + ve. Other factors which may have played an etiologic role in the induction of primary liver cancer included alcohol, Chinese herbal medicines, aflatoxin and habitual use of medicated rubbing oils.

Hepatic resection: the logical approach to surgical management of major trauma to the liver.

Recent reports on the management of hepatic trauma have discouraged hepatic resection and supported hepatic artery ligation, "resectional debridement" and even packing. These nonresectional procedures are based on misguided principles and should never replace resection. Traditional methods of conducting hepatic resection in an emergency as used in the West probably cause delay in achieving immediate hemostasis, thus contributing to mortality. Compared with Western reports, our mortality for major hepatic resections is considerably low. This is probably due to faster resection and achievement of hemostasis by our clamping techniques. We conclude that it is quite logical to perform resection as the first line of treatment in major hepatic trauma.

Hepatic resection. Pillars of success built on the foundation of 15 years of experience.

Two hundred eight-eight hepatic resections performed over the past 15 years are discussed. The safety and success achieved are attributed to the original work in Malaysia on the anatomy of the liver and its anomalies, the use of surgical instruments specially designed for hepatic resection, various types of resections devised and studies on aids to liver regeneration after resection. The diversity of the principles and practice of surgery in the Western countries compared with those in Malaysia is illustrated.

Hepatic resections 1964-1979: vignettes drawn from the Malaysian experience.

We present a study of 288 hepatic resections carried out in Malaysia for the past fifteen years. First, we describe our indications for hepatic resectins which are not limited to hepatic trauma and hepatomas, but also include hepatic abscesses, cysts, intrahepatic calculi and hemangiomas. Second, we give a simplified classification of hepatic resections using accurate terminology. Third, we describe the safety of hepatic resections in our hands which we believe is due to specially designed surgical instruments and the accurate decision making process at surgery. We have had minimum postoperative mortality and no intraoperative deaths so far. Finally, while analysing each indication we have drawn vignettes from our experience for the past fifteen years.

Hepatic resection for malignant tumors of the liver: essentials for a unified surgical approach.

A unified surgical approach to hepatic resection and a simplified terminology in the classification of hepatic resections are presented based on experience with several hundred hepatic resections using specially designed instruments.

Peutz-Jeghers syndrome and its complications. First case report from Malaysia with review of literature.

We report for the first time from Malaysia a patient with Peutz-Jeghers syndrome complicated by successive intussusceptions requiring extensive small bowel resection. Our experience is compared with that of other authors by a review of the literature highlighting important points in the diagnosis and management of complications in Peutz-Jeghers syndrome.

Chromosomes and B and T cells in mycosis fungoides.

Because mycosis fungoides (MF) and Sézary syndrome (SS) share several features, some investigators have considered them to be different stages of the same disease. Others view them as separate entities. Cytogenetic studies in four typical MF patients showed that the chromosomal abnormalities were different from those reported in SS patients, and the abnormalities were found with almost equal frequency in both B and T cells. In addition, we found the frequencies of the T cells in six of the eight peripheral blood determinations in three patients were within normal range. These observations support the possibility that MF and SS are two separate disease entities.

Alveolar cell carcinoma in identical twins. Similarity in time of onset, histochemistry, and site of metastasis.

Identical male twins had alveolar cell carcinoma with nearly synchronous onset and similar histopathologic features, both metastatic to the brain. The hypothesis is advanced that there are genes shared by these twins that determine not only the susceptibility of pulmonary cells to malignant transformation but also the character of the resultant neoplasm, including its histologic features and metastatic behavior.

Sickle beta-thalassemia: identical twins differing in severity implicate nongenetic factors influencing course.

25-yr old female identical twins of Italian-American origin concordant for sickle beta-thalassemia were studied to explain their clinical differences. One of them has been severely affected from childhood with one aplastic crisis, an earlier onset of vaso-occlusive crises, and recent cardiac decompensation; the other twin shows no cardiac decompensation. Similar are their degree of anemia, RBC indices, blood volumes, absence of splenic sequestration, depression of pO2, elevation of p50 and 2,3-DPG, hemoglobin composition, and peripheral blood globin-synthetic rates. Regarding differences, the more severely affected has a shorter 51Cr RBC life span, a greater menstrual blood loss, and is more overweight, whereas the less severely affected has functional asplenia by 99mTc scanning and a larger proportion of RBC with decreased cellular deformability. We conclude that in sickle beta-thalassemia: (1) genotype alone does not determine the clinical course; (2) significant differences in clinical course can occur with almost identical hemoglobin composition and globin synthetic rates; (3) cellular deformability changes do not correlate exactly with clinical course; and (4) functional asplenia and leanness may be advantageous.