Analysis of trimodal and bimodal therapy in a selective-surgery paradigm for locally advanced oesophageal squamous cell carcinoma.

BACKGROUND: Long-term survival outcomes of trimodal therapy (TMT; chemoradiation plus surgery) and bimodal therapy (BMT; chemoradiation) have seldom been analysed. In a selective-surgery paradigm, the benefit of TMT in patients with a complete clinical response is controversial. Factors associated with survival in patients with a clinical complete response to chemoradiation were evaluated. METHODS: Patients with stage II-III oesophageal squamous cell carcinoma treated with TMT or BMT from 2002 to 2017 were evaluated. The BMT group consisted of patients who were otherwise eligible for surgery but underwent chemoradiation alone followed by observation. This group included patients who later had salvage oesophagectomy. Survival was evaluated and compared between TMT and BMT groups. Elastic net regularization was performed to select co-variables for Cox multivariable survival analysis in patients with a clinical complete response. RESULTS: Of 143 patients, 60 (41.9 per cent) underwent TMT and 83 (58.0 per cent) BMT. Patients who underwent TMT had longer median overall survival than those who had BMT (77 versus 33 months; P = 0.019). For patients with a clinical complete response, TMT achieved longer median overall survival than BMT (123 versus 55 months; P = 0.04). BMT had a high locoregional recurrence rate (48 versus 6 per cent; P < 0.001); 26 of 29 patients with locoregional recurrence in the BMT groupunderwent salvage resection. Cox multivariable analysis demonstrated that upper-mid oesophageal tumour location (hazard ratio (HR) 2.04; P = 0.024) and tumour length (HR 1.18; P = 0.046) were associated with worse survival. Although TMT was not associated with survival, it was a predictor of reduced recurrence (HR 0.28; P = 0.028). The maximum standardized uptake value after chemoradiation also predicted recurrence (HR 1.33; P < 0.001). CONCLUSION: In patients who achieve a clinical complete response, TMT reduces locoregional recurrence but may not prolong survival. The differences in survival outcomes may be due to patient selection; therefore, a selective-surgery strategy in oesophageal squamous cell carcinoma is a reasonable approach.

Morbidity following salvage esophagectomy for squamous cell carcinoma: the MD Anderson experience.

The survival advantage associated with the addition of surgical therapy in esophageal squamous cell carcinoma (ESCC) patients who demonstrate a complete clinical response to chemoradiotherapy is unclear, and many institutions have adopted an organ-preserving strategy of selective surgery in this population. We sought to characterize our institutional experience of salvage esophagectomy (for failure of definitive bimodality therapy) and planned esophagectomy (as a component of trimodality therapy) by retrospectively analyzing patients with ESCC of the thoracic esophagus and GEJ who underwent esophagectomy following chemoradiotherapy between 2004 and 2016. Of 76 patients who met inclusion criteria, 46.1% (35) underwent salvage esophagectomy. Major postoperative complications (major cardiovascular and pulmonary events, anastomotic leak [grade ≥ 2], and 90-day mortality) were frequent and occurred in 52.6% of the cohort (planned resection: 36.6% [15/41]; salvage esophagectomy: 71.4% [25/35]). Observed rates of 30- and 90-day mortality for the entire cohort were 7.9% (planned: 7.3% [3/41]; salvage: 8.6% [3/35]) and 13.2% (planned: 9.8% [4/41]; salvage: 17.1% [6/35]), respectively. In summary, esophagectomy following chemoradiotherapy for ESCC at our institution has been associated with frequent postoperative morbidity and considerable rates of mortality in both planned and salvage settings. Although a selective approach to surgery may permit organ preservation in many patients with ESCC, these results highlight that salvage esophagectomy for failure of definitive-intent treatment of ESCC may also constitute a difficult clinical undertaking in some cases.

The treatment of "cimetidine resistant" peptic ulcers by ranitidine hydrochloride: a new histamine H2-receptor antagonist.

Twelve patients with endoscopically confirmed peptic ulcers which had failed to heal despite standard cimetidine therapy were treated with 300 mg ranitidine hydrochloride daily for 4 to 8 weeks. Nine patients had complete symptomatic relief although the ulcer was found to have healed endoscopically in only six. Two patients derived no benefit from treatment and in 1 patient symptoms continued despite ulcer healing. Ranitidine would appear, therefore, to be of benefit in some "cimetidine resistant" patients.

A two-compartment model for zinc in humans.

The oral absorption of zinc, from a test meal of minced beef, mashed potatoes and peas, have been measured in 19 healthy adults using the radiotracer 65Zn. The oral absorption, expressed as a percentage of the administered dose, was 20 +/- 5% (mean +/- 1 SD) in good agreement with previous results. In a subset of 9 subjects, tracer retention in whole body and whole blood was followed out to one year. The data were fitted to a simple two compartment model yielding total body zinc (TBZn), the zinc content in each of the 2 compartments and zinc turnover. The TBZn values ranged from 15.5 to 35.9 mmol while zinc turnover ranged from 0.043 to 0.073 mmol/d in keeping with results reported for significantly more complicated compartmental models applied to more comprehensive 65Zn tracer data sets. Additionally, TBZn correlated well with total body potassium, a measure of lean body mass, measured by whole body counting of the naturally-occurring potassium radioisotope, 40K. The zinc content of the more rapidly turning over compartment ranged from 3.2 to 5.6 mmol in reasonable agreement with exchangeable zinc pool estimations reported for short term studies using stable zinc isotopes. Therefore, the simple dataset and model employed in the present study yielded information on the short- and long-term behaviour of zinc compatible with both more complex radiotracer studies and analytically more demanding stable isotope studies.

Ranitidine: prophylaxis of duodenal ulcer recurrence.

Ninety-two patients with healed duodenal ulcer received prophylactic treatment with ranitidine, 150 mg at night, to prevent relapse. Patients were reviewed at 4-monthly intervals for clinical assessment and endoscopy. Eighty-two patients completed the trial. After one year sixty-two patients (76%) were in endoscopic remission; ten patients (12%) suffered symptomatic relapse and ten others had asymptomatic ulcers during treatment. There were no clinically significant untoward effects associated with the drug. A single nocturnal dose of 150 mg ranitidine reduces the relapse rate after duodenal ulcer healing.

Attenuation and reacquisition of foraging behavior in a patchy environment.

The present experiment examined the attenuation and reacquisition of foraging behavior of pigeons on a restricted diet. Using the procedure of Roberts (1988), thirty-two feeders were arranged in four circular patches of eight feeders each. The feeders were baited so that each patch contained a different density of food. Pigeons learned to forage among the patches. During this initial acquisition phase, visits to the patches by the pigeons differed as a function of the food density of the patches. After this initial foraging training phase, each pigeon received one of two response elimination procedures. For half of the subjects, food was not present during the response elimination phase. For the remaining subjects, food was placed exclusively outside the patches during this phase. Foraging behavior decreased quickly and somewhat similarly for both conditions. During a final phase in which the retraining of the original foraging behavior occurred, the group given food outside the patches during response elimination provided evidence of superior foraging with respect to sensitivity to the different patch food densities. The results are discussed with regard to previously published response elimination effects.

The effect of trimipramine (Surmontil) on the gastric secretion of acid and pepsin in patients with duodenal ulceration.

Twenty-three patients with endoscopically proven, symptomatic duodenal ulceration were randomized to receive trimipramine 50 mg daily or placebo. Maximal acid output studies and estimations of pepsin levels were performed before treatment, for 4 weeks while on drug or placebo and for 4 weeks after cessation of treatment. Gastric acid secretion was significantly reduced after 3 weeks treatment with trimipramine and this reduction was maintained for the duration of the study. Gastric pepsin levels were unaffected by the administration of the drug.

Analgesia by wound infiltration after surgical excision of benign breast lumps.

Wound infiltration with bupivacaine provided complete postoperative pain relief in 14 of 19 women undergoing excision biopsy of a benign breast lump under general anaesthesia. Fifteen patients formed a control group in whom the wound was infiltrated with saline. They had inadequate relief of pain despite receiving significantly more opioid analgesia than the bupivacaine group in the postoperative period. The analgesia from bupivacaine usually outlasted the postoperative pain. No adverse reactions were apparent.

Infantile hypertrophic pyloric stenosis.

A brief review of the development of the surgical management of infantile hypertrophic pyloric stenosis is made. The incidence, investigation, management and complications of cases treated at the Royal Hospital for Sick Children, Glasgow over a period of six decades is reported. The mortality fell from 59 per cent in 1925 to 0 per cent in 1975. Pyloromyotomy in infants with hypertrophic pyloric stenosis is shown to be a very effective treatment for this potentially lethal condition and must rank as one of the most cost-effective forms of treatment in medical practice.

Skin reactions related to surgical scrub-up: results of a Scottish survey.

The prevalence of skin reactions associated with surgical scrub-up among a representative sample of theatre personnel in Scotland was 37.2 per cent. Only 5 per cent of the sample had severe symptoms as judged by the necessity to consult a dermatologist. A skin reaction following surgical scrub-up is most likely to be due to a drying effect from frequent scrubs, and moisturizing creams are effective in controlling symptoms in up to 25 per cent of those developing reactions. Individuals who have other allergic symptoms appear more likely to develop skin reactions than those with no other allergic symptoms. These individuals may benefit from regular use of hand creams or using a scrub routine which causes less trauma to their skin as a prophylactic measure.

The effect of the non-steroidal anti-inflammatory drug choline magnesium trisalicylate on gastric mucosal cell exfoliation.

Gastric mucosal cell exfoliation was measured in 10 normal subjects taking choline magnesium trisalicylate (CMT), aspirin and placebo. Both drugs resulted in significantly elevated rates of exfoliation although the serum salicylate levels achieved with aspirin were lower than those achieved by CMT. Side-effects of tinnitus, nausea and increased faecal blood loss were more common while subjects were taking CMT.

Pyloric diaphragm, antral web, congenital antral membrane--a surgery rarity?

Three cases of pyloric diaphragm in elderly patients are reported. The finding of these patients within a 2-year period (1976-8) suggests that the condition is not as rare as previously thought. Diagnosis was achieved endoscopically and the condition managed surgically. While there has been controversy in the past over whether the disorder is acquired or congenital, the histological evidence of the cases presented here tends to suggest that it is a late presentation of a congenital abnormality.

A double-blind study of trimipramine in the treatment of active duodenal ulceration.

Thirty-six patients with endoscopically proven active duodenal ulcers entered a randomized double-blind trial. Five patients were excluded or lost to follow-up. Fifteen patients received 50 mg trimipramine at night and 16 patients received placebo. Endoscopy at 4 weeks showed ulcer healing in 11 patients (73%) receiving trimipramine and in 6 patients (38%) receiving placebo. Three patients were withdrawn at this stage, and the remainder were followed up for a further 4 weeks while receiving antacids only for symptomatic relief. At final endoscopy after 8 weeks, no further healing had occurred in the trimipramine group, whereas one further patient in the placebo group showed ulcer healing. The frequency and severity of night pain and waking were reduced and antacid consumption was lower int he trimipramine group, but initial drowsiness was greater. Trimipramine appears to be of some value in the treatment of duodenal ulceration.

Candida colonization of the oral cavity.

A quantitative study of candida colonization of the oral cavity was made in 20 normal persons, 20 patients receiving regular dialysis treatment, 21 patients who underwent operation and were in a general surgical ward and in 20 critically ill patients who had undergone operation and were in an intensive therapy unit. Candida colonization was common in the patients who had operations, and levels were highest in those receiving antibiotics. However, the administration of antibiotics was not the only factor accounting for high candida colonization, since many of the patients studied, receiving regular dialysis treatment and antibiotic therapy, had only low levels of colonization. Candida levels in the oral cavity were highest in the critically ill patients, two of whom had candida infection of the oral cavity and one patient who had systemic candidiasis. Within this group, candida colonization was not significantly different, according to the clinical outcome or the response to recall antigens. This increased candida colonization of the oral cavity may be important in the development of candida infection in these patients.

A simple blood sample method for measuring oral zinc absorption in clinical practice.

Tracer activity in blood 14 days after the oral ingestion of zinc-65 has been compared with zinc absorption measured by whole-body counting in 10 controls and 25 subjects with Crohn's disease. Highly significant linear correlations (P less than 0.001) were obtained between blood tracer activity and zinc absorption for both the control group (previously reported) and the Crohn's disease group, thus allowing zinc absorption to be predicted from blood tracer activity with an accuracy of +/- 7.1% for the control group, +/- 17.1% for an active Crohn's disease sub-group and +/- 18.0% for a quiescent Crohn's disease sub-group. Relative to the whole-body counting method, the prediction of zinc absorption from blood tracer activity had a sensitivity of approximately 88%, a specificity of approximately 89% and an overall performance accuracy of approximately 88%. Therefore, where whole-body counting facilities are not available, the blood tracer technique for predicting zinc absorption could be a useful alternative.

Endocarditis as a manifestation of Chlamydia B infection (psittacosis).

A case of Chlamydia B (psittacosis) endocarditis is described in a patient with no known previous valve disease. After mitral valve replacement a fall in Chlamydia B antibody titre occurred. At repeat mitral valve replacement five months later for a paravalve leak no evidence of continuing endocarditis was present. Direct confirmation of infection in the patient's apparently healthy budgerigar was obtained. Aspects of the pathogenesis, diagnosis, and treatment are discussed.