Long-term survival after bilateral adrenalectomy for metastatic lung cancer: a case report.

Selected patients with solitary metastases from non-small cell lung cancer can benefit from an aggressive treatment approach that includes resection of the metastases. This approach has been used for solitary adrenal metastases, but successful long-term treatment of bilateral adrenal metastases has not been previously reported. This is the report of a patient with bilateral adrenal metastases from lung cancer who is disease-free 9 years after bilateral adrenalectomy and chemotherapy. From this evidence, one may hypothesize that adrenal metastases are occasionally lymphatic in origin and that metastases with this route of spread are more amenable to aggressive curative treatment than adrenal metastases of hematogenous origin.

Coverage of full-thickness burns with bilayered skin equivalents: a preliminary clinical trial.

A total of six patients have received bilayered skin-equivalent coverage of full-thickness burns, with takes of 50% to 70% in the later patients. These skin-equivalent grafts are constructed by combining allogeneic fibroblasts with collagen to form a sheet and adding a suspension of autologous epidermal cells to the surface of the collagen matrix. These bilayered skin-equivalent grafts have provided an expansion of at least fifteenfold to twentyfold for the area covered by the donor epidermis. By 8 months after grafting, the skin-equivalent grafts appeared smooth and approximated the color of normal skin. Long-term problems associated with hypertrophic scarring or graft fragility have not developed during the 18-month period of follow-up.

Subungual melanoma: an eighteen-year review.

BACKGROUND: Subungual melanoma is a rare lesion comprising 1% to 3% of all melanoma cases. METHODS: Records of twenty-two patients with subungual melanoma treated at Roswell Park Cancer Institute during the period September 1971 to September 1989 were reviewed in a retrospective manner. Most common sites of involvement were the great toe on the foot (n = 7), the thumb (n = 4), and the index (n = 3) and ring fingers (n = 3) on the hand. Common signs included pigmentation of the nail bed, nail loss, and nail destruction. RESULTS: Thickness of the lesion could be determined in 10 patients. All four patients with lesions 1.0 mm and thinner at the time of biopsy were alive and disease free at 19, 20, 55, and 78 months, whereas three of six patients with lesions thicker than 1.0 mm were dead at 15, 51, and 56 months. Patients with ulcerated lesions had an estimated 5-year survival rate of 39% as compared with 80% for the group without ulceration. Seven patients underwent finger amputations distal to the metacarpophalangeal joint, and none experienced local recurrence. Four amputations were just proximal to the distal interphalangeal joint, and three were just proximal to the proximal interphalangeal joint. One of these patients died of metastatic melanoma at 56 months, and the other six were alive and disease free at 13, 19, 20, 32, 72, and 78 months from the time of diagnosis. CONCLUSIONS: More distal amputations of subungual melanomas of the hand preserve function and do not compromise survival or local control.

Review of gunshot wounds in Dayton, Ohio. Demographics, anatomic areas, results, and costs.

A retrospective review of 210 admissions for gunshot wounds was performed to evaluate the frequency that various anatomic areas were injured, complication rates, results of treatment, and costs. Seventy-two percent of patients had a single anatomic site involved. The complication rate was 13% and the death rate was 10.9%. A good result was obtained in 72%, but 12.4% had long-term disabilities. The average length of stay was 11 days with an average cost of +5,682 per patient. Application of today's prospective payment under diagnosis-related groups suggests this system of payment may adversely affect the delivery of trauma care in this country.

A correlation of response time and results of abdominal gunshot wounds.

Gunshot wounds to the abdomen are an indication for exploratory laparotomy in all cases except those involving the most superficial abdominal wall injuries. The charts of 123 patients admitted for abdominal gunshot wounds were reviewed for times of arrival on the scene by paramedics, in the emergency room, and in the operating room, as well as for number of admissions. Results of therapy were also graded and correlated with response times. The mean paramedic response time was 4 minutes 30 s. An average of 24 minutes 24 s was spent at the scene and in transport. The average delay from admission to arrival in the operating room was 1 hour 49 minutes. Patients who died spent an average of 54.4 minutes in the emergency room prior to surgical intervention. These results may represent justification for regionalization of trauma and direct transport to the operating room for abdominal gunshot wounds.

Surgical aspects of the Tenckhoff peritoneal dialysis catheter. A 7 year experience.

The experience with CAPD using the Tenckhoff catheter in 115 patients over a 7 year period has been reviewed. The general indications for CAPD in the patient with chronic renal failure are the mental and physical ability of the patient or his relatives to perform CAPD. In our series, diabetes mellitus has been a relative indication for CAPD, because diabetic patients often have vascular disease severe enough to make long-term hemodialysis difficult. The general contraindications are abdominal problems such as hernias, abdominal wall infections, inflammatory bowel disease, adhesions, and gastrointestinal stomas. Other contraindications are lumbar disk disease and respiratory insufficiency. The surgical principles of catheter insertion have been described. Complications associated with the Tenckhoff catheter were either mechanical (intraabdominal organ injury, incisional hernia, catheter leakage, catheter occlusion, or catheter dislodgement), or infectious (peritonitis or abdominal wall infection). The single most common organism isolated from effluent dialysate in 65 patients with peritonitis was Staphylococcus epidermidis in six patients (9.2 percent), and in 20 patients (30.8 percent), no organism could be isolated. For those patients who had peritonitis, the average frequency was at 8.9 months of CAPD. There were only three deaths (3 percent) directly related to the Tenckhoff catheter and these were due to peritonitis and sepsis. Only 22 (19 percent) of the 115 patients in this series had to discontinue CAPD because of its ineffectiveness or the patient's or relative's inability to perform CAPD.

Results of surgical resection of pulmonary metastases of squamous cell carcinoma of the head and neck.

In this retrospective review of 58 patients (12 females and 46 males) with pulmonary metastases of squamous cell carcinoma of the head and neck treated between January 1, 1970, and December 31, 1989, we evaluated their clinical courses and analyzed the outcomes of those who underwent pulmonary resection. For the entire group of patients, factors predictive of survival in those patients with a diagnosis of pulmonary metastases included pulmonary resection of metastases (p = 0.0001), locoregional control of the head and neck primary tumor at the time of diagnosis of pulmonary metastases (p = 0.007), TNM stage of the head and neck primary tumor (p = 0.02), a single nodule seen on the chest radiograph (p = 0.02), and disease-free interval (DFI) from the primary tumor of the head and neck of 2 years or more (p = 0.05). Twenty-four of 58 patients underwent thoracotomy for resection of metastases. Four (17%) were found to have a second primary tumor of the lung. Of the 20 remaining patients who underwent explorative surgery for possible pulmonary resection, 18 (90%) underwent complete resection of all malignant disease with an estimated 5-year survival of 29%. In these patients, a DFI of less than 1 year was associated with a 5-year survival rate of 0%, whereas a DFI of 1 to 2 years was associated with a 5-year survival rate of 43% and a DFI of 2 years or longer had a 5-year survival rate of 33%. The number of malignant pulmonary nodules that were resected ranged from one to five and was not significant in predicting survival (p = 0.19). Of eight patients who underwent the resection of more than one malignant pulmonary nodule, 50% survived 2 years, but none survived 5 years. Resection of a solitary pulmonary metastasis from squamous cell carcinoma of the head and neck resulted in long-term survival in selected patients. Important prognostic factors included locoregional control of the head and neck primary tumor, the number of nodules seen on chest radiograph, the TNM stage of the primary tumor, and the DFI from the head and neck primary tumor. The value of resection in patients with more than one malignant pulmonary nodule remains to be defined for this group of patients.

Nutritional indicators of postburn bacteremic sepsis.

The potential of nutritional assessment parameters in predicting sepsis in burn patients was investigated. Sixty-two consecutive patients (mean age 41 years) with an average burn size of 19% were studied. Values were obtained on postburn day 10 for serum albumin, transferrin, nitrogen balance, total lymphocyte count, skin test reactivity, and percentage of ideal body weight. Parameters predictive of imminent septic episode included serum albumin less than 3.0 g/dl (p less than 0.001), total lymphocyte count less than 1500/mm3 (p less than 0.001), anergy (p less than 0.001), and serum transferrin less than 150 mg/dl (p less than 0.001). Nitrogen balance and percentage of ideal body weight were not found to contribute to group discrimination.

Mesenteric venous thrombosis.

Six cases of mesenteric venous thrombosis have occurred in the metropolitan area from 1982 through 1985. The most common findings were nonspecific abdominal pain associated with nausea and vomiting, subjective distress disproportionate to the objective findings, and signs of decreased intravascular fluid volume. In all six cases there was a rapid progression of physical findings to a level commensurate with the initial complaint. The most consistent laboratory abnormalities were an increase in leukocyte precursors, an elevated lactate dehydrogenase, and a mild metabolic acidosis. Mesenteric venous thrombosis is an unusual disease that is difficult to diagnose and manage.

The use of phleborheography to detect deep venous obstruction.

Phleborheography is a noninvasive test to diagnose deep venous occlusion. Agreement with venography was 89 per cent in 147 examinations. Twenty-six hundred limbs were tested. Sixteen per cent (356 tests) demonstrated deep venous occlusion.

Immediate excision of burn wounds.

Early excision and grafting of body burns is a safe and efficient means of treatment. It reduces hospital stay and probably reduces septic complications. A group of 41 patients were so treated at Miami Valley Hospital Burn Therapy Program. Their hospital stay was less than that of patients treated and reported to the National Institute of Burn Medicine.

Elimination of urinary retention following inguinal herniorrhaphy.

In a group of 880 patients undergoing inguinal herniorrhaphy using local anesthesia, the incidence of postoperative urinary retention was 0.2 per cent. During the same period, a similar group of 200 patients had their hernias repaired using general or spinal anesthesia. The incidence of postoperative urinary retention was 13 per cent. The authors contend that the use of local anesthesia in inguinal hernia repair almost eliminates postoperative urinary retention.

Acute appendicitis during pregnancy.

Forty-one appendectomies were performed on pregnant patients during the period 1973-1983. The preoperative diagnosis of acute appendicitis was correct in 57 per cent of the cases (24 patients). Presenting complaints, physical examinations, and laboratory analysis did not prove helpful in establishing the diagnosis. The incidence of acute appendicitis during pregnancy was 1:4172 (birth/pregnancy). Rapid surgical intervention probably contributed to the low (25%) incidence of perforated appendices. A transverse incision and general anesthesia were preferred. There was no maternal mortality and a 2 per cent rate of fetal loss.

Wilms' tumors in adults.

Four cases of adult Wilms' tumor are reported comparing their diagnoses, treatment, and survival with the world literature. The oldest recorded patient is herein described at age 84. Aggressive surgical and medical therapy is necessary to improve survival. Surgical exploration should be through a transperitoneal approach with the patient positioned such that access to the chest can be obtained for maximum exposure and resection. Chemotherapy consisting of actinomycin D and vincristine should be instituted in all patients. Radiation therapy must also be considered in any patient with the diagnosis of nephroblastoma.

Treatment of exposed bilateral Achilles tendons with use of the Dynasplint. A case report.

Third- and fourth-degree burns, which extend beyond the layers of the skin, are the most severe and difficult to rehabilitate. In this case report, a patient's recovery from exposed Achilles tendons bilaterally secondary to a severe burn injury is described. The Dynasplint, a spring-loaded orthosis designed to deliver a low-load, prolonged stretch to healing connective tissue, was used to facilitate the patient's recovery from an initial loss of -29 and -27 degrees of dorsiflexion of the right and left ankles, respectively. The patient's progress is reported from bed rest to independent ambulation at the time of discharge from the hospital.

Micrografts. II: Evaluation of 25:1, 50:1, and 100:1 expansion skin grafts in the porcine model.

This study was undertaken to evaluate 25:1, 50:1, and 100:1 expansions of micronized skin grafts in a porcine model. Two full-thickness skin excisions (graft and control) were performed on each of 30 immature pigs (20 pounds). The pigs were divided into three groups of 10 animals each: group A, 25 cm2; group B, 50 cm2; and group C, 100 cm2. One square centimeter of the excised skin was thinned to produce a thick split-thickness skin graft. Four 90-degree passes were made through a skin mesher with the smooth side of the plastic mesh carrier to produce uniform pieces of skin. These pieces were applied to one area on each pig. Both the graft and control sites were covered with film. The film was removed on postoperative day 7, and excision sites were photographed on postoperative days 7, 10, 14, and 21. Healing was evaluated with a 12 x 12 inch digitizing pad to estimate the percent area healed. Healing was compared via analysis of variance, with percent area healed used as the dependent variable and treatment (control or graft) and postoperative day and expansion size used as the independent variables. No difference was found on postoperative day 7. On postoperative day 10, 25:1 grafts healed better than the 50:1 grafts, which were healed more than the 100:1 grafts. No difference was seen between 25:1 and 50:1 grafts on postoperative day 14; however, they were healed better than the 100:1 expansion grafts. No difference was seen between the graft sites on postoperative day 21.(ABSTRACT TRUNCATED AT 250 WORDS)

Burn size estimate reliability: a study.

A study was undertaken to assess any differences between physicians' and nurses' estimates of burn size from drawings of 10 hypothetical patients with burns. Patient drawings were sent to the 199 burn facilities that are listed in the American Burn Association's Burn Care Resources in North America 1989-1990. The mailings were randomized between physicians and nurses. In order to have an even distribution, the cover letter asked the individual who received the forms to fill them out himself or herself rather than to pass them on to someone else. Forty-one nurses and 16 doctors (29%) returned the completed forms. The length of experience in burn care for the nurses averaged 9.3 years (range, 2 to 20 years), and the length of experience in burn care for the physicians averaged 14.7 years (range, 1 to 30 years [p = 0.01]). There were significant differences in the estimate of mean burn size between the physicians and nurses for only the two smallest drawings; in these cases, size may have been hard to translate from the patient to the drawing. There were four smaller burn charts (less than 20% body surface area), and in two (50%) of these, there were significant differences in the estimation of the burn size. For the six larger burn charts (greater than 20% body surface area), there were no differences in the size estimates. With regression analysis, no trend was noted that correlated the size estimates with the length of experience in burn care for either the physicians or the nurses. Additionally, the participants were asked to indicate which method of estimating burn size was used in their units. Thirty-five percent use the Rule of Nines, 33% use the Lund & Browder chart, 5.3% use Berkow's method, 3% use other methods, and 1.75% use a combination of the Lund & Browder chart and the Rule of Nines. Twenty-one percent failed to indicate any preferred method. Estimates of burn sizes with the use of standardized burn forms were consistently the same whether estimates were made by physicians or nurses. Sixty-eight percent of the respondents used the Rule of Nines or the Lund & Browder chart to estimate burn size, but 21% of the respondents failed to answer the question about which method is used in their units. In conclusion, there appears to be little variance in estimation of burn size as made by experienced burn nurses and physicians, and use of these estimates in a centralized data bank should be reliable.

A comparison of the Tanner and Bioplasty skin mesher systems for maximal skin graft expansion.

Maximizing wound coverage of patients with burns who have meshed autografts is a primary intervention for wound closure. This study compared the Tanner and Bioplasty skin graft meshing systems for optimal skin graft expansion. Twenty patients for skin grafting were randomly assigned to either a Tanner or Bioplasty skin mesher group. Skin expansion ratios used with the Tanner group were 1.5:1 and 3:1, while Bioplasty ratios included 2:1 and 4:1. The patients' thighs were used exclusively as donor sites, and all grafts were harvested by the same surgeon. Expanded skin ratios were compared as to the difference in percent of predicted expansion outcome compared with the actual areas of the measured skin grafts. Comparing the differences of actual skin expansion with expected expansion, statistically significant results were found. When meshed skin grafts are used for wound closure, a 12.9% to 58.6% greater than anticipated area of donor skin should be harvested based on the expansion ratio selected.

Micrografts: the "super" expansion graft.

A novel technique for producing micronized skin grafts that was introduced in a paper presented at the 1990 ABA meeting was evaluated to quantify maximum expansion. Twenty Sprague-Dawley rats were divided into two groups representing 10:1 and 25:1 expanded micrograft ratios, respectively. Grafted sites in both groups were shown to heal better than those of the control group, and both grafted groups showed comparable healing at day 10.

The use of intestinal antibiotics to delay or prevent infections in patients with burns.

Bacterial colonization and infection of wounds in seriously burned patients often comes from the patient's indigenous bowel flora. A prospective randomized clinical trial that involved 30 patients with 20% or greater total body surface area burns was undertaken to evaluate the use of a standard antibiotic bowel preparation in the delay or prevention of bacterial colonization of the burn wound and sepsis. Certain enteric bacteria were seen less frequently in the treated group (Enterobacter organisms), but other bacteria appeared more often in the treated group (Proteus organisms and enterococci). The average time of colonization of the burn wounds was 6.1 days in the treated group and 6.7 days in the control group. Blood cultures were positive for enteric organisms earlier in the treatment group. Pseudomonads appeared earlier in the wound and blood cultures of the treated group than in the control group. The effect of antibiotic bowel suppression in patients with burns is varied and unpredictable. The bowel preparation may select certain organisms and lead to earlier colonization of the wounds. Overall outcome and survival was not improved by the use of an antibiotic bowel preparation in these patients.