Acute mesenteric ischemia - a persistent problem.

Acute mesenteric ischemia is a disease with a relatively low incidence (0,02-0,9% of acute surgical hospitalizations) but a very high mortality rate which can reach up to 100% without early revascularization. Given the above, prompt and accurate diagnosis and subsequent surgical intervention is the cornerstone of treatment and essential to reduce the high mortality rate. Early revascularization can reduce overall mortality by up to 50%. Treatment of acute mesenteric ischemia requires the cooperation of gastrointestinal surgeons, vascular surgeons and interventional radiologists. Thorough clinical examination, contrast computed tomography performed at the initial stage, and the current possibilities of interventional radiology are the keys to improving the results of treatment of acute mesenteric ischemia. The purpose of this paper is to refresh knowledge in the management of acute mesenteric ischemia and summarize the most up-to-date information on the diagnosis and treatment of this disease.

Intermittent vs maintenance medication in schizophrenia. Two-year results.

This is a 2-year, double-blind, placebo-controlled study of 101 patients, evaluating the relative efficacy of intermittent medication (given only when the patient shows early signs of relapse) compared with moderate doses of maintenance medication for stable schizophrenic outpatients. Patients were dropped from the study if they had three prodromal episodes in 1 year or if an episode lasted more than 9 weeks. Fourteen percent of patients given maintenance treatment were dropped from the study compared with 46% of intermittently treated patients. Relapse rates were 16% for patients given maintenance treatment and 30% for intermittently treated patients, a nonsignificant difference. Intermittently treated patients were receiving significantly less medication, but there were no differences found in drug side effects. There appears to be no advantage in using the intermittent approach, but we found that the use of an early intervention strategy reduced the relapse and rehospitalization rates for these patients.

Relations among alcohol consumption measures derived from the Cognitive Lifetime Drinking History.

Few studies have been conducted of chronic alcohol effects on health and social outcomes. To evaluate the utility and feasibility of such studies, correlations between lifetime and current measures of total alcohol consumption (ounces) and times intoxicated were examined to determine whether these dimensions of drinking are distinct. Studies were conducted in 2142 respondents ages 35 to 70 selected from lists of licensed drivers and individuals eligible for Medicare. Lifetime measures of alcohol consumption and times intoxicated were derived from the Cognitive Lifetime Drinking History (CLDH). Depending on age and sex of the subgroups examined, current consumption accounted for only about 10-25% of the variability in lifetime alcohol consumption; current and lifetime times intoxicated were even less highly correlated. Lifetime and current measures of alcohol consumption accounted for approximately 40-50% of the variability in corresponding lifetime and current measures of times intoxicated in younger cohorts, but this fell to 25% and less in older cohorts. These findings support the use of lifetime measures of alcohol consumption and times intoxicated based on the CLDH together with current measures to investigate chronic and acute alcohol effects on health and social outcomes.

[Massive localized lymphedema in an extremely obese patient]. / Massives lokalisiertes Lymphödem einer extrem fettleibigen Patientin.

Soft tissue tumors are commonly encountered in all surgical departments. The authors present a case of a very rare large tumor lesion, with macroscopic signs of liposarcoma.

[Massive localized lymphedema: a reactive lesion simulating liposarcoma (case report]. / Masívny lokalizovaný lymfedém: reaktívna lézia simulujúca liposarkóm (Kazuistika).

The authors present a case-history of massive localized lymphedema in a 54 year old female patient (height 167 cm, weight 113 kg). The history of the lymphedema lasted about 1 year. Its growth was not accompained with subjective complaints. It was diagnosed as a pendulous tumor of soft tissues in the thigh, 70 x 65 cm large. In preoperative diagnosis it was classified as a liposarcoma. The tumor lesion was removed and sent for bioptic examinations. Both histological and immunohistochemical biopsies denied benign or malignant nature of the soft tissue tumors and confirmed the diagnosis of a massive localized lymphedema.

[Perforation of the large intestine]. / Perforácie hrubého creva.

AIM: The aim of this study was to evaluate surgical options and therapeutic results of the large intestine perforation treatment, conducted by the authors' team. METHODOLOGY: During a four-year-period, a retrospective study including 53 patient subjects suffering from the large intestine perforation followed by peritonitis was conducted by the authors' team. The peritonitis-related risks were classified according to the Mannheim Peritonitis Index--the MPI score. RESULTS: The mean value of the MPI score reached 24.4 points in the assessed group. The total mortality rate reached 18.9% in the assessed group. The MPI score was significantly lower in the surviving patients group, compared to the exited patients group. Furthermore, the MPI score was significantly lower in the group of patients suffering from benign disorders of the large intestine, compared to the group of patients with malignancies. Resection with primary anastomosis (RPA), as a surgical treatment method, was successful in 32.1% of all cases in the group and in 73.9% of the patients treated using RPA. CONCLUSION: In indicated cases, the RPA method remains the appropriate surgical approach for the patients with the large intestine perforation, even when diffuse peritonitis concurs. The MPI score represents a simple and sufficiently reliable assessment system for the patients suffering from the large intestine perforation.

[Undiagnosed primary Boerhaave syndrome]. / Primárne nepoznaný Boerhaave syndrom.

Spontaneous rupture of the oesophagus (Boerhaave syndrome) is a rare acute condition. Successful treatment of this life threatening condition depends on early diagnosis, the patient's general condition and subsequent treatment. The authors describe two cases of successful treatment of patients with primarily unrecognized spontaneous perforation of the oesophagus.

[Appendicitis and salmonellosis, a coincidence or etiopathogenically related?]. / Appendicitída a salmonelóza, náhoda ci etiopatogenetická súvislost'?

The authors describe a rare case report of a female patient with acute appendicitis, where the course was masked by gastroenteritis complicated with sepsis with a simultaneous course of imported infection with Salmonella type C (Kentucky). The attention is drawn to the fact that even such frequent abdominal emergency as appendicitis is, may cause diagnostic hesitations, if it is masked by a simultaneous alimentary infection. In spite of the application of a broad scope of examination methods a final decision of indication for laparotomy depends on clinical findings of the examining surgeon.

[Appendiceal mucocele causing pseudomyxoma peritonei]. / Appendixmukozele als Ursache von Pseudomyxoma peritonei (Gallertbauch).

The authors present the case of a very rare pseudomyxoma peritonei as a late complication of appendectomy. The definite diagnosis was established 11 years after appendectomy for appendiceal mucocele. In the paper the authors emphasize the need for correct retrospective evaluation of all data in patients with unusual diagnoses.

The academic health center and the healthy community.

US medical care reflects the priorities and influence of academic health centers. This paper describes the leadership role assumed by one academic health center, the State University at Buffalo's School of Medicine and Biomedical Sciences and its eight affiliated hospitals, to serve its region by promoting shared governance in educating graduate physicians and in influencing the cost and quality of patient care. Cooperation among hospitals, health insurance payers, the business community, state government, and physicians helped establish priorities to meet community needs and reduce duplication of resources and services; to train more primary care physicians; to introduce shared governance into rural health care delivery; to develop a regional management information system; and to implement health policy. This approach, spearheaded by an academic health center without walls, may serve as a model for other academic health centers as they adapt to health care reform.

Trends in diagnosis and management of breast cancer in the U.S.: from the surveys of the American College of Surgeons.

The results of a comparative study of a series of 15,132 cases of breast cancer diagnosed in 1972 and a series of 14,577 cases diagnosed in 1977 are presented. Data were collected through surveys of 670 hospitals in the United States conducted by the Commission on Cancer--American College of Surgeons. There has been significant improvement in the stage at which breast cancer is diagnosed in black patients. The proportion of cases diagnosed at the localized stage increased from 38.5% in the 1972 series to 45.2% in 1977. During the same time period, the average size of the tumor in black patients decreased from 4.5 cm to 3.5 cm and the average number of positive axillary nodes decreased from 6.6 to 5.5. Less change in the stage of disease at diagnosis or in the size of the tumor was observed in white patients and no significant change was found in the average number of positive axillary nodes. The average number of axillary nodes examined increased from 14.5 nodes to 16.0 nodes in white patients and from 16.4 to 17.3 in black patients. The proportion of all cases treated by surgery with axillary dissection increased from 79.8% in 1972 to 85.8% in 1977. Recent cases were more likely to be treated with surgery alone. Use of radiotherapy alone or in combination decreased for both races but the use of chemotherapy increased. A marked shift from Halsted radical mastectomy to modified radical mastectomy was evident at every level of age, stage of the disease, and size of tumor, and was observed in hospitals of all sizes. A significant increase in the average number of nodes examined was observed for each surgical procedure involving axillary dissection. No increase was observed in the use of conservative surgery (wedge excision, total mastectomy, or total mastectomy with low axillary dissection).

Noninvasive breast carcinoma: results of a national survey by the American College of Surgeons.

This study evaluates the data of noninvasive (in situ) lobular (ISLC) and ductal (ISDC) carcinoma, collected from 498 hospitals in a National Breast Cancer Survey, carried out by the American College of Surgeons in 1978. ISLC and ISDC were identified in 323 (3.2%) of 10,054 female patients with lobular and ductal carcinoma, of the total of 23,972 patients with histologically proven breast cancer surveyed (1.4%). The frequency of ISLC was significantly higher (18.5%) than ISDC (2.1%) suggesting a less agressive nature of ISLC, with a slower progression to invasion than ISDC. There was a different age distribution of ISLC and ISDC: about 80% of ISLC and 50% of ISDC were diagnosed in patients who were less than 54 years old, and the incidence showed a marked decrease in the older age groups in ISLC, whereas the incidence remained high in the following decade in ISDC. In this series there was a distinctly better five-year cure rate in the patients with ISLC (83.5%) than in the patients with ISDC (68.8%), in spite of the fact that radical surgery was performed more frequently in ISDC (67.8%) than ISLC (36.3%). The recurrence rate was five times higher (10.5%) in ISDC than in ISLC (2.5%). In black patients the recurrence rate (21.3%) was significantly higher in ISDC than in white patients (9.3%). In the present study there were no statistically significant differences in the five-year cure and recurrence rate in patients with noninvasive carcinoma, treated by more conservative procedures (72.9% and 8.5%) and those treated by more extensive surgeries (76.2% and 7.7%). The results of this study suggests that the biologic behavior of ISLC and ISDC may be different with regard to their propensity to invade and their overall prognosis. In contrast, the infiltrative form of lobular and ductal carcinoma, were found to have the same prognosis, regardless of the type of operative procedure performed.

Survey of primary liver tumors and oral contraceptive use.

The American College of Surgeons' survey data on 378 female and 165 male cases of primary liver tumors reported by 477 hospitals in the United States during 1970--1975 are presented. In males, 91.5% of the tumors were malignant, confirming the rarity of benign liver tumors in males. Among females, 43.9% were malignant and 56.1% were benign. Of the 212 benign tumors, 96 were hepatic cell adenomas and 58 were focal nodular hyperplasias. A positive history of oral contraceptive use was found in nearly half of all tumors, 65% of benign tumors, 74% of hepatic cell adenomas, and 74% of focal nodular hyperplasias. High frequencies of benign tumors were observed in the age group 20--30 yr. More than 80% of the tumors in this age group were found in oral contraceptive users. Symptomatology was more severe among users. No case of intraperitoneal bleeding was observed in nonusers. The findings confirm the suggested association between use of oral contraceptives and hepatic cell adenomas and focal nodular hyperplasias.

PIP: The American College of Surgeons conducted a survey of primary liver tumors in cancer-approved hospitals throughout the U.S. in the 6-year period, 1970-75. Of the 165 male cases identified, 91.5% were malignant, indicating the rarity of benign liver tumors in males. Of the 378 female cases located, 43.9% were malignant and 56.1% were benign. Nearly 50% of all primary liver tumors were found in women with a positive history of OC (oral contraceptive) usage, with OC history unknown in 29% of the study population. OC users accounted for 65% of all benign tumors reported, 74% of all hepatic cell adenomas, 74% of all focal nodular hyperplasias, 80% of benign tumors in the 20-30 year age group, and almost 90% of hepatic cell adenomas in the age group 26-30. This incidence survey confirms the reported association between OC usage and some types of benign liver tumors, especially hepatic cell adenomas and focal nodular hyperplasias. It is pointed out, and illustrated with graphs, that the age pattern for benign tumores corresponds to the age pattern for OC use. More of the OC users who developed benign tumors had used mestranol, results confirming earlier reported associations. However, this may simply be due to the fact of mestranol's earlier availability. Symptomatology, particularly with regard to pain and mass, was more pronounced in OC users. Results on duration of OC use and any association with tumor development were inconclusive. The incidence of benign liver tumors has increased from 1970 to 1975.

Primary liver tumors and oral contraceptives. Results of a survey.

Data on 378 (in females) and 165 (in males) cases of primary liver tumors reported by 477 hospitals in the United States during 1970 to 1975 show that in males, 91.5% of the tumors were malignant, and in females, 43.9% were malignant and 59.1% were benign. Of the 212 benign tumors in females, 96 were hepatic cell adenomas and 58 were focal nodular hyperplasias. A history of oral contraceptive use was found in nearly half of all women: 65% with benign tumors, 74% with hepatic cell adenomas, and 74% with focal nodular hyperplasias. Symptoms were more severe among users. No case of intraperitoneal bleeding was observed in nonusers. The findings confirm the suggested association between oral contraceptive use and hepatic cell adenomas and focal nodular hyperplasias.

Management and survival of female patients with "minimal" breast cancer: as observed in the long-term and short-term surveys of the American College of Surgeons.

The American College of Surgeons' long-term breast cancer survey in 1978 included 16,894 pathologically confirmed carcinomas of the female breast, in situ or infiltrative, with negative or positive nodes. Of these, 1.9% were in situ carcinoma of any size, and 8.4% were minimal invasive carcinomas 1 cm or less in diameter. No significant difference was found between the survival of patients with in situ tumors of any size and minimal invasive tumors with negative axillary nodes measuring 1 cm or less in diameter. In patients with invasive tumors with negative axillary lymph nodes, no statistically significant difference was found in survival of patients with tumors of 0.5 cm or less, when compared either with survival of patients with tumors measuring 0.6-1.0 cm. Recurrence rates observed in those groups were not statistically significant. Among 157 patients with invasive tumors measuring 0.5 cm or less, 23.0% presented with axillary lymph node metastasis. Tumors measuring 0.6 to 1.0 cm showed 20.9% positive axillary nodes in 964 patients. Statistically significant differences in survival and recurrence rates were achieved only for invasive tumors smaller than 1 cm. Survival and recurrence rates were significantly better (P less than 0.001) in patients with minimal invasive cancer with negative axillary nodes (P less than 0.001) than rates of patients with invasive tumors larger than 1 cm and with negative lymph nodes. Similar statistical results were obtained for patients with positive axillary nodes only for invasive cancers smaller than 1 cm. However, survival and recurrence rates observed in invasive cancers of 1 cm or less with positive axillary nodes suggest that tumor size alone cannot be used as the only defining criterion for minimal invasive breast cancer. Only the status of axillary nodes may determine whether a small invasive tumor below 1 cm may be considered as minimal breast cancer.

Management and survival of carcinoma of the colon: results of a national survey by the American College of Surgeons.

Survey results of long- and short-term outcome audits of colon cancer in participating hospitals with cancer programs conducted during 1976-7 by the American College of Surgeons are presented. In the long-term audit of 38,621 cases reported by 327 hospitals in 46 states, the overall percentage of cases in localized stage (29.3%) is significantly lower than in the recent series from the National Cancer Institute. The observed survival was substantially lower than the survival rates published in recent smaller series; however, survival approaches the end results for the period 1967-1973. In the short-term audit, the analysis of 11,655 cases diagnosed in 1976 and reported by 491 hospitals from fifty states showed that while 41% of patients had symptoms for less than a month, only 29.5% were diagnosed in the localized stage. Surgery was the predominant treatment modality with an overall resectable rate of 83%. No difference was observed in the stage at diagnosis when the short-term audit (1976) was compared with that found in the long-term audit (1971). The results suggest that the early diagnosis of symptomatic patients may not always substantially improve the cure and survival rate. The screening of asymptomatic patients is suggested as the more promising approach to the substantial improvement of presently less than ideal end results.

Breast cancer in the medial half. Results of 1978 National Survey of the American College of Surgeons.

In their previous report on the 1978 survey of breast cancer by the American College of Surgeons, the authors observed that the five-year cure rate was lower, but only marginally, in patients having tumors located in the medial half of the breast than those in the lateral half. In order to identify factors which might explain this difference, as well as to evaluate the contribution of additional irradiation towards improving the cure rates, further analysis was made of the group of 9401 women in the long-term survey, with particular attention to the size of the tumor, the age of the patient, and the extent of the nodal metastasis. This analysis demonstrates that the prognosis is quite similar between groups of patients with tumors in medial or lateral half of the breast. Irradiation given in addition to mastectomy did not appear to improve the prognosis of the patients as compared to that of those treated by mastectomy alone.

Management and survival of female breast cancer: results of a national survey by the American College of Surgeons.

This is a resume of a Breast Cancer Survey carried out by the American College of Surgeons in 1978. Four hundred and ninety-eight hospitals in 47 states, Washington, D.C., and Puerto Rico participated, contributing a total of 24,136 female patients with histologically confirmed breast cancer. In these patients, five-year cure rates were 60.5% for clinically localized disease and 33.9% for regional disease. Five-year survival rates were 72.8% for localized disease and 49.1% for regional disease. From the 1960's into the early 1970's, there was a gradual shift away from radical mastectomy towards so-called modified radical mastectomy. In a group of patients treated by either radical or modified mastectomies, the axillary nodal status, size of the tumor, and location of the tumor were examined in relation to the prognosis. In the study of number of metastatic nodes in the axilla, there were reduced cure and survival rates in patients with one or more positive nodes as compared to those with negative axillary nodes. With the increase in the number of positive nodes, there was a continuing associated decline in survival and cure. The clinical size of the tumor also correlated well to the prognosis. With the increase in the size of the tumor, there was a gradual increase in the probability of axillary nodal involvement. However, in the group of patients with tumor size smaller than 1 cm, axillary metastasis occurred in 25%. When the axillary nodes were involved, the cure rate in those patients was not significantly better than the rates for those with larger primary tumors in this study. Tumors located in the medial half of the breast were associated with a slightly lower cure rate than those in the lateral half. Young women under 35 years of age had poorer survival and cure rates, although in women 35-44 years of age, the five-year results were comparable to the older group of patients. In blacks, breast cancer was diagnosed in a relatively more advanced stage than in whites. Survival and cure rates were generally lower for blacks, and such lower rates seem to be associated with the relatively advanced stage of the disease.

The histology of liver tumors in oral contraceptive users observed during a national survey by the American College of Surgeons Commission on Cancer.

As part of the national survey on the tumorigenesis of oral contraceptive drugs conducted by the American College of Surgeons' Commission on Cancer, a histologic study was made of 94 cases of liver tumors in users and non-users of oral contraceptives. Pathologic criteria were established and then the slides were studied; the results were tabulated to determine the significance of each of the criteria as related to the use of contraceptives. These criteria included tumor size, peliosis hepatis, hemorrhage, necrosis, fibrosis, thrombosis, and vascular alterations of the intima and media. Cases of focal nodular hyperplasia in pill users exhibited greater vascular alterations, fibrosis, peliosis, and tumor size as compared to focal nodular hyperplasia observed in non-pill users. In addition, hemorrhage, necrosis, and peliosis were much more common in hepatic cell adenoma than in focal nodular hyperplasia. In the material reported in this series there were no hepatic cell adenoma cases observed in non-pill users. Focal nodular hyperplasia cases exhibited an overwhelmingly greater degree of vascular intimal and medial alterations than hepatic cell adenoma. The results suggest that the effects of oral contraceptives on the liver may be primarily upon the vasculature.

Test-retest reliability of the cognitive lifetime drinking history.

A new measure of lifetime alcohol consumption, the Cognitive Lifetime Drinking History (CLDH) uses beverage-specific questions on drink sizes and assesses drinking patterns to enhance recall. Two methods of establishing drinking intervals were examined: 1) floating--the respondent's report of when drinking changed, and 2) fixed--defined in terms of decades. Test-retest reliability for lifetime ounces of alcohol consumed and times intoxicated in lifetime estimated at visits 1 week or more apart was assessed in postmyocardial infarction patients (n = 81) and controls (n = 138) who had had at least 12 drinks in a year during their lifetimes. No significant differences in estimates of lifetime ounces of alcohol or times intoxicated were observed. Spearman's r ranged between 0.85 and 0.92 for the floating and fixed versions of the CLDH administered at a single visit and between 0.74 and 0.85 for the floating or fixed administered at both visits. Time between visits did not influence correlations. Intervals reported on the floating CLDH were comparable for postmyocardial infarction patients and controls. It took approximately 5 minutes longer to administer the floating CLDH than the fixed CLDH. Findings support use of the CLDH for case-control studies and suggest that the floating and fixed versions would yield comparable results.